The Programme The HSMA : • Identifies and undertakes modelling projects within and for their own organisations • Uses Discrete Event Simulation and “What if” analysis to predict the impact of changes to pathways or changes to resource capacities • Is trained by PenCHORD to use advanced modelling software packages, such as Simul8 (licence provided by Simul8 Corporation) • Is supported by a PenCHORD Mentor, who provides advice and guidance to support the completion of projects and ongoing skills development • Is part of a Learning Set of HSMAs who meet monthly to share experiences and support • Presents their project work both within their own organisations and at the PenCHORD Seminar, Showcase and Workshop series • Champions the use of Operational Research in their organisation, and helps to raise awareness of Operational Research and the capacity building initiatives run by PenCHORD and the wider CLAHRC • Is released for one day per week to undertake this work, for a period of 12 months NIHR CLAHRC for the South West Peninsula
The HSMA Projects Royal Cornwall Hospitals Trust What are the current bottlenecks within the acute eye service, and how can we improve? Royal Devon and Exeter NHS Foundation Trust How would the addition of a Clinical Decision Unit (CDU) affect patient flow and waiting times at R D & E? South West Ambulance Service Trust What are the bottlenecks in getting cardiac arrest patients to definitive care? Devon Partnership Trust How do we reduce delayed discharge in the Mental Health Acute Care pathway? Northern Devon Healthcare Trust Modelling A & E flow rates at North Devon District Hospital Plymouth Hospitals NHS Trust What would be the impact of various strategies to improve weekend discharge rates? NIHR CLAHRC for the South West Peninsula
Contact Us penchord@exeter.ac.uk Email us at : PenCLAHRC PenCHORD @penclahrc @penclahrcOR Join the conversation : #penclahrc #penclahrcOR Website : http://clahrc-peninsula.nihr.ac.uk/penchord.php NIHR CLAHRC for the South West Peninsula
PenCHORD Project Work Examples PenCHORD @penclahrcOR @penclahrc NIHR CLAHRC for the South West Peninsula
Reducing mental health assessment waiting times in Devon
High-sensitivity troponin for the diagnosis of acute myocardial infarction in A&E
What are the factors that most influence the demand for ambulances in South West England?
Cornwall mental health inpatient pathway modelling
Reducing delays in the bladder cancer pathway at Royal Cornwall Hospital
Radiographer-led discharge at Yeovil District Hospital
Optimising resource configurations to match demand in A & E at Royal Cornwall Hospital
Optimising the location of outpatient clinics in Cornwall
Optimising polypharmacy prescribing practice using behavioural modelling
Redesigning emergency stroke pathways to maximise thrombolysis rates
Modelling in Health and Social Care Module 3 : Structuring Problems for Modelling Introduction to Problem Structuring
Modelling in Health and Social Care Module 3 : Structuring Problems for Modelling Who Are You? In pairs / small groups : • Name • Organisation • Role • Why Have You Come? • What experience do you have (if any) with problem structuring methods?
Modelling in Health and Social Care Module 3 : Structuring Problems for Modelling The Modelling Process PROBLEM SITUATION ANALYSIS & IMPLEMENTATION CONCEPTUALISATION OPERATIONAL CONCEPTUAL VALIDITY VALIDITY DATA CONCEPTUAL SOLUTION VALIDITY MODEL EXPERIMENTAL LOGICAL VALIDITY VALIDITY OBTAINING FORMAL SOLUTIONS MODELLING FORMAL MODEL 52 The modelling-validating process (Landry, Malouin and Oral 1983, p.212)
Modelling in Health and Social Care Module 3 : Structuring Problems for Modelling The Modelling Process PROBLEM SITUATION ANALYSIS & IMPLEMENTATION CONCEPTUALISATION OPERATIONAL CONCEPTUAL VALIDITY VALIDITY DATA CONCEPTUAL SOLUTION VALIDITY MODEL EXPERIMENTAL LOGICAL VALIDITY VALIDITY OBTAINING FORMAL SOLUTIONS MODELLING FORMAL MODEL Modules 1 and 2 53 The modelling-validating process (Landry, Malouin and Oral 1983, p.212)
Modelling in Health and Social Care Module 3 : Structuring Problems for Modelling The Modelling Process Module 3 PROBLEM SITUATION ANALYSIS & IMPLEMENTATION CONCEPTUALISATION OPERATIONAL CONCEPTUAL VALIDITY VALIDITY DATA CONCEPTUAL SOLUTION VALIDITY MODEL EXPERIMENTAL LOGICAL VALIDITY VALIDITY OBTAINING FORMAL SOLUTIONS MODELLING FORMAL MODEL Modules 1 and 2 54 The modelling-validating process (Landry, Malouin and Oral 1983, p.212)
Modelling in Health and Social Care Module 3 : Structuring Problems for Modelling Transforming our view of a problem…
Modelling in Health and Social Care Module 3 : Structuring Problems for Modelling Transforming our view of a problem…
Modelling in Health and Social Care Module 3 : Structuring Problems for Modelling Transforming our view of a problem…
Modelling in Health and Social Care Module 3 : Structuring Problems for Modelling Transforming our view of a problem…
Modelling in Health and Social Care Module 3 : Structuring Problems for Modelling Transforming our view of a problem…
Modelling in Health and Social Care Module 3 : Structuring Problems for Modelling Why do we need to structure problems? • Real world problems are often messy and complex • Different people have different perceptions about the same systems • Things in the real world often change over time – they are dynamic How can problem structuring help? • By helping to clarify our view of the problem • By helping to seek consensus and develop a common language • By determining the key elements of the problem to better allow us to solve it
Modelling in Health and Social Care Module 3 : Structuring Problems for Modelling A Well- Structured Problem
Modelling in Health and Social Care Module 3 : Structuring Problems for Modelling Question • What are you asking? • Specific • Clear • Clear goals A Well- Structured Problem
Modelling in Health and Social Care Module 3 : Structuring Problems for Modelling Scope Question • • Intricacy (level of detail What are you asking? • required) Specific • • Boundaries (how wide Clear • is the world view?) Clear goals A Well- Structured Problem
Modelling in Health and Social Care Module 3 : Structuring Problems for Modelling Scope Question Constraints and • • Intricacy (level of detail What are you asking? Assumptions • • required) What are the limits to our Specific • • knowledge? Boundaries (how wide Clear • What must we assume? • is the world view?) Clear goals A Well- Structured Problem
Modelling in Health and Social Care Module 3 : Structuring Problems for Modelling Scope Question Constraints and • • Intricacy (level of detail What are you asking? Assumptions • • required) What are the limits to our Specific • • knowledge? Boundaries (how wide Clear • What must we assume? • is the world view?) Clear goals A Well- Structured Problem Resources and Stakeholders • What resources (people, data, time etc) do you have to solve the problem? • Who are the parties interested in / affected by the solving this problem?
Modelling in Health and Social Care Module 3 : Structuring Problems for Modelling Scope Question Constraints and • • Intricacy (level of detail What are you asking? Assumptions • • required) What are the limits to our Specific • • knowledge? Boundaries (how wide Clear • What must we assume? • is the world view?) Clear goals A Well- Structured Problem Resources and Stakeholders Methods • • What resources (people, data, time How could the problem be solved? • etc) do you have to solve the What is the preferred method for problem? solving the problem? • Who are the parties interested in / affected by the solving this problem?
Modelling in Health and Social Care Module 3 : Structuring Problems for Modelling Problem Structuring Methods • Problem Structuring Methods (PSMs) provide a means of structuring messy problems • PSMs are a type of modelling known as ‘Soft Modelling’ (or ‘Soft Operational Research’), because they tend to use qualitative rather than quantitative methods. Structured Mathematical Messy Problem Model / Simulation PSMs Math / Problem In-Silico “What Modelling If?” Analysis Solution
Contact Us penchord@exeter.ac.uk Email us at : PenCLAHRC PenCHORD @penclahrc @penclahrcOR Join the conversation : #penclahrc #penclahrcOR #thisisOR PenCHORD Live Wall Stream : penchord.livewallstream.com Website : http://clahrc-peninsula.nihr.ac.uk/penchord NIHR CLAHRC for the South West Peninsula
Modelling in Health and Social Care Module 3 : Structuring Problems for Modelling Introduction to Your Problems
Modelling in Health and Social Care Module 3 : Structuring Problems for Modelling What’s Next? For the rest of the day, we’ll be working with your problems. You will split into pairs. Each pair will tackle both of the problems brought with you, spending half the time in each activity on each problem. Those who do not wish to work on a problem of their own should join another pair (but work on your one if you can!). By the end of the day, you should have turned this messy / complex problem into a well-structured one, ripe for further analysis (maybe even modelling!)
Modelling in Health and Social Care Module 3 : Structuring Problems for Modelling Step 1 : Split into Pairs Please now arrange yourself into pairs.
Modelling in Health and Social Care Module 3 : Structuring Problems for Modelling Step 2 : Presenting the Potential Problems For the next 10 minutes, you will discuss the problems you have brought with each other. If you have brought more than one problem, use this as an opportunity to decide on which one you will work on. When picking your problem, don’t shy away from the messy and the complex – that’s how PSMs can help!
Modelling in Health and Social Care Module 3 : Structuring Problems for Modelling Step 3 : Presenting your Chosen Problems to the Room Everybody should now give a brief 1 minute summary of the problem you will be working on.
Contact Us penchord@exeter.ac.uk Email us at : PenCLAHRC PenCHORD @penclahrc @penclahrcOR Join the conversation : #penclahrc #penclahrcOR #thisisOR PenCHORD Live Wall Stream : penchord.livewallstream.com Website : http://clahrc-peninsula.nihr.ac.uk/penchord NIHR CLAHRC for the South West Peninsula
Qualitative System Dynamics The first step to help focus your questions is to understand the nature of the problem, and where the likely problem areas are. This helps to identify area(s) to focus on. NIHR CLAHRC for the South West Peninsula
System Dynamics (Whole Systems Modelling) What is it? What is its typical use in health and social care modelling? A way to model the flows Modelling larger scale health and social care systems, and between the various the flows of patients between providers in the system components of a high-level or abstracted system Modelling the inter-connected influencing factors that lead to a “trigger” (e.g. admission, ambulance call etc)
Qualitative System Dynamics • Create map of influences and their directionality • Identify feedback loops within the map (the “causal loop diagram”) • Draw insight from the map and its associated feedback loops to better understand system behaviour NIHR CLAHRC for the South West Peninsula
Example influences + Number of people accessing Waiting time to see GP GP services As the number of people accessing GP services increases , the waiting time to see a GP increases (Both go in the same direction) - Number of people admitted Number of beds available in to hospital hospital As the number of people admitted to hospital increases , the number of beds available in the hospital decreases (Each goes in opposite directions) NIHR CLAHRC for the South West Peninsula
Reinforcing Loops (“Vicious Circles”) Number of people accessing GP services + + Waiting time to see GP Number of sick people in the community + Reinforcing Loops have an even number of ( or zero ) minus signs. Therefore the same conclusion is reached each time you loop. NIHR CLAHRC for the South West Peninsula
Reinforcing Loops (“Vicious Circles”) Number of people accessing GP services + Number of people attending A & E + + Waiting time to see GP Number of sick people in the community + Reinforcing Loops have an even number of ( or zero ) minus signs. Therefore the same conclusion is reached each time you loop. NIHR CLAHRC for the South West Peninsula
Balancing Loops Number of people admitted to hospital + - Number of beds available in hospital + Capacity to admit patients Balancing Loops have an odd number of minus signs. Therefore a contradictory conclusion is reached each time you loop. NIHR CLAHRC for the South West Peninsula
Exercise 1 : Qualitative System Dynamics (Total Time = 2 hours) 1. In your pairs, take your first problem. Write down the problem as a problem statement. Make sure this is a problem, and not a question, or a potential solution. 2. Spend 5 minutes listing as many factors as you can think of that are directly contributing to the problem. 3. Once you’ve done this, start to map out these factors, identifying how each contributes to your problem (directionality of influence), and how they influence and / or are influenced by other factors. For each factor you add, ask if it influences or is influenced by any of the factors you have already identified. Then ask if there are other relevant factors not yet identified that it influences or is influenced by. You will have 30 minutes to do this. 4. Then spend 20 minutes identifying the reinforcing and balancing loops in your model. What insights can you draw from this? 5. After this, change over and do the same for your other problem. 6. At the end of the exercise, we will ask selected pairs to present their models and insights to the room.
Modelling in Health and Social Care Module 3 : Structuring Problems for Modelling Stakeholder Analysis
Modelling in Health and Social Care Module 3 : Structuring Problems for Modelling Who are Stakeholders? Those people who have an interest in and / or influence on a problem and / or its solution. These questions may help you identify them : 1) Who owns the problem? 2) Who might benefit from its solution? 3) Who might suffer from its solution? 4) Who has a legitimate interest in the problem and / or its solution? 5) Who has the power to influence the process of solving the problem and implementing the solution?
Modelling in Health and Social Care Module 3 : Structuring Problems for Modelling Why Consider the Stakeholders? Why is it important to consider who are the stakeholders?
Modelling in Health and Social Care Module 3 : Structuring Problems for Modelling Why Consider the Stakeholders? Why is it important to consider who are the stakeholders? • You need to know who holds information and / or data you’ll need • You need to know who might help or hinder solving the problem or implementing the solution • You need to understand the nature of any conflicts (or potential conflicts), how that might impact the work, and how they might be mitigated
Modelling in Health and Social Care Module 3 : Structuring Problems for Modelling Stakeholder Analysis There are various methods for identifying and visualising the stakeholders : • Organisational Charts • Interest / Influence Diagram • Strategy Group Diagram
Modelling in Health and Social Care Module 3 : Structuring Problems for Modelling Organisational Charts Charts of the staff and hierarchy within an organisation. • Can be useful to identify key contacts But : • Organisations frequently don’t have them • They may not represent all stakeholders in the project • The hierarchy may not necessarily equate to interest in (or even influence on) the project.
Modelling in Health and Social Care Module 3 : Structuring Problems for Modelling Interest / Influence Diagram Influence Low Interest High Interest High Influence High Influence Low Interest High Interest Low Influence Low Influence Interest
Modelling in Health and Social Care Module 3 : Structuring Problems for Modelling Interest / Influence Diagram Influence PLAYERS CONTEXT SETTERS Keep informed Key players - Engage closely CROWD SUBJECTS Monitor (minimal effort) Keep satisfied Interest
Modelling in Health and Social Care Module 3 : Structuring Problems for Modelling Interest / Influence Diagram Influence Stakeholder A Stakeholder B Stakeholder C Interest
Modelling in Health and Social Care Module 3 : Structuring Problems for Modelling Exercise 2 : Build an Interest / Influence Diagram • In your pairs, using the large sheets and sticky notes provided, you’ll now build a Stakeholder Interest / Influence Diagram for each of your problems. • You should spend 30 minutes on each problem (total exercise time = 60 minutes). At the end of the exercise, selected individuals will present their diagrams. Remember, to identify stakeholders think about : 1) Who owns the problem? 2) Who might benefit from its solution? 3) Who might suffer from its solution? 4) Who has a legitimate interest in the problem and / or its solution? 5) Who has the power to influence the process of solving the problem and implementing the solution?
Contact Us penchord@exeter.ac.uk Email us at : PenCLAHRC PenCHORD @penclahrc @penclahrcOR Join the conversation : #penclahrc #penclahrcOR #thisisOR PenCHORD Live Wall Stream : penchord.livewallstream.com Website : http://clahrc-peninsula.nihr.ac.uk/penchord NIHR CLAHRC for the South West Peninsula
Modelling in Health and Social Care Module 3 : Structuring Problems for Modelling Process Mapping
Modelling in Health and Social Care Module 3 : Structuring Problems for Modelling What is Process Mapping? A means of capturing the discrete processes within a system, and the potential inputs and outputs to these processes, in order to better understand how a system works. Process Mapping is a vital tool for understanding how your system works. How can you improve a system if you don’t know what your system looks like?
Modelling in Health and Social Care Module 3 : Structuring Problems for Modelling What is a Process? Processes are activities that have a number of steps and which transform inputs into outputs . In this way, processes can be thought of as functions. Output = function (inputs) Y = f(x) Inputs Outputs
Modelling in Health and Social Care Module 3 : Structuring Problems for Modelling The “Secret” of Process Mapping Process mapping is extremely easy if you just bear in mind one simple rule :
Modelling in Health and Social Care Module 3 : Structuring Problems for Modelling The “Secret” of Process Mapping Process mapping is extremely easy if you just bear in mind one simple rule : Say what you see!
Modelling in Health and Social Care Module 3 : Structuring Problems for Modelling Top Process Mapping Tips • Have clear start and end points (there may be multiple of each – that’s fine as long as they’re well defined) • Describe what really happens, not what should happen • Don’t worry about one -off exceptions to the process unless they’re important for your question • Process map as a team – everyone has a different perception of the “true” system and everyone should contribute • Think about the patient journey – how do they flow between processes in your system? • Create a visual representation of your system – a Process Map
Example Process Maps
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