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7/31/2019 Deborah Nightingale
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A Lean Enterprise Systems Approach toHealthcare Transformation
Professor Deborah NightingaleMIT Conference on Systems Thinking for Contemporary Challenges
Massachusetts Institute of TechnologyOctober 23, 2009
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7/31/2019 Deborah Nightingale
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MIT Conference on Systems Thinking for Contemporary Challenges 2009 Massachusetts Institute of Technology D. Nightingale 10/23/09- 2 http://lean.mit.edu
Agenda
Research Motivation Cross-Industry Knowledge on Enterprises
Case Examples Ongoing Research
LAI Enterprise Healthcare Vision
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Quality
98,000 deaths attributed to medical errors Adults on average only receive 55% of recommended careEmergency Departments are overcrowded nationwideProvider fragmentation unable of creating sufficient volume
Cost
Over 16% of US GDP spent in healthcare expenses
Hospital care represents 30.8% of total expenditure49% of expenditure concentrated in only 5% of populationIndividuals over 65 years old expected to increaseover 50% by 2020
Access
45 million Americans are uninsuredFragmented provider network, 75% being small or single practicesRecent survey indicated 40% of Americans received uncoordinated careFragmented payment systems, health plans, information systems, etc
Research Motivation
Life Expectancy at Birthand GDP Per Capita
2005 OECD Data
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MIT Conference on Systems Thinking for Contemporary Challenges 2009 Massachusetts Institute of Technology D. Nightingale 10/23/09- 4 http://lean.mit.edu
Agenda
Research Motivation Cross-Industry Knowledge on Enterprises
Case Examples Ongoing Research
LAI Enterprise Healthcare Vision
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MIT Conference on Systems Thinking for Contemporary Challenges 2009 Massachusetts Institute of Technology D. Nightingale 10/23/09- 5 http://lean.mit.edu
The Challenges of Complex Enterprises
Requires a Systems Approach
New strategic systems perspective
Viewing enterprises as holistic and highly networkedsystems
Integrating leadership processes, lifecycle processes and
enabling infrastructure systems Balancing needs of multiple stakeholders working across
boundaries
MOVING FROM THE PAST(hierarchical) enterprise
TOWARDS THE FUTURE(networked) enterprise
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LAI - A Consortium Dedicated ToCross Industry Enterprise Performance
Enable Enterprises to effectively, efficiently and reliablycreate value in a complex and dynamic environment
Enable focused and accelerated transformation of complex enterprises
Collaborative engagement of all stakeholders inGovernment, Industry and Academia
Understand, develop, and institutionalize principles,processes, behaviors and tools
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MIT Studies on Industrial Productivity
1989
Identified sources of major weaknesses in
US productivity,including commercialaircraft & education.
1990
Identified Lean,based upon ToyotaProduction Systemas a successor tomass production.
2002
Translated Leanprinciples to
aerospace andenterprise context.
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MIT Conference on Systems Thinking for Contemporary Challenges 2009 Massachusetts Institute of Technology D. Nightingale 10/23/09- 8 http://lean.mit.edu
Cross Industry
Enterprise Challenges
Overarching commitment to ensureglobal peace and security
Incumbent higher, faster, farther mindset
Declining defense dollars after ColdWar (fewer military aircraft programs;industry consolidation)
Inherently complex industry: Multiple stakeholders with misaligned
objectives and numerous constraints Capital Intensive Complex product development
Uncertain outcome in contract awarding
Aerospace Healthcare
Overarching commitment to provideworld class medical care
Incumbent overuse, underuse, andmisuse mindset
Overburdened healthcare expenditureas a % of GDP (proliferation of fragmented disjointed providers)
Inherently complex industry Multiple stakeholders with misaligned
objectives and numerous constraints Capital Intensive Complex service provision
Uncertain outcome in value sharing
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MIT Conference on Systems Thinking for Contemporary Challenges 2009 Massachusetts Institute of Technology D. Nightingale 10/23/09- 9 http://lean.mit.edu
Source: D. Nightingale and J.K Srinivasan, MIT 2008
7.Emphasize
organizationallearning.
6.Cultivate
leadership tosupport and drive
enterprisebehaviors.
5.Ensure stability
and flow withinand across the
enterprise.
4. Address internal
and externalenterpriseinterdependencies.
3.Focus onenterprise
effectivenessbefore efficiency.
2.Identify relevantstakeholders anddetermine their
value propositions.
1. Adopt a holisticapproach toenterprise
transformation.
Leveraging LAIs
Cross Industry Experience7 Principles of Lean Enterprise Thinking
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UnderstandCurrent
State
PLANNING CYCLE
DetermineStrategic
Imperative
Capabilities & Deficiencies Identified
Lean Enterprise Vision
Long-TermCorrectiveAction
Short-TermCorrective
Action
Strategic Implications of Transformation
Envision & DesignFuture
Enterprise
Nurture,Process & EmbedLean Enterprise
Thinking
A Committed Leadership Team
Implementation Results
Implement &Coordinate
TransformationPlan
AlignEnterprise
Infrastructure
Source: Nightingale, Srinivasan and Mize
Pursue &Sustain
EnterpriseTransformation
EngageLeadership
in Transformation
STRATEGICCYCLE
AlignmentRequirements
Identified
EXECUTION CYCLE
CreateTransformation
Plan 2009 Massachusetts Institute of Technology D. Nightingale - MM/DD/YY- 10
Lean Enterprise Transformation Roadmap
http://lean.mit.edu
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MIT Conference on Systems Thinking for Contemporary Challenges 2009 Massachusetts Institute of Technology D. Nightingale 10/23/09- 11http://lean.mit.edu
Agenda
Research Motivation Cross-Industry Knowledge on Enterprises
Case Examples Ongoing Research
LAI Enterprise Healthcare Vision
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7/31/2019 Deborah Nightingale
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MIT Conference on Systems Thinking for Contemporary Challenges 2009 Massachusetts Institute of Technology D. Nightingale 10/23/09- 12 http://lean.mit.edu
Healthcare Case Examples
Case 1
Case 2
An Emergency Department of a Hospital Provider Non profit Hospital Provider contracts with 11 primary caresatellites and owns 3 hospitalsProblem statement:
Emergency Department waiting time is considerableStaff low moral leading to churningPatients leaving without being seen
A Primary Care Satellite of a Hospital Provider For profit Hospital Provider owns 5 primary care satellites that refer patientsto main hospitalProblem statement:
Considerable amount of patient no showsBacklog of patients scheduled for appointmentsCapacity constraints
Case 3 The New England Veterans Affairs Medical Center
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MIT Conference on Systems Thinking for Contemporary Challenges 2009 Massachusetts Institute of Technology D. Nightingale 10/23/09- 13 http://lean.mit.edu
Case 1: A Primary Care Satellite of
a Hospital ProviderWho is the customer? Satellite administration concerned with
attracting physicians and patients Physicians concerned with patient care
Hospital concerned with insurers
Primary Care Satellite Owned by main hospital provider Refers patients to main hospital services Physicians are not salaried
Hospital Provider Has patients from multiple insurance
companies Has multiple referral primary care
satellites
Insurer A
Insurer B
Insurer C
Satellite A
SatelliteB
Patients
Physi-cians
Hospital
What are the metrics? Insurers focus on different sets of metrics
related to costs & preventive care Hospital focuses on total patient visits per
satellite Satellite focuses on total patient waiting
time and physician utilization
What are some of the systemic issues? Hospital attempts to satisfy different
metrics from different insurers Hospital sets quality of care at a minimum
(i.e. what insurance wants) and foregoescontinuous improvement
Satellite focuses on total throughput andneglects departmental variability
Patients dont feel the burden of carecosts, are unhappy with wait times, and
contribute to no show rate
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Case 1: Key Process InteractionsDynamics of Patient No-Shows
Pat ient Timein Syst em
PatientSatisfaction
No-Shows
SystemVariability
Factors Bedside Manner Comp assion ofSuppor t St aff
Factors DemandSmoothing Wait ListMethods
Factors Hire Doct ors Limit New Pat ient s Floor level improvement s
Factors Transport at ion Convenience Socio-Economic Fact ors Pat ient Compr ehension of Scheduli ng Impact s
No Show Polici es
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MIT Conference on Systems Thinking for Contemporary Challenges 2009 Massachusetts Institute of Technology D. Nightingale 10/23/09- 15 http://lean.mit.edu
Case 1: Satellite as a Lean EnterpriseRecommendation
Objectives should bewell understood,actionable, andmeasurable
Objectives should beObjectives should bewell understood,well understood,actionable, andactionable, andmeasurablemeasurable
No clear strategic objectives No clear strategic No clear strategic objectives objectives
Lean Lean Transition Transition
Strategic Strategic
Direction Direction Setting Setting
Metrics need to beconsistent andstandard
Metrics need to beMetrics need to beconsistent andconsistent andstandardstandard
Current metrics do not gauge enterprise performance
Current metrics do Current metrics do not gauge enterprise not gauge enterprise performance performance
Measurement Measurement
Shift focus fromshareholders to
stakeholders
Shift focus fromShift focus fromshareholders toshareholders to
stakeholdersstakeholders
Focus is primarily on enterprise
shareholders
Focus is primarily on Focus is primarily on enterprise enterprise
shareholders shareholders
Stakeholder Stakeholder
Focus Focus
Cross functional /Cross departmentalknowledge reviewforums
Cross functional /Cross functional /Cross departmentalCross departmentalknowledge reviewknowledge reviewforumsforums
Infrastructure for cross-department knowledge sharing not in place today
Infrastructure for Infrastructure for cross cross - - department department knowledge sharing knowledge sharing not in place today not in place today
Knowledge Knowledge Management Management
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MIT Conference on Systems Thinking for Contemporary Challenges 2009 Massachusetts Institute of Technology D. Nightingale 10/23/09- 16 http://lean.mit.edu
Case 2: Greater Boston Hospital Case(Jorge Fradinho Oliveira, ESD PhD Candidate)
Leading multi specialty physician led group practicewith national and international recognition (i.e.neuro, liver, heart & vascular, etc)
Emergency Visits: 38,631 Total Beds: 293 Total Staff: 4263 Total Income: $679,454,000 Total Expenses: $628,525,000
Operating Income: $50,929,000
2006 Highlights
Emergency Department (ED)struggling to keep up with demand
Long wait times in the ED andpatient leaving without being seen
ED staff blame inpatient staff andvice versa
ED staff turnover levels significant
Problem Statement
What can be done to speed patient flow in the ED?Where should a process improvement initiative focus?
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MIT Conference on Systems Thinking for Contemporary Challenges 2009 Massachusetts Institute of Technology D. Nightingale 10/23/09- 18 http://lean.mit.edu
Emergency Department Analysis
Description of patient time spent in ED Description of patient arrivals and departures
Simulation Modeling
Average time for each step of the patient process
Source: Jorge Fradinho Oliveira, MIT
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MIT Conference on Systems Thinking for Contemporary Challenges 2009 Massachusetts Institute of Technology D. Nightingale 10/23/09- 19 http://lean.mit.edu
Processes
Policy
Information
Knowledge
Services
Strategy
Organization
EnterpriseArchitecting
Multi-Attribute Model Provides Framework
for Evaluating Emergency Department
Products
Source: Nightingale/Rhodes, MIT 2007
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MIT Conference on Systems Thinking for Contemporary Challenges 2009 Massachusetts Institute of Technology D. Nightingale 10/23/09- 20 http://lean.mit.edu
Enterprise Findings
EmergencyDepartment
Policy/ External Issues : Uninsured population Primary care unavailability Safety net compromised Fee for service payment
Result in: 6% of expenses not covered 30% non urgent care patients
Lack of continuous care monitoringoften resulting in poorer health andgreater expenditure
Encounter based patient carementality vs. continuous care
Strategy Issues: Focus on revenue generating
elective surgery 16 strategic objectives (trying to be
all things to all people) ED absent of strategic plan
Result in: Lack of strategic focus ED competing for internal
resources sought by electivesurgery
ED neglected
HospitalLeadership
ElectiveSurgery
Units
Source: Jorge Fradinho Oliveira, MIT
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MIT Conference on Systems Thinking for Contemporary Challenges 2009 Massachusetts Institute of Technology D. Nightingale 10/23/09- 21http://lean.mit.edu
EmergencyDepartment
Process Issues : Non standardized admitting
process
InpatientSpecialty
# 1
InpatientSpecialty
# N
Result in: Variability that leads to waste and
compromises provision of timely care
Patient boarding (admittedpatients without inpatient bedremain in ED)
Costly process bolt ons
(pharmacy dispensing units) andcostly care (ED cost structure)and image deterioration
AncillaryServices(lab, etc)
Silo process definitions
Lost opportunity to speed patientthroughput
Enterprise Findings
Source: Jorge Fradinho Oliveira, MIT
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MIT Conference on Systems Thinking for Contemporary Challenges 2009 Massachusetts Institute of Technology D. Nightingale 10/23/09- 22 http://lean.mit.edu
EmergencyDepartment
Organization Issues : Low staff morale Salaried physicians Physician cultural rifts
Result in: High staff turnover volume Lack of productivity incentive Finger pointing between ED
and elsewhere
Knowledge Issues: Vast amount of evidence basedmedicine
Reliance on heroes and bed czars
Incomplete patient records
Result in: Less than ideal recommended
care provision Prone to staff exhaustion and
waste (i.e. empty bed goes
unnoticed) Patient health put at risk due to
unknown medical history
Enterprise Findings
Source: Jorge Fradinho Oliveira, MIT
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MIT Conference on Systems Thinking for Contemporary Challenges 2009 Massachusetts Institute of Technology D. Nightingale 10/23/09- 23 http://lean.mit.edu
EmergencyDepartment
Information Technology Backbone Issues : Fragmented information systems Proprietary legacy software
Result in: Redundant human data entry tasksprone to error
Frustrated patients requested toprovide same information over andover again
Expensive IT integration consultingfees
Silo based view of informationacross the hospital (i.e. unable tosee end to end value)
Enterprise Findings
Source: Jorge Fradinho Oliveira, MIT
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MIT Conference on Systems Thinking for Contemporary Challenges 2009 Massachusetts Institute of Technology D. Nightingale 10/23/09- 24 http://lean.mit.edu
Policy / External FactorsPolicy / External Factors
ProcessProcess
OrganizationOrganization
StrategyStrategy
Info/InfrastructureInfo/Infrastructure
AProducts /Services
Products /Services
KnowledgeKnowledge
Focus on revenue generatingelective surgery; 16 strategic
objectives; ED absent of strategicplan
Non standardized admitting process;patient boarding (i.e. admittedpatients held in ED due to lack ofinpatient beds); costly bolt ons
Timely provision of carecompromised; overall hospital imagecompromised
Uninsured population; primary careunavailability; safety net compromised;fee for service payment model
Reliance on heroes and bedczars; incomplete patientrecord; high variation ofevidence based medicine withinand across providers
Low staff morale; physician cultural rifts; high volumeof staff turnover; lack of productivity; finger pointingbetween ED and elsewhere
Fragmented information systems; costly proprietarysoftware
Hospital Enterprise Architecture
Diagnostic
Source: Jorge Fradinho Oliveira, adapted from Nightingale/Rhodes 2007, MIT
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MIT Conference on Systems Thinking for Contemporary Challenges 2009 Massachusetts Institute of Technology D. Nightingale 10/23/09- 25 http://lean.mit.edu
Preliminary Findings
The problem of redesign gets harder and the evidence weaker as onemoves from the microsystem to the organization.Donald Berwick, President of Institute for Healthcare Improvement, 2002
QuestionsFor
FurtherStudy
MainFindings
ED average length of stay considered problematic, but non-admitted
patients took 4 hours, whereas admitted patients took over 8 hoursED interacted well with some patient wards but not with othersED heroic employee efforts said to be common rather than sporadicED metrics and strategic goals misaligned with overall hospital (X-Matrix)
Why was the ED managed as a silo rather than end-to-end?Was the varying performance of ED interactions due to the payment model?Could it be that different observed EA configurations were directly related tothe different observed performance levels ?
Source: Jorge Fradinho Oliveira, MIT
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Payer Patient
Provider
Regulator
InterestGroups
Insurer
Supplier
Labs Pharmacy
Hospital
HomeCare
NursingHome
Flu Clinic
Ancillary
Services
SpecialistCare
PrimaryCare
OperatingRooms
InpatientUnits
EmergencyDepartment Radiology
PrimaryCare
Nurse Physician
SupplyTechnician
Cleaning
Admin staff
Studentresident
Psychologist
Health Care is a Complex
Socio-Technical System
Labs Pharmacy
Source: Jorge Fradinho Oliveira, MIT
Simply stated, the U.S.does not have a
healthcare system.William Brody,
President of Johns Hopkins University, 2007
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Emergency Services
VA Urgent Care Transfer
VA ER Transfer
Non VA ER Transfer
Inpatient Treatment
Chronic Care
Acute Care
Residential Programs
Substance Abuse
PTSD
General Mental Health
Women
Community Residential
Domiciliary
Bedford Stabilization Program
Enabling Infrastructure
Purchasing
Patient Data Mgmt
Research
Quality Assurance
Payroll
Human Resources
Outpatient Treatment
Treatment
Scheduling
Non Emergency
Walk In to Outpatient
Referral from Primary Care
Outpatient ClinicsWest RoxburyJamaica PlainBrockton Outside the Enterprise
Case 3: New England Veterans Affairs
Partnership and Preliminary Insights
Richness of VA enterprise dataset which is shared across multiple regions Ability to control for potential misaligned behavior induced by traditional
commercial and public healthcare payment models
Evolving recent partnership between LAI and theNew England Veterans Administration (VISN 1)
Rationale
It is not impossible to get your head around the processes and activities in
health care. Performance, demand, and structure can be modeled and can beused to improve the enterprise.
Context
Enterprise Strategic Analysisfor Transformation
(ESAT) Analysis YieldedMultiple Insights
Even if profit is not a significant factor, it is still worthwhile creating andunderstanding your strategic goals and using them to drive your enterpriseforward.
It is not enough just to serve patients as they enter, we must also plan aheadin health care, and work towards being proactive rather than re-active.
We must align the enterprise on all levels and empower management on alllevels with an understanding of the greater strategic goals.
Insights
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Case 3: X-Matrix
MetricsStakeholder
Values
KeyProcesses
StrategicObjectives
MetricsStakeholder
Values
KeyProcesses
StrategicObjectives
StakeholderValues
K e y
P r o
c e s s e s
EnterpriseMetrics
S t r a
t e g
i c
G o a
l sVery strong alignmentwith most metrics ontarget
Goals are not formal or documentedResearch is a goal butnot measured locally
Very strong alignmentwith most metrics ontarget
Goals are not formal or documentedResearch is a goal butnot measured locally
Metrics vs. Objectives
Values vs. Goals
Strong alignment withareas in service, care, &research
Gap lies in aligninggoals to values such as:
Operating within budget Well-documented
monetary transactions
Strong alignment withareas in service, care, &research
Gap lies in aligninggoals to values such as:
Operating within budget Well-documented
monetary transactions
Strong alignment inareas of service,research, & quality
Processes addressingthe least stakeholder values are primarilypatient movement
Strong alignment inareas of service,research, & quality
Processes addressingthe least stakeholder values are primarilypatient movement
Processes vs. Values
Strong alignment withoutpatient treatment andclinic wait times
Missing metrics for key
processes Transfers to inpatient Program referrals
Strong alignment withoutpatient treatment andclinic wait times
Missing metrics for key
processes Transfers to inpatient Program referrals
Metrics vs. Processes
Strong AlignmentWeak Alignment
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MIT Conference on Systems Thinking for Contemporary Challenges 2009 Massachusetts Institute of Technology D. Nightingale 10/23/09- 29 http://lean.mit.edu
Case 3: X-Matrix
s w s w 4 2 2
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s w s s w w 6 3 3
s w s w 4 2 2
w s w s w 5 2 3
s w s s w w 6 3 3s w s w 4 2 2
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s w w w 4 1 3
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s w s w 4 2 2
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w w w w s s s s s w 10 5 5
s s s s s s w w w s 10 7 3
s s w w s s w w s 9 5 4
s w w w s 5 2 3
s w s s s s w 7 5 29 16 15 7 1 3 3 2 9 2 13 3 3 21 2 37 9 5 5 1 1 3 2 5 1 10 1 1 4 2 12 7 10 2 0 2 0 0 4 1 3 2 2 17 0 2
U p s
t a n d
i n g
m e m
b e r o f
l o c a
l
c o m m u n
i t y
Transfer from VA ER to Inpatient
C o r r e c t n e s s o f
d i a g n o s i s a n
d
t r e a
t m e n
t
T i m e l
i n e s s o f
d i a g n o s i s a n
d
t r e a
t m e n
t
R e s e a r c
h A d v a n c e m e n
t
K n o w
l e d g e T r a n s
f e r
Q u a
l i t y o f p a t
i e n t e x p e r i e n c e
( m i n i m a l
d i s c o m
f o r t , r e s p e c
t f u l , e t c .
)
T i m e l y a n d a c c u r a
t e i n f o r m a t
i o n
f l o w
S a f e t y /
S e c u r
i t y o f p r e m
i s e s
C l e a n , H
i g h Q u a
l i t y
F a c
i l i t y
R e a s o n a
b l e e x p e c t a t
i o n s a n
d
r e s p e c
t f u l t r e a t m e n
t o f e m p l o y e e s
C o m m u n
i c a t
i o n a n
d I m p l e m e n
t a t i o n
o f V A c u
l t u r e a n
d v a
l u e s
E f f i c i e n
t R e s o u r c e
M a n a g e m e n
t
A c c u r a t e a n d w e l
l - d o c u m e n
t e d
m o n e t a r y t r a n s a c
t i o n s
Transfer from Urgent Care to Inpatient
O p e r a
t i n g w
i t h i n b u d g e t
F a i r W a g e s
f o r s e r v
i c e s
S u f
f i c i e n t I n p a t
i e n t a n
d O u t p a
t i e n t
C a p a c
i t y
A c c u r a t e P a t
i e n t
R e c o r
d s
A v a
i l a b i l i t y o f m e d
i c a t
i o n s , s
u p p l
i e s ,
a n d e q u i p m e n
t
Referral to Inpatient
Transfer from Outside ER to Inpatient
Inpatient Treatment
Transfer from Inpatient to Residential
Discharge from Inpatient
Residential Treatment
Transfer from Residential to Inpatient
Discharge from Residential
Transfer to Outside Facility
Outpatient Treatment
Referral to Residential
Walk-in to Outpatient
Human Resources
Purchasing (Supplies & Services)
Patient Data Management
Research
Facilities and Maintance
Quality Assurance
Payroll
MetricsStakeholder
Values
Key Processes
StrategicObjectives
MetricsStakeholder
Values
Key Processes
StrategicObjectives
Key Processes vs. Stakeholder Values Key Processes are primarily focused onsatisfying specific stakeholders however allare taken into account.
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MIT Conference on Systems Thinking for Contemporary Challenges 2009 Massachusetts Institute of Technology D. Nightingale 10/23/09- 30 http://lean.mit.edu
Agenda
Research Motivation
Cross-Industry Knowledge on Enterprises
Case Examples
Ongoing Research
LAI Enterprise Healthcare Vision
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MIT Conference on Systems Thinking for Contemporary Challenges 2009 Massachusetts Institute of Technology D. Nightingale 10/23/09- 31http://lean.mit.edu
Ongoing Research
High Performing Hospital Enterprise Architecture
(Jorge Oliveira) New England Veteran Affairs: Ongoing Research in
Process Classification(Jordan Peck)
NEWDIGS Drug Development Enterprise Systems Analysis(Center for Biomedical Innovation)
Impact of Advanced DNA Sequencing Technologies onClinical Microbiology Processes(Rob Nicol)
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High Performing Hospital Enterprise Architectures
(Jorge Oliveira, ESD PhD Candidate) Two multi-method exploratory cases conducted at leading US and
UK hospitals identified the following research questions andemergent phenomena:
How is hospital enterprise performancecurrently measured?
How could hospital enterpriseperformance measurement beimproved using lean enterpriseprinciples?
What are different internalorganizational design configurationscapable of supporting higher performance for different service unitcomplexities?
Nightingale/Rhodes 2007
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Ongoing Research
High Performing Hospital Enterprise Architecture
(Jorge Oliveira) New England Veteran Affairs: Ongoing Research in
Process Classification(Jordan Peck)
NEWDIGS Drug Development Enterprise Systems Analysis(Center for Biomedical Innovation)
Impact of Advanced DNA Sequencing Technologies onClinical Microbiology Processes(Rob Nicol)
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MIT Conference on Systems Thinking for Contemporary Challenges 2009 Massachusetts Institute of Technology D. Nightingale 10/23/09- 34 http://lean.mit.edu
New England Veteran AffairsOngoing Research in Process Classification
(Jordan Peck, ESD Ph.D.)
Health Care Professionals are starting to recognize predictability
T 1 5
T 1 6
T 1 7
T 1 8
T 1 9
T 2 0
T 2 1
T 2 2
T 2 3
T 2 4 W
1 W 2
W 3
W 4
W 5
W 6
W 7
W 8
W 9
W 1 0
W 1 1
W 1 2
W 1 3
W 1 4
W 1 5
W 1 6
W 1 7
W 1 8
W 1 9
W 2 0
W 2 1
W 2 2
W 2 3
W 2 4 T
1 T 2
T 3
T 4
T 5
Wednesday
1 2 3 4 5
Emergency Severity Index (ESI)a five-level emergency department triage algorithm that provides clinically relevantstratification of patients into five groups from 1 (most urgent) to 5 (least urgent) on the basis of acuity and resource needs.
0
50
100
150
200
250
300
350
ESI 1 ESI 2 ESI 3 ESI 4 ESI 5 S p r e a
d o
f T i m e i n
E R ( M e a n +
/ - S t a n
d a r d
D e v
i a t i o n
)
Mean
-
+
0
50
100
150
200
250
300
350
ESI 1 ESI 2 ESI 3 ESI 4 ESI 5 S p r e a
d o
f T i m e i n
E R ( M e a n +
/ - S t a n
d a r d
D e v
i a t i o n
)
Mean
-
+
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New England Veteran AffairsSimulation and Modeling
How can we model Control Options and Interventions?
How well can solutions cross between hospitals?
Source: www.va.gov
Source: Jordan Peck, MIT
How do the people fit in?
VAManchester, NH
VATogus, ME
VABoston, MA
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MIT Conference on Systems Thinking for Contemporary Challenges 2009 Massachusetts Institute of Technology D. Nightingale 10/23/09- 36 http://lean.mit.edu
Ongoing Research
High Performing Hospital Enterprise Architecture
(Jorge Oliveira) New England Veteran Affairs: Ongoing Research in
Process Classification(Jordan Peck)
NEWDIGS Drug Development - Enterprise Systems Analysis(Center for Biomedical Innovation)
Impact of Advanced DNA Sequencing Technologies onClinical Microbiology Processes(Rob Nicol)
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MIT Conference on Systems Thinking for Contemporary Challenges 2009 Massachusetts Institute of Technology D. Nightingale 10/23/09- 37 http://lean.mit.edu
NEW D rug Development Parad IGmS
(NEWDIGS )
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Providers
Patient
Advocacy
MIT Center for
BiomedicalInnovation
FDA & Other
HHS Agencies
NGOs
Biotechs &
PharmasPayers
Diagnostics
SystemsIntegrators
CBIs NEWDIGS Drug DevelopmentEnterprise Strategic AnalysisConsortium of Stakeholders
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MIT Conference on Systems Thinking for Contemporary Challenges 2009 Massachusetts Institute of Technology D. Nightingale 10/23/09- 39 http://lean.mit.edu
Mission:Improve therapeutic product innovation in healthcare
Preliminary Objectives Develop products that are more effective than existing therapeutic
options Reduce time to market, cost, and late stage attrition Improve knowledge about benefit/risk profile of new products
Additional strategic objectives: Catalyze change across the industry Transformational, not incremental Strategic, not just tactical Global, not just US Cross-stakeholder, not just pharma
CBIs NEWDIGS Drug DevelopmentEnterprise Strategic Analysis
Mission and Strategic Objectives
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MIT Conference on Systems Thinking for Contemporary Challenges 2009 Massachusetts Institute of Technology D. Nightingale 10/23/09- 40 http://lean.mit.edu
May June July August September October November
Meeting #1May 28
Washington, DC
BeginCurrent State
Assessment
Meeting #2July 14
MIT
ContinueCurrent State
Assessment
Meeting #3August 19 & 20
Washington, DC
CreateFuture State
Vision
Meeting #4October 15
MIT
Create ActionPlan
Research teamsynthesizes outputs,
performs interviews, &
customizes methodology
CBIs NEWDIGS Drug DevelopmentEnterprise Strategic Analysis
Timeline
Meeting #5November 5
MIT
StakeholdersMeeting
Share findingsand solicit input
from CBIMembers
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MIT Conference on Systems Thinking for Contemporary Challenges 2009 Massachusetts Institute of Technology D. Nightingale 10/23/09- 41http://lean.mit.edu
An organization that: is lean and highly collaborative with all stakeholders from across the entire value chain;
is not tied to developing one particular product (i.e., responsive to market need, flexible,adaptive) and rather focuses on integrated healthcare solutions; has expertise to understand market and customer(s) health needs and to design potential
solutions that intervene earlier in the disease continuum than currently occurs; is informed by knowledge generated internally and externally (through pre-competitive,
cross-stakeholder data sharing/collaboration) and processes that enable rapid-cyclelearning (e.g., Learning Healthcare System);
has relationships with best-in-class providers of solution components (industry, academia,non-profits), and collaborates effectively with them to develop solutions;
operates successfully in an outcomes-based reimbursement environment; delivers dramatically increased value over the current approach (faster, more efficient,
reduced resource expenditure without compromise in outcomes); and find solutions focused on patient outcomes driven by patient and payor value as well as
scientific/medical community value.
CBIs NEWDIGS Drug DevelopmentEnterprise Strategic Analysis
Draft High Level Future Vision
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MIT Conference on Systems Thinking for Contemporary Challenges 2009 Massachusetts Institute of Technology D. Nightingale 10/23/09- 42 http://lean.mit.edu
NEWDIGS
Process Knowledge ITPolicy &ExternalFactors
Products &Services Organization
DemonstrationProjects
(TBD)
What decisions must be made, when, and by whom? What evidence is required to inform these decisions? What data is required to generate the necessaryevidence? What can we do in NEWDIGS to optimize all of theabove?
#1
#2
Workstreams1) New Paradigms: Modeling, Simulation,
& Decision Support2) Data, Evidence, and
Decision-making3) Policy Design4) Organizational Design5) Others TBD .
#3
OrganizationalDesign
NEWDIGS andthe broader
LearningHealthcare
System
Policy asenabler of
scientifically& ethically
soundinnovation
New Paradigms:Modeling,Simulation,
Decision-Support
#4
CBIs NEWDIGS Drug DevelopmentEnterprise Strategic Analysis
Proposed Initial Workstreams
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7/31/2019 Deborah Nightingale
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MIT Conference on Systems Thinking for Contemporary Challenges 2009 Massachusetts Institute of Technology D. Nightingale 10/23/09- 43 http://lean.mit.edu
Ongoing Research
High Performing Hospital Enterprise Architecture(Jorge Oliveira)
New England Veteran Affairs: Ongoing Research inProcess Classification(Jordan Peck)
NEWDIGS Drug Development - Enterprise Systems Analysis(Center for Biomedical Innovation)
Impact of Advanced DNA Sequencing Technologies onClinical Microbiology Processes(Rob Nicol)
Mot iva t ion / Problem Rob Nicol
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2009 Robert Nicol, Engineering Systems Division, Massachusetts Institute of Technology
Antibiotic Resistance Surveillance: Key Healthcare Problem Rapidly increasing resistance Few effective antibiotics remain Limited system level surveillance
Process improvement difficult
Complex Healthcare Processes Large number of tasks and rapidly changing technology
Numerous disconnected stakeholders Vast technical design space Highly distributed information (tacit and explicit)
Severe Health and Cost Impacts 2 Million hospital acquired infections per year $5 Billion (est.) and over 90,000 deaths per year (source: IDSA)
Mot iva t ion / Problem
Source: CDC; MRSA =methicillin-resistant Staphylococcus aureus ; VRE=Vancomycin-resistant enteroccoci ; FQRP =Fluoroquinolone-resistant Pseudomonas aeruginosa
K ey Ques t ions Rob Nicol
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2009 Robert Nicol, Engineering Systems Division, Massachusetts Institute of Technology
How can the true system levelcomplexity of healthcare processesbe modeled and measured?
How does this system level processmodel and complexity measureswork on a real world healthcareprocess design and implementationeffort?
How does process complexityimpact change and adoption inhealthcare?
K ey Ques t ions
Cont r ibu t ions Rob Nicol
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2009 Robert Nicol, Engineering Systems Division, Massachusetts Institute of Technology
Novel Network Based Process Representation andComplexity Analysis Methodology (model)
Novel Theory for Process Innovation Adoption as a
Function of Process Complexity (model observations) First Specification of a Whole Genome Clinical Microbiology
Process for MRSA Surveillance (test case for model)
First Operational Demonstration of a Whole GenomeClinical Microbiology Process for MRSA Surveillance(test case for model and complexity measures)
First Whole Genome MRSA Diversity Study(real biological results showing policy change needed)
Contributions (Significant Biology Too) Rob Nicol
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2009 Robert Nicol, Engineering Systems Division, Massachusetts Institute of Technology
MRSA Surveillance Process designed and implemented aspart of thesis yielded significant insight into MRSA biologywhich in turn suggests system policy changes needed
( g gy )
Multiple Genome Alignment of BWH SamplesCompared to Reference at the Top
50 Genomes Sequenced(
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Agenda
Research Motivation Cross-Industry Knowledge on Enterprises Case Examples Ongoing Research LAI Enterprise Healthcare Vision
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LAI Enterprise Healthcare Vision
In 1992 US Air Force asked:Can the concepts, principles and practices of the Toyota Production System (TPS) be applied to the military aircraft industry?
MIT answered: YES!Over a decade of significant research was conducted well beyond TPS to the Enterprise system level and ultimately delivering superior results for aerospace commercial and governmental sectors
In 2009 the Healthcare Community asks:Can the concepts, principles and practices of Lean Enterprise Value be applied to the
healthcare industry?
Our Research to date says: YES!?
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MIT Conference on Systems Thinking for Contemporary Challenges 2009 Massachusetts Institute of Technology D. Nightingale 10/23/09- 50 http://lean.mit.edu
What processes arerequired to support
the enhancement,shortening, andimprovement of technology and
pharma innovation ?
What role shouldInformation Technology
play in improvinginformation accessibility
and flow?
What can belearned from other
industries withregards to holisticenterprise analysis
and redesign?
What are enhancedmethods for evaluating
and assessing futurestate health care
systems?(e.g., simulation,)
Relevant Research Questions
What are keyknowledge and
decision support toolsthat enable healthcaresystem effectiveness?
How doeshospital enterpriseperformance relate
to its enterprisearchitecture ?
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Relevant Research Questions
What are thekey incentives
that drivestakeholder behavior?
What areappropriatehealth careenterprisemetrics?
How canlong-term value
propositionsbe created
across multipleproviders?
What are newcollaborativestakeholder
models?
What are thestrategies capableof achieving and
sustaining multiplestakeholder alignment?
Metrics and Stakeholder Alignment
How shouldhospital/healthcareservice complexity
be measured?
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Questions and Answers
Deborah [email protected]
http://lean.mit.edu