Dr Mark Mackay Mr Keith Stockman Professor Robert Adams Professor - - PowerPoint PPT Presentation

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

• f the presentation

Remember - if you don’t know, it’s likely

• thers 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

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A multi-D and multi-country Group! Plus authors from UK CI!

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

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Politicians and Media…& Health

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Sustained Period of Costs Increasing

For every dollar spent in health it means it’s one dollar not spent elsewhere or on additional patients.

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Why the Focus on Hospitals?

Hospitals represent a significant component of the health care budget – hence the focus by governments on ways to improve costs.

Source: Ducket S and Breadon P (2014). Controlling costly care: a billion- dollar hospital opportunity. Grattan Institute, Sydney, Australia. 8

Getting Ready for Change!

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First published in The health advocate Oct 2013

What’s a System?

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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. 2. Each element contributes to the system’s behaviour and is affected by it. 3. A system exhibits emergent properties that none of its components have individually. Emergence is a characteristic of the particular case. 4. Sub-groups of a system may have the above properties – they form sub-systems. 5. A system has an outside – its environment and boundaries that 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

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Systems Thinking

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https://youtu.be/eXdzKBWDraM

Complicated

• A plane is

complicated

• But it has

reliable performance – you can expect the same result each time

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Mapping patient flow across the hospital system

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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

Hospitals are Complex Service Environments

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

• utcomes.

They may be planned or unintended consequences of design problems.

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Design Thinking

• 1. How we got to here
• 2. What is it
• 3. Some key properties
• 4. Our experiences

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How we got to here

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Every system is perfectly designed to achieve the results it achieves Berwick

Berwick DM (1996). A primer

• n leading the improvement of
• systems. BMJ, 312: 619-22.

http://www.systemdynamics.org/DL-IntroSysDyn/bwb.htm

Painful lessons learnt

Horses for courses

Diagram by Dave Snowden, Cynefin 21

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We are not alone

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What is DT?

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https://www.youtube.com/watch?v=VQHlZVKqWL0

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Diagram by Hugh Dubberly 28

Diagram by Hugh Dubberly 29

Designing Thinking Process

Diagram by Jeanne Liedtka 30

“It’s a systematic approach to problem solving”

Liedtka & Ogilvie 2011 Designing for Growth, Columbia Business School, New York, pg. 5

Some Key Properties

• Human Centred

–Experience, needs & desires –Empathy –Multiple perspectives

• Constraints part of the fun!

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• Divergence

then convergence + synthesis

• Systems

Thinking in action!

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Extensive use of models & visualisation Large set of methods & tools

Diagram by Hugh Dubberly 35

• Prototyping
• Test user

insights & experience interactively

• “Fail often,

fail early”

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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

• Less prone to “picking from our favourite solutions –

again!”

• Encourages creativity
• User co-design goes well beyond asking “What do

you want”

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Our experiences

• Avoidable hospitalisation
• Hand Hygiene
• Make-a-thon series
• Long-stays
• Arrival at hospital
• Mental Health
• Community care

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Pain points - implementation needs good design

• all design has a political dimension

Challenges for DT

• Health staff understanding and skills
• Adequate time and “creative energy”
• Mixing it more with the Designers
• utside health
• Organizational nurturance
• Evidence of value

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Outcomes from Design Thinking can

• nly 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

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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,

• perations research or similar basis –

application is a matter of judgment and/or art.

Simulation and Health Care

• While you may not have encountered it - it’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.

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So What is Simulation Modelling?

• Simulation is one of

OR’s tools

• It’s a means of

creating a computerised model

• f a real system
• Various uses –

asking “what-if” questions, understanding, etc.

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We’re not talking about simulation for training health professionals e.g., “smart” manikins for training purposes

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Simulation Demonstration

http://youtu.be/P45WgRlc2sI

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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.

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Systems Thinking & Design Thinking &…

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Operations Management Design Thinking Systems Thinking Best Solutions – takes it all

Giving Some Context to Operations Management

Ambulance Ramping

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ED Overcrowding

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Enough Beds?

Waiting for Services

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Logistics

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10/05/2016 55

Logistics (cont.) - Work Time Lost

Valuable time spent on logistics – waiting for things to be found or provided

Proportion of Time Spent by Function

Forecasting

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Variation

Not all hospitals are the same!

Re-crea on

• f

Ducke and Breadon 2014 Figure 11: Cost

• f

laparoscopic cholecystectomies, high volume hospitals, 2010-11

• cost.of.procedure

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Case Study: Stroke Care

Modelling stroke care systems : Evidence of the benefits in the NHS*

• Simulation to test-drive options for managing suspected stroke

patients

– minimise time to treat and maximise the benefit to patients.

• Two process changes following the modelling.

– First, ambulances by-pass A&E with all suspected stroke patients.

• The acute stroke team are instead alerted to pending arrivals as patients are

transported to hospital.

– Second, senior A&E nurses alert the acute stroke team of any suspected strokes that have self-presented as they are triaged.

• This by-passes any lengthy wait for physicians in A&E.
• As a result of this, the Royal Devon and Exeter Foundation Trust

now treats four times as many stroke patients in half the time.

*cumberland-initiative.org

Results

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Results (cont.)

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Do We Really Need to Model?

From Cumberland Initiaitve and the Stroke Model: The question is why did we need to model it? The trouble is that many ‘obvious’ improvements are simply not implemented successfully or sustainably. You need to convince a lot of people to change their practice and the model helped to do just that. In this case modelling translated the evidence of the clinical effectiveness of rtPA into a local context. The magnitude of the improvement predicted by the model both in terms of treatment rates and post-stroke disability made it more real for clinicians in the hospital and convinced them to implement the changes. Benefits (Monks T, (2015) Modelling stroke care systems : Evidence of the

• benefits. www.cumberland-initiative.org date accessed 2 September 2015).

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The flaw of averages

• In 1950s USAF accidents were very common
• Problem thought to be cockpit design and size
• Initial solution- measure 4000 pilots and get average

dimensions and use in design

• Then someone asked, “How many pilots are actually

average?”

• So, calculated average of 10 physical dimensions

– Average was defined as middle 30% of range on each

• Found-

– not 1 of 4,063 pilots were within the average range on all 10 dimensions – Less than 3.5% were average on any 3 dimensions

Implications

• There was no such thing as an average pilot. If you’ve designed

a cockpit to fit the average pilot, you’ve actually designed it to fit no one.

• “The tendency to think in terms of the ‘average man’ is a pitfall

into which many persons blunder,”

• Lt. Gilbert S. Daniels

1952

• “any system designed around the average person is doomed to

fail

• environments need to fit the individual rather than the average”

The End of Average L Todd Rose

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Other Uses?

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Duckett’s Advice

• Although anecdotes help to sell policies, they

shouldn’t be the basis of policy development. If they are, they will almost certainly distort policymakers’ perceptions and start them down the wrong paths.

• Data should be used to … model the effects of new

policies.

• Organisations need to invest in the mindset and skills

to use data in policy, and have the mandate to do so.

Duckkett, S (2014). Forget the co-payment… Seven tips for an affordable, quality health system. The Conversation, 19 August 2014.

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Making it Happen It starts with a good question!

Do Good Questions Matter?

• Yes!
• Jeff Foote (NZ) – set out to determine an

algorithm for improving hospital capacity (PhD) – determined it couldn’t be done

• SA Health simulation project – project leader

realised that they’d been asking the wrong questions

• Researchers also ask the question e.g.,
• Fackler, J., & Spaeder, M. (2011, December). Why doesn't healthcare

embrace simulation and modeling? What would it take?. In Simulation Conference (WSC), Proceedings of the 2011 Winter (pp. 1137-1142). IEEE.

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So What Does it Take to Ask A Good Question? Understanding:

• Constraints
• Politics
• Methods
• Timing
• Stakeholders
• Knowing what the real problem is
• Appreciation of the system
• Understanding your biases

Context Alters the Frame or Perspective

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Consideration of the systemic characteristics

• f an operation

management project should lead to a better question and method

Context & boundaries Participants perspectives

YOU

knowledge Context & boundaries Participants’ perspectives Issue/problem methodology purpose

Politics power ethics Action Learning Projects – Understanding the Characteristics

• f the Project

Alternative – start with the method and make the situation fit the

• method. Reduce

probability of delivering what’s needed – but happens.

Based on a slide by Dr Don Houston, Centre for University Education, Flinders University

And of course … it takes a variety of people

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Making it Happen

Computer Scientists

Medical Officers

Allied Health

Patients

Process Improvement Teams

Economists Statisticians

Nurses Mathematicians Social Scientists Psychologists

It’s multi-disciplinary

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So What is Happening Locally?

Want to Learn More

• A Cumberland.au website coming soon

– email us if you want to be on a contact list

• A conference is planned for later this

year – keynote speakers include Hugh Dubberly (USA) and Terry Young (UK)

• Take some courses (e.g., MHA at

Flinders includes a subject on

• perations management)

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And Finally…

Know Your Business

To manage a business or any part of that business you need to … know your

• business. This means understanding:
• How it functions
• What resources it has, and
• Its strengths and weaknesses.

And have some tools to help improve it! Simulation is one of these tools!

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It’s Time to Address the Streetlight Effect

And… health services research has a role to play in improving health care management

Questions Contact: mark.mackay@flinders.edu.au robert.adams@adelaide.edu.au Keith.Stockman@monashhealth.org Donald.Campbell@monashhealth.org