Health Systems

, Volume 3, Issue 3, pp 159–164 | Cite as

Integrating systems engineering practice with health-care delivery

  • William V Padula
  • Michael P Duffy
  • Taygan Yilmaz
  • Manish K Mishra
Original Article

Abstract

Health-care delivery is a complex and fragmented system with work-around culture. Improving health-care delivery requires innovating system interventions that redesign processes for consistent implementation of evidence-based practices (EBPs). Systems engineering is an approach that involves anticipating ineffective processes that jeopardize quality, and designing interventions to overcome such shortcomings. This approach is based on systems teaching about reflexivity, which when addressed can support consistent EBP and assesses how the newly designed system meets this consistency. Integrating a systems engineering approach to implementing EBP may effectively address complex issues such as hospital-acquired pressure ulcer prevention, which has an EBP protocol that is not consistently implemented without system redesign. Engineering approaches and methods including Plan-Do-Study-Act (PDSA), Situation-Background-Assessment-Recommendations (SBAR), stochastic modeling, House of Quality, and statistical process control charts with lean six sigma provide a structured approach to identifying points of successful implementation for EBPs that can subvert work-around culture. This perspective piece reviews successful approaches of systems engineering to solve the problem of clinical work-arounds and puts forward the case for its wider application to health-care delivery systems that could benefit from standardized EBPs.

Keywords

systems engineering health-care delivery pressure ulcer quality improvement 

References

  1. Azzolini J (1995) Essential systems engineering: a life-cycle process. 5th Annual International Symposium. International Council of Systems Engineering. St. Louis, MS.Google Scholar
  2. Benneyan JC, Lloyd RC and Plsek PE (2003) Statistical process control as a tool for research and healthcare improvement. Quality and Safety in Health Care 12 (6), 458–464.CrossRefGoogle Scholar
  3. Berwick DM (2002) A user’s manual for the IOM’s ‘quality chasm’ report. Health Affairs (Millwood) 21 (3), 80–90.CrossRefGoogle Scholar
  4. Berwick DM (2007) Foreword: the clinical microsystem. In Quality by Design (Nelson EC, Batalden PB and Godfrey MM, Eds), Jossey-Bass, San Francisco, CA.Google Scholar
  5. Berwick DM (2009) What ‘patient-centered’ should mean: confessions of an extremist. Health Affairs (Millwood) 28 (4), w555–w565.CrossRefGoogle Scholar
  6. Bosk CL (1979) Forgive and Remember: Managing Medical Failure. University of Chicago Press, Chicago.Google Scholar
  7. Carey RG (2003) Improving Healthcare with Control Charts: Basic and Advanced SPC Methods and Case Studies. ASQ Quality Press, Milwaukee, WI.Google Scholar
  8. Comfort E (2008) Reducing pressure ulcer incidence through Braden scale risk assessment and support surface use. Advances in Skin and Wound Care 21 (7), 330–334.CrossRefGoogle Scholar
  9. Deming WE (1986) Out of Crisis. MIT Center for Advanced Engineering Study, Cambridge, MA.Google Scholar
  10. Desneves KJ, Todorovic BE, Cassar A and Crowe TC (2005) Treatment with supplementary arginine, vitamin C, and zinc in patients with pressure ulcers: a randomised controlled trial. Clinical Nutrition 24 (6), 979–987.CrossRefGoogle Scholar
  11. Donahue M, Miller M, Smith L, Dykes P and Fitzpatrick JJ (2011) A leadership initiative to improve communication and enhance safety. American Journal of Medical Qualilty 26 (3), 206–211.CrossRefGoogle Scholar
  12. Edmondson AC (2004) Learning from failure in health care: frequent opportunities, pervasive barriers. Quality and Safety in Health Care 13 (6), 3–9.Google Scholar
  13. Espin S, Lingard L, Baker GR and Regehr G (2006) Persistence of unsafe practice in everyday work: an exploration of organization and psychological constraining safety in the operating room. Quality and Safety in Health Care 15 (3), 165–170.CrossRefGoogle Scholar
  14. Frye E (2007) Knowledge with Know-How: Thayer School of Engineering at Dartmouth. University Press of New England, Hanover, NH.Google Scholar
  15. Gay SB, Sobel AH, Young LQ and Dwyer SJ (2002) Processes involved in reading imaging studies: workflow analysis and implications for workstation development. Journal of Digital Imaging 15 (3), 171–177.CrossRefGoogle Scholar
  16. George ML, Rowlands D, Price M and Maxey J (2005) The Lean Six Sigma Pocket Toolbook. McGraw-Hill, New York.Google Scholar
  17. Glouberman S and Zimmerman B (2002) Complicated and complex systems: the reform of medicare in Canada: Discussion Paper no. 8. The Commission on the Future of Health Care in Canada.Google Scholar
  18. Godfrey MM, Melin CN, Muething SE, Batalden PB and Nelson EC (2008) Clinical microsystems, part 3: transformation of two hospitals using microsystem, mesosystem, and macrosystem strategies. Joint Commission Journal on Quality & Patient Safety 34 (10), 591–603.CrossRefGoogle Scholar
  19. Gonzales R, Handley MA, Ackerman S and O’sullivan PS (2012) A framework for training health professionals in implementation and dissemination science. Academic Medicine 87 (3), 271–278.Google Scholar
  20. Graves SC, Leff HS, Natkins J and Senger M (1983) A simple stochastic model for facility planning in a mental health care system. Interfaces 13 (5), 101–110.CrossRefGoogle Scholar
  21. Hauser JR (1993) How Puritan-Bennet used the house of quality. Sloan Management Review 34 (3), 61–70.Google Scholar
  22. Haynes A et al (2009) A surgical safety checklist to reduce morbidity and mortality in a global population. New England Journal of Medicine 360 (5), 491–499.CrossRefGoogle Scholar
  23. Kuo MH, Borycki EM, Kushniruk AW and Lee TS (2009) Integrating A3 reports and the house of quality: improving workflow in the recovery room using information technology. In Medical Informatics in a United and Healthy Europe 2009 (Adlassnig KP, Ed), European Federation for Medical Informatics, Copenhagen, pp 409–420.Google Scholar
  24. Kurtzman E and Buerhaus PI (2008) New medicare payment rules: danger or opportunity for nursing? American Journal of Nursing 108 (6), 30–35.CrossRefGoogle Scholar
  25. Leonard M, Bonacum D and Graham S (2011) SBAR technique for communication: a situational briefing model. [WWW document] http://www.ihi.org, (accessed 8 February 2011).
  26. Llewellyn-Thomas HA (1997) Investigating patients’ preferences for different treatment options. The Canadian Journal of Nursing Research 23 (3), 45–64.Google Scholar
  27. Lyder CH, Grady J, Mathur D, Petrillo MK and Meehan TP (2004) Preventing pressure ulcers in Connecticut hospitals by using the plan-do-study-act model of quality improvement. Joint Commission Journal on Quality & Patient Safety 30 (4), 205–214.CrossRefGoogle Scholar
  28. Lyder CH et al (1998) Braden scale for the prediction of pressure ulcer risk in blacks and Latino/Hispanic elders: a pilot study. Ostomy Wound Manage 44 (3A Suppl), 42S–49S, discussion 50S.Google Scholar
  29. Makic MB, Vonreuden KT, Rauen CA and Chadwick J (2011) Evidence-based practice habits: putting more sacred cows out to pasture. Critical Care Nursing 31 (2), 38–61.CrossRefGoogle Scholar
  30. Merrill CT, Stocks C and Stranges E (2009) Trends in Uninsured Hospital Stays, 1997–2006. Healthcare Cost and Utilization Project. Agency for Healthcare Research and Quality. Bethesda, MD, USA.Google Scholar
  31. Morton A, Mengersen K, Waterhouse M and Steiner S (2010) Analysis of aggregated hospital infection data for accountability. Journal of Hospital Infection 76 (4), 287–291.CrossRefGoogle Scholar
  32. National Aeronautics and Space Administration. (2007) NASA Systems Engineering Handbook. NASA, Washington DC, Scientific and Technical Information.Google Scholar
  33. Nelson EC, Batalden PB and Godfrey MM (2007) Quality by Design. Jossey-Bass, San Francisco, CA.Google Scholar
  34. Nelson EC, Batalden PB, Godfrey MM and Lazar JS (2011) Value by Design. Jossey-Bass, San Francisco.Google Scholar
  35. Nelson WA, Gardent PB, Shulman E and Splaine ME (2010) Preventing ethics conflicts and improving healthcare quality through system redesign. Quality and Safety in Health Care 19 (6), 526–530.Google Scholar
  36. Padula WV and Breteler MJM (2013) Sharing perspectives on HTA from both sides of the pond – lessons learned by graduate students at ISPOR’s 15th annual European congress. ISPOR Connections 19 (1), 15.Google Scholar
  37. Padula WV, Mishra MK, Makic MB and Sullivan PW (2011) Improving the quality of pressure ulcer care with prevention: a cost-effectiveness analysis. Medical Care 49 (4), 385–392.CrossRefGoogle Scholar
  38. Padula WV, Mishra MK, Weaver CD, Yilmaz T and Splaine ME (2012) Building information for systematic improvement of the prevention of hospital-acquired pressure ulcers with statistical process control charts and regression. BMJ Quality & Safety 21 (6), 473–480.CrossRefGoogle Scholar
  39. Ratliff CR et al (2003) Guideline for prevention and management of pressure ulcers. In WOCN Clinical Practice Guideline; No. 2. Wound, Ostomy, and Continence Nurses Society (WOCN), Glenview, IL, p. 52.Google Scholar
  40. Sadiq S, Orlowska M, Sadiq W and Foulger C (2003) Data Flow and Validation in Workflow Modelling. Australian Computer Society 2004. (Schewe KD and Dunedin WH, Eds), Conferences in Research and Practice in Information Technology. 27, New Zealand.Google Scholar
  41. Schaffer A (2008) Fighting bedsores with a team approach. The New York Times.Google Scholar
  42. Sedlack JD (2010) The utilization of six-sigma and statistical process control techniques in surgical quality improvement. Journal of Healthcare Quality 32 (6), 18–26.CrossRefGoogle Scholar
  43. Tucker AL (2004) The impact of operational failures on hospital nurses and their patients. Journal of Operations Management 22 (2), 151–157.CrossRefGoogle Scholar
  44. Tucker AL (2010) Harvard Business School Faculty Research Symposium. In (Edmondson AC, Ed), The Work-Around Culture: Unintended Consequences of Organizational Heroes. President & Fellows of Harvard College, Boston, MA.Google Scholar
  45. Tucker AL and Edmondson AC (2003) Why hospitals don’t learn from failures: organizational and psychological dynamics that inhibit system change. California Management Review 45 (2), 55–72.CrossRefGoogle Scholar
  46. Tucker AL, Nembhard IM and Edmondson AC (2007) Implementing new practices: an empirical study of organizational learning in hospital intensive care units. Management Science 53 (6), 894–907.CrossRefGoogle Scholar
  47. Tucker AL and Spear SJ (2006) Operational failures and interruptions in hospital nursing. Health Services Research 41 (3), 642–662.Google Scholar
  48. van Loon E and Zuiderent-Jerak T (2012) Framing reflexivity in quality improvement devices in the care for older people. Health Care Analysis 20 (2), 119–138.CrossRefGoogle Scholar
  49. Wald HL and Kramer AM (2007) Nonpayment for harms resulting from medical care: catheter-associated urinary tract infections. Journal of the American Medical Association 298 (23), 2782–2784.CrossRefGoogle Scholar
  50. Weeks WB and Bagian JP (2000) Developing a culture of safety in the veterans health administration. Effective Clinical Practice 3 (6), 270–276.Google Scholar
  51. Weinstein MC and Skinner JA (2010) Comparative effectiveness and health care spending – implications for reform. New England Journal of Medicine 362 (5), 460–465.CrossRefGoogle Scholar
  52. Welton JM (2008) Implications of medicare reimbursement changes related to inpatient nursing care quality. Journal of Nursing Administration 38 (7–8), 325–330.CrossRefGoogle Scholar
  53. Yarnoff C et al (2003) EDC glossary. In EDC 2003: An Introduction to Engineering Design and Communication. p 223, Northwestern University Press, Evanston, IL.Google Scholar
  54. Zimmerman B, Lindberg C and Plsek P (2001) A complexity science primer. In Edgeware, Insights from Complexity Science for Health Care Leaders (Zimmerman B, Lindberg C and Pisek P, Eds), pp 3–20, VHA, Irving, TX.Google Scholar

Copyright information

© Operational Research Society Ltd 2014

Authors and Affiliations

  • William V Padula
    • 1
  • Michael P Duffy
    • 2
  • Taygan Yilmaz
    • 3
  • Manish K Mishra
    • 4
  1. 1.Department of MedicineUniversity of ChicagoChicagoU.S.A.
  2. 2.Department of Orthopaedic SurgeryTechnology Implementation Research Center, Massachusetts General HospitalBostonU.S.A.
  3. 3.Visual Services DepartmentHarvard Vanguard Medical AssociatesBostonU.S.A.
  4. 4.Department of PsychiatryDartmouth-Hitchcock Medical CenterLebanonU.S.A.

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