Improving Health Systems – The Role of Design Thinking and Operations Research Dr Mark Mackay Mr Keith Stockman Professor Robert Adams Professor Don Campbell 10 May 2016
Questions? Use the Ask a Question Box to type in Questions at any time during our presentation We may answer it when we see it or at the end of the presentation Remember - if you don’t know, it’s likely others don’t know too, so please ask your questions.
The Cumberland Initiative • Cumberland Initiative – promotes the use of operational research and systems thinking in health • Aim to save 20% of annual NHS budget by 2020 ( ok a stretch target) ! • See www.cumberland-initiative.org • Australian “branch” cumberland.au
A multi-D and multi-country Group! Plus authors from UK CI! 4
Cumberland.au • The Australian arm of the UK Cumberland Initiative • Most recently a joint piece in “The Conversation” • Various grant activities e.g., Adelaide we are modelling RAH ICU and embarking on other modelling • Monash has been applying this work for some time 5
Politicians and Media…& Health 6
Sustained Period of Costs Increasing For every dollar spent in health it means it’s one dollar not spent elsewhere or on additional patients. 7
Why the Focus on Hospitals? Source: Ducket S and Breadon P (2014) . Controlling costly care: a billion- dollar hospital opportunity . Grattan Institute, Sydney, Australia. Hospitals represent a significant component of the health care budget – hence the focus by governments on ways to improve costs. 8
Getting Ready for Change! First published in The health advocate Oct 2013 9
What’s a System? 10
Critical Systems Thinking and Practice 1. A system is an organized assembly of elements and special relationships between the elements. If the elements or relationships change the system changes. Each element contributes to the system’s behaviour and is 2. affected by it. 3. A system exhibits emergent properties that none of its components have individually. Emergence is a characteristic of the particular case. Sub-groups of a system may have the above properties – they 4. form sub-systems . A system has an outside – its environment and boundaries that 5. determine what is in the system or not in the system. [A system can influence but not control its environment.] 6. A system transforms inputs from the environment to outputs to the environment Slide by Dr Don Houston, Centre for University Education, Flinders University
A hospital – a systems dynamics view 12
Systems Thinking https://youtu.be/eXdzKBWDraM 13
Complicated • A plane is complicated • But it has reliable performance – you can expect the same result each time 14
Hospitals are Complex Service Environments There has been many attempts to improve patient flow – usually based upon simple “fixes”. For every complex problem there is an answer that is clear, simple, and wrong. H. L. Mencken Mapping patient flow across the hospital system 15
Design and Health Every system is perfectly designed to achieve the results it achieves Berwick (1996, pg 619) . [highlight is my emphasis] Berwick DM (1996). A primer on leading the improvement of systems. BMJ, 312: 619-22. So all the bugs in the system – they’re design outcomes. They may be planned or unintended consequences of design problems. 16
Design Thinking 1. How we got to here 2. What is it 3. Some key properties 4. Our experiences 17
How we got to here
Every system is perfectly designed to achieve the results it achieves Berwick Berwick DM (1996). A primer on leading the improvement of systems. BMJ, 312: 619-22. 19
Painful lessons learnt http://www.systemdynamics.org/DL-IntroSysDyn/bwb.htm
Horses for courses Diagram by Dave Snowden, Cynefin 21
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We are not alone 23
What is DT?
https://www.youtube.com/watch?v=VQHlZVKqWL0 25
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28 Diagram by Hugh Dubberly
29 Diagram by Hugh Dubberly
Designing Thinking Process “It’s a systematic approach to problem solving” Liedtka & Ogilvie 2011 Designing for Growth, Columbia Business School, New York, pg. 5 30 Diagram by Jeanne Liedtka
Some Key Properties
• Human Centred – Experience, needs & desires – Empathy – Multiple perspectives • Constraints part of the fun! 32
• Divergence then convergence + synthesis • Systems Thinking in action! 33
Extensive use of models & visualisation Large set of methods & tools 34
35 Diagram by Hugh Dubberly
• Prototyping • Test user insights & experience interactively • “Fail often, fail early ” 36
How is DT different from the re-design we have been doing for years? • Complementary to other system design approaches such as LEAN, TOC, Six Sigma • Useful in the Complex Domain in which there are many ”Wicked Problems” • More emphasis on understanding consumer experience and needs from multiple perspectives • L ess prone to “picking from our favourite solutions – again!” • Encourages creativity • User co- design goes well beyond asking “What do you want” 37
Our experiences • Avoidable hospitalisation • Hand Hygiene • Make-a-thon series • Long-stays • Arrival at hospital • Mental Health • Community care Pain points - implementation needs good design - all design has a political dimension 38
Challenges for DT • Health staff understanding and skills • Adequate time and “creative energy” • Mixing it more with the Designers outside health • Organizational nurturance • Evidence of value 39
Outcomes from Design Thinking can only be judged via scientific evaluation. Ultimately that is the only way to judge Design Thinking itself Evaluation needs to include consumer experience which is in the end how value manifest 40
A Definition & Implications “Planning and control of processes that transform inputs into outputs ” (Vissers and Beech, 2005) Really it brings together many areas that you study – knowledge of organisations, people and $ - and combines them with some tools. While the tools may have an engineering, operations research or similar basis – application is a matter of judgment and/or art.
Simulation and Health Care • While you may not have encountered it - i t’s not new! • Discrete event simulation (useful for modelling processes) has been used for: – Planning new capacity (ED, outpatients, etc.) – Improving patient flow or workflow • There are many papers • As Fone et al. (2003) highlighted – little evaluation of such work & to date this is still true. 43
So What is Simulation Modelling? • Simulation is one of OR’s tools • It’s a means of creating a computerised model of a real system • Various uses – asking “what - if” questions, understanding, etc. 44
We’re not talking about simulation for training health professionals e.g., “smart” manikins for training purposes 45
Simulation Demonstration http://youtu.be/P45WgRlc2sI 46
The Point of Simulation • Given that the system is complex and isn’t perfect, how should “bugs” be fixed or improvements tested… without causing more harm? • Simulation is the answer! • It provides a mechanism to pre-test ideas – many more ideas than could be tried in real life – without investing in any real change. 47
Systems Thinking & Design Thinking &… Design Thinking Operations Management Systems Thinking Best Solutions – takes it all 48
Giving Some Context to Operations Management
Ambulance Ramping 50
ED Overcrowding 51
Enough Beds?
Waiting for Services 53
Logistics 54
Logistics (cont.) - Work Time Lost Proportion of Time Spent by Function 600 Rostered & other breaks 5% 500 Research 0% 400 Workforce Management 16% 300 Logistic Support 8% 100 Service Delivery 62% 200 Administrative Duties 9% Valuable time spent on logistics – waiting for things to be found or provided 55 10/05/2016
Forecasting 56
Variation Re-crea on� of� Ducke � and� Breadon� 2014� Figure� 11:� Cost� of� laparoscopic� cholecystectomies,� high� volume� hospitals,� 2010-11� � � 18,000� 16,000� 14,000� 12,000� 10,000� $� Cost� 8,000� cost.of.procedure� median_cost� 6,000� 4,000� 2,000� 0� 0� 1� 2� 3� 4� 5� Hospital� Not all hospitals are the same! 57
Case Study: Stroke Care 58
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