Seeing the System

PC1: Improvement Science Basics

Monday, March 2, 2015

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

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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5

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

An improvement case

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Why?

1,500 hospital

admissions due

to Asthma per year

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?

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?

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?

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?

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

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

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?

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

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.

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

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.

“If I had 20 days to solve a problem,

I would take 19 to define it.” - Albert Einstein

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?

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

The Problem:

New teacher support and retention

1987-1988

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

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?

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

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

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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