chapter 6. tools for problem solving and decision making an integrated approach to improving quality...

Chapter 6. Tools for Problem Solving and Decision Making

An Integrated Approach to Improving Quality and Efficiency

Daniel B. McLaughlinJulie M. Hays

Healthcare Operations Management

Copyright 2008 Health Administration Press. All rights reserved. 6-2

Chapter 6. Tools for Problem Solving and Decision Making

• Decision-making framework• Framing• Basic process improvement• Root cause analysis• Failure mode and effects analysis (FMEA)• Decision trees• Optimization• Theory of Constraints (TOC)• Force field analysis


Decision-Making Framework

• Framing- Identifying and framing the issue or problem

• Gathering intelligence- Generating or determining possible courses of action

and evaluating those alternatives

• Coming to conclusions- Choosing and implementing the best solution or

alternative

• Learning from feedback- Reviewing and reflecting on the above steps and

outcomes


Barriers to Good Decision Making

Key Elements Barriers to Brilliant Decision Making

Framing the question Plunging in

Frame blindness

Lack of frame control

Gathering intelligence Overconfidence in your judgment

Shortsighted shortcuts

Coming to conclusions Shooting from the hip

Group failure

Learning/failing to learn from feedback

Fooling yourself about feedback

Not keeping track

Failing to audit your decision process


A Test of Your Problem-Solving Abilities

4 If a doctor gave you three pills and said to take one every half hour, how long would they last?

1 Can a man living in Milwaukee,Wisconsin, be buried west of the Mississippi?

2 If you had only one match and entered a room where there was a lamp, an oil heater, and some kindling wood, which would you light first?

3 How many animals of eachspecies did Moses take alongon the ark?

5 If you have two U.S. coins totaling 55 cents and one of the coins is not a nickel, what are the two coins?


Mind Mapping

Diagram created in

Inspiration® by

Inspiration Software®,

Inc.


Process Mapping/Flowcharting

• Graphical depiction of a process showing inputs, outputs, and steps in the process

• Used to understand and optimize a process

• Integral part of most improvement initiatives including Six Sigma, Lean, Balanced Scorecard, RCA, FMEA, and so forth


Process Mapping Steps

1. Assemble and train the team.2. Determine process boundaries and

desired level of detail.3. Determine and order major process tasks.4. Draw a formal flowchart.5. Check the accuracy of the formal

flowchart.6. Collect more data and information as

needed.


Flowchart Standard Symbols

Microsoft Visio® screen shots reprinted with permission from

Microsoft Corporation.

A rectangle is used to

show a task or activity.

A diamond is used to show those point in the process where a choice

can be made or alternate paths can be

followed.

Arrows show the direction of flow of

the process.

End

Feedback loop

D shapes are used to show

delays.

An oval is used to show inputs/outputs to the

process or start/end of the process.


Activity and Role Lane Mapping

Role

Activity Clerk Nurse Porter Doctor

Take insurance information x

Move patient x x

Record vital signs x x

Take history x x

Examine patient x

Write pathology request x

Deliver pathology request x


Service Blueprinting

Microsoft Visio® screen shots reprinted with permission from Microsoft Corporation.

Customer gives

prescription to clerk

Clerk enters data

Clerk gives prescription

to pharmacist

Pharmacist fills

prescription

Clerk gives medicine to customer

Clerk retrieves medicine

Pharmacist gives

medicine to clerk

Customer receives medicineLine of interaction

Line of visibility

CustomerActions

Onstage Actions

Backstage Actions


Root Cause Analysis

• Structured, step-by-step techniques for problem solving

• Aimed at determining and correcting the ultimate causes of a problem

• What happened?

• Why did it happen?

• What can be done to prevent it from happening again?


Five Whys Technique

• Ask why the condition occurred.

• Ask why for each answer (five times is a good rule of thumb).


Cause and Effect Diagram

Waiting Time

Waiting Time

Methods

Machines Man

Mother Nature(Environment)


Cause and Effect Diagram

Old inner-city building

Lack of treatment

rooms

Elevators broken

Wheelchairsunavailable

Transport arrives late

Process takestoo long

Excessive paperwork

Unexpected patients

Wrong patients

Staff not available

Corridorblocked

Sick

Late

Files unorganized

Bureaucracy

Incorrect referrals

Lack of technology

Poor scheduling

Poor maintenance

HIPAA regulations

Waiting Time

Methods

Machines Man

Mother Nature(Environment)

Original appointment missed


Failure Mode and Effects Analysis (FMEA)

Steps

in th

e Pro

cess

Failu

re M

ode

Failu

re C

ause

s

Failu

re E

ffect

s

Likel

ihood o

f

Occurre

nce (1

–10)

Likel

ihood o

f

Detec

tion (1

–10)

Sever

ity (1

–10)

Risk

Priorit

y Num

ber

(RPN)

Actio

ns to

Red

uce

Occurre

nce o

f Fai

lure

12345678

Total RPN (sum of all RPNs):


Failure Mode and Effects Analysis (FMEA)

• Failure mode: What could go wrong?• Failure causes: Why would the failure happen?• Failure effects: What would be the consequences of

failure?• Likelihood of occurrence: 1–10, 10 = very likely to occur• Likelihood of detection: 1–10, 10 = very unlikely to detect• Severity: 1–10, 10 = most severe effect• Risk priority number (RPN): Likelihood of occurrence ×

Likelihood of detection × Severity


Theory of Constraints

• The Goal (Goldratt and Cox 1986)

• Every organization is subject to at least one constraint, which limits it from moving toward its goal.

• Eliminating or alleviating the constraint can enable the organization to come closer to its goal.


Theory of Constraints Five Steps

1. Identify the constraint (or bottleneck).

2. Exploit the constraint.

3. Subordinate everything else to the constraint.

4. Elevate the constraint.

5. Repeat the process for the new constraint.


Optimization

• A technique used to determine the optimal allocation of limited resources, given a desired goal

• Resources- People- Money- Equipment

• Linear or nonlinear

• Goal or objective- Maximize profit or

revenue- Minimize cost


Optimization

Optimization models have three basic elements:

1. An objective function, which is the quantity that needs to be minimized or maximized

2. The controllable inputs or decision variables that affect the value of the objective function

3. Constraints that limit the values the decision variables can take on


Decision Trees

70.0% 0.70 -7

Flu-7 -7

30.0% 0.3 60.0% 00 -7 -6 -13

Costs-7 -12.2

Vaccination 40.0% 0Vaccination 70.0%

Vaccination Program #2 -4 -11

program #1 0 -10.4 60.0% 0-7 -12 -12

CostsFlu -10.4

0 -7.28 0 40.0% 030.0% 0 -8 -8

0 0

HMO vaccination

decision

Program

Flu outbreak

No flu outbreak

Flu outbreak

No flu outbreak

Program

No program

C

D

A

B

Choose this path because expected costs of $10.4 million are

Choose this path because expected costs of $7 million are less than $7.28 million.

No program

The tree diagram in this figure was drawn with the help of PrecisionTree,

a software product of Palisade Corp., Ithaca,

NY; www.palisade.com.

Choose this path because expected costs of $10.4 million are less than $12.2 million

Choose this path because expected costs of $7 million are less than $7.28 million


Decision TreeRisk Analysis

Initial Vaccination Program

No Initial Vaccination Program

# X P X P

1 –7 1 –12 0.42

2 –8 0.28

3 0 0.30


Force Field Analysis

• A technique for evaluating all the forces for (driving) and against (restraining) a proposed change

• Used to decide whether a proposed change can be implemented successfully

• Used to develop strategies that will enable successful implementation of a change


Force Field Analysis

Plan:Change

to bedside

shift handover

Critical incidents on the increase

Staff knowledgeable in change management

Increase in discharge against medical advice

Complaints from patients and doctors increasing

Care given predominantly biomedical in orientation

Ritualism and tradition

Fear that this may lead to more work

Fear of increased accountability

Problems associated with late arrivals

Possible disclosure of confidential information

Total: 19

4

4

3

5

5

Total: 21

Driving ForcesDriving Forces Restraining ForcesRestraining Forces

4

5

3

3

4

Total: 19 Total: 21


Conclusion

The tools and techniques outlined in this chapter are intended to help organizations along the path of continuous improvement. The choice of tool and when to use that tool are dependent on the problem to be solved. In many situations, several tools from this and other chapters should be used to ensure that the best possible solution has been found.

chapter 6. tools for problem solving and decision making an integrated approach to improving quality...

Documents

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decision process slide

process boundaries

process integral

process mapping steps

brilliant decision making

good decision

order major process