Systems Thinking: Learning Session #2app.ihi.org/extranetng/content/3af9ffd2-07e1-4239... ·...
Transcript of Systems Thinking: Learning Session #2app.ihi.org/extranetng/content/3af9ffd2-07e1-4239... ·...
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Systems Thinking:Learning Session #2
David Munch M.D.
Faculty IHI
Chief Clinical Officer
Healthcare Performance Partners
May 14th, 2014
Objectives
Participants will be able to discuss systems thinking.
Participants will be able to relate the lessons learned to
their present methods of improvement.
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Dr. W. Edwards Deming:
System of Profound Knowledge
Appreciation for a
System
Understanding
Variation
Theory of Knowledge
Psychology“The various segments of the system of profound knowledge cannot be separated. They interact with each other.”
Appreciation for a System
A system is an interdependent group of items, people
and processes with a common aim.
All work is done through processes.
Every system is perfectly designed to achieve exactly
the results it gets.
If each part of a system, considered separately is made
to operate as efficiently as possible, then the system as
a whole will not operate as effectively as possible.
People are a key part of systems in organizations: they
want to do a good job and take pride in their work.
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Individual
Individual and System5
• Individual performance is
influenced by the system
• The performance of the
system as a whole is
influenced by the
individuals
• How do you determine:
• Who owns what?
• What is your role?
• How will you know about
system problems?
If We Want a New Level of Performance,
We Must Get a New System
Most problems in organizations do not come from
individual workers.
Most problems come from the structure of the systems
themselves, and people are only parts of those systems.
Changing the people, or pushing them to "try harder" or
"do better" will not result in improved performance.
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Human Error Models
Personal ModelNames, Blames and Shames
Assumptions of negligence, carelessness, lack of skill, knowledge or motivation
Uses fear and discipline as response
Lowers morale, hides problems
Systems ModelPoor system design causes or contributes to error
“Latent Failure Conditions”: culture, interactions, influences
Recognizes that humans have limits and error is inevitable
Design systems to anticipate, prevent and mitigate errors caused by humans
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Example: Inpatient Warfarin Prescribing8
Decision to Prescribe
Earlier in the Day
Need INR Value
Need Blood Draw
Need Lab Results
Results Communicated with Clinician
Change in prescribing to an earlier time of the day
What can go wrong?
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Systems Thinking
What is the problem we actually have (not perceive)?
What are the causes of the problem? – Why is the defect occurring?
– How do the parts relate to the whole?
– How does the system influence the problem?
What are we going to do to fix the problem?– Cycles of PDSA
– Note: Are we fixing the problem or putting a Band-Aid on it?
How will we know our changes are effective?
What systems and structures will be establish to support and sustain?
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Principles of a Safe System
Prevent
– Through standardization, simplification
Detect
– Improve methods to identify errors when they occur
– Should not be the primary strategy
Mitigate
– Prevent error from causing harm
– Mitigate the severity of the harm
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Systems: Processes and Interactions at All
Levels
Governance
Therapies
Leadership
Supply Chain
TransitionEvaluation
Management
FacilitiesHR
Entry
Staff
I.T.Revenue
Cycle
Drivers
Mainstay
Support
The Patient
Scorecard Used in Daily Management
Systems
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Satisfaction Financial Quality Growth
Outcome Metrics
Reason For Miss
A3s
ProcessMetrics
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Visual ManagementWhat the Executive Evaluates What the Manager Evaluates
Are the metrics correct? (strategically aligned)
Last updated? Are there targets or
specifications? Does performance
meet the standard? Are reasons for misses
documented AND driving problem solving activity?
Is the visual mgmtsystem being updated regularly and driving behavior?
Are things getting better?
Does performance meet standard?
Are there standards that need to be tightened?
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Develop “True North” and align the organization to that pursuit
Strategy development and deploymentDevelop systems and structures
Develop and support all staff in continuous improvement
Developing Lean LeadersA3 Deployment
Organizational Development and Learning
Engage staff in surfacing and
solving problemsA3 Problem Solving
Safety Culture
Eliminate waste and make the right work
easier to doLeadership Standard Work
Visual ManagementKaizen
5S
Exercise: Write Your Progress Report
Spend 10 minutes at your table discussing the
possible causes as to why your improvement effort
did not achieve desired results1. What influenced the ability of staff to carry out the steps?
2. What got in their way?
3. What other part of the system did not support the change?
Spend 5 minutes discussing what you will do to
keep that from happening going forward.
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Thank You