chapter 6. tools for problem solving and decision making an integrated approach to improving quality...
TRANSCRIPT
Chapter 6. Tools for Problem Solving and Decision Making
An Integrated Approach to Improving Quality and Efficiency
Daniel B. McLaughlinJulie M. Hays
Healthcare Operations Management
Copyright 2008 Health Administration Press. All rights reserved. 6-2
Chapter 6. Tools for Problem Solving and Decision Making
• Decision-making framework• Framing• Basic process improvement• Root cause analysis• Failure mode and effects analysis (FMEA)• Decision trees• Optimization• Theory of Constraints (TOC)• Force field analysis
Copyright 2008 Health Administration Press. All rights reserved. 6-3
Decision-Making Framework
• Framing- Identifying and framing the issue or problem
• Gathering intelligence- Generating or determining possible courses of action
and evaluating those alternatives
• Coming to conclusions- Choosing and implementing the best solution or
alternative
• Learning from feedback- Reviewing and reflecting on the above steps and
outcomes
Copyright 2008 Health Administration Press. All rights reserved. 6-4
Barriers to Good Decision Making
Key Elements Barriers to Brilliant Decision Making
Framing the question Plunging in
Frame blindness
Lack of frame control
Gathering intelligence Overconfidence in your judgment
Shortsighted shortcuts
Coming to conclusions Shooting from the hip
Group failure
Learning/failing to learn from feedback
Fooling yourself about feedback
Not keeping track
Failing to audit your decision process
Copyright 2008 Health Administration Press. All rights reserved. 6-5
A Test of Your Problem-Solving Abilities
4 If a doctor gave you three pills and said to take one every half hour, how long would they last?
1 Can a man living in Milwaukee,Wisconsin, be buried west of the Mississippi?
2 If you had only one match and entered a room where there was a lamp, an oil heater, and some kindling wood, which would you light first?
3 How many animals of eachspecies did Moses take alongon the ark?
5 If you have two U.S. coins totaling 55 cents and one of the coins is not a nickel, what are the two coins?
Copyright 2008 Health Administration Press. All rights reserved. 6-6
Mind Mapping
Diagram created in
Inspiration® by
Inspiration Software®,
Inc.
Copyright 2008 Health Administration Press. All rights reserved. 6-7
Process Mapping/Flowcharting
• Graphical depiction of a process showing inputs, outputs, and steps in the process
• Used to understand and optimize a process
• Integral part of most improvement initiatives including Six Sigma, Lean, Balanced Scorecard, RCA, FMEA, and so forth
Copyright 2008 Health Administration Press. All rights reserved. 6-8
Process Mapping Steps
1. Assemble and train the team.2. Determine process boundaries and
desired level of detail.3. Determine and order major process tasks.4. Draw a formal flowchart.5. Check the accuracy of the formal
flowchart.6. Collect more data and information as
needed.
Copyright 2008 Health Administration Press. All rights reserved. 6-9
Flowchart Standard Symbols
Microsoft Visio® screen shots reprinted with permission from
Microsoft Corporation.
A rectangle is used to
show a task or activity.
A diamond is used to show those point in the process where a choice
can be made or alternate paths can be
followed.
Arrows show the direction of flow of
the process.
End
Feedback loop
D shapes are used to show
delays.
An oval is used to show inputs/outputs to the
process or start/end of the process.
Copyright 2008 Health Administration Press. All rights reserved. 6-10
Activity and Role Lane Mapping
Role
Activity Clerk Nurse Porter Doctor
Take insurance information x
Move patient x x
Record vital signs x x
Take history x x
Examine patient x
Write pathology request x
Deliver pathology request x
Copyright 2008 Health Administration Press. All rights reserved. 6-11
Service Blueprinting
Microsoft Visio® screen shots reprinted with permission from Microsoft Corporation.
Customer gives
prescription to clerk
Clerk enters data
Clerk gives prescription
to pharmacist
Pharmacist fills
prescription
Clerk gives medicine to customer
Clerk retrieves medicine
Pharmacist gives
medicine to clerk
Customer receives medicineLine of interaction
Line of visibility
CustomerActions
Onstage Actions
Backstage Actions
Copyright 2008 Health Administration Press. All rights reserved. 6-12
Root Cause Analysis
• Structured, step-by-step techniques for problem solving
• Aimed at determining and correcting the ultimate causes of a problem
• What happened?
• Why did it happen?
• What can be done to prevent it from happening again?
Copyright 2008 Health Administration Press. All rights reserved. 6-13
Five Whys Technique
• Ask why the condition occurred.
• Ask why for each answer (five times is a good rule of thumb).
Copyright 2008 Health Administration Press. All rights reserved. 6-14
Cause and Effect Diagram
Waiting Time
Waiting Time
Methods
Machines Man
Mother Nature(Environment)
Copyright 2008 Health Administration Press. All rights reserved. 6-15
Cause and Effect Diagram
Old inner-city building
Lack of treatment
rooms
Elevators broken
Wheelchairsunavailable
Transport arrives late
Process takestoo long
Excessive paperwork
Unexpected patients
Wrong patients
Staff not available
Corridorblocked
Sick
Late
Files unorganized
Bureaucracy
Incorrect referrals
Lack of technology
Poor scheduling
Poor maintenance
HIPAA regulations
Waiting Time
Methods
Machines Man
Mother Nature(Environment)
Original appointment missed
Copyright 2008 Health Administration Press. All rights reserved. 6-16
Failure Mode and Effects Analysis (FMEA)
Steps
in th
e Pro
cess
Failu
re M
ode
Failu
re C
ause
s
Failu
re E
ffect
s
Likel
ihood o
f
Occurre
nce (1
–10)
Likel
ihood o
f
Detec
tion (1
–10)
Sever
ity (1
–10)
Risk
Priorit
y Num
ber
(RPN)
Actio
ns to
Red
uce
Occurre
nce o
f Fai
lure
12345678
Total RPN (sum of all RPNs):
Copyright 2008 Health Administration Press. All rights reserved. 6-17
Failure Mode and Effects Analysis (FMEA)
• Failure mode: What could go wrong?• Failure causes: Why would the failure happen?• Failure effects: What would be the consequences of
failure?• Likelihood of occurrence: 1–10, 10 = very likely to occur• Likelihood of detection: 1–10, 10 = very unlikely to detect• Severity: 1–10, 10 = most severe effect• Risk priority number (RPN): Likelihood of occurrence ×
Likelihood of detection × Severity
Copyright 2008 Health Administration Press. All rights reserved. 6-18
Theory of Constraints
• The Goal (Goldratt and Cox 1986)
• Every organization is subject to at least one constraint, which limits it from moving toward its goal.
• Eliminating or alleviating the constraint can enable the organization to come closer to its goal.
Copyright 2008 Health Administration Press. All rights reserved. 6-19
Theory of Constraints Five Steps
1. Identify the constraint (or bottleneck).
2. Exploit the constraint.
3. Subordinate everything else to the constraint.
4. Elevate the constraint.
5. Repeat the process for the new constraint.
Copyright 2008 Health Administration Press. All rights reserved. 6-20
Optimization
• A technique used to determine the optimal allocation of limited resources, given a desired goal
• Resources- People- Money- Equipment
• Linear or nonlinear
• Goal or objective- Maximize profit or
revenue- Minimize cost
Copyright 2008 Health Administration Press. All rights reserved. 6-21
Optimization
Optimization models have three basic elements:
1. An objective function, which is the quantity that needs to be minimized or maximized
2. The controllable inputs or decision variables that affect the value of the objective function
3. Constraints that limit the values the decision variables can take on
Copyright 2008 Health Administration Press. All rights reserved. 6-22
Decision Trees
70.0% 0.70 -7
Flu-7 -7
30.0% 0.3 60.0% 00 -7 -6 -13
Costs-7 -12.2
Vaccination 40.0% 0Vaccination 70.0%
Vaccination Program #2 -4 -11
program #1 0 -10.4 60.0% 0-7 -12 -12
CostsFlu -10.4
0 -7.28 0 40.0% 030.0% 0 -8 -8
0 0
HMO vaccination
decision
Program
Flu outbreak
No flu outbreak
Flu outbreak
No flu outbreak
Program
No program
C
D
A
B
Choose this path because expected costs of $10.4 million are
Choose this path because expected costs of $7 million are less than $7.28 million.
No program
The tree diagram in this figure was drawn with the help of PrecisionTree,
a software product of Palisade Corp., Ithaca,
NY; www.palisade.com.
Choose this path because expected costs of $10.4 million are less than $12.2 million
Choose this path because expected costs of $7 million are less than $7.28 million
Copyright 2008 Health Administration Press. All rights reserved. 6-23
Decision TreeRisk Analysis
Initial Vaccination Program
No Initial Vaccination Program
# X P X P
1 –7 1 –12 0.42
2 –8 0.28
3 0 0.30
Copyright 2008 Health Administration Press. All rights reserved. 6-24
Force Field Analysis
• A technique for evaluating all the forces for (driving) and against (restraining) a proposed change
• Used to decide whether a proposed change can be implemented successfully
• Used to develop strategies that will enable successful implementation of a change
Copyright 2008 Health Administration Press. All rights reserved. 6-25
Force Field Analysis
Plan:Change
to bedside
shift handover
Critical incidents on the increase
Staff knowledgeable in change management
Increase in discharge against medical advice
Complaints from patients and doctors increasing
Care given predominantly biomedical in orientation
Ritualism and tradition
Fear that this may lead to more work
Fear of increased accountability
Problems associated with late arrivals
Possible disclosure of confidential information
Total: 19
4
4
3
5
5
Total: 21
Driving ForcesDriving Forces Restraining ForcesRestraining Forces
4
5
3
3
4
Total: 19 Total: 21
Copyright 2008 Health Administration Press. All rights reserved. 6-26
Conclusion
The tools and techniques outlined in this chapter are intended to help organizations along the path of continuous improvement. The choice of tool and when to use that tool are dependent on the problem to be solved. In many situations, several tools from this and other chapters should be used to ensure that the best possible solution has been found.