Coping with Complexity in Healthcare: guidelines and innovative - - PowerPoint PPT Presentation

Coping with Complexity in Healthcare: guidelines and innovative methods

• Prof. Tarcisio A. Saurin

saurin@ufrgs.br www.ufrgs.br

Porto Alegre

• Founded in 1896
• > 8,300 undergraduate

students

• ~ 2,200 graduate students
• 400-600 engineers per year
• > 300 Master and PhD per year
• ~ 240 Academics and

Sessionals

• ~ 120 Professional Staff

School of Engineering

• Ind. Eng. Postgrad. Program

www.ufrgs.br/producao

• One of the two top ranked in Brazil (score 7 – highest

possible)

• Founded in 1991
• 16 academics, all are PhD supervisors
• 20 Master and 12 PhD students enroll every year
• Master

– 24 credits (face-to-face workload) – 2 years (4 semesters)

• PhD

– 42 credits (MSc credits can be used) – 4 years

Interaction with industry

• R&D projects in collaboration with industry partners

– Hospitals, distribution and generation of energy, manufacturing,

• Executive courses (specialization 360 h, over 1 year)

– Safety and ergonomics, Lean Production, Project Management, Finance Engineering, Logistics

• Professional Masters (more practical approach, weekends,

fees)

• Professional PhD (under evaluation)
• Consulting company managed by undergraduate students

Our Main Lab for Studying Complexity in Healthcare

Hospital de Clinicas de Porto Alegre (HCPA) UFRGS´ teaching hospital

• Similar definitions in many disciplines

Similar definitions in many disciplines Similar definitions in many disciplines Similar definitions in many disciplines

• Biology, Computer Science, Engineering Design, Management, etc.

Biology, Computer Science, Engineering Design, Management, etc. Biology, Computer Science, Engineering Design, Management, etc. Biology, Computer Science, Engineering Design, Management, etc.

What is complexity?

structural and functional structural

functional functional

Coping with Complexity: Six Guidelines

• Small (and big) changes may interact in

Small (and big) changes may interact in Small (and big) changes may interact in Small (and big) changes may interact in unexpected ways unexpected ways unexpected ways unexpected ways

• There

There There There are no definitive solutions in complex are no definitive solutions in complex are no definitive solutions in complex are no definitive solutions in complex systems systems systems systems

• Broad range of outcome

Broad range of outcome Broad range of outcome Broad range of outcome measures, neighboring systems, measures, neighboring systems, measures, neighboring systems, measures, neighboring systems, evaluation in the evaluation in the evaluation in the evaluation in the long long long long-

• run,

run, run, run, quali quali quali quali and and and and quanti quanti quanti quanti Monitoring unintended consequences

Play video butterfly effect

• Take advantage of diversity to reduce uncertainty

Take advantage of diversity to reduce uncertainty Take advantage of diversity to reduce uncertainty Take advantage of diversity to reduce uncertainty

• Requirements

Requirements Requirements Requirements

• Trust, low power differences, capable decision

Trust, low power differences, capable decision Trust, low power differences, capable decision Trust, low power differences, capable decision-

• makers

makers makers makers

• Hard to implement under time pressure

Hard to implement under time pressure Hard to implement under time pressure Hard to implement under time pressure

• Collaboration

Collaboration Collaboration Collaboration costs costs costs costs

• Unintended consequences

Unintended consequences Unintended consequences Unintended consequences

Diversity of perspectives in design

• Mechanism for

Mechanism for Mechanism for Mechanism for reducing interdependencies reducing interdependencies reducing interdependencies reducing interdependencies and and and and minimizing the minimizing the minimizing the minimizing the possibility of one process affecting possibility of one process affecting possibility of one process affecting possibility of one process affecting another another another another, and thus it makes processes , and thus it makes processes , and thus it makes processes , and thus it makes processes loosely loosely loosely loosely-

• coupled

coupled coupled coupled

• Several types of slack resources

Several types of slack resources Several types of slack resources Several types of slack resources

• People, equipment, money, space, time,…

People, equipment, money, space, time,… People, equipment, money, space, time,… People, equipment, money, space, time,…

Design slack (or buffers)

Bundles of practices, early detection of the need for changing care plans, spare beds in the ICU, multisdisciplinary rounds, capacity gains due to greater efficiency,....

• Degrees of freedom

Degrees of freedom Degrees of freedom Degrees of freedom when requesting medication when requesting medication when requesting medication when requesting medication

• Anytime, if urgent (not life

Anytime, if urgent (not life Anytime, if urgent (not life Anytime, if urgent (not life-

• threatening situations)

threatening situations) threatening situations) threatening situations)

• Supplied in less than 20 minutes

Supplied in less than 20 minutes Supplied in less than 20 minutes Supplied in less than 20 minutes

A Practical Example

• This

This This This gap is unavoidable in complex systems gap is unavoidable in complex systems gap is unavoidable in complex systems gap is unavoidable in complex systems

• It is not necessarily detrimental

It is not necessarily detrimental It is not necessarily detrimental It is not necessarily detrimental

• Filling in the gaps in procedures can

Filling in the gaps in procedures can Filling in the gaps in procedures can Filling in the gaps in procedures can be the reason for safe be the reason for safe be the reason for safe be the reason for safe performance ( performance ( performance ( performance (Hollnagel Hollnagel Hollnagel Hollnagel) ) ) )

• This is why we

This is why we This is why we This is why we need to learn from what goes need to learn from what goes need to learn from what goes need to learn from what goes right right right right

• It

It It It is worth spending time understanding WAD before is worth spending time understanding WAD before is worth spending time understanding WAD before is worth spending time understanding WAD before intervening intervening intervening intervening

• Previous

Previous Previous Previous guidelines applied when designing WAI guidelines applied when designing WAI guidelines applied when designing WAI guidelines applied when designing WAI

Monitoring the gap between WAI and WAD

• Reduce perceived

Reduce perceived Reduce perceived Reduce perceived complexity complexity complexity complexity

• All human senses, not only vision

All human senses, not only vision All human senses, not only vision All human senses, not only vision

• Status

Status Status Status of slack

• f slack
• f slack
• f slack resources

resources resources resources

• E.g. dashboards

E.g. dashboards E.g. dashboards E.g. dashboards

• Support

Support Support Support visibility of visibility of visibility of visibility of informal informal informal informal work work work work

• How gaps in procedures are filled in

How gaps in procedures are filled in How gaps in procedures are filled in How gaps in procedures are filled in

• Normalized deviances

Normalized deviances Normalized deviances Normalized deviances

Supporting visibility

• It can be

It can be It can be It can be influenced and supported influenced and supported influenced and supported influenced and supported by design by design by design by design

• Apply the previous guidelines

Apply the previous guidelines Apply the previous guidelines Apply the previous guidelines

• And others…

And others… And others… And others…fail fail fail fail-

• safe devices

safe devices safe devices safe devices, delegate authority to front , delegate authority to front , delegate authority to front , delegate authority to front-

• line professionals,…

line professionals,… line professionals,… line professionals,…

• People development, resilient

People development, resilient People development, resilient People development, resilient skills skills skills skills

• Complex

Complex Complex Complex controller to cope with a complex process controller to cope with a complex process controller to cope with a complex process controller to cope with a complex process

Creating an environment that supports resilience

Examples of Practical Applications:

Work-as-done Slack

Integrated Analysis and (Re)Design of Procedures and Training for Resilience

Work-as-done

►Procedure of administering medications to patients

hospitalized in an ED

Practical application

The adopted approach

Resilience skills

► Are the goals of the activity stated in the procedure? ► Are the minimum inputs and preconditions required to

start the activity stated?

► Are there examples of under / no specification that should

have been specified?

► Are there work constraints that can make it difficult to

follow the procedure stated?

► Are there over specifications? ► Are the direct relationships with other procedures

mentioned?

Content analysis of procedures

► Examples of salient gaps in procedures

► “to observe adverse reactions of the patient, during

and after medication administration”

► “the medications must be prepared and administered in a

safe manner”

► Training implications of these gaps

Gaps in procedures

►Cognitive task analysis

► Interviews, observations, documents,…

►Work constraints

► Difficulty to find patient within the ED ► Long stay of hospitalization in the ED ► Several people requesting information at the same time

►Resilience skills

► Analyze the charts and prioritize critical or difficult patients ► Devise strategy to find patient within the overcrowded ED

Identification of RSs

►Design of training scenarios

► Story, work constraints, resilience skills ► Debriefing ► Insights into work system and procedures redesign

► Table with information

• n the dilution of medications

Scenario-Based-Training

A Framework for the Analysis of Slack in Socio-Technical Systems

►How much is enough? ►Is it in the right location? ►How to make its status visible?

Some design questions

Joint analysis of slack resources of different natures Shared taxonomy and construct (UoS) Prioritization of variability sources Accounts for

• pportunistic slack

Continuous improvement cycle

►Major private hospital in Brazil

• Obstetrics emergency, obstetrics center, neonatal ICU, in-patient

wards

Applying the framework

Prioritization of variability sources Risk versus Protection Score

►Hiring an anesthetist dedicated to the obstetrics

emergency

►Maternity´s representative assigned as a member of

the hospital committee that manages the blood bank Defend slack against efficiency pressures

Practical changes

►Intensive Care Unit

► Social network analysis for measuring resilience ► Clinical decision making: formal and informal decision

making, as a continuous process. Special interest in the role played by multidisciplinary ward rounds

► Patient flow: transportation ICU – radiology ► Role played by the built environment as a support for

care processes and resilience

► Insights to new ICU

Current Projects

Building Information Modelling (BIM) Structural requirements of the ICU

FRAM with built environment requirements

FRAM model without built environment requirements

► Investigation of the minimum necessary information for

requesting exams in radiology

► Many incomplete and superficial requests ► Failure of past initiatives – e.g. requirement for at least 15

characters when filling in the form

► Investigation of how complexity affects the nursing work

environment (e.g. leadership, opportunities for participation, etc.)

► Application of the Practice Environment Scale (magnet hospitals) ► Assessment of complexity attributes

Current Projects

Other projects

Thank you!