Ch. 6 Slides_edited

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Chapter 6. Tools for Problem Solving and

Decision Making

An Integrated Approach to

Improving Quality and Efficiency

Daniel B. McLaughlinJulie M. Hays

Healthcare OperationsManagement



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




Decision-Making Framework

� Framing

- Identifying and framing the issue or problem

� Gathering intelligence

- Generating or determining possible courses of actionand 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




Barriers to Good DecisionMaking

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




A Test of Your Problem-SolvingAbilities

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 somekindling wood, which would you light first?

3 How many animals of each

species did Moses take along

on 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?




Mind Mapping

Diagramcreated in

Inspiration®by

InspirationSoftware®,

Inc.




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




Process Mapping Steps

1. Assemble and train the team.

2. Determine process boundaries anddesired 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.




Flowchart Standard Symbols

Microsoft Visio® screen shots

reprinted with permission fromMicrosoft Corporation.




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




Service Blueprinting

Microsoft Visio® screen shots reprinted withpermission from Microsoft Corporation.

Customer

givesprescription

to clerk

Clerk entersdata

Clerk gives

prescriptionto

pharmacist

Pharmacistfills

prescription

Clerk givesmedicine tocustomer

Clerkretrievesmedicine

Pharmacist

gives

medicine toclerk

Customer receivesmedicineLine of interaction

Line of visibility

Customer Actions

OnstageActions

BackstageActions




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?




Five Whys Technique

� Ask why the condition occurred.

� Ask why for each answer (five times is a

good rule of thumb).




Cause and Effect Diagram

Waiting

Time

Waiting

Time

Methods

Machines Man

Mother Nature(Environment)




Cause and Effect Diagram

Old inner-citybuilding

Lack of

treatment

rooms

Elevators

broken

Wheelchairs

unavailable

Transport arrives late

Process takes

too long

Excessive paperwork

Unexpected

patients

Wrong

patients

Staff not available

Corridor

blocked

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




Failure Mode and EffectsAnalysis (FMEA)

1

2

3

45

6

7

8

Total RPN (sum of all RPNs):




Failure Mode and EffectsAnalysis (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




Theory of Constraints

� T he 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.




Theory of ConstraintsFive Steps

1. Identify the constraint (or bottleneck).

2. Exploit the constraint.

3. Subordinate everything else to theconstraint.

4. Elevate the constraint.

5. Repeat the process for the new constraint.




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




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 decisionvariables can take on




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




Force Field Analysis

� A technique for evaluating all the forces for

(driving) and against (restraining) a

proposed change

� Used to decide whether a proposed changecan be implemented successfully

� Used to develop strategies that will enable

successful implementation of a change




Force Field Analysis

Plan:

Changeto

bedsideshift

handover

Critical incidentson the increase

Staff knowledgeable in

change management

Increase in dischargeagainst medical advice

Complaints from patientsand doctors increasing

Care given predominantlybiomedical in orientation

Ritualism andtradition

Fear that this may lead

to more work

Fear of increasedaccountability

Problems associatedwith 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




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 toolare dependent on the problem to be solved.

In many situations, several tools from this

and other chapters should be used toensure that the best possible solution has

been found.

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