[MUSIC] The last lecture we defined a problem in the health care space. In this lecture, we'll plan the solution that we will implement by re-engineering our work flow. Specifically we'll start using the Plan-Do-Study-Act or the PDSA cycle to implement a health informatics solution. As I mentioned we'll use the PDSA cycle. In this lecture we are tackling the first part, that's the plan part. In which we'll talk about how do we analyze the problem, form a team, and then propose an informatic solution. We'll stress again this is a cycle. In this lecture, we are only doing the plan part. In subsequent lectures, we'll implement our solution. We'll study the initial results then we act on this results, come back, plan a better solution and the cycle will continue until we reach the ideal solution. So let me ask you, what is the first step in creating a solution? I would say the first step is to analyze the problem, then analyze it again, and then analyze it again, and keep on analyzing until you go to the root cause of the problem. And how do you analyze the problem especially in the health care space? You go and ask the front line staff. Do not try to the health care related problem by seating in their office and by multiple meetings. Go ask the front line stuffs they are the people who are actually living the problem. They have the most insight about the problem and are most invested in the solution. And the second recommendation is to go to the gemba. What does that mean? Go to the place where the problem is occurring. So if patients are missing therapy in a particular unit go to that unit. Use all your senses to collect all possible information about why the problem is occurring. And then, when you have collected all of the information, there are tools that you can use to analyze this information to find the root cause of this problem. Here is one of those tools. This is called a fishbone diagram. I'll explain a little bit about this diagram. The mouth of the fish is actually the problem that happened. In this case, I'm talking about a patient who fell. The bones of the fish wines to all the multiple factors that have ultimately contributed to this problem. This is an excellent tool to brainstorm, to find out all possible causes that may lead to this problem. Another tool that you can use probably much simpler than the fishbone diagram is the method of 5 whys. The idea is that you keep on asking whys in sequence. And by the time you reach the fifth why, you are much closer to the root cause of the problem. This is very simple to implement. It's a very fast process, but it has had some recent criticism. And I would encourage you to read this article that I have cited here about the pros and cons of 5 whys. So let's say we have done a total analysis of our problem. To come back to our example, our problem was missed physical and occupational therapy treatments for patients across the hospital. That was the problem at the first glance. When we did further analysis, we said that the current problem is occurring because the workflow for corrective action. When a patient has missed therapy, is not working. Which means that the process in which a new therapist is sent to the bedside of the patient because he or she is missing therapy is not working as it should be. Why was that happening? Well, let's do some workflow analysis. Red dot on the top is when a patient has missed therapy. By the time that this information reaches the person, that's the green dot, who can take some corrective action. Which means that this information reaches the therapy coordinators who can send more therapist to that unit so that all the patients are covered. It was taking very long, about half a day to one day. Now let's put on our informatic hat. What was exactly happening? What was happening is that the information of the defect, patient has missed therapy is taking too long which the person who can take corrective action. And this is happening because we are relying on a sequential process of information transfer across multiple stake holders. And that comes to the root cause of our problem. So once you have analyzed the problem the next step I would say is to create a team. And again, we can argue which one comes first or both can happen simultaneously. Important thing to remember is that when creating a team, who should be the team members? The team members should be the ones who are familiar with all the different parts of the process. Front line clinic and staff, physicians, nurses, front line workers. And at the other end you should have bind from leadership and have some kind of an executive sponsor. And that would lead your team to success. Let's say you have created a team. What's the next step? You have to develop a shared vision. A vision is something grand, something that motivates your team. For example, our vision was that we will deliver therapy that is physical and occupational therapy services as a treatment modality with the goal of restoring patients to their highest level of function. After you've defined your vision and everybody's motivated, you really have to go granular and figure out what are the moving parts that you need to move to realize your vision, and that becomes your strategy. Again, coming back to our case, our strategy was that we will track patient's function. That is their mobility and activity status. Identify patients with functional impairments who are missing therapy, and prioritize therapy for these patients. That was our strategy. And finally, you have to come up with numbers to define success. So at the end of the day, or at the end of the month or week, you can see whether you are successful or you have not been successful. Coming back to our example our numbers were that we will decrease the missed that is delivered versus recommended therapy sessions in our medicine unit by at least 5%. It was a very clearly defined number that we could measure going forward. Time again to put on your informatics hat. Next you have to think that for your team to realize the vision, to implement the strategy, to hit the numbers, what changes in information flow will be required to support the above goals? And once you have figured that out, then we need to figure out what redesign of the health IT systems are needed to support the changes in the above mentioned information flow. Let's come back to our example. What did we say? We said that one of the biggest problem was that information, that patient has missed therapy It's taking a long time to reach the person who can actually take the corrective action; that's the therapy coordinators. So our informative solution that we said we would implement was to have a parallel information flow, not a sequential information flow. And this parallel information flow will allow therapy coordinators to know in near real time which patients are missing therapy. So that is our proposed solution for work for redesign using informatics. If you remember, I told you that we should always think what triple aim are we serving while doing any kind of workflow redesign or re-engineering in healthcare. So let's see, how we measure up? If you recall, these are the IHI Triple Aim. I would argue that by solving this problem we are trying to improve patients experience of care. Because we are preventing patients who really need therapy from missing any therapy. I also told you that while we are doing workflow redesign or re-engineering we should try to incorporate the institute of medicine's guidelines for workflow redesign. So after ensuring that we are serving at least one of the triple aims, let's see how we are measuring up against the recommended guidelines for workflow redesign. Again, I would argue that we are fulfilling at least some of the guidelines. For example, let's see number two. It says that care is customized according to patient's needs and values. I would argue we were doing that. Because our goal was to give therapy to patients who truly needed therapy. Look at number four, it said the workflow redesign should promote that knowledge is shared and information flows freely. That's exactly what we were doing, we were taking away this sequential flow of information, making it near real time and parallel flow of information for better patient care. Number five, decision making is evidence based. Absolutely, we were not saying that we'll give physical therapy to every patient. We were saying that we will measure patients function. We'll see patients who need therapy or missing therapy, and we'll give therapy to those patients. So we were serving some of the institute of medicines, rules for redesign or re-engineering, and that's why we thought we were set out for success. Let's recap. What did we learn in this lecture? In this lecture we started with the plan section of the plan, do, study, act or the PDSA cycle. And we said that the most important component in planning our solution was to analyze and reanalyze the problem to find the root cause of the problem. Then we said how do we form a team, and we said we needed a vision to motivate our team. We needed a strategy and then we talked about the importance of having solid numbers to measure our success or failure. And then we took our example, and we revisited the triple aim, and the rules for redesign. And demonstrated that our example was measuring up favorably against the triple aims and the rules for redesign. And this is something that you should always do when you are implementing a workflow re-engineering or redesign in the health care space. Before I let you go, I want to ask you a question. Can you name a method for root cause analysis that we discussed in this lecture? And I will give you a hint. While you are thinking about the answer, I will go and have my fish and chips, and we'll be back in five minutes. Well, if you answered fishbone diagram or 5 Whys, you're absolutely correct.
