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A Roundtable Discussion
Systems Thinking: Spurring a Transformation In the Delivery of Healthcare Roundtable Participants Mary K. Logan, JD, CAE, is president and CEO of AAMI. E-mail: mlogan@ aami.org
Michael Appel is a practicing anesthesiologist and the chief patient safety officer at Northeast Georgia Health System in Gainesville, GA. E-mail: [email protected] Steven W. Badelt is outreach director for the Biomedical and Healthcare Working Group with the International Council on Systems Engineering; he is based in Los Angeles. E-mail: [email protected] Pat Baird is director of engineering at Baxter Healthcare Corporation in Round Lake, IL. E-mail: pat_baird@ baxter.com
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Mary Logan Our timing for this roundtable
Lane Desborough A system already exists. The
question is to what extent was the system architected, engineered, or integrated? In other President’s Council of Advisors on Science and words, to what degree was systems engineering Technology (PCAST) released a report this past involved in the evolution of the current healthspring on the need for systems engineering in care system? I would assert that it was not healthcare. How far along are we in successfully architected in a way that allowed the correct introducing systems thinking and engineering in properties to emerge; therefore, were are seeing healthcare, on a practical level? negative emergent properties. So it’s not as safe, effective, and reliable as we would like, and it’s Ken Hoyme In the healthcare environment, certainly not cost effective. We are limited in our systems engineering is applied at several ability to proactively introduce systems engidifferent levels. At the lowest level, device neering concepts at the architectural level. manufacturers use the principles of systems These principles have value in engineering to create safe True systems governance, in business planning and devices and determine how thinking is seeing design, at the regulatory level, and in they will verify, document, terms of architecting a particular everything as and submit information to application or system in a medical regulatory bodies. Larger interconnected. device company. companies appear to discussion is serendipitous, given that the
understand systems engineering and are applying those principles in developing individual devices. The next level is the need to engineer networks of interoperable medical devices and health IT systems. On this level, we’re struggling because the responsibilities for device integration are dispersed among many organizations with a wide range of skills. We need to look at how systems engineering can be effectively applied to drive the integration and interoperability of devices within health delivery organizations. A higher level is reflected in the PCAST report: Systems engineering can help us design how the country delivers healthcare and measures health trends across the population. Horizons Fall 2014
Alan Ravitz Systems thinking is about recogniz-
ing that all kinds of interconnections and interdependencies exist among different aspects of healthcare, both in terms of cultural workflow and technology. A lot could be done in terms of rearchitecting how all those factors fit together using the principles of systems thinking. True systems thinking is seeing everything as interconnected. Just because you’re doing great systems engineering at the local level doesn’t mean that you’ll have a great end result from a systems-thinking perspective. Lane Desborough While the bottoms-up, local
approach to systems engineering may not be
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working, a top-down approach is not necessarily a panacea either. Other domains involving multi-decade top-down complex system design, such as defense acquisition programs, have rarely been successful. So I think systems thinking requires a balanced perspective.
evidence resulting from the application of systems engineering will expedite its increased application in practice.
Ken Hoyme I agree that education is needed within health delivery organizations on how they view their overall structure from a systems engineering perspective. It’s a marketplace Alan Ravitz The ideal approach would be if challenge because there are so many different systems concepts started out top down but were health delivery organizations, manufacturers implemented from the bottom up, then came struggle to find a common voice that will drive together in the middle. requirements and elicit change. It will not be Alford Taylor Recently, a columnist in Design useful if a hospital system asks a manufacturer News asked a number of experts, “What’s a to fulfill one set of requirements because a system?” Most of the answers revolved around thousand other hospital systems will ask that the idea that a system is a manufacturer for something collection of stuff that is put slightly different. One reason for the lack together to achieve an Manufacturers and health of success in introducing objective. If you’re a design delivery organizations need to systems thinking is that engineer, and many of us are, find common ground in that’s a reasonable descripwe’re still undervaluing terms of interoperability tion. But in the real world, the role of clinical standards through organizamany systems that protions such as AAMI and IHE engineers in hospitals. foundly affect our lives have (Integrating the Healthcare emerged without the benefit Enterprise). We need to think about how we can of conscious design. To the question that Mary engineer good systems solutions that work well asked: We have a lot of de facto systems in in such a diverse set of HDOs. healthcare. ISO [the International Organization for Standardization] defines a system as a set of Michael Appel From my viewpoint as a hospital interacting or interrelated elements, which I worker, the fact that “human factors engineerbelieve is an elegant formulation in its simplicing” has not been deliberately designed into the ity. De facto systems are no less amenable to healthcare delivery system is a major barrier. improvement than those that were preconceived That manifests most significantly in our bias and created with intent. You don’t need to be an toward blaming the individual for what we engineer to identify one of those systems and detect as undesirable outcomes. study its composition behavior. Lane Desborough I would extend those comA couple weeks ago, I was reading a paper by ments beyond the clinical setting to ambulatory our own Alan Ravitz on enhancing quality of settings and the chronic disease device level, care in the ICU [intensive care unit]. One specifically for diabetes. sentence read as follows: “Our health care system too often harms patients, is too costly, Patricia Trbovich One reason for the lack of and too often relies on the heroism of clinicians success in introducing systems thinking is that rather than good system design.”1 To me, that we’re still undervaluing the role of clinical sentence says it all. engineers in hospitals. We continue to hear clinical engineers described as “the people who Steven Witz Many of the comments thus far take sit in the basement fixing devices,” whereas they on a device, manufacturing, or engineering do a lot more than just fix equipment. For perspective. In healthcare, systems engineering example, they are involved in ensuring regulais increasingly being recognized and of interest. tory compliance, investigating incidents, and However, it’s still early in its implementation. actively participating in the training and Healthcare delivery organizations [HDOs] education of technical and medical personnel. definitely are making positive strides in adoptThey have a major role in the realization of a ing systems engineering and implementing systems-thinking approach. systems thinking. The continued reporting of
Horizons Fall 2014
Roundtable Participants Lane Desborough is chief engineer, insulin delivery/ closed loop at Medtronic Diabetes in Northridge, CA. E-mail: lane. [email protected] William L. Holden is network and interoperability architect for the Connected Care Solution Business Unit at Philips Healthcare in Andover, MA. E-mail: [email protected] Ken Hoyme, MS, is a distinguished scientist at Adventium Labs in Minneapolis, MN. E-mail: ken.hoyme@ adventiumlabs.com Daniel McFarlane, ScD, MS, is a senior research scientist in Patient Care and Monitoring Solutions at Philips Healthcare in Andover, MA. E-mail: dan. [email protected] Anne O‘Neil is director of industry outreach at the International Council on Systems Engineering, which is headquartered in San Diego, CA. E-mail: anneconeil@ gmail.com Alan Ravitz is program manager for biomedical systems at Johns Hopkins University in Laurel, MD. E-mail: alan.ravitz@ jhuapl.edu
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Roundtable Participants Alford Taylor Jr., OSEL, is a laboratory-based electrical engineer at the Center for Devices and Radiological Health of the U.S. Food and Drug Administration in Rockville, MD. E-mail: [email protected] Patricia Trbovich is research lead with the HumanEra Team at the University Health Network of Toronto General Hospital in Toronto, Canada, and an assistant professor at the University of Toronto. E-mail: patricia.trbovich@ uhn.on.ca Steven Witz, PhD, MPH, is director of the Regenstrief Center for Healthcare Engineering at Purdue University in West Lafayette, IN. E-mail: [email protected]
By listening to how people answer the questions you pose, the systems thinkers naturally will emerge.
Mary Logan I would like to provide an example of what happens when clinical engineering is not brought in and things aren’t looked at from a systems perspective. It involves a fairly recent standard on humidity levels in the operating room (OR) that was adopted by ASHRAE. Facilities engineers at hospitals wanted lower humidity levels to be allowed in the OR and ASHRAE took up the cause, dropping the standard for the lowest acceptable humidity level in the OR from 30% to 20%. ASHRAE consulted with healthcare workers in the OR, and people brought up issues about whether the lower humidity level would affect infection control. So that was a good thing; that was partial systems thinking. However, those involved overlooked the fact that in an OR, factors other than people are in play, such as technology and supplies. For instance, the standard didn’t take into consideration the effect of humidity levels on sterile supplies or electro-medical equipment, which are affected by humidity levels. Therefore, the standard is going to have to be revisited. The lesson here is that if healthcare technology management—also known as clinical engineering—had been consulted, at least the technology side would have been taken into consideration. It’s also likely that they would have raised other questions about humidity requirements in the OR because they are used to dealing with specifications for equipment and supplies. This is a practical example of what happens when all aspects of a system are not taken into consideration, and this one has implications for all hospitals nationwide.
Mary Logan That brings us to our next question: How do we go about finding the systems thinkers in our midst? Furthermore, what can be done to identify and nurture great systems engineers? Steven Badelt Speaking of my own hiring
practices, this will be more of a soft-skill assessment. In discussions with people, I look for how broadly they define the problem statements. When asking someone to define a problem statement in their domain of expertise, I attempt to ascertain their consideration of external influences and the inputs and outputs of their system. By listening to how people answer the questions you pose, the systems thinkers naturally will emerge.
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Anne O’Neil Developing a sense of systems
awareness is important in healthcare, as it’s an industry that hasn’t traditionally talked much about or applied systems engineering or necessarily even used that terminology. A lot can be done to share examples that give people a greater awareness that they are part of a bigger whole— one of many contributors in the healthcare system. That can help them realize that the decisions they make in their immediate area have implications more broadly in terms of how it contributes to the effect, behavior, and performance of the overall system. Lane Desborough The people whom I have found
to be the closest to systems thinkers or systems engineers have been the people who are closest to the customers or, ideally, have been customers themselves. So, at least in the medical device company where I work, the employees who actually live with diabetes have the best appreciation of the fact that it’s a system and do not find themselves being narrow in their thinking about a particular product, service, or widget. They are expansive in their thinking because they have to be in order to survive. Alan Ravitz To encourage and nurture systems thinking, it’s important to send new folks out into the field. There’s nothing better for getting them up to speed than for them to watch the people who are struggling to get their jobs done. To identify systems thinkers, I would play off of Mary’s example about humidity in the OR. In that scenario, the people who raise their hands and say, “Wait a minute. Have you thought about X, Y, and Z?” They realized that a change in one area of the system can induce a change elsewhere in the system and therefore just revealed themselves as systems thinkers. So, the best way is to throw people into those types of situations, and the systems thinkers will surface. Of course, you also will need forward-thinking management that gives these workers opportunities to expand their experience and gravitate toward systemsthinking roles. Steven Badelt In addition to letting systems thinkers emerge, I also think it’s possible to develop people’s capacity to be systems thinkers by training them appropriately. In business, employees need to be put in situations where they are exposed to and can consider the viewpoints of the systems and teams to whom they
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interface. Through creating exposure to alternative perspectives, they expand their ability to see the overall system. We’ve got to encourage people to consider what is “outside the box” by framing their perspective of where their own box resides. People don’t always start as systems thinkers, but there are ways to encourage that behavior. Patricia Trbovich Enabling healthcare workers to
have applied work experience at all levels of the system will help nurture systems thinkers. In addition to observing workers on the frontline, they could sit on various committees of management or even higher up in the organization, perhaps even at the regulatory level, in order to get a better understanding of how various people approach a problem. Ken Hoyme Because the training of professionals
in different areas of healthcare varies, it can have an effect on their propensity for systems thinking. For instance, many physicians are taught pattern matching—the diagnostic process of observing patients’ symptoms and matching those symptoms with potential diagnoses. In some ways, the dynamic of this pattern-matching
education can be in opposition to cultivating systems thinking, which tries to look at greater aspects of the whole. I suspect that the best physicians are the ones who think about the patient and their body as a complex set of interacting systems. Training and environment can have a major impact on someone’s ability to engage in a systems-thinking approach. Pat Baird I have noticed that in general, systems
engineers can have difficulty staying inside the lines. For example, you might ask someone to go fix problem B, but when you talk to them a week later, not only have they fixed B, but they also improved A and sorted out C as well. So they don’t always stay on the task that they were given. Last week, I was interviewing applicants for a systems engineering position. I asked them: “If you had a college intern for the summer and you could have that intern research any topic, what topic would you have them research?” Their answer gives me insight into whether they feel confined within their domain and want to learn more about that domain or whether they want to venture out into other domains and expand their horizons in systems engineering.
Horizons Fall 2014
Training and environment can have a major impact on someone’s ability to engage in a systemsthinking approach.
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It’s almost a cultural challenge to start weaning ourselves from a “more is better” philosophy. So how do we start to acknowledge that reliability will improve when complexity decreases?
Finding and nurturing the systems thinkers in our midst will be essential to realizing forward-thinking healthcare solutions.
Mary Logan How can systems thinking and systems engineering transform healthcare into a high-reliability industry? Lane Desborough Generally speaking, complex
systems aren’t reliable, and reliable systems aren’t complex. Therefore, perhaps we need to ask the question: What motivates us to add complexity? Working toward simplicity would add reliability. This is where the notion of Lean Six Sigma and Standardized Work comes into play, or even the development of devices that don’t have a lot of customizable capabilities, so as to drive some level of consistency of operation. It’s almost a cultural challenge to start weaning ourselves from a “more is better” philosophy. So how do we start to acknowledge that reliability will improve when complexity decreases? Alan Ravitz A system could be 100% reliable, but
it may not be safe and it may not be the most effective or efficient way to do things. Thinking holistically and through a systems perspective, reliability is just one component among others. If you bake in safety, reliability, and other “ilities” at the front end of the systems 12
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engineering process, from an ideal perspective, you’re more likely to realize a system that meets the overall objectives. Daniel McFarlane Systems thinking produces
different kinds of performance metrics than the individual components that science and engineering will produce. One way for systems engineering to increase reliability is to articulate the high-level metrics for what the overall system is supposed to be and do. That can be a new thing and a unifying thing to get everybody else behind, and the result can be better realization of those metrics, one of which can be reliability. Michael Appel Whenever I am assessing a
system to see how likely it is to fail, particularly from the point of view of safety, I consider the “system safety attributes.” These are six attributes that are necessary and sufficient to be able to predict reliability and safety: responsibility, authority, procedures, interfaces, quality assurance metrics, and real-time controls of those processes. These attributes are amazingly effective at predicting whether a process is likely to fail. This is the process that the FAA [Federal
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Aviation Administration] uses when it assesses an airline’s current level of safety, based on attributes of the systems that they have in place. So it’s extremely predictive, and it’s amazing how it translates into healthcare. Alford Taylor The culture of the medical device
sector is that manufacturers compete vigorously on product features, user interface design, and so forth. People have said publicly that device manufacturers shouldn’t be competing on safety. However, the reality is that medical device manufacturers and car manufacturers do compete on safety, and some might even argue that that competition yields safer products. We need to learn how to compete and cooperate at the same time, and standards play a big role in that. Another part of the answer involves shifting the design and marketing focus from product features to how the product plays in the system in which it’s used. Elon Musk recently announced that he’s opening Tesla’s patent portfolio to his competitors. Basically, he’s betting that sharing Tesla’s intellectual property will grow the market for electric cars and benefit
everyone. But thinking about that from our perspective, what he’s saying is not only should we not be competing on safety, but we also shouldn’t be competing on effectiveness—and that’s truly radical. I wonder what the impact might be, if that kind of cultural paradigm shift took place in our world. Steven Witz Greater emphasis on clarification of true systems performance goals would help that shift in culture. In healthcare, suboptimal system performance may occur as a result of specialization among healthcare professions. Each specialty group has performance goals for their component of healthcare delivery. Systems performance goals will focus efforts of specialists on their interdependence and promote high-reliable systems performance. As we try to concentrate on these broader, more comprehensive goals, it forces healthcare delivery into a mindset of thinking more broadly. That will lead to a greater recognition of “systemness” and the role of systems in creating high-reliability organizations.
Horizons Fall 2014
Each specialty group has performance goals for their component of healthcare delivery. Systems performance goals will focus efforts of specialists on their interdependence and promote high-reliable systems performance.
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Knights in Shining Armor, Cheese, and Patient Safety A couple other roundtable invitees—Larry Fennigkoh and Rick Schrenker—were unable to make the call, so Horizons caught up with them to capture their thoughts on this important topic.
How is this way of thinking affecting the design and development of medical devices?
Fennigkoh
Schrenker
Fennigkoh is professor of biomedical engineering at the Milwaukee School of Engineering in Milwaukee, WI, and Schrenker is systems engineering manager in the Department of Biomedical Engineering at Massachusetts General Hospital in Boston. How far along are we in successfully introducing systems thinking and engineering in the healthcare setting, on a practical level? Schrenker In my work with systems engineers from other
domains, I get a little concerned that they often say things like, “There is no systems engineering in healthcare.” Then, they go on to suggest that they should ride in like knights in shining armor to rescue healthcare. I’m trying to push back with arguments that can be summarized as, “Seek first to understand, then to be understood.” I don’t believe “we” set ourselves up well to bring systems engineering into healthcare when “we” identify ourselves as healthcare technology management (HTM) professionals, whatever that means. Systems engineering, at least in the professional sense, requires a broader perspective. What does ramping up systems thinking mean for HTM professionals? Fennigkoh Somewhat unfortunately, the HTM community has
lost and is continuing to lose much of its early momentum and founding promise of having in-house systems experts, as more and more clinical engineers leave the hospital environment. The value-added, systems thinking that many degreed clinical engineers initially and naturally brought to healthcare never really seemed to reach a critical mass of acceptance, utilization, or appreciation. Increasingly, it also was difficult to quantify the benefits of these systems-thinking skills. With what seems to be a growing awareness within healthcare on the value of systems science; however, it now may be easier to reintroduce and expand upon the natural use of systems thinking already being done by many HTM professionals.
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Schrenker We are beginning to see systems thinking gain momentum within medical device companies, but progress across companies has been slow. For that to change, it becomes incumbent for customers to insist upon systems approaches. Cross-discipline healthcare teams working on aspects of system-level issues (e.g., human factors from home, to hospital, to home) need to share their findings and embed them in purchasing requirements. However, that is not enough, because it remains in a very real sense reactive. Research and/or development activities geared toward answering the question, “How could we do things differently?,” need to take place. To make that slightly more concrete, for example: If we didn’t have the current regulatory system, how might we design one? To guide our journey, we might ask, “Why do other regulatory domains (e.g., Federal Aviation Administration, Nuclear Regulatory Commission, Department of Transportation) attend to technology developers as well as users, whereas our regulatory bodies do not?” Fennigkoh Systems thinking is and has been an integral,
inextricable part of all engineering design in general and medical devices in particular. Simply, good design cannot be done without a systems, multidisciplinary approach. Even the design of user-unfriendly devices requires a systems approach. Although the growing attention being given to human factors is great, including the human user as part of the system is not new—just a very important part of the design process. How can systems thinking help manage risk? Fennigkoh Here, James Reason’s classic “Swiss Cheese”
model of accident causation (see figure on next page) provides a great systems metaphor for identifying and managing risk. In viewing risk from this perspective, the threats, barriers (slices of cheese), and weakness in these barriers (holes in the cheese) now can be more clearly identified and latent defects revealed. Again, in systems terms, the threats to patient safety are the inputs, patient harm is the output, and each slice of cheese is a process that attempts to block or mitigate the threats. The use of such a model also removes much of the abstraction associated with risk management techniques, making implementation and staff buy-in easier and more likely. n
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A healthcare application of the Swiss Cheese model of error management. Adapted from: Reason J. Human error: models and management. BMJ. 2000;320(7237):768–70.
William Holden I really like the idea of using high
availability or reliability as a way of getting people to think about systems, because those terms embody system measurements more so than simply the individual components. I really like the idea of talking about the measures at the system level in which the components need to play, so that we can strive and create a highly available overall solution. Maybe that will help everybody to understand that not only do they need to be a good player to make the entire system work, but that all parts need to be good players and supportive for the entire system to work. Those measures could be used to get people to start thinking of the broader picture. Mary Logan What would be some examples in healthcare of what those measures might look like?
hospital admission, and up to 60 days postsurgery. Rather than thinking of the outcome of the individual work of the healthcare providers in those three components, we are encouraged to think about the outcome and cost for the patient for the episode. Therefore, the focus would be on the total interaction and effect of the healthcare providers involved. Other examples of healthcare reimbursement incentivizing systems performance are included in the ACA [Affordable Care Act]; capitated provider reimbursement encourages a systems perspective in healthcare delivery. Pat Baird To summarize, systems thinking helps
us measure the right things. We should continue to brainstorm outcome measures, as that is an effective approach toward envisioning systems thinking.
And, if there aren’t any in healthcare, maybe give a
Daniel McFarlane Another cross-over point, in
couple from outside healthcare.
addition to the IT network, that affects the overall outcome for the patient, is frontline clinicians. Perhaps metrics could look at the clinical nurses, for example: Are they overwhelmed with multitasking? Are they in high-stress situations?
William Holden High-availability measurements
can be taken from IT [information technology] systems. Some of our products end up in virtual systems, on networks that are redundant, in an effort to make the overall solution highly available. Steven Witz One example that comes to my mind
is defining cost and quality parameters for bundled payment reimbursement, where the bundled payment covers an episode of care that could involve 30 days before surgery, a surgical
Systems thinking helps us measure the right things.
Lane Desborough A system does what it is “paid” to do. Or, perhaps more nuanced, a system does what it is measured to do. When we talked about reliability or safety, some of those emergent properties are quite difficult to measure. For
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instance, safety is the absence of a bad thing happening and you cannot measure the absence of something. So it’s really just a reinforcement of the need to understand that our systems are doing exactly what they were incented to do. To change it to do something else, we need to make those incentives and measures more visible. Ken Hoyme Another aspect of identifying the
We don’t have a learning culture in the industry to be able to figure out what went wrong and what went right—we don’t have a black box.
right kinds of metrics to measure is understanding where the system is failing. We have a wealth of statistics on the number of adverse events and their various causes. Those are evidence of the unreliability of the healthcare system, when it comes to delivering effective patient care. To investigate the root causes of adverse events, better cooperation across the healthcare system and industry is needed. Once we have data from those investigations, we then can put the processes and systems in place, measure them, and demonstrate that adverse events are decreasing—that they’re effectively being driven out of the system. William Holden While we are creating high-
reliability or high-availability measures, we could simultaneously drive toward consistency. As a medical device provider, if I have a thousand customers, I have a thousand diverse systems that I need to fit into, which makes it very difficult for me to be everything for everyone. For example, if there was a set of 10 patterns that I could fit into, then demonstrate that devices fitting into that pattern perform for whatever measure you apply, then I think you could drive those 10 patterns to be acceptable across the industry. That would streamline all of the components that fit best into those 10 patterns. You then could drive those patterns to be as safe, reliable, and available as possible. Alan Ravitz I definitely agree that capturing metrics related to adverse events is important. However, I don’t want to do that at the expense of keeping track of when things go right, so that elements of the system that led to the right things happening don’t get designed out of the system in the future.
Mary Logan Alan: How do you do that? Alan Ravitz When you’re defining the metrics, don’t be exclusively focused on the occurrence of adverse events. It’s also learning from when 16
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things go right. I think about this from the perspective of aviation. We all know about the black box, the flight data recorder, because we hear about it when something bad happens. However, aircraft manufacturers gather a lot of information about the nature of each flight and the status of the systems on board. Therefore, they know what’s working and what’s not working. Mary Logan What major barriers need to be removed in order for systems engineering to become embedded in the delivery of healthcare? Michael Appel A large, pervasive barrier is that decisions are either not being made or are being made passively. In addition, the entities making those decisions often are not responsible for the consequences of those decisions. That’s a feature of the healthcare industry, as a function of how it’s evolved as a non–deliberately designed system. As an example, historically physicians have been solely responsible for bad outcomes, even if it’s for something beyond their control. First came the medical legal crisis that sprung up in the 1980s, where doctors began to practice defensive medicine because of the fear of being sued. More recently, this has given way to the general idea that it’s the individual’s fault whenever something goes wrong. As a result, we’re not seeing the transparency in information. We don’t have a learning culture in the industry to be able to figure out what went wrong and what went right—we don’t have a black box. Therefore, process-level decisions at the frontline—the sharp end—are driven by the worker’s immediate need for self-preservation. But the key system-level decisions often are being made by people with inadequate knowledge of how the sharp end operates. Lane Desborough Blame is the enemy of systems
engineering. Alford Taylor That thought has come up about
five times during this roundtable. So, the question is: What can you do about it? In the healthcare sector, business and liability concerns often reinforce or motivate the suppression or concealing of information that you need to expose. We talk about how senior management needs to be committed to improvement, but that means that people throughout the organization
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have to be trusted and empowered to speak truth to managers and to each other. This is a difficult people problem, and systems engineering has tools to address it. Daniel McFarlane In the military, where systems
engineering principles have been implemented to a greater degree, a noteworthy aspect is a shared perspective exists regarding what it means to win as a team. This is because there’s a war and everybody knows whether we are winning. In healthcare, however, no unifying definition of success exists. The discussion of success may involve statistics and the percentages of people who have good outcomes. What’s missing is a community of care and whether we win on individual patients and not just on percentages. It feels kind of like when the military talks about a war of attrition and how there’s this percentage of winning. In that kind of situation, the military doesn’t come together either.
efforts of a very large number of companies. This reinforces many of the comments we’re making today. It is a barrier that we’re taking a system that wasn’t designed to work together in an integrated fashion and seeking for it to deliver desired outcomes. Nonetheless, we’re now trying to rally people and rethink this paradigm so that we actually can realign incentives with delivering desired system performance, such as patient outcomes. That refocusing certainly is going to be a challenge for an industry that has not historically thought in that context. We can use systems thinking to redefine overall performance measures and begin transforming the industry. n
Reference 1. Tropello SP, Ravitz AD, Roming M, et al. Enhancing the Quality of Care in the Intensive Care Unit: A Systems Engineering Approach. Crit Care Clin. 2013;29(1):113–24.
Anne O’Neil The PCAST report reminds us that
the existing healthcare system was not designed but emerged out of separate uncoordinated
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A Roundtable Discussion
Systems Thinking: Spurring a Transformation In the Delivery of Healthcare Roundtable Participants Mary K. Logan, JD, CAE, is president and CEO of AAMI. E-mail: mlogan@ aami.org
Michael Appel is a practicing anesthesiologist and the chief patient safety officer at Northeast Georgia Health System in Gainesville, GA. E-mail: [email protected] Steven W. Badelt is outreach director for the Biomedical and Healthcare Working Group with the International Council on Systems Engineering; he is based in Los Angeles. E-mail: [email protected] Pat Baird is director of engineering at Baxter Healthcare Corporation in Round Lake, IL. E-mail: pat_baird@ baxter.com
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Mary Logan Our timing for this roundtable
Lane Desborough A system already exists. The
question is to what extent was the system architected, engineered, or integrated? In other President’s Council of Advisors on Science and words, to what degree was systems engineering Technology (PCAST) released a report this past involved in the evolution of the current healthspring on the need for systems engineering in care system? I would assert that it was not healthcare. How far along are we in successfully architected in a way that allowed the correct introducing systems thinking and engineering in properties to emerge; therefore, were are seeing healthcare, on a practical level? negative emergent properties. So it’s not as safe, effective, and reliable as we would like, and it’s Ken Hoyme In the healthcare environment, certainly not cost effective. We are limited in our systems engineering is applied at several ability to proactively introduce systems engidifferent levels. At the lowest level, device neering concepts at the architectural level. manufacturers use the principles of systems These principles have value in engineering to create safe True systems governance, in business planning and devices and determine how thinking is seeing design, at the regulatory level, and in they will verify, document, terms of architecting a particular everything as and submit information to application or system in a medical regulatory bodies. Larger interconnected. device company. companies appear to discussion is serendipitous, given that the
understand systems engineering and are applying those principles in developing individual devices. The next level is the need to engineer networks of interoperable medical devices and health IT systems. On this level, we’re struggling because the responsibilities for device integration are dispersed among many organizations with a wide range of skills. We need to look at how systems engineering can be effectively applied to drive the integration and interoperability of devices within health delivery organizations. A higher level is reflected in the PCAST report: Systems engineering can help us design how the country delivers healthcare and measures health trends across the population. Horizons Fall 2014
Alan Ravitz Systems thinking is about recogniz-
ing that all kinds of interconnections and interdependencies exist among different aspects of healthcare, both in terms of cultural workflow and technology. A lot could be done in terms of rearchitecting how all those factors fit together using the principles of systems thinking. True systems thinking is seeing everything as interconnected. Just because you’re doing great systems engineering at the local level doesn’t mean that you’ll have a great end result from a systems-thinking perspective. Lane Desborough While the bottoms-up, local
approach to systems engineering may not be
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working, a top-down approach is not necessarily a panacea either. Other domains involving multi-decade top-down complex system design, such as defense acquisition programs, have rarely been successful. So I think systems thinking requires a balanced perspective.
evidence resulting from the application of systems engineering will expedite its increased application in practice.
Ken Hoyme I agree that education is needed within health delivery organizations on how they view their overall structure from a systems engineering perspective. It’s a marketplace Alan Ravitz The ideal approach would be if challenge because there are so many different systems concepts started out top down but were health delivery organizations, manufacturers implemented from the bottom up, then came struggle to find a common voice that will drive together in the middle. requirements and elicit change. It will not be Alford Taylor Recently, a columnist in Design useful if a hospital system asks a manufacturer News asked a number of experts, “What’s a to fulfill one set of requirements because a system?” Most of the answers revolved around thousand other hospital systems will ask that the idea that a system is a manufacturer for something collection of stuff that is put slightly different. One reason for the lack together to achieve an Manufacturers and health of success in introducing objective. If you’re a design delivery organizations need to systems thinking is that engineer, and many of us are, find common ground in that’s a reasonable descripwe’re still undervaluing terms of interoperability tion. But in the real world, the role of clinical standards through organizamany systems that protions such as AAMI and IHE engineers in hospitals. foundly affect our lives have (Integrating the Healthcare emerged without the benefit Enterprise). We need to think about how we can of conscious design. To the question that Mary engineer good systems solutions that work well asked: We have a lot of de facto systems in in such a diverse set of HDOs. healthcare. ISO [the International Organization for Standardization] defines a system as a set of Michael Appel From my viewpoint as a hospital interacting or interrelated elements, which I worker, the fact that “human factors engineerbelieve is an elegant formulation in its simplicing” has not been deliberately designed into the ity. De facto systems are no less amenable to healthcare delivery system is a major barrier. improvement than those that were preconceived That manifests most significantly in our bias and created with intent. You don’t need to be an toward blaming the individual for what we engineer to identify one of those systems and detect as undesirable outcomes. study its composition behavior. Lane Desborough I would extend those comA couple weeks ago, I was reading a paper by ments beyond the clinical setting to ambulatory our own Alan Ravitz on enhancing quality of settings and the chronic disease device level, care in the ICU [intensive care unit]. One specifically for diabetes. sentence read as follows: “Our health care system too often harms patients, is too costly, Patricia Trbovich One reason for the lack of and too often relies on the heroism of clinicians success in introducing systems thinking is that rather than good system design.”1 To me, that we’re still undervaluing the role of clinical sentence says it all. engineers in hospitals. We continue to hear clinical engineers described as “the people who Steven Witz Many of the comments thus far take sit in the basement fixing devices,” whereas they on a device, manufacturing, or engineering do a lot more than just fix equipment. For perspective. In healthcare, systems engineering example, they are involved in ensuring regulais increasingly being recognized and of interest. tory compliance, investigating incidents, and However, it’s still early in its implementation. actively participating in the training and Healthcare delivery organizations [HDOs] education of technical and medical personnel. definitely are making positive strides in adoptThey have a major role in the realization of a ing systems engineering and implementing systems-thinking approach. systems thinking. The continued reporting of
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Roundtable Participants Lane Desborough is chief engineer, insulin delivery/ closed loop at Medtronic Diabetes in Northridge, CA. E-mail: lane. [email protected] William L. Holden is network and interoperability architect for the Connected Care Solution Business Unit at Philips Healthcare in Andover, MA. E-mail: [email protected] Ken Hoyme, MS, is a distinguished scientist at Adventium Labs in Minneapolis, MN. E-mail: ken.hoyme@ adventiumlabs.com Daniel McFarlane, ScD, MS, is a senior research scientist in Patient Care and Monitoring Solutions at Philips Healthcare in Andover, MA. E-mail: dan. [email protected] Anne O‘Neil is director of industry outreach at the International Council on Systems Engineering, which is headquartered in San Diego, CA. E-mail: anneconeil@ gmail.com Alan Ravitz is program manager for biomedical systems at Johns Hopkins University in Laurel, MD. E-mail: alan.ravitz@ jhuapl.edu
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Roundtable Participants Alford Taylor Jr., OSEL, is a laboratory-based electrical engineer at the Center for Devices and Radiological Health of the U.S. Food and Drug Administration in Rockville, MD. E-mail: [email protected] Patricia Trbovich is research lead with the HumanEra Team at the University Health Network of Toronto General Hospital in Toronto, Canada, and an assistant professor at the University of Toronto. E-mail: patricia.trbovich@ uhn.on.ca Steven Witz, PhD, MPH, is director of the Regenstrief Center for Healthcare Engineering at Purdue University in West Lafayette, IN. E-mail: [email protected]
By listening to how people answer the questions you pose, the systems thinkers naturally will emerge.
Mary Logan I would like to provide an example of what happens when clinical engineering is not brought in and things aren’t looked at from a systems perspective. It involves a fairly recent standard on humidity levels in the operating room (OR) that was adopted by ASHRAE. Facilities engineers at hospitals wanted lower humidity levels to be allowed in the OR and ASHRAE took up the cause, dropping the standard for the lowest acceptable humidity level in the OR from 30% to 20%. ASHRAE consulted with healthcare workers in the OR, and people brought up issues about whether the lower humidity level would affect infection control. So that was a good thing; that was partial systems thinking. However, those involved overlooked the fact that in an OR, factors other than people are in play, such as technology and supplies. For instance, the standard didn’t take into consideration the effect of humidity levels on sterile supplies or electro-medical equipment, which are affected by humidity levels. Therefore, the standard is going to have to be revisited. The lesson here is that if healthcare technology management—also known as clinical engineering—had been consulted, at least the technology side would have been taken into consideration. It’s also likely that they would have raised other questions about humidity requirements in the OR because they are used to dealing with specifications for equipment and supplies. This is a practical example of what happens when all aspects of a system are not taken into consideration, and this one has implications for all hospitals nationwide.
Mary Logan That brings us to our next question: How do we go about finding the systems thinkers in our midst? Furthermore, what can be done to identify and nurture great systems engineers? Steven Badelt Speaking of my own hiring
practices, this will be more of a soft-skill assessment. In discussions with people, I look for how broadly they define the problem statements. When asking someone to define a problem statement in their domain of expertise, I attempt to ascertain their consideration of external influences and the inputs and outputs of their system. By listening to how people answer the questions you pose, the systems thinkers naturally will emerge.
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Anne O’Neil Developing a sense of systems
awareness is important in healthcare, as it’s an industry that hasn’t traditionally talked much about or applied systems engineering or necessarily even used that terminology. A lot can be done to share examples that give people a greater awareness that they are part of a bigger whole— one of many contributors in the healthcare system. That can help them realize that the decisions they make in their immediate area have implications more broadly in terms of how it contributes to the effect, behavior, and performance of the overall system. Lane Desborough The people whom I have found
to be the closest to systems thinkers or systems engineers have been the people who are closest to the customers or, ideally, have been customers themselves. So, at least in the medical device company where I work, the employees who actually live with diabetes have the best appreciation of the fact that it’s a system and do not find themselves being narrow in their thinking about a particular product, service, or widget. They are expansive in their thinking because they have to be in order to survive. Alan Ravitz To encourage and nurture systems thinking, it’s important to send new folks out into the field. There’s nothing better for getting them up to speed than for them to watch the people who are struggling to get their jobs done. To identify systems thinkers, I would play off of Mary’s example about humidity in the OR. In that scenario, the people who raise their hands and say, “Wait a minute. Have you thought about X, Y, and Z?” They realized that a change in one area of the system can induce a change elsewhere in the system and therefore just revealed themselves as systems thinkers. So, the best way is to throw people into those types of situations, and the systems thinkers will surface. Of course, you also will need forward-thinking management that gives these workers opportunities to expand their experience and gravitate toward systemsthinking roles. Steven Badelt In addition to letting systems thinkers emerge, I also think it’s possible to develop people’s capacity to be systems thinkers by training them appropriately. In business, employees need to be put in situations where they are exposed to and can consider the viewpoints of the systems and teams to whom they
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interface. Through creating exposure to alternative perspectives, they expand their ability to see the overall system. We’ve got to encourage people to consider what is “outside the box” by framing their perspective of where their own box resides. People don’t always start as systems thinkers, but there are ways to encourage that behavior. Patricia Trbovich Enabling healthcare workers to
have applied work experience at all levels of the system will help nurture systems thinkers. In addition to observing workers on the frontline, they could sit on various committees of management or even higher up in the organization, perhaps even at the regulatory level, in order to get a better understanding of how various people approach a problem. Ken Hoyme Because the training of professionals
in different areas of healthcare varies, it can have an effect on their propensity for systems thinking. For instance, many physicians are taught pattern matching—the diagnostic process of observing patients’ symptoms and matching those symptoms with potential diagnoses. In some ways, the dynamic of this pattern-matching
education can be in opposition to cultivating systems thinking, which tries to look at greater aspects of the whole. I suspect that the best physicians are the ones who think about the patient and their body as a complex set of interacting systems. Training and environment can have a major impact on someone’s ability to engage in a systems-thinking approach. Pat Baird I have noticed that in general, systems
engineers can have difficulty staying inside the lines. For example, you might ask someone to go fix problem B, but when you talk to them a week later, not only have they fixed B, but they also improved A and sorted out C as well. So they don’t always stay on the task that they were given. Last week, I was interviewing applicants for a systems engineering position. I asked them: “If you had a college intern for the summer and you could have that intern research any topic, what topic would you have them research?” Their answer gives me insight into whether they feel confined within their domain and want to learn more about that domain or whether they want to venture out into other domains and expand their horizons in systems engineering.
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Training and environment can have a major impact on someone’s ability to engage in a systemsthinking approach.
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It’s almost a cultural challenge to start weaning ourselves from a “more is better” philosophy. So how do we start to acknowledge that reliability will improve when complexity decreases?
Finding and nurturing the systems thinkers in our midst will be essential to realizing forward-thinking healthcare solutions.
Mary Logan How can systems thinking and systems engineering transform healthcare into a high-reliability industry? Lane Desborough Generally speaking, complex
systems aren’t reliable, and reliable systems aren’t complex. Therefore, perhaps we need to ask the question: What motivates us to add complexity? Working toward simplicity would add reliability. This is where the notion of Lean Six Sigma and Standardized Work comes into play, or even the development of devices that don’t have a lot of customizable capabilities, so as to drive some level of consistency of operation. It’s almost a cultural challenge to start weaning ourselves from a “more is better” philosophy. So how do we start to acknowledge that reliability will improve when complexity decreases? Alan Ravitz A system could be 100% reliable, but
it may not be safe and it may not be the most effective or efficient way to do things. Thinking holistically and through a systems perspective, reliability is just one component among others. If you bake in safety, reliability, and other “ilities” at the front end of the systems 12
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engineering process, from an ideal perspective, you’re more likely to realize a system that meets the overall objectives. Daniel McFarlane Systems thinking produces
different kinds of performance metrics than the individual components that science and engineering will produce. One way for systems engineering to increase reliability is to articulate the high-level metrics for what the overall system is supposed to be and do. That can be a new thing and a unifying thing to get everybody else behind, and the result can be better realization of those metrics, one of which can be reliability. Michael Appel Whenever I am assessing a
system to see how likely it is to fail, particularly from the point of view of safety, I consider the “system safety attributes.” These are six attributes that are necessary and sufficient to be able to predict reliability and safety: responsibility, authority, procedures, interfaces, quality assurance metrics, and real-time controls of those processes. These attributes are amazingly effective at predicting whether a process is likely to fail. This is the process that the FAA [Federal
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Aviation Administration] uses when it assesses an airline’s current level of safety, based on attributes of the systems that they have in place. So it’s extremely predictive, and it’s amazing how it translates into healthcare. Alford Taylor The culture of the medical device
sector is that manufacturers compete vigorously on product features, user interface design, and so forth. People have said publicly that device manufacturers shouldn’t be competing on safety. However, the reality is that medical device manufacturers and car manufacturers do compete on safety, and some might even argue that that competition yields safer products. We need to learn how to compete and cooperate at the same time, and standards play a big role in that. Another part of the answer involves shifting the design and marketing focus from product features to how the product plays in the system in which it’s used. Elon Musk recently announced that he’s opening Tesla’s patent portfolio to his competitors. Basically, he’s betting that sharing Tesla’s intellectual property will grow the market for electric cars and benefit
everyone. But thinking about that from our perspective, what he’s saying is not only should we not be competing on safety, but we also shouldn’t be competing on effectiveness—and that’s truly radical. I wonder what the impact might be, if that kind of cultural paradigm shift took place in our world. Steven Witz Greater emphasis on clarification of true systems performance goals would help that shift in culture. In healthcare, suboptimal system performance may occur as a result of specialization among healthcare professions. Each specialty group has performance goals for their component of healthcare delivery. Systems performance goals will focus efforts of specialists on their interdependence and promote high-reliable systems performance. As we try to concentrate on these broader, more comprehensive goals, it forces healthcare delivery into a mindset of thinking more broadly. That will lead to a greater recognition of “systemness” and the role of systems in creating high-reliability organizations.
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Each specialty group has performance goals for their component of healthcare delivery. Systems performance goals will focus efforts of specialists on their interdependence and promote high-reliable systems performance.
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Knights in Shining Armor, Cheese, and Patient Safety A couple other roundtable invitees—Larry Fennigkoh and Rick Schrenker—were unable to make the call, so Horizons caught up with them to capture their thoughts on this important topic.
How is this way of thinking affecting the design and development of medical devices?
Fennigkoh
Schrenker
Fennigkoh is professor of biomedical engineering at the Milwaukee School of Engineering in Milwaukee, WI, and Schrenker is systems engineering manager in the Department of Biomedical Engineering at Massachusetts General Hospital in Boston. How far along are we in successfully introducing systems thinking and engineering in the healthcare setting, on a practical level? Schrenker In my work with systems engineers from other
domains, I get a little concerned that they often say things like, “There is no systems engineering in healthcare.” Then, they go on to suggest that they should ride in like knights in shining armor to rescue healthcare. I’m trying to push back with arguments that can be summarized as, “Seek first to understand, then to be understood.” I don’t believe “we” set ourselves up well to bring systems engineering into healthcare when “we” identify ourselves as healthcare technology management (HTM) professionals, whatever that means. Systems engineering, at least in the professional sense, requires a broader perspective. What does ramping up systems thinking mean for HTM professionals? Fennigkoh Somewhat unfortunately, the HTM community has
lost and is continuing to lose much of its early momentum and founding promise of having in-house systems experts, as more and more clinical engineers leave the hospital environment. The value-added, systems thinking that many degreed clinical engineers initially and naturally brought to healthcare never really seemed to reach a critical mass of acceptance, utilization, or appreciation. Increasingly, it also was difficult to quantify the benefits of these systems-thinking skills. With what seems to be a growing awareness within healthcare on the value of systems science; however, it now may be easier to reintroduce and expand upon the natural use of systems thinking already being done by many HTM professionals.
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Schrenker We are beginning to see systems thinking gain momentum within medical device companies, but progress across companies has been slow. For that to change, it becomes incumbent for customers to insist upon systems approaches. Cross-discipline healthcare teams working on aspects of system-level issues (e.g., human factors from home, to hospital, to home) need to share their findings and embed them in purchasing requirements. However, that is not enough, because it remains in a very real sense reactive. Research and/or development activities geared toward answering the question, “How could we do things differently?,” need to take place. To make that slightly more concrete, for example: If we didn’t have the current regulatory system, how might we design one? To guide our journey, we might ask, “Why do other regulatory domains (e.g., Federal Aviation Administration, Nuclear Regulatory Commission, Department of Transportation) attend to technology developers as well as users, whereas our regulatory bodies do not?” Fennigkoh Systems thinking is and has been an integral,
inextricable part of all engineering design in general and medical devices in particular. Simply, good design cannot be done without a systems, multidisciplinary approach. Even the design of user-unfriendly devices requires a systems approach. Although the growing attention being given to human factors is great, including the human user as part of the system is not new—just a very important part of the design process. How can systems thinking help manage risk? Fennigkoh Here, James Reason’s classic “Swiss Cheese”
model of accident causation (see figure on next page) provides a great systems metaphor for identifying and managing risk. In viewing risk from this perspective, the threats, barriers (slices of cheese), and weakness in these barriers (holes in the cheese) now can be more clearly identified and latent defects revealed. Again, in systems terms, the threats to patient safety are the inputs, patient harm is the output, and each slice of cheese is a process that attempts to block or mitigate the threats. The use of such a model also removes much of the abstraction associated with risk management techniques, making implementation and staff buy-in easier and more likely. n
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A healthcare application of the Swiss Cheese model of error management. Adapted from: Reason J. Human error: models and management. BMJ. 2000;320(7237):768–70.
William Holden I really like the idea of using high
availability or reliability as a way of getting people to think about systems, because those terms embody system measurements more so than simply the individual components. I really like the idea of talking about the measures at the system level in which the components need to play, so that we can strive and create a highly available overall solution. Maybe that will help everybody to understand that not only do they need to be a good player to make the entire system work, but that all parts need to be good players and supportive for the entire system to work. Those measures could be used to get people to start thinking of the broader picture. Mary Logan What would be some examples in healthcare of what those measures might look like?
hospital admission, and up to 60 days postsurgery. Rather than thinking of the outcome of the individual work of the healthcare providers in those three components, we are encouraged to think about the outcome and cost for the patient for the episode. Therefore, the focus would be on the total interaction and effect of the healthcare providers involved. Other examples of healthcare reimbursement incentivizing systems performance are included in the ACA [Affordable Care Act]; capitated provider reimbursement encourages a systems perspective in healthcare delivery. Pat Baird To summarize, systems thinking helps
us measure the right things. We should continue to brainstorm outcome measures, as that is an effective approach toward envisioning systems thinking.
And, if there aren’t any in healthcare, maybe give a
Daniel McFarlane Another cross-over point, in
couple from outside healthcare.
addition to the IT network, that affects the overall outcome for the patient, is frontline clinicians. Perhaps metrics could look at the clinical nurses, for example: Are they overwhelmed with multitasking? Are they in high-stress situations?
William Holden High-availability measurements
can be taken from IT [information technology] systems. Some of our products end up in virtual systems, on networks that are redundant, in an effort to make the overall solution highly available. Steven Witz One example that comes to my mind
is defining cost and quality parameters for bundled payment reimbursement, where the bundled payment covers an episode of care that could involve 30 days before surgery, a surgical
Systems thinking helps us measure the right things.
Lane Desborough A system does what it is “paid” to do. Or, perhaps more nuanced, a system does what it is measured to do. When we talked about reliability or safety, some of those emergent properties are quite difficult to measure. For
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instance, safety is the absence of a bad thing happening and you cannot measure the absence of something. So it’s really just a reinforcement of the need to understand that our systems are doing exactly what they were incented to do. To change it to do something else, we need to make those incentives and measures more visible. Ken Hoyme Another aspect of identifying the
We don’t have a learning culture in the industry to be able to figure out what went wrong and what went right—we don’t have a black box.
right kinds of metrics to measure is understanding where the system is failing. We have a wealth of statistics on the number of adverse events and their various causes. Those are evidence of the unreliability of the healthcare system, when it comes to delivering effective patient care. To investigate the root causes of adverse events, better cooperation across the healthcare system and industry is needed. Once we have data from those investigations, we then can put the processes and systems in place, measure them, and demonstrate that adverse events are decreasing—that they’re effectively being driven out of the system. William Holden While we are creating high-
reliability or high-availability measures, we could simultaneously drive toward consistency. As a medical device provider, if I have a thousand customers, I have a thousand diverse systems that I need to fit into, which makes it very difficult for me to be everything for everyone. For example, if there was a set of 10 patterns that I could fit into, then demonstrate that devices fitting into that pattern perform for whatever measure you apply, then I think you could drive those 10 patterns to be acceptable across the industry. That would streamline all of the components that fit best into those 10 patterns. You then could drive those patterns to be as safe, reliable, and available as possible. Alan Ravitz I definitely agree that capturing metrics related to adverse events is important. However, I don’t want to do that at the expense of keeping track of when things go right, so that elements of the system that led to the right things happening don’t get designed out of the system in the future.
Mary Logan Alan: How do you do that? Alan Ravitz When you’re defining the metrics, don’t be exclusively focused on the occurrence of adverse events. It’s also learning from when 16
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things go right. I think about this from the perspective of aviation. We all know about the black box, the flight data recorder, because we hear about it when something bad happens. However, aircraft manufacturers gather a lot of information about the nature of each flight and the status of the systems on board. Therefore, they know what’s working and what’s not working. Mary Logan What major barriers need to be removed in order for systems engineering to become embedded in the delivery of healthcare? Michael Appel A large, pervasive barrier is that decisions are either not being made or are being made passively. In addition, the entities making those decisions often are not responsible for the consequences of those decisions. That’s a feature of the healthcare industry, as a function of how it’s evolved as a non–deliberately designed system. As an example, historically physicians have been solely responsible for bad outcomes, even if it’s for something beyond their control. First came the medical legal crisis that sprung up in the 1980s, where doctors began to practice defensive medicine because of the fear of being sued. More recently, this has given way to the general idea that it’s the individual’s fault whenever something goes wrong. As a result, we’re not seeing the transparency in information. We don’t have a learning culture in the industry to be able to figure out what went wrong and what went right—we don’t have a black box. Therefore, process-level decisions at the frontline—the sharp end—are driven by the worker’s immediate need for self-preservation. But the key system-level decisions often are being made by people with inadequate knowledge of how the sharp end operates. Lane Desborough Blame is the enemy of systems
engineering. Alford Taylor That thought has come up about
five times during this roundtable. So, the question is: What can you do about it? In the healthcare sector, business and liability concerns often reinforce or motivate the suppression or concealing of information that you need to expose. We talk about how senior management needs to be committed to improvement, but that means that people throughout the organization
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have to be trusted and empowered to speak truth to managers and to each other. This is a difficult people problem, and systems engineering has tools to address it. Daniel McFarlane In the military, where systems
engineering principles have been implemented to a greater degree, a noteworthy aspect is a shared perspective exists regarding what it means to win as a team. This is because there’s a war and everybody knows whether we are winning. In healthcare, however, no unifying definition of success exists. The discussion of success may involve statistics and the percentages of people who have good outcomes. What’s missing is a community of care and whether we win on individual patients and not just on percentages. It feels kind of like when the military talks about a war of attrition and how there’s this percentage of winning. In that kind of situation, the military doesn’t come together either.
efforts of a very large number of companies. This reinforces many of the comments we’re making today. It is a barrier that we’re taking a system that wasn’t designed to work together in an integrated fashion and seeking for it to deliver desired outcomes. Nonetheless, we’re now trying to rally people and rethink this paradigm so that we actually can realign incentives with delivering desired system performance, such as patient outcomes. That refocusing certainly is going to be a challenge for an industry that has not historically thought in that context. We can use systems thinking to redefine overall performance measures and begin transforming the industry. n
Reference 1. Tropello SP, Ravitz AD, Roming M, et al. Enhancing the Quality of Care in the Intensive Care Unit: A Systems Engineering Approach. Crit Care Clin. 2013;29(1):113–24.
Anne O’Neil The PCAST report reminds us that
the existing healthcare system was not designed but emerged out of separate uncoordinated
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