Healthcare Operations
Management
An Integrated Approach to
Improving Quality and Efficiency
Chapter 6. Tools for Problem Solving and
Decision Making
Daniel B. McLaughlin
Julie M. Hays
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.
6-2
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.
6-3
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.
6-4
1
A Test of Your Problem-Solving
Abilities
Can a man living in Milwaukee,
Wisconsin, be buried west of the Mississippi?
2
3
5
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?
If a doctor gave you
4
How many animals of each
three pills and said to
species did Moses take along
take one every half
on the ark?
hour, how long would
they last?
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.
6-5
Mind Mapping
Diagram
created in
Inspiration®
by
Inspiration
Software®,
Inc.
Copyright 2008 Health Administration Press. All rights reserved.
6-6
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.
6-7
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.
6-8
Flowchart Standard Symbols
Arrows show the
direction of flow of
the process.
A
An oval is used to show
rectangle
Block arrows
inputs/outputs to the
is used to
are used to show
process or start/end of the
show a
transports.
task or
process.
activity.
A diamond is used to
show those point in the
process where a choice
can be made or
alternate paths can be
followed.
D shapes are
used to show
delays.
End
Feedback
loop
Microsoft Visio® screen shots
reprinted with permission from
Microsoft Corporation.
Copyright 2008 Health Administration Press. All rights reserved.
6-9
Activity and Role Lane Mapping
Role
Activity
Take insurance information
Clerk
x
Nurse Porter Doctor
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.
6-10
Service Blueprinting
Customer
Actions
Onstage
Actions
Customer
gives
prescription
to clerk
Clerk enters
data
Line of interaction
Clerk gives
prescription
to
pharmacist
Clerk
retrieves
medicine
Pharmacist
fills
prescription
Pharmacist
gives
medicine to
clerk
Line of visibility
Backstage
Actions
Customer
receives
medicine
Clerk gives
medicine to
customer
Microsoft Visio® screen shots reprinted with
permission from Microsoft Corporation.
Copyright 2008 Health Administration Press. All rights reserved.
6-11
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?
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6-12
Five Whys Technique
• Ask why the condition occurred.
• Ask why for each answer (five times is a
good rule of thumb).
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6-13
Cause and Effect Diagram
Waiting
Time
Mother Nature
(Environment)
Methods
Waiting
Time
Machines
Copyright 2008 Health Administration Press. All rights reserved.
Man
6-14
Cause and Effect Diagram
Mother Nature
(Environment)
Methods
Files unorganized
Transport arrives late
Lack of
treatment
rooms
Excessive paperwork
Poor scheduling
Old inner-city
building
Corridor
Lack of technology
blocked
Process takes
too long
Poor maintenance
Machines
Bureaucracy
Waiting Time
Unexpected
patients
Elevators
broken
Wheelchairs
unavailable
HIPAA regulations
Incorrect referrals
Original appointment missed
Wrong
patients
Sick
Staff not available
Late
Man
Copyright 2008 Health Administration Press. All rights reserved.
6-15
Failure Mode and Effects
Analysis (FMEA)
1
2
3
4
5
6
7
8
Total RPN (sum of all RPNs):
Copyright 2008 Health Administration Press. All rights reserved.
6-16
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.
6-17
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.
6-18
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.
6-19
Optimization
• A technique used to determine the optimal
allocation of limited resources, given a desired
goal
• Resources
- People
- Money
- Equipment
• Goal or objective
- Maximize profit or
revenue
- Minimize cost
• Linear or nonlinear
Copyright 2008 Health Administration Press. All rights reserved.
6-20
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.
6-21
Decision Trees
Choose
this
Choose this
path because
because
path
expected costs
expected
of $7 million
costs
ofthan
$7
are less
$7.28 million
million
are
less than
$7.28 million.
HMO
vaccination
decision
Choose
this
Choose this
path because
path
because
expected costs
expected
of $10.4 million
costs
ofthan
$10.4
are less
$12.2 million
million
are
Program
-7
Vaccination
program #1
-7
No
program
0
70.0%
Flu
0
outbreak
Flu
-7
No flu
30.0%
outbreak
0
Flu
outbreak
70.0%
0
Flu
-7.28
30.0%
No flu
0
outbreak
Copyright 2008 Health Administration Press. All rights reserved.
0.7
-7
The tree diagram in this
figure was drawn with the
help of PrecisionTree,
a software product of
Palisade Corp., Ithaca,
NY; www.palisade.com.
0.3
-7
Program
A 60.0%
-6
Costs
-12.2
B 40.0%
-4
C 60.0%
-12
Costs
-10.4
D 40.0%
-8
-7
Vaccination
Program #2
-10.4
No
program
0
0
0
0
-13
0
-11
0
-12
0
-8
6-22
Decision Tree
Risk Analysis
#
1
2
3
Initial Vaccination No Initial Vaccination
Program
Program
X
P
X
P
–7
1
–12
0.42
–8
0.28
0
0.30
Copyright 2008 Health Administration Press. All rights reserved.
6-23
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
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6-24
Force Field Analysis
Driving Forces
4
Restraining Forces
Critical incidents
on the increase
Staff knowledgeable in
4
change management
Increase in discharge
3 against medical advice
5
Complaints from patients
and doctors increasing
3
Care given predominantly
biomedical in orientation
Plan:
Change
to
bedside
shift
handover
Total: 19
Copyright 2008 Health Administration Press. All rights reserved.
Ritualism and
tradition
4
Fear that this may lead
to more work
4
Fear of increased 3
accountability
Problems associated
with late arrivals
Possible disclosure of
confidential information
5
5
Total: 21
6-25
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.
Copyright 2008 Health Administration Press. All rights reserved.
6-26