Systems Thinking for Healthcare

Diana M. Luan, PhD

Uniformed Services University of the Health Sciences&

Center for Disaster Assistance & Humanitarian Medicine

The Issue in Healthcare

• We understand what we do, but not how we do it

• Fail to see problems within their context• Fail to understand the processes• Jump to solutions before understanding the

problem

• Sharpens our awareness of whole and of how the parts within the whole interrelate

• Provides a vocabulary for discussing the dynamic complexity of our environment.

• Allows for the iterative unfolding of the interrelationships and processes within a system

• Understanding the drivers of behavior

Systems

• Network of interdependent components that work together to accomplish the aim of the system

Systems are Embedded within Systems

Macro Organization

System

Meso Organization

System

Community, Market, Social Policy System

Microsystem

Patient/Provider System

Complex Adaptive System

• A collection of smaller systems - microsystems

• Share an environment• Microsystems act independently • Microsystems are interconnected• Action by any part affects the whole• Movement between the context and

organization occurs freely

Systems Thinking

• VUMC is a complex adaptive system• Requires consideration of:

– Context of the parts– Linkages of parts– Behaviors

• Recognizes connections and interrelationship where:– Cause and effects are distant in both time and space– Feedback may be delayed– Solutions may have unintended consequences

Microsystems are Embedded within Larger Systems of Care

Macro Organization

System

Self-Care System

Meso Organization

System

Community, Market, Social Policy System

Microsystem

Patient/Provider System

DoD Military Health SystemVanderbilt Healthcare System

The Challenge

• To operate safely • Provide quality, patient-centered care• Measurably improve outcomes & patient

satisfaction• Continually remove real costs, waste &

rework• Create an environment that is honest, open,

and respectful

11

The Current State

Staff Response to Quality & Safety Initiatives

It is a Burden The Solution

Microsystem Definition

“A small group of people who work together on a regular basis to provide care to discrete

subpopulations of patients.”

“It has clinical and business aims, linked processes, and a shared information environment, and it produces

performance outcomes.”

Day 1

Nelson, EC, Batalden, PB, et al (2002). “Microsystems in Health Care: Learning from High-Performing Front-Line Clinical Units.: J. on Quality Improvement vol. 28, no. 9,

472-497.

14

The FocusSmallest Replicable Unit (SRU)

• The smallest possible unit of interaction that connects the core competencies of the organization to the beneficiaries

• The interaction between the patient and the health system• The quality, safety and value of care for any single patient

(or cohort of patients) is a function of the sum of each interaction the patient has with the system

Patient

Provider=SRU

Quinn, J.B. Intelligent Enterprise. 1992. Free Press, NY, pg 103.

SRU

15

Clinical Microsystems• Processes are organized around the needs

of the patient • Enhances every interface with the patient

Patient

Provider

The Encounter

Clinical Microsystem

Clinical Biological

Patient Satisfaction System

Outcomes

Admissions

Information Flow

Communications

Other Services

Reverses the Organizational Traditional Pyramid

ED OR Radiology

ICUPAD PACU

Ward

Lab Housekeeping

ProgramsWomen’s healthCardiovascular care

DepartmentsMedicineNursingInformation Technology

Mesosystem

Front Line Microsystems

Senior Leaders

A B C D E

Clinical Evidence Base

1 2 3 4 5

Clinical Safety & Quality Metrics

Services

JCAHO

NPSF, NCQA

Market & Regulatory Environment

IOM - Chasm

NQF - Metrics

Scientific Studies

Intellectual Environment TMAVANDY

Microsystem Improvement Model

Entry,Assignment Orientation

InitialWork-up,

Plan for care

Disenrollment

Biological

Functional

Expectations

Costs

Biological

Functional

Satisfaction

Costs

Acute care

Chronic care

Preventive care

Palliative care

Microsystems Thinking

• Creates an awareness of the work being done• Designed to engage everyone in making

improvement part of the daily work– It is a culture change– Long-term transformation

• Understanding how care is delivered– Reliability of care

It involves…

Context

Analysis

Planning

ExecutionEvaluating

Microsystem Framework is a Process

Assessment

Theme

Global Aim

Specific Aim

Change Ideas

Measures

Fishbones

Flowcharts

Meeting Skills

1

2

3

PDSA Improvement

Ramp

Standardize

Assessment Diagnosis Treatment Follow-Up

Change Perspective

• Look at the your work from a variety of different angles and differing points of view

• Understand how things are accomplished in a dynamic system

Microsystem Process

Assessment

Theme

Global Aim

Specific Aim

Change Ideas

Measures

Fishbones

Flowcharts

Meeting Skills

1

2

3

PDSA Improvement

Ramp

Standardize

Assessment Involves

• Understand the system's elements and behaviors

• Reflect and use the tension for change to develop a deeper understanding of the system

Assessment Knowledge• What is your mission?• Who do you serve? • Who do you work with? • How do you do the

work? • How do you

characterize your work?

• How do you improve?

– Clinical Aim/Purpose– Pt. Characteristics– Professionals– Processes– Patterns

• What information do you share?

• Metrics do you care about?

• What variation is there?

– Culture

24

W. Edwards Deming

• “The aim precedes the organizational system and those that work in it.”

26

What is your mission?(Purpose)

• Focuses the team on the patient population• Identifies the services necessary to meet the

specific needs of that patient population• Aligns the clinical aim and organizational

mission to meet strategic goals

Vanderbilt University

• Vanderbilt University is a center for scholarly research, informed and creative teaching, and service to the community and society at large. Vanderbilt will uphold the highest standards and be a leader in the– quest for new knowledge through scholarship,– dissemination of knowledge through teaching and

outreach,– creative experimentation of ideas and concepts.

Who do you serve?(Patients)

• What are the characteristics of your patient population?

• What are their needs?• Characteristics of the Patient Population

– Age– Gender– Top 5 Diagnoses– Top 5 Consumer of Resources

28

Understanding the Patient Population

• Processes necessary to meet those needs• Creates patient-centered care that ensures

patients receive– Right services– When needed– In the amount needed– At the time needed

30

Clinic Patients

• # Patients seen each day 330• # Patients seen each week 1649• # Patients seen each month 7102

* Based on data for May & June 2007

31

Clinic Age Distribution

• Birth – 4 years 11%• 5 – 17 years 18%• 18 – 24 years 25%• 25 – 34 years 26%• 35 – 44 years 16%• 45 – 64 years 3%• Age 65+ 0.01%

*** Females 42%

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Clinic Top 10 Diagnoses• Well Child Visit• Well Woman/GYN Exam• Deployment Physical Exam• Acute URI, NOS• Administrative visit, unspecified• Joint pain – L/leg• Acute Pharyngitis• Essential HTN, unspecified• Need Prophylactic Vaccination• Other General Medical Examination

Who do you work with?(Professionals)

• Characteristics of Staff– Military, Contractor, GS– Per Diem– Physicians, Nurses, Others– Housekeeping

• What activitites do they engage in? – Research– Administrative– Clinical time

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Understanding the Professionals

• Necessary depth and breadth of capabilities• Defined roles and responsibilities

– Accountability• Reduces redundancies but allows for back-up• Maximizes the talents of the care team• Creates shared mental models of the work

– Shared expectations– Shared attitudes

• Increases collegiality, communication and teamwork

3504/19/2023

Ward Nursing Staff

Military Nurses 19 (Available)

Registered Nurses (RNs) 12.5

Contract Nurses (RNs): 2

LVNs 11

Licensed Vocation Nurses: 3

Nursing assistants 2

Nursing Aides 10

Telemetry 4

Technicians Ward Clerks 2.5

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How do you characterize the work?(Patterns)

• Understanding patterns is the key to identifying improvements

• Understanding the work environment enables identification of areas for improvements

• Sustainment of change involves making the change part of the daily work

Patterns

• Cycle time• Key supporting

processes• Indirect patient pulls

– The things that pull/distract from direct patient care

• Communication• Culture

• Outcomes– Satisfaction– Mortality– Morbidity– Biological markers– Costs– Productivity

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Outcomes

• Addresses the issues of:– How are we doing?– Are we making an improvement?– What do we need to change?

• We need to be data driven at the local level– Using data to focus our efforts– Justify what we do– Improve the safety and quality of the care

How do you do the work?(Process)

• Allows for agreement on the steps involved in the delivery of care– Creates standardized, measurable processes– Doing the basics reliably and safely each and every

time• Delineates unexpected complexity, problem areas

and redundancies– Manage the unexpected

• Identifies where data can be collected and investigated– Reduces variation 39

40

Tension for Change

• Start with the process map

• Identify places where the process are unsafe, or need improvement

• Examined system bottlenecks or failures or gaps

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One Day He Followed the Specimen

draw, label, send receive,

call,hold

locate,dispatch

receive,log,test

callnote,send

receive,use

carry

carry

carry

Plume, SK. (2004). Dartmouth Medical School

42

L&D Clinic Process (Outpatient)

Staff member greets patient

Staff pulls patient chart

Patient taken to room

Orient patient to room

Patient ID Card

Patient History

Order Labs

Patient urine sample

Sample delivery to lab

Log patient into OB trace vue

Place fetal monitor on patient

Monitor patient

Vital signs

Asses patient & review pt data

Contact Physician

Admit Pt?

Yes

No

Physician dictates orders

Physician reviews pt data

Physician assesses pt

Physician dictates orders

Provide pt with discharge

instructions

Close out encounter in

AHLTA

Patient moved to labor room

A

Other procedure orders

Monitor PatientALTHA notes in

text box

Orient pt to new room

1

Outpatient process in L&D Clinic

Inpatient process in L&D Ward

Patient arrives at L&D Clinic

Patient discharged to home

Understanding the processes allows the identification of change points

• Leveraging change is "....seeing where actions and changes in (process) structure can lead to significant, enduring improvements.“ (Senge, 1990)

– Structure, process, interdependencies, and feedback within a system are important to producing outcomes

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Improved Process

draw, label, send

send via tube

receive,log,test

call

receive,use

carry

Plume, SK. (2004). Dartmouth Medical School

Check Results and Changes

• Constantly monitor and evaluate the behavior of the system

• Takes action when needed to assure the system continues to produce the desired results

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Improved Turnaround Time

0

10

20

30

40

50

60

70

80

90

100

Elapsed Time

Process Change

Plume, SK. (2004), Dartmouth Medical School

Consider Short and Long Term Consequences of Action

• Weigh the possible short and long-term outcomes of change

• Consider change implications both up stream and down stream from change

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Implications

• Decreased risk for the patient– Infection– Time on pump– Morbidity and mortality

• Increased OR efficiencies– Improved surgical team satisfaction– Improved OR turnaround times

• Improved relationship with the lab microsystem

Identify Unintended Consequences

• Think about evidence-based solutions• Try to anticipate unintended consequences

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Unexpected Outcomes

• Others ask to participate in improvement• Physicians became engaged• Other departments become engaged

• “Removal of internally perceived barriers, leading us more towards ‘how can we do this?’ and away from ‘I don’t think we can do this.’”

– Team Member

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Model for Improvement

Act Plan

Study Do

Aim: What are we trying to accomplish?Measures: How will we know that a change is an

improvement?Changes: What changes can we make that will result in an

improvement?

After Langley, Nolan, et. al.

Microsystems is a Transformation Process

• Create a new culture– Become systems thinkers– Use data to understand the

system• Working on the work

– Understanding how care is delivered

• Think about the SRU– Patient-centered care– Outcomes are created by

teams– Impressions are delivered

by the individual

Assessment

Theme

Global Aim

Specific Aim

Change Ideas

Measures

Fishbones

Flowcharts

Meeting Skills

1

2

3

PDSA Improvement

Ramp

Standardize

Sharp End Focus

• Focus must be at the sharp end, the point where the patient interacts with the system

• Locus of most work & policy– Good outcomes are made at the front line not the

front office• Center for variables relevant to patient

– Place where “value (quality) is added” and “safe” care is made

54

Healthcare Professionals must Recognize

• Healthcare today requires a new mental model – About the work– About process– About change

• “Success in the past has no implication for success in the future….the formulas for yesterday’s success are almost guaranteed to be formulas for failure tomorrow.” Michael Hammer

• Improvement, safety and quality must continually be re-invented

55

Healthcare Paradigm Shift

• Yesterday– Relationship 1:1– Care based upon a visit– Mono-disease– Physician autonomy– Reaction to patient needs– Professional knowledge– Do no harm– Secrecy– Professional individualism

• Today– Relationship multiple:1– Care based on continuum– Alleviate burden of illness– Patient centered– Anticipation of patient needs– Evidence-based decisions– Safety is a system issue– Transparency– Teamwork

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Remember That…

“Every system is perfectly designed to get the results it gets.”

• If we persist in holding the beliefs we have always held, and

• Insist on taking the action we have always taken,

• We should expect to continue to get the same results we have always gotten.

Paul Batalden, MDDirector Health Care Improvement Leadership Development

The Dartmouth InstituteCo-Founder Institute for Healthcare Improvement

If you are still unsure about improving care…

Consider the Business Case

Healthcare

• Driven by volume– Patients– Procedures

• Reducing “volume” impacts the bottom line• Payment changes

– “Never events” impact volume– Volume sustains the bottom-line

Institute of Medicine (IOM)Building a Better Delivery System (2005)

• $0.30-0.40 of every dollar spent on healthcare is associated with• Overuse• Underuse• Misuse• Duplication• System failures• Inefficiencies

• Half the patients seen receive evidence-based care

• 98,000 patients die • 1 million sustain injuries

from medical errors

CMS Billing Data on Hospital Acquired Conditions for 2006

Number Events Average Cost

Retained foreign object 764 $61,962/case

Air embolism 45 $66,00/case

Blood incompatibility 33 $46,492/case

UTI, cath assoc 11,780 $40,347/case

Pressure ulcer 322,946 $40,381/case

IV assoc infection unknown unknown

Mediastinitis post-CABG

108 $304,747/case

Fall from bed 2,591 $24,962/case

The Reality is…

• Hospital-acquired conditions accounted for 12.2% of total legal liability costs (1 in 6 claims)• Injuries - falls and fractures• Pressure ulcers• Foreign objects left in the body

• Pressure Ulcers - most frequently reported and most expensive• $145,000 on average for claims per incident• $25,000 cost to the insurance payor

Now Consider

• 4% defect rate for the hospital– 17,000 annual admissions– 16,000 surgical procedures

• Annual Errors – 640 surgical defects– 501 transfusion defects – 40,000 errors in medication administration

Expense to the System

• Quality and safety shortfalls lead to declining profits and decreased health for the patients

• Increased demand for accountability and public reporting

Now think about…

• What could we do with the money we save?– Services– Staffing– Equipment– Facilities

• What could we do with time we would save?• What could we do with the knowledge we

would acquire?

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Solution

• Better systems– Prevent errors– Improve quality

• Systems must ensure the provision of effective care– Evidence-based practice

Leape, LL, Berwick, DM, Bates, DW. “What practices will most improve safety? Evidence-based medicine meets patient

safety.” JAMA, July 24, 2002. Vol 288, No. 4

66

Questions

Structure

• Team is skilled, practiced, motivated• Operating within an enabling structure

Structure

• What does this structure do to the performance of the same team?

Elements of Structure that Drive Behavior

• Physical layout & environment

• Information flows

• Policies, procedures

• Practices, norms

• Values

• Organizational performance metrics

• Reporting relationships

• Reward systems

• Mental models

• Language

Force Field AnalysisCOLLABORATION

DRIVING RESTRAINING

•Shared vision of ideal state

•Desire to satisfy customer

•Pressure to be a team player

•Performance measures linked to dept. budgets

•No feedback re: impact of local decisions on others

•Culture glorifies the “hero”

Conclusion

• “Rational” actions may have unintended (and undesirable) consequences

• Cause and effect are often distant in time and space

• Structure drives behavior– What were the processes that lead to the results?