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
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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
34
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
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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
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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
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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
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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?