Coping with Complexity in Healthcare: guidelines and innovative methods Prof. Tarcisio A. Saurin saurin@ufrgs.br www.ufrgs.br
Porto Alegre
School of Engineering Founded in 1896 > 8,300 undergraduate students ~ 2,200 graduate students 400-600 engineers per year > 300 Master and PhD per year ~ 240 Academics and Sessionals ~ 120 Professional Staff
Ind. Eng. Postgrad. Program www.ufrgs.br/producao • One of the two top ranked in Brazil (score 7 – highest possible) • Founded in 1991 • 16 academics, all are PhD supervisors • 20 Master and 12 PhD students enroll every year • Master – 24 credits (face-to-face workload) – 2 years (4 semesters) • PhD – 42 credits (MSc credits can be used) – 4 years
Interaction with industry • R&D projects in collaboration with industry partners – Hospitals, distribution and generation of energy, manufacturing, • Executive courses (specialization 360 h, over 1 year) – Safety and ergonomics, Lean Production, Project Management, Finance Engineering, Logistics • Professional Masters (more practical approach, weekends, fees) • Professional PhD (under evaluation) • Consulting company managed by undergraduate students
Our Main Lab for Studying Complexity in Healthcare Hospital de Clinicas de Porto Alegre (HCPA) UFRGS´ teaching hospital
What is complexity ? • Similar definitions in many disciplines Similar definitions in many disciplines Similar definitions in many disciplines Similar definitions in many disciplines • Biology, Computer Science, Engineering Design, Management, etc. Biology, Computer Science, Engineering Design, Management, etc. Biology, Computer Science, Engineering Design, Management, etc. Biology, Computer Science, Engineering Design, Management, etc. structural structural and functional functional functional
Coping with Complexity: Six Guidelines
Monitoring unintended consequences • Small (and big) changes may interact in Small (and big) changes may interact in Small (and big) changes may interact in Small (and big) changes may interact in unexpected ways unexpected ways unexpected ways unexpected ways • There There There There are no definitive solutions in complex are no definitive solutions in complex are no definitive solutions in complex are no definitive solutions in complex systems systems systems systems • Broad range of outcome Broad range of outcome Broad range of outcome Broad range of outcome measures, neighboring systems, measures, neighboring systems, measures, neighboring systems, measures, neighboring systems, evaluation in the evaluation in the evaluation in the evaluation in the Play video butterfly effect long long- long long - - -run, run, run, quali run, quali quali and quali and and and quanti quanti quanti quanti
Diversity of perspectives in design • Take advantage of diversity to reduce uncertainty Take advantage of diversity to reduce uncertainty Take advantage of diversity to reduce uncertainty Take advantage of diversity to reduce uncertainty • Requirements Requirements Requirements Requirements • Trust, low power differences, capable decision Trust, low power differences, capable decision Trust, low power differences, capable decision Trust, low power differences, capable decision- - -makers - makers makers makers • Hard to implement under time pressure Hard to implement under time pressure Hard to implement under time pressure Hard to implement under time pressure • Collaboration Collaboration Collaboration Collaboration costs costs costs costs • Unintended consequences Unintended consequences Unintended consequences Unintended consequences
Design slack (or buffers) • Mechanism for Mechanism for Mechanism for reducing interdependencies Mechanism for reducing interdependencies reducing interdependencies reducing interdependencies and and and and minimizing the possibility of one process affecting minimizing the minimizing the minimizing the possibility of one process affecting possibility of one process affecting possibility of one process affecting another another another another, and thus it makes processes , and thus it makes processes loosely , and thus it makes processes , and thus it makes processes loosely loosely- loosely - - -coupled coupled coupled coupled • Several types of slack resources Several types of slack resources Several types of slack resources Several types of slack resources • People, equipment, money, space, time,… People, equipment, money, space, time,… People, equipment, money, space, time,… People, equipment, money, space, time,… Bundles of practices, early detection of the need for changing care plans, spare beds in the ICU, multisdisciplinary rounds, capacity gains due to greater efficiency,....
A Practical Example • Degrees of freedom Degrees of freedom Degrees of freedom when requesting medication Degrees of freedom when requesting medication when requesting medication when requesting medication • Anytime, if urgent (not life Anytime, if urgent (not life Anytime, if urgent (not life Anytime, if urgent (not life- - - -threatening situations) threatening situations) threatening situations) threatening situations) • Supplied in less than 20 minutes Supplied in less than 20 minutes Supplied in less than 20 minutes Supplied in less than 20 minutes
Monitoring the gap between WAI and WAD • This This gap is unavoidable in complex systems gap is unavoidable in complex systems This This gap is unavoidable in complex systems gap is unavoidable in complex systems • It is not necessarily detrimental It is not necessarily detrimental It is not necessarily detrimental It is not necessarily detrimental • Filling in the gaps in procedures can Filling in the gaps in procedures can be the reason for safe be the reason for safe Filling in the gaps in procedures can Filling in the gaps in procedures can be the reason for safe be the reason for safe performance ( performance ( performance (Hollnagel performance ( Hollnagel Hollnagel Hollnagel) ) ) ) • This is why we This is why we This is why we This is why we need to learn from what goes need to learn from what goes need to learn from what goes need to learn from what goes right right right right • It It It It is worth spending time understanding WAD before is worth spending time understanding WAD before is worth spending time understanding WAD before is worth spending time understanding WAD before intervening intervening intervening intervening • Previous Previous Previous Previous guidelines applied when designing WAI guidelines applied when designing WAI guidelines applied when designing WAI guidelines applied when designing WAI
Supporting visibility • Reduce perceived Reduce perceived complexity complexity Reduce perceived Reduce perceived complexity complexity • All human senses, not only vision All human senses, not only vision All human senses, not only vision All human senses, not only vision • Status Status of slack Status Status of slack of slack of slack resources resources resources resources • E.g. dashboards E.g. dashboards E.g. dashboards E.g. dashboards • Support Support Support Support visibility of visibility of visibility of visibility of informal informal informal informal work work work work • How gaps in procedures are filled in How gaps in procedures are filled in How gaps in procedures are filled in How gaps in procedures are filled in • Normalized deviances Normalized deviances Normalized deviances Normalized deviances
Creating an environment that supports resilience • It can be It can be influenced and supported It can be It can be influenced and supported influenced and supported influenced and supported by design by design by design by design • Apply the previous guidelines Apply the previous guidelines Apply the previous guidelines Apply the previous guidelines • And others… And others…fail And others… And others… fail fail fail- - - -safe devices safe devices, delegate authority to front safe devices safe devices , delegate authority to front , delegate authority to front , delegate authority to front- - - - line professionals,… line professionals,… line professionals,… line professionals,… • People development, resilient People development, resilient skills People development, resilient People development, resilient skills skills skills • Complex Complex Complex Complex controller to cope with a complex process controller to cope with a complex process controller to cope with a complex process controller to cope with a complex process
Examples of Practical Applications: Work-as-done Slack
Integrated Analysis and (Re)Design of Procedures and Training for Resilience Work-as-done
Practical application ► Procedure of administering medications to patients hospitalized in an ED
The adopted approach Resilience skills
Content analysis of procedures ► Are the goals of the activity stated in the procedure? ► Are the minimum inputs and preconditions required to start the activity stated? ► Are there examples of under / no specification that should have been specified? ► Are there work constraints that can make it difficult to follow the procedure stated? ► Are there over specifications ? ► Are the direct relationships with other procedures mentioned?
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