problem structuring masterclass - improvement academy...problem structuring masterclass wednesday...

Problem Structuring Masterclass

Wednesday 15th March 2017

Leeds

e: [email protected] / t: 01274 383966 www.improvementacademy.org

@improvementacademy

Housekeeping

Welcome and introduction

Professor Mohammed A Mohammed

Professor of Healthcare, Quality & Effectiveness, University of Bradford

What is Operational Research? The ED Game

Dr Daniel Chalk Research Fellow in Applied Healthcare Modelling and

Analysis

PenCHORD @penclahrcOR

NIHR CLAHRC for the South West Peninsula


What is Operational Research?

Let’s demonstrate using a simple exercise.



Imagine you are in charge of an Emergency Department. You need to cut costs, and quickly. You have come up with two options : 1) Get rid of a Senior Nurse 2) Get rid of a Treatment Cubicle

Let’s assume the costs of each are the same.



In your ED, patients arrive, are registered at the registration desk, are triaged by a Senior Nurse, are treated in a Treatment Cubicle, and then are either admitted or discharged.


What is Operational Research? You have looked at your data over the last 12 months : • You currently have 2 Senior Nurses • You currently have 4 Treatment Cubicles • On average :

• A patient arrives at the ED every 8 minutes • It takes them 2 minutes to be registered once they

are seen at the desk • It takes them 5 minutes to be triaged once they

are seen by a Senior Nurse • It takes them 30 minutes to be treated once a

cubicle is free


What is Operational Research? Split into pairs. You will have 3 minutes to discuss and come up with answers for these three questions : 1) How long (on average) do you think a patient spends

in the ED now? (Imagine an average over 48 hours) 2) What cost-saving decision are you going to make (get

rid of a nurse or a cubicle?), so as to minimise the impact on the time patients spend in the ED?

3) What do you predict is going to be the impact of your decision on the average time patients spend in the ED? (ie how much longer do you think patients will spend in the ED as a result of your decision?)


1) How long (on average) do you think a patient spends in the ED now? (Imagine an average over 48 hours)

2) What cost-saving decision are you going to make (get rid of a nurse or a cubicle?), so as to minimise the impact on the time patients spend in the ED?

3) What do you predict is going to be the impact of your decision on the average time patients spend in the ED? (ie how much longer do you think patients will spend in the ED as a result of your decision?)

• You currently have 2 Senior Nurses

• You currently have 4 Treatment Cubicles

• On average : • A patient arrives at the ED

every 8 minutes • It takes them 2 minutes to

be registered once they are seen at the desk

• It takes them 5 minutes to be triaged once they are seen by a Senior Nurse

• It takes them 30 minutes to be treated once a cubicle is free



Let’s hear your answers.



We could have built a model to help us answer this question.



Base Case Scenario A model of the current system. How are things running now? We can use this to see how well the current system works, validate the model and identify bottlenecks. 1) How long (on average) do you think a patient spends in the ED now? 2) What cost-saving decision are you going to make?

“What If” Analysis Adapting the model to reflect potential future scenarios. How might things run if we were to change x, y and / or z? We can use this to predict the impact of decisions, and help the decision maker to make an informed evidence-based decision. 2) What cost-saving decision are you going to make? 3) What do you predict is going to be the impact of your decision on the average time patients spend in the ED?



We could have built a model to help us answer this question.



Let’s run the model for the Base Case Scenario to answer Q1. Then use “What If” Analysis to answer Q2 and Q3.


What is Operational Research? Answers from the model : 1) How long (on average) do you think a patient spends in the ED

now? ~91 minutes

2) What cost-saving decision are you going to make so as to minimise the impact on the time patients spend in the ED?

3) What do you predict is going to be the impact of your decision on the average time patients spend in the ED?

Removal of 1 nurse : ~3 minute increase Removal of 1 cubicle : ~231 minute (~4 hours!) increase


What is Operational Research? Answers from the model : 1) How long (on average) do you think a patient spends in the ED

now? ~91 minutes

2) What cost-saving decision are you going to make so as to minimise the impact on the time patients spend in the ED? Removal of 1 nurse

3) What do you predict is going to be the impact of your decision on the average time patients spend in the ED?

Removal of 1 nurse : ~3 minute increase Removal of 1 cubicle : ~231 minute (~4 hours!) increase



Applying modelling, simulation and analysis techniques to help inform decisions, and improve decision making.

Contact Us

PenCLAHRC @penclahrc

#penclahrc #penclahrcOR Join the conversation :

PenCHORD Live Wall Stream : penchord.livewallstream.com

http://clahrc-peninsula.nihr.ac.uk/penchord.php

Website :



Email us at : [email protected]

Introduction to PenCLAHRC & PenCHORD

NIHR - CLAHRCs

• Collaboration for Leadership in Applied Health Research and Care

• Funded by NIHR – National Institute for Health Research – 1st phase 2009-13 nine CLAHRCs in the England

– 2nd phase 2014-18 thirteen CLAHRCs

• Collaboration

• Closing the gap…

• Research based on practice

• Practice based on research

Aims of PenCLAHRC

• Increase involvement in research that reflects real clinical concerns

• Support and inform implementation of change to improve health and health care

• Increase the capacity of the health service to inform and use research evidence

PenCHORD

Example OR Methods

Forecasting

Spatial/Geographical Modelling

Bayesian Methods

Information

Visualisation

Mathematical

Models

Lack of Implementation

“… we were unable to reach any conclusions on the value of modelling in health care because the evidence of implementation

was so scant.”

Fone D, Hollinghurst S, Temple M et al. Systematic review of the use and value of computer simulation modelling in population health and health care delivery. J Publ Health Med 2003; 25: 325-335

PenCHORD

OR: Many relevant approaches/tools.

Solutions/tools

Guidance/Collaboration

Empowerment/Learning

Needs

Data

Resources

PenCHORD

Project Specification Need for: •Clear timelines (differentiation) •Objectives (manage expectations)

•Defined deliverables •Resource use (staff time) •Specification of Contributions from trusts etc. •Data requirements •Dissemination plan ?

PenCHORD Training Programme : Modelling in Health and Social Care

Modelling in Health and Social Care


Module 2 : Geographic Modelling • Understand the role and

potential applications of geographic modelling

• Obtain shortest travel time calculations

• Build a geographic model in Excel

• Use the geographic model to predict the impact of service closures, and assess the optimal location for services

• Visualise the results of the geographic modelling



PenCHORD Health Service Modelling Associates (HSMA) Programme



The Programme


The HSMA : • Identifies and undertakes modelling projects within and for their own

organisations • Uses Discrete Event Simulation and “What if” analysis to predict the

impact of changes to pathways or changes to resource capacities • Is trained by PenCHORD to use advanced modelling software

packages, such as Simul8 (licence provided by Simul8 Corporation) • Is supported by a PenCHORD Mentor, who provides advice and

guidance to support the completion of projects and ongoing skills development

• Is part of a Learning Set of HSMAs who meet monthly to share experiences and support

• Presents their project work both within their own organisations and at the PenCHORD Seminar, Showcase and Workshop series

• Champions the use of Operational Research in their organisation, and helps to raise awareness of Operational Research and the capacity building initiatives run by PenCHORD and the wider CLAHRC

• Is released for one day per week to undertake this work, for a period of 12 months

The HSMA Projects


Royal Cornwall Hospitals Trust What are the current bottlenecks within the acute eye service, and how can we improve? Royal Devon and Exeter NHS Foundation Trust How would the addition of a Clinical Decision Unit (CDU) affect patient flow and waiting times at R D & E? South West Ambulance Service Trust What are the bottlenecks in getting cardiac arrest patients to definitive care? Devon Partnership Trust How do we reduce delayed discharge in the Mental Health Acute Care pathway? Northern Devon Healthcare Trust Modelling A & E flow rates at North Devon District Hospital Plymouth Hospitals NHS Trust What would be the impact of various strategies to improve weekend discharge rates?

Contact Us



http://clahrc-peninsula.nihr.ac.uk/penchord.php

Website :




PenCHORD Project Work Examples


@penclahrc


Reducing mental health assessment waiting times in Devon

High-sensitivity troponin for the diagnosis of acute myocardial infarction in A&E

What are the factors that most influence the demand for ambulances in South West England?

Cornwall mental health inpatient pathway modelling

Reducing delays in the bladder cancer pathway at Royal Cornwall Hospital

Radiographer-led discharge at Yeovil District Hospital

Optimising resource configurations to match demand in A & E at Royal Cornwall Hospital

Optimising the location of outpatient clinics in Cornwall

Optimising polypharmacy prescribing practice using behavioural modelling

Redesigning emergency stroke pathways to maximise thrombolysis rates

Introduction to Problem Structuring


Module 3 : Structuring Problems for Modelling



In pairs / small groups : • Name • Organisation • Role • Why Have You Come? • What experience do you have (if any) with problem

structuring methods?

Who Are You?



CONCEPTUAL VALIDITY

OPERATIONAL VALIDITY

EXPERIMENTAL VALIDITY

LOGICAL VALIDITY

FORMAL MODELLING

ANALYSIS & CONCEPTUALISATION

IMPLEMENTATION

OBTAINING SOLUTIONS

PROBLEM SITUATION

FORMAL MODEL

CONCEPTUAL MODEL

SOLUTION DATA

VALIDITY

The modelling-validating process (Landry, Malouin and Oral 1983, p.212)

52

The Modelling Process



CONCEPTUAL VALIDITY



LOGICAL VALIDITY

FORMAL MODELLING


IMPLEMENTATION

OBTAINING SOLUTIONS

PROBLEM SITUATION

FORMAL MODEL

CONCEPTUAL MODEL

SOLUTION DATA

VALIDITY


53


Modules 1 and 2



CONCEPTUAL VALIDITY



LOGICAL VALIDITY

FORMAL MODELLING


IMPLEMENTATION

OBTAINING SOLUTIONS

PROBLEM SITUATION

FORMAL MODEL

CONCEPTUAL MODEL

SOLUTION DATA

VALIDITY


54


Modules 1 and 2

Module 3



Transforming our view of a problem…



• Real world problems are often messy and complex • Different people have different perceptions about the same

systems • Things in the real world often change over time – they are dynamic

Why do we need to structure problems?

How can problem structuring help? • By helping to clarify our view of the problem • By helping to seek consensus and develop a common language • By determining the key elements of the problem to better allow us

to solve it



A Well-Structured Problem




Question • What are you asking? • Specific • Clear • Clear goals





Scope • Intricacy (level of detail

required) • Boundaries (how wide

is the world view?)







is the world view?)

Constraints and Assumptions • What are the limits to our

knowledge? • What must we assume?







is the world view?)



Resources and Stakeholders • What resources (people, data, time

etc) do you have to solve the problem?

• Who are the parties interested in / affected by the solving this problem?







is the world view?)



Resources and Stakeholders • What resources (people, data, time

etc) do you have to solve the problem?

• Who are the parties interested in / affected by the solving this problem?

Methods • How could the problem be solved? • What is the preferred method for

solving the problem?



• Problem Structuring Methods (PSMs) provide a means of structuring messy problems

• PSMs are a type of modelling known as ‘Soft Modelling’ (or ‘Soft Operational Research’), because they tend to use qualitative rather than quantitative methods.

Problem Structuring Methods

Messy Problem

Structured Problem

Mathematical Model / Simulation PSMs Math /

In-Silico Modelling

Solution

“What If?” Analysis

Contact Us




http://clahrc-peninsula.nihr.ac.uk/penchord

Website :




#thisisOR

Introduction to Your Problems





For the rest of the day, we’ll be working with your problems. You will split into pairs. Each pair will tackle both of the problems brought with you, spending half the time in each activity on each problem. Those who do not wish to work on a problem of their own should join another pair (but work on your one if you can!). By the end of the day, you should have turned this messy / complex problem into a well-structured one, ripe for further analysis (maybe even modelling!)

What’s Next?



Please now arrange yourself into pairs.

Step 1 : Split into Pairs



For the next 10 minutes, you will discuss the problems you have brought with each other. If you have brought more than one problem, use this as an opportunity to decide on which one you will work on. When picking your problem, don’t shy away from the messy and the complex – that’s how PSMs can help!

Step 2 : Presenting the Potential Problems



Everybody should now give a brief 1 minute summary of the problem you will be working on.

Step 3 : Presenting your Chosen Problems to the Room

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Qualitative System Dynamics


The first step to help focus your questions is to understand the nature of the problem, and where the likely problem areas are.

This helps to identify area(s) to focus on.

System Dynamics (Whole Systems Modelling) What is it? A way to model the flows between the various components of a high-level or abstracted system

What is its typical use in health and social care modelling? Modelling larger scale health and social care systems, and the flows of patients between providers in the system Modelling the inter-connected influencing factors that lead to a “trigger” (e.g. admission, ambulance call etc)

Qualitative System Dynamics


• Create map of influences and their directionality

• Identify feedback loops within the map (the “causal loop diagram”)

• Draw insight from the map and its associated feedback loops to better understand system behaviour

Example influences


Number of people accessing GP services

Waiting time to see GP +

Number of people admitted to hospital

Number of beds available in hospital

-

As the number of people accessing GP services increases, the waiting time to see a GP increases (Both go in the same direction)

As the number of people admitted to hospital increases, the number of beds available in the hospital decreases (Each goes in opposite directions)

Reinforcing Loops (“Vicious Circles”)


Waiting time to see GP

Number of sick people in the community


+

+

+

Reinforcing Loops have an even number of (or zero) minus signs. Therefore the same conclusion is reached each time you loop.

Reinforcing Loops (“Vicious Circles”)


Waiting time to see GP

Number of sick people in the community


+

+

+

Reinforcing Loops have an even number of (or zero) minus signs. Therefore the same conclusion is reached each time you loop.

Number of people attending A & E

+

Balancing Loops


Number of beds available in hospital

Capacity to admit patients

Number of people admitted to hospital

-

+

+

Balancing Loops have an odd number of minus signs. Therefore a contradictory conclusion is reached each time you loop.

Exercise 1 : Qualitative System Dynamics (Total Time = 2 hours) 1. In your pairs, take your first problem. Write down the problem

as a problem statement. Make sure this is a problem, and not a question, or a potential solution.

2. Spend 5 minutes listing as many factors as you can think of that are directly contributing to the problem.

3. Once you’ve done this, start to map out these factors, identifying how each contributes to your problem (directionality of influence), and how they influence and / or are influenced by other factors. For each factor you add, ask if it influences or is influenced by any of the factors you have already identified. Then ask if there are other relevant factors not yet identified that it influences or is influenced by. You will have 30 minutes to do this.

4. Then spend 20 minutes identifying the reinforcing and balancing loops in your model. What insights can you draw from this?

5. After this, change over and do the same for your other problem. 6. At the end of the exercise, we will ask selected pairs to present

their models and insights to the room.

Stakeholder Analysis





Those people who have an interest in and / or influence on a problem and / or its solution. These questions may help you identify them : 1) Who owns the problem? 2) Who might benefit from its solution? 3) Who might suffer from its solution? 4) Who has a legitimate interest in the problem and / or its

solution? 5) Who has the power to influence the process of solving

the problem and implementing the solution?

Who are Stakeholders?



Why is it important to consider who are the stakeholders?

Why Consider the Stakeholders?



Why is it important to consider who are the stakeholders? • You need to know who holds information and / or data

you’ll need • You need to know who might help or hinder solving the

problem or implementing the solution • You need to understand the nature of any conflicts (or

potential conflicts), how that might impact the work, and how they might be mitigated

Why Consider the Stakeholders?



There are various methods for identifying and visualising the stakeholders : • Organisational Charts • Interest / Influence Diagram • Strategy Group Diagram

Stakeholder Analysis



Charts of the staff and hierarchy within an organisation. • Can be useful to identify key contacts But : • Organisations frequently don’t have them • They may not represent all stakeholders in the project • The hierarchy may not necessarily equate to interest in

(or even influence on) the project.

Organisational Charts



Interest / Influence Diagram

Influence

Interest

High Interest High Influence

Low Interest High Influence

High Interest Low Influence

Low Interest Low Influence




Influence

Interest

PLAYERS

Key players - Engage closely

SUBJECTS

Keep satisfied

CONTEXT SETTERS

Keep informed

CROWD

Monitor (minimal effort)




Influence

Interest

Stakeholder B

Stakeholder A

Stakeholder C



Exercise 2 : Build an Interest / Influence Diagram

• In your pairs, using the large sheets and sticky notes provided, you’ll now build a Stakeholder Interest / Influence Diagram for each of your problems.

• You should spend 30 minutes on each problem (total exercise time = 60 minutes). At the end of the exercise, selected individuals will present their diagrams.

Remember, to identify stakeholders think about : 1) Who owns the problem? 2) Who might benefit from its solution? 3) Who might suffer from its solution? 4) Who has a legitimate interest in the problem and / or its solution? 5) Who has the power to influence the process of solving the

problem and implementing the solution?

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Process Mapping





A means of capturing the discrete processes within a system, and the potential inputs and outputs to these processes, in order to better understand how a system works. Process Mapping is a vital tool for understanding how your system works. How can you improve a system if you don’t know what your system looks like?

What is Process Mapping?



Processes are activities that have a number of steps and which transform inputs into outputs. In this way, processes can be thought of as functions.

Output = function (inputs)

Y = f(x)

What is a Process?

Inputs Outputs



Process mapping is extremely easy if you just bear in mind one simple rule :

The “Secret” of Process Mapping



Process mapping is extremely easy if you just bear in mind one simple rule :

The “Secret” of Process Mapping

Say what you see!



• Have clear start and end points (there may be multiple of each – that’s fine as long as they’re well defined)

• Describe what really happens, not what should happen • Don’t worry about one-off exceptions to the process

unless they’re important for your question • Process map as a team – everyone has a different

perception of the “true” system and everyone should contribute

• Think about the patient journey – how do they flow between processes in your system?

• Create a visual representation of your system – a Process Map

Top Process Mapping Tips

Example Process Maps



There are different ways to visualise process maps, and there is no single “right” way of doing things. However, it is common to use elements of Flow Chart nomenclature as a framework for developing a Process Map, because it allows you to capture the flows, processes, decisions, start and end points that are common in a process map.

Format of Process Maps



Format of Process Maps

Activity / Process / Sub-Process

Decision Point /

Question

Flow (and direction of flow)

Activity / Process / Sub-Process

Flow if Decision A made

Entry point to system

Exit point from system

Flow if Decision B made



Different Levels of Process Map

Registration Triage Treatment Admit?

Yes

No

HIGH-LEVEL




Patient queues

LOW-LEVEL

Is it Monday

?

Julie signs in patient with

red folder

Yes

Is it an odd numbered

month?

No

John signs in patient with blue folder

Yes

No

Derek collates red and blue

folders

etc…



Which is best – high level? Low level? Answer : it depends on the question / problem you’re trying to solve. Typically though, it’s something in the middle. Good rule of thumb : Ask yourself, if we didn’t include this process, would it make any difference to the question we’re asking?




Process Mapping in Practice

Three ingredients : 1) Sticky notes 2) Large sheet(s)

of paper 3) Two or more

people who have a view about the system you’re mapping

• Swim Lane Diagrams are an alternative way to visualise processes within a system.

• Unlike a flowchart, a Swim Lane Diagram divides processes into broader categories or ‘lanes’.

• Each ‘lane’ represents an individual / group / organisation, and the processes in this lane are those for which this individual / group / organisation is responsible.

• This allows us to understand not only the processes in a system, but who is responsible for each part of the system.

Swim Lane Diagrams

Swim Lane Diagrams



Exercise 3 : Build a Process Map

• In your pairs, using the sticky notes and large sheets provided, you’ll now build a Process Map reflecting the system in wach of your chosen problems.

• You can choose to either develop your Process Map as a Flow Chart or a Swim Lane Diagram

• You will have 1 hour to complete this exercise (30 minutes per problem), and then selected individuals will present their diagrams.

Remember : • Have clear start and end points (there may be multiple of each) • Describe what really happens, not what should happen • Don’t worry about one-off exceptions to the process • Process map as a team • Think about the patient journey

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The Final Questions





Exercise 4 : Reflection and Formulating the Questions

• It’s now time to reflect on the outputs you’ve generated today. • In your pairs, using the outputs from your Qualitative System

Dynamics models, Stakeholder Analysis and Process Mapping, you should discuss and come up with the following for each problem : • The specific question(s) you want to answer • What methods you might use to answer the question

(modelling? Other? If modelling, which aspects of the system are you looking to model? What would be your “what if” analyses?)

• What are the deliverables? (the tangible outputs of the project) • Who you would want in your project “working group”?

• You will need to complete the provided forms, and will have 30 minutes to complete this exercise.



Other Problem Structuring Methods / Tools for Thinking

• Root Cause Analysis • SWOT Analysis • Rich Pictures • Cognitive Mapping • Causal Mapping • Influence Diagrams • Soft Systems Methodology (SSM) • Strategic Options Decision Analysis (SODA) • Strategic Choice Approach (SCA)

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Forthcoming Improvement Academy Events

21st Apr 2017 Achieving Behaviour Change (Leadership Fellows), The Studio, Leeds

26th Apr 2017 Silver Quality Improvement Training, Principal York Hotel, York

13th Jul 2017 Silver Quality Improvement Training, Cedar Court Hotel, Wakefield

26th May 2017 Achieving Behaviour Change (open to all), The Studio, Leeds

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problem structuring masterclass - improvement academy...problem structuring masterclass wednesday...

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