pragmatic problem solving for healthcare

7/30/2019 Pragmatic problem solving for healthcare

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Pragmatic ProblemPragmatic Problem--Solving forSolving forHealthcare: Principles, Tools,Healthcare: Principles, Tools,

and Applicationand ApplicationManimayManimay GhoshGhosh

Dr.Dr. DurwardDurward K.K. SobekSobek, II, II

Mechanical and Industrial Engineering Dept,Mechanical and Industrial Engineering Dept,Montana State University, Bozeman, MTMontana State University, Bozeman, MT


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AcknowledgementAcknowledgement

Funding for this project is provided byFunding for this project is provided byNational Science Foundation (Grant #National Science Foundation (Grant #

0115352)0115352)


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Healthcare in CrisisHealthcare in Crisis

Huge wastes (35% employeesHuge wastes (35% employees time spenttime spenton wasteful work)on wasteful work)

High errors (nearly 100,000 Americans dieHigh errors (nearly 100,000 Americans dieeach year)each year)

High costs (in 2002, healthcare cost perHigh costs (in 2002, healthcare cost perpersonperson -- $5267, increasing @ 8$5267, increasing @ 8--9% per9% peryear)year)


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Healthcare in CrisisHealthcare in Crisis

Broken work systemsBroken work systems

Experts suggest operational failuresExperts suggest operational failures


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Problem Solving Technique inProblem Solving Technique in

HealthcareHealthcareTotal Quality Management (TQM)Total Quality Management (TQM)

PDCA approachPDCA approach

Applied mid1980sApplied mid1980s Limited successLimited success


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Problem Solving Technique inProblem Solving Technique in

HealthcareHealthcareSix SigmaSix Sigma

DMAIC approachDMAIC approach

Applied late 1990sApplied late 1990s Some success, not widely usedSome success, not widely used


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Toyota Production SystemToyota Production System

(TPS)(TPS)Very successful in the industrial worldVery successful in the industrial world

Mostly applied in manufacturingMostly applied in manufacturing

Applied in healthcareApplied in healthcare early 2000early 2000


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ReasonReasons for Success of TPSs for Success of TPS

Old Explanations:Old Explanations:

Elimination of waste in any formElimination of waste in any form

Use of specific tools in productionUse of specific tools in production


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ReasonReasons for Success of TPSs for Success of TPS

New explanation (by Spear and Bowen,New explanation (by Spear and Bowen,1999)1999)

RulesRules--inin--UseUseThree design rules to construct work processesThree design rules to construct work processes

One rule for systematic problem solvingOne rule for systematic problem solving


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Goal of this PresentationGoal of this Presentation

The goal is to demonstrate the efficacy ofThe goal is to demonstrate the efficacy ofTPS design rules to improve processTPS design rules to improve process

performance in a nonperformance in a non--manufacturingmanufacturingenvironmentenvironment


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Our AgendaOur Agenda

Present the 4 RulesPresent the 4 Rules--inin--Use of ToyotaUse of Toyota

Present a case examplePresent a case example

Discuss the case in light of the RulesDiscuss the case in light of the Rules--inin--UseUse

Concluding remarksConcluding remarks


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3 Design Rules of TPS3 Design Rules of TPS

Three Building blocks of ProductionThree Building blocks of ProductionSystemSystem

ActivityActivity ConnectionConnection

PathwayPathway


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Design Rule 1 of TPSDesign Rule 1 of TPS

(Activity)(Activity)All work shall be highly specified as toAll work shall be highly specified as to

ContentContent

SequenceSequence TimingTiming

OutcomeOutcome


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(Connection)(Connection)Every customerEvery customer--supplier connection mustsupplier connection mustbe direct and there must be anbe direct and there must be an

unambiguous yesunambiguous yes

--oror

--no way to sendno way to send

requests and receive responsesrequests and receive responses


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(Pathway)(Pathway)The pathway for every product and serviceThe pathway for every product and servicemust be simple and directmust be simple and direct


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Rule 4 of TPSRule 4 of TPS

(Problem(Problem--Solving)Solving)Any improvement must be made inAny improvement must be made inaccordance with the scientific methodaccordance with the scientific method

under the guidance of a teacher, at theunder the guidance of a teacher, at thelowest possible level in the organizationlowest possible level in the organization


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TPSTPSss Notion of IdealNotion of Ideal

The RulesThe Rules--inin--Use move the organizationUse move the organizationtoward ideal:toward ideal:

Defect freeDefect free Delivered one at a timeDelivered one at a time

On demandOn demand

ImmediatelyImmediately


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TPSTPSss Notion of IdealNotion of Ideal

No waste of resourcesNo waste of resources

In an environment physically, emotionally,In an environment physically, emotionally,

and professionally safe for employeesand professionally safe for employees


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Problem Solving ToolProblem Solving Tool

Toyota has several kinds of A3 reportsToyota has several kinds of A3 reports

We adapted an A3 report (metricWe adapted an A3 report (metricequivalent of 11equivalent of 111717) from Toyota) from Toyota

The A3 report guides in systematicThe A3 report guides in systematicproblem solving (Rule 4)problem solving (Rule 4)


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Case ExampleCase Example

Group meal therapy (2Group meal therapy (2--3 patients) in3 patients) inRehabilitation Nursing Unit (R.N.U)Rehabilitation Nursing Unit (R.N.U)

45 minute duration45 minute durationLocation: Common AreaLocation: Common Area


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Statement of the ProblemStatement of the Problem

The therapist in R.N.U. during group mealThe therapist in R.N.U. during group mealtherapy were involved more in nontherapy were involved more in non--valuevalueadded activities leading to inconsistentadded activities leading to inconsistentand ineffective patient careand ineffective patient care


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Problem Solving TeamProblem Solving Team

Initiator (Speech Language Therapist)Initiator (Speech Language Therapist)

A front line staffA front line staff

# of participants# of participants 5050Other participants (mostly front line)Other participants (mostly front line)

Occupational and Speech TherapistsOccupational and Speech Therapists

Secretary and DietitianSecretary and Dietitian

RNs and techsRNs and techs


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Outline of the CaseOutline of the Case

Observed the problem firstObserved the problem first--handhand

Drew the current stateDrew the current state

Conducted root cause analysis (5 Whys)Conducted root cause analysis (5 Whys)Developed countermeasuresDeveloped countermeasures

Drew the target stateDrew the target state

Developed implementation planDeveloped implementation planCollected resultsCollected results


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Observed the Problem at SiteObserved the Problem at Site

Observed the problem firstObserved the problem first--hand at sitehand at site

The therapist collected schedule from schedulerThe therapist collected schedule from scheduler

S/he brought patients (no fixed rule on who will bringS/he brought patients (no fixed rule on who will bring

patients)patients) S/he collected supplies from different places (noS/he collected supplies from different places (no

designated place)designated place)

S/he conducted therapy (unclear on goals to achieve,S/he conducted therapy (unclear on goals to achieve,

inconsistencies)inconsistencies) S/he returned patients (unclear on who will returnS/he returned patients (unclear on who will return

patients) and cleaned common areapatients) and cleaned common area


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Current State DrawingCurrent State Drawing


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Root Cause AnalysisRoot Cause Analysis

Absence of therapy goals led toAbsence of therapy goals led toinconsistency in treatmentinconsistency in treatment

Absence of REHAB protocol led toAbsence of REHAB protocol led toconfusion at every step in the processconfusion at every step in the process

Who is responsible for whatWho is responsible for what


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CountermeasuresCountermeasures

Developed goal page for therapyDeveloped goal page for therapy

Feeding goalsFeeding goals

Positioning goalsPositioning goals

Swallowing goalsSwallowing goals

Cognition goalsCognition goals

Communication goalsCommunication goals

Developed protocol for group meal therapyDeveloped protocol for group meal therapy

Responsibilities of each caregiver and how s/he willResponsibilities of each caregiver and how s/he willconnect with others in the process chainconnect with others in the process chain


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Target State DrawingTarget State Drawing


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Consensus BuildingConsensus Building

The initiator collected input from allThe initiator collected input from allcaregiverscaregivers TherapistsTherapists

RNsRNs

TechsTechs

SecretarySecretary

DietitianDietitian

She drew the target state drawing andShe drew the target state drawing andasked others for confirmationasked others for confirmation


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Implementation PlanImplementation Plan

Developed implementation plan in termsDeveloped implementation plan in termsof:of:

What actions to be takenWhat actions to be taken

Who is responsible for that actionWho is responsible for that action

When that action will be completedWhen that action will be completed

Outcome of such actionOutcome of such action


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ResultsResults


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Case in Light of TPS RulesCase in Light of TPS Rules

(Activity: Rule 1)(Activity: Rule 1)Before A3Before A3

Unclear therapy goalsUnclear therapy goalsduring therapyduring therapy

(unspecified activities)(unspecified activities)

Medical supplies notMedical supplies not

arranged beforearranged beforetherapy (unspecifiedtherapy (unspecifiedactivity)activity)

After A3After A3

Clear therapy goalsClear therapy goals

Developed goal pageDeveloped goal page

(specifying activities)(specifying activities)

Medical suppliesMedical supplies

arranged in advancearranged in advance(specified activity)(specified activity)


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(Connection: Rule 2)(Connection: Rule 2)Before A3Before A3

Unclear on who willUnclear on who willbring patients to thebring patients to the

common area andcommon area andreturnreturn

Unclear connectionsUnclear connections

After A3After A3

Techs will bringTechs will bringpatients to thepatients to the

common area andcommon area andreturnreturn

Clear connectionsClear connections


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(Pathway: Rule 3)(Pathway: Rule 3)Before A3Before A3

Process path complexProcess path complex

Unfolded differentlyUnfolded differently

Confusing at everyConfusing at everystepstep

After A3After A3

Process pathProcess pathsimplifiedsimplified

Clear and directClear and direct


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(Rule 1,2,3)(Rule 1,2,3)Specifying activitiesSpecifying activities Defining clearDefining clear

connectionsconnections

Simplified PathwaysSimplified Pathways


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(Problem Solving: Rule 4)(Problem Solving: Rule 4)

Before A3Before A3

Problem solvingProblem solvinginitiated by senior levelinitiated by senior level

employeesemployees

After A3After A3

Problem solvingProblem solvinginitiated by front lineinitiated by front line

employeesemployees Situated at problemSituated at problem

sitesite

Scientific approachScientific approach

Collaborative effortCollaborative effort


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Few Examples of SimilarFew Examples of Similar

ApplicationApplicationLabeling of specimens from OR to LabLabeling of specimens from OR to Lab

Ordering of specimens from OR to LabOrdering of specimens from OR to Lab

Transporting specimens from OR to LabTransporting specimens from OR to Lab

Transporting patients from the floors to theTransporting patients from the floors to theclinical departmentsclinical departments


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ConclusionsConclusions

We studied numerous work processesWe studied numerous work processes

Applied TPS design rules to improveApplied TPS design rules to improve

Results were very satisfactory in all casesResults were very satisfactory in all casesGave us confidence that the rules doesGave us confidence that the rules doesapply in the nonapply in the non--manufacturing sector asmanufacturing sector aswellwell

Systemic changeSystemic change


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ConclusionsConclusions

The collaborative problem solving tookThe collaborative problem solving tookplace at the front lineplace at the front line

Speech Language Therapists, RNsSpeech Language Therapists, RNs

Dietitian, Secretary, Occupational therapistsDietitian, Secretary, Occupational therapists

They took ownership for the success ofThey took ownership for the success ofthe processthe process

They ensured its sustenanceThey ensured its sustenance


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THANK YOU!

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pragmatic problem solving for healthcare

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