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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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Design Rule 2 of TPSDesign Rule 2 of TPS
(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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Design Rule 3 of TPSDesign Rule 3 of TPS
(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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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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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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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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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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Case in Light of TPS RulesCase in Light of TPS Rules
(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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Case in Light of TPS RulesCase in Light of TPS Rules
(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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Case in Light of TPS RulesCase in Light of TPS Rules
(Rule 1,2,3)(Rule 1,2,3)Specifying activitiesSpecifying activities Defining clearDefining clear
connectionsconnections
Simplified PathwaysSimplified Pathways
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Case in Light of TPS RulesCase in Light of TPS Rules
(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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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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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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