carnegie foundation summit on improvement in education: seeing the system
TRANSCRIPT
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Seeing the System
PC1: Improvement Science Basics
Monday, March 2, 2015
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The Improvement Journey
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Problem
P D
S A
Understand
the
problem
See the
system Set an aim
Develop a
theory of
improvement
Test
changes
Spread
changes Identify
measures
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Atul Gawande
TED Talk: How do we heal medicine?
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We Need to Improve Systems
“We are rewarding cowboys…but it’s pit crews we need.”
“…Get all of the different pieces…to come together into a whole.”
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A different assumption
Every system is perfectly designed to get exactly the
results that it gets
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Asthma
Asthma is the #1 source of hospital admissions &
hospital stays for children and youth Black children are 2x more
likely to be hospitalized and 4x more likely to die
14.4 million school days are missed
because of Asthma
Asthma
Chronic disease that affects more than 9 million
children
$20 Billion in healthcare costs annually
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An improvement case
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Why?
1,500 hospital
admissions due
to Asthma per year
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Understanding the problem
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Medicaid Youth: 23% return to the ED
within 90 days
Non-Medicaid Youth: 12-15% return to the
ED within 90-days
Gap in Asthma
Outcomes
Why?
Cause #1: Contact with environmental triggers (tobacco smoke, dust
mites, mold, rodents and cockroaches)
Why?
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Environmental triggers are noted
in the child’s record
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Doctor has an initial consultation
with the family
Environmental triggers are noted
in the child’s record
Agency follows up and removes
trigger
Child arrives at the ED or clinic
Why?
Doctor has an initial consultation
with the family
Why?
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Understanding the problem
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Medacaid Youth: 23% return to the ED
within 90 days
Non-medacaid Youth: 12-15% return to the
ED within 90-days
Gap in Asthma
Outcomes
Why?
Cause #1: Contact with environmental triggers (tobacco smoke, dust
mites, mold, rodents and cockroaches)
Why?
Cause #2: Inconsistent medication use
Why?
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Start administration
Parents pick up meds from the
pharmacy
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Doctor prescribes meds
Parents pick up meds from the
pharmacy
Start administration
Why? Why?
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Understanding the problem
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Medicaid Youth: 23% return to the ED
within 90 days
Non-medicaid Youth: 12-15% return to the
ED within 90-days
Gap in Asthma
Outcomes
Cause #1: Contact with environmental triggers (tobacco smoke, dust
mites, mold, rodents and cockroaches)
Why?
Cause #2: Inconsistent medication use
Why?
Re-engineer
the system
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Reengineering the System
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Medicaid Youth: 16% return to the ED
within 90 days
Non-medicaid Youth: 12-15% return to the
ED within 90-days Gap in Asthma
Outcomes
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Table Discussion
Reflect on the Gawande video and the Cincinnati Children’s case:
–What is striking about their approach to improvement?
–How is this similar or different than what is currently occurring in educational improvement?
–How does it complement current efforts?
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Systems Thinking
Beliefs about the causes of the current outcomes
– An assumption: People want to do a good job and take pride in their work.
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Improvement is About Systems
“At the heart of a scientifically grounded theory for improving healthcare is the premise that quality is a system property, and that, therefore, what primarily determines the level of performance is the design of a healthcare system, not simply the will, native skill, or attitude of the people who work in that system.”
D Berwick, “Improvement, trust, and the healthcare workforce,” Qual Saf Health Care 2003;12(Suppl 1):i2-i6
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Systems Thinking
Beliefs about the causes of the current outcomes
– An assumption: People want to do a good job and take pride in their work.
Skills: Seeing the system
– An interdependent group of items, people, and processes with a common aim
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Tools for Seeing the System
Measures:
– “When you are a specialist you can’t see the end result very well. You have to become really interested in data, unsexy as that sounds.”
Gawande
Visualizing processes:
– Process Maps
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Viewing Processes:
BTEN Feedback Management Process
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Principal assigns BT to
Case Manager and Support
Provider
Principal has initial
conference with BT to identify
focus area
BT ready for observation?
BT meets indicator
of success?
Every two
weeks
NO
NO
YES
YES
Case Manager has follow-up
conference with BT
Case Manager observes
BT
Case Manager has post-
observation Conference
with BT
Support provider
works with BT
Support provider
works with BT
Case Manager and BT
determine next focus
area
Principal assesses BT
performance
Principal, Case Manager, Support
Provider meet regularly to
communicate about BT’s progress
Within 48 hrs.
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Tools for Seeing the System
Measures:
– “When you are a specialist you can’t see the end result very well. You have to become really interested in data, unsexy as that sounds.”
Gawande
Visualizing processes:
– Process Maps
– Linkage of Processes
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Developing
calendar Determining
activities
Designing
curriculum Interfacing
with
community
Talking with
previous or
subsequent
schools
Getting
feedback from
teachers
Interfacing
with alumni
Working with
parents or
present
students
Recruiting
students for
specific
programs
Running
Headstart
Admitting
students
Orientating
new students
Selecting
classes
Scheduling
classes
Teaching
courses
Conducting
labs
Tutoring
students
Giving exams
Grading
Promoting
students
Counseling Assessing
student’s needs
Evaluating
teachers
Attending
professional
meetings
Developing
teachers
Conducting
faculty meetings
Training new
teachers
Hiring teachers
Recruiting
teachers
Setting
requirements
for teachers
Setting pay
scale for
teachers
Providing food
services for
students
Providing
school supplies
Conducting
activities
Managing
facility and
grounds
Fund raising Dealing with
school board
Complying
with state
Setting rules
and
regulations
Disciplining
students
Accounting
Providing
health services
to students
Products:
• Curriculum
• Exams
• Newsletter
Suppliers:
• Parents
• Previous schools
Input:
• Children
Customers:
• New schools
• Society
Outcome:
• Children with
knowledge
Sample Linkage of Processes
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The Power of Understanding Systems
Peter Senge, 1990: The Fifth Discipline
The disciplines of seeing interrelationships gradually
undermines older attitudes of blame and guilt. We begin to see that
all of us are trapped in structures, structures embedded both in our
ways of thinking and in the interpersonal and social milieus in which
we live. Our knee-jerk tendencies to find fault with one another
gradually fade, leaving a much deeper appreciation of the forces
within which we all operate.
This does not imply that people are simply victims of the
systems that dictate their behavior. Often, the structures are of our
own creation. But this has little meaning until those structures are
seen. For most of us, the structures within which we operate are
invisible. We are neither victims nor culprits but human beings
controlled by forces we have not yet learned how to perceive.
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“If I had 20 days to solve a problem,
I would take 19 to define it.” - Albert Einstein
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Understanding the problem
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Medacaid Youth: 23% return to the ED
within 90 days
Non-medacaid Youth: 12-15% return to the
ED within 90-days
Gap in Asthma
Outcomes
Why?
Cause #1: Contact with environmental triggers (tobacco smoke, dust
mites, mold, rodents and cockroaches)
Why?
Cause #2: Inconsistent medication use
Why?
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What is a Causal Systems Analysis (CSA)?
CSA is an improvement process that helps you identify the initiating causes of a problem.
Tool: Ishikawa Fishbone
or “Cause-and-Effect” Diagram
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BRANCH: CATEGORY
BRANCH: CATEGORY
BRANCH: CATEGORY
BRANCH: CATEGORY
PROBLEM STATEMENT
BONE: CAUSE
BONE: CAUSE
BONE: CAUSE
BONE: CAUSE
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The Problem:
New teacher support and retention
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1987-1988
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2007-2008
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WEAK RELATIONSHIP WITH PRINCIPAL
INADEQUATE FEEDBACK
INEFFECTIVE RECRUITING, HIRING & PLACEMENT SYSTEMS
LACK OF PROFESSIONAL COMMUNITY
INEFFECTIVE PROFESSIONAL DEVELOPMENT
TURNOVER RATES FOR NEW TEACHERS ARE HIGH AND NEW TEACHERS ARE NOT
EFFECTIVE FAST ENOUGH
POOR WORKING CONDITIONS
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WEAK RELATIONSHIP WITH PRINCIPAL
INADEQUATE FEEDBACK
INEFFECTIVE RECRUITING, HIRING & PLACEMENT SYSTEMS
LACK OF PROFESSIONAL COMMUNITY
INEFFECTIVE PROFESSIONAL DEVELOPMENT
TURNOVER RATES FOR NEW TEACHERS ARE HIGH AND NEW TEACHERS ARE NOT
EFFECTIVE FAST ENOUGH
POOR WORKING CONDITIONS
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Activity: Identifying Root Causes
Imagine you are a school leadership team.
Choose one “category” that’s not feedback
Brainstorm some potential causes.
For a couple of causes, ask “why?” again and again to dig deeper.
– Stop when you feel that you’ve gotten to a root cause – write it on your fishbone.
– If you get to something you can’t influence, step back to the cause before.
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Examples
Teachers are receiving inadequate feedback.
Why?
There’s not enough time to
give feedback.
Why?
Administrators are too busy
with building management and
student discipline.
Why?
There are only two
administrators in the building.
Why?
The instructional coach is
not being deployed.
Why?
The instructional coach is often
assigned to cover classes.
The process to request
substitutes is not working
efficiently.
Why?
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Activity: Identifying Root Causes
Imagine you are a school leadership team.
Choose one “category” that’s not feedback
Brainstorm some potential causes.
For a couple of causes, ask “why?” again and again to dig deeper.
– Stop when you feel that you’ve gotten to a root cause – write it on your fishbone.
– If you get to something you can’t influence, step back to the cause before.
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Poll Everywhere
What is one root cause your team identified?
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Go to pollev.com/cfsummit
or text cfsummit to 22333
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Tips for Crafting a Fishbone Diagram
INTERROGATE YOUR SYSTEM
Always ask “why” to dig deeper.
Be open-minded about what you discover.
STAY USER-CENTERED
Talk to users to understand their experience.
See the system from different points of view.
USE DATA WHEN POSSIBLE
Measure the gap you’re trying to close.
Test causes against data. 37
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Closing
Two key assumptions of improvement work:
–See the system causing current outcomes
–Understand the problem before jumping to solutions
Useful throughout the improvement journey: particularly important at the beginning, but you may return to them regularly.
There are tools that can help you, but really they are skills to invest in.
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