tools for problem solving and decision making

8/12/2019 Tools for Problem Solving and Decision Making

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Chapter 6. Tools for Problem Solving andDecision Making

An Integrated Approach to

Improving Quality and Efficiency

Daniel B. McLaughlinJulie M. Hays

Healthcare Operations

Management


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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


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Decision-Making Framework

Framing- Identifying and framing the issue or problem

Gathering intelligence

- Generating or determining possible courses of actionand 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


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Barriers to Good DecisionMaking

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 failureLearning/failing to learn from

feedback

Fooling yourself about feedback

Not keeping track

Failing to audit your decision

process


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A Test of Your Problem-SolvingAbilities

4 If a doctor gave youthree pills and said to

take one every half

hour, how long wouldthey 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 roomwhere 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 along

on the ark?

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


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Mind Mapping

Diagram

created in

Inspiration

by

Inspiration

Software,

Inc.


7/26Copyright 2008 Health Administration Press. All rights reserved. 6-7

Process Mapping/Flowcharting

Graphical depiction of a process showinginputs, 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.

Arectangle

is used to

show a

task or

activity.

A diamond is used toshow those point in the

process where a choice

can be made or

alternate paths can be

followed.

Arrows show thedirection of flow of

the process.

End

Feedback

loop

D shapes are

used to show

delays.

Blockarrowsareused toshow

transports.

An oval is used to show

inputs/outputs to the

process or start/end of the

process.


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Service Blueprinting

Microsoft Visio screen shots reprinted with

permission from Microsoft Corporation.

Customergives

prescriptionto clerk

Clerk enters

data

Clerk gives

prescription

topharmacist

Pharmacist

fillsprescription

Clerk gives

medicine tocustomer

Clerk

retrievesmedicine

Pharmacist

gives

medicine to

clerk

Customer

receives

medicineLine of interaction

Line of visibility

CustomerActions

OnstageActions

BackstageActions



Root Cause Analysis

Structured, step-by-step techniques forproblem 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?


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Five Whys Technique

Ask why the condition occurred.

Ask why for each answer (five times is a

good rule of thumb).


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Cause and Effect Diagram

Waiting

Time

Waiting

Time

Methods

Machines Man

Mother Nature(Environment)


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Cause and Effect Diagram

Old inner-citybuilding

Lack of

treatment

rooms

Elevators

broken

Wheelchairsunavailable

Transpo rt arr ives late

Process takestoo long

Excessive paperwo rk

Unexpected

pat ients

Wrong

patients

Staff not avai lable

Corr idor

blocked

Sick

Late

Files unorganized

Bureaucracy

Incorrect referrals

Lack of technology

Poor scheduling

Poor maintenance

HIPAA regu lat ions

Waiting Time

Methods

Machines Man

Mother Nature(Environment)

Original appointment missed


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Failure Mode and EffectsAnalysis(FMEA)

1

2

3

45

6

7

8

Total RPN (sum of all RPNs):


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Failure Mode and EffectsAnalysis(FMEA)

Failure mode: What could go wrong?

Failure causes: Why would the failure happen?

Failure effects: What would be the consequences offailure?

Likelihood of occurrence: 110, 10 = very likely to occur

Likelihood of detection: 110, 10 = very unlikely to detect

Severity: 1

10, 10 = most severe effect Risk priority number (RPN): Likelihood of occurrence

Likelihood of detection Severity


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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.
http://images.google.com/imgres?imgurl=http://www.friendsacrossamerica.com/colorboyscout.gif&imgrefurl=http://www.friendsacrossamerica.com/colorboyscout.html&h=599&w=477&sz=10&hl=en&start=17&tbnid=MDXg8-fW5U3RXM:&tbnh=135&tbnw=108&prev=/images%3Fq%3Dboy%2Bscout%26ndsp%3D20%26svnum%3D10%26hl%3Den%26lr%3D%26sa%3DNhttp://images.google.com/imgres?imgurl=http://www.friendsacrossamerica.com/colorboyscout.gif&imgrefurl=http://www.friendsacrossamerica.com/colorboyscout.html&h=599&w=477&sz=10&hl=en&start=17&tbnid=MDXg8-fW5U3RXM:&tbnh=135&tbnw=108&prev=/images%3Fq%3Dboy%2Bscout%26ndsp%3D20%26svnum%3D10%26hl%3Den%26lr%3D%26sa%3DNhttp://images.google.com/imgres?imgurl=http://www.friendsacrossamerica.com/colorboyscout.gif&imgrefurl=http://www.friendsacrossamerica.com/colorboyscout.html&h=599&w=477&sz=10&hl=en&start=17&tbnid=MDXg8-fW5U3RXM:&tbnh=135&tbnw=108&prev=/images%3Fq%3Dboy%2Bscout%26ndsp%3D20%26svnum%3D10%26hl%3Den%26lr%3D%26sa%3DNhttp://images.google.com/imgres?imgurl=http://www.friendsacrossamerica.com/colorboyscout.gif&imgrefurl=http://www.friendsacrossamerica.com/colorboyscout.html&h=599&w=477&sz=10&hl=en&start=17&tbnid=MDXg8-fW5U3RXM:&tbnh=135&tbnw=108&prev=/images%3Fq%3Dboy%2Bscout%26ndsp%3D20%26svnum%3D10%26hl%3Den%26lr%3D%26sa%3DN


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Theory of ConstraintsFive Steps

1. Identify the constraint (or bottleneck).

2. Exploit the constraint.

3. Subordinate everything else to theconstraint.

4. Elevate the constraint.

5. Repeat the process for the new constraint.


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Optimization

A technique used to determine the optimalallocation of limited resources, given a desired

goal

Resources

- People

- Money

- Equipment

Linear or nonlinear

Goal or objective

- Maximize profit or

revenue

- Minimize cost


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Optimization

Optimization models have three basicelements:

1. An objective function, which is the quantity

that needs to be minimized or maximized2. 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


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Decision Trees

70.0% 0.70 -7

Flu

-7 -7

30.0% 0.3 60.0% 0

0 -7 -6 -13

Costs-7 -12.2

Vaccination 40.0% 0

Vaccination 70.0%

Program #2 -4 -11

program #1 0 -10.4 60.0% 0

-7 -12 -12

Costs

Flu -10.4

0 -7.28 0 40.0% 0

30.0% 0 -8 -8

0 0

HMO

vaccination

decision

Program

Fluoutbreak

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 thispath becauseexpected costsof $10.4 millionare less than$12.2 million

Choose thispath becauseexpected costsof $7 millionare less than$7.28 million


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Decision TreeRisk Analysis

Initial Vaccination

Program

No Initial Vaccination

Program

# X P X P1 7 1 12 0.42

2 8 0.28

3 0 0.30


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Force Field Analysis

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

proposed change

Used to decide whether a proposed changecan be implemented successfully

Used to develop strategies that will enable

successful implementation of a change


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Force Field Analysis

Plan:

Changetobedside

shifthandover

Critical incidentson the increase

Staff knowledgeable inchange management

Increase in dischargeagainst medical advice

Complaints from patientsand doctors increasing

Care given predominantlybiomedical in orientation

Ritualism andtradition

Fear that this may lead

to more work

Fear of increasedaccountability

Problems associatedwith late arrivals

Possible disclosure ofconfidential information

Total: 19

4

4

3

5

5

Total: 21

Driving ForcesRestraining Forces

4

5

3

3

4

Total: 19 Total: 21


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Copyright 2008 Health Administration Press All rights reserved 6 26

Conclusion

The tools and techniques outlined in thischapter are intended to help organizations

along the path of continuous improvement.

The choice of tool and when to use that toolare dependent on the problem to be solved.

In many situations, several tools from this

and other chapters should be used toensure that the best possible solution has

been found.

tools for problem solving and decision making

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