11. สาเหตุของความผิดพลาดทางการแพทย
(Causes of Medical Errors)
Cognitive Errors Cognitive Errors Latent Errors
(“Slips”) (“Mistakes”)
• Habit • Biases memory • Design of work that
• Interruptions • Overemphasis on exceeds the capacity of
• Hurry discrepant the human brain
• Fatigue • Availability of heuristic • Condition of work that
• Anger • Confirmation bias generate known causes
• Anxiety • Overconfidence of errors
• Boredom • Coning of attention • Poorly design &
• Fear • Reversion under stress maintenance of
equipment
• Inadequate training
11
Modified from: Leap (1994)
12. กายวิภาคของความผิดพลาด
(Anatomy of Errors)
The Real Word Levels of Safety
Healthy appearing decrepit 69 year old male, mentally Design, Management,
alert but forgetful
“Blunt” Training, Policies,
The skin was moist and dry.
Regulations
Occasional, constant, infrequent headaches.
Rules
Patient was alert and unresponsive
Rectal examination revealed a normal sized thyroid. Provider
She stated that she had been constipated for most of her
life, until she got a divorce. “Sharp”
Error
Accident Causation Model Contributing Factors (Vincent) 12
Modified from: Leap (1994); Pix source: free-ed.net/free-ed/HealthCare/Physiology/default.asp
enses
enses
Latent Systems Triggering Unsafe Errors
Errors Defects Factors Acts
13. Organizational Accidental Causation Model
Accident Causation Model Con
Defenses
Defenses
Latent Systems Triggering Unsafe Errors
Errors Defects Factors Acts
W
T
In
ACCIDENT
Accident
T
P
O
In
13
Modified
from:
James
Reason
(1993):
Pix
source:
simulaCon.londondeanery.ac.uk
20. นิยามของคุณภาพการบริการทางการแพทย
• The Institute of Medicine (IOM) definition of “healthcare quality”:
The degree to which health services for individuals and populations increase the
likelihood of desired health outcomes and are consistent with current professional
knowledge (IOM, 1990).
• Thus, the nature of healthcare problems is one of overuse, misuse, and underuse
of healthcare services (Chassen et al. 1998).
IOM (2002)
High-quality healthcare should be:
• Safe
• Effective
• Patient-centered
• Timely
• Efficient
20
Pix
source:
nap.edu
• Equitable
21. • Hospital Accreditation Standards (HA Thailand)
• Joint Commission International Accreditation Standards
for Hospital (JCI)
• Malcolm Baldrige National Quality Award (MBNQA)
• Thailand Quality Award (TQA)
“ทำไมถึงมีหลายมาตรฐานคุณภาพเหลือเกิน?”
21
Pix source: patentspostgrant.com
22. • Toyota Production System (TPS)
• Lean Thinking
• Just-In-Time Management (JIT)
• Six Sigma
• Theory of Constraints (TOC)/
• Total Quality Management (TQM) Constraints Management
• Deming Cycle (PDCA) • Patient Safety
• Modified Deming (FOCUS-PDCA) • Clinical Microsystems
• Kaizen-Gemba • Routine to Research (R2R)
“ยิ่งหลาย concepts ยิ่งสับสน”
22
Pix source: sinai.edublogs.org
23. • 5-S • Checklist
• 5-Whys • Control Chart & Run Chart/
• Ishikawa Cause-and-Effect Diagram Statistical Process Control (SPC)
(Root Cause Analysis) • Clinical Decision Support System
• Pareto Diagram (CDSS)
(Pareto Analysis)
• Spaghetti Diagram (Physical Flow
& Distance Analysis)
• Value Compass
• Value Stream Mapping (VSM)
“ยิ่งมากเครื่องมือ ยิ่งสับสนมากขึ้น”
23
Pix source: psychsurvivor2.wordpress.com/tools
24. “การบริหารเปนศาสตรหรือศิลป?”
• Late 1800s: Frederick W. Taylor (Scientific Management)
– Frank & Lillian Gilbreth
(the concept of Time, Motion & Fatigue study)
– Henry Gantt (Project Management)
24
Pix source: facebook.com/history; shadetreemechanic.com; en.wikipedia.org; buckmanb.wordpress.com
25. คุณภาพในโรงงาน (Manufacturing)
• Early 1900s: Henry Ford vs. Alfred P. Sloan
– Ford’s Model T 1913: 1st assembly line for mass production
(“You can have any color so long as it is black.”)
– Sloan’s General Motor (GM) operated autonomous
divisions coordinated through a general office (GMC,
Chevrolet, Cadillac, Buick, Pontiac, etc.)
– “Operations strategy”:
classic productivity dilemma:
economies of scale vs. economies of scope
25
Pix
source:
facebook.com/history;
shadetreemechanic.com;
en.wikipedia.org;
nndb.com
26. การตรวจสอบและควบคุมคุณภาพ
• 1920s: Walter A. Shewart laid the foundations
behind Statistical Process Control (SPC)
while working at Bell Laboratories.
• Up until 1960s: the Western approach to quality:
1) Workers are responsible for quantity through
production quotas and incentives.
2) Quality is addressed through inspection & handled
by a quality control (QC) group.
26
Pix
source:
facebook.com/history;
en.wikipedia.org;
openclipart.org;
clker.com
27. การพัฒนากระบวนการทำงาน
• 1950S: Small and fragmented Japanese Auto Market,
required a more flexible & efficient manufacturing system.
• 1960s: Ohno Taiichi, Toyota Production Engineer
developed the “Just-In-Time (JIT) production”, or
the "Toyota Production System (TPS)”.
– Mapping the work flow & eliminating the unnecessary steps
(“lean thinking”)
– Using teamwork to identify and fix problems as and where they
occurred (“Kaizen-Gemba”, “integrated socio-technical system”).
27
Pix
source:
facebook.com/history;
starnostar.com
28. TQM/CQI
• 1980s: Total Quality Management:
– W. Edward Deming: 15% of quality problems
are actually due to worker errors, while 85% of
quality problems are caused by systems and management.
Managers Workers
• เปนผูรับผิดชอบเปาหมายการผลิต • เปนผูรับผิดชอบคุณภาพงาน
(เชน จัดการทำงานนอกเวลา) • ไดรับอำนาจ (empowered) ที่จะ
• ไมตองควบคุมคนงานแตเนนการ หยุดสายการผลิตไดหากเกิดปญหาที่
ทำงานวางแผน ออกแบบกระบวนการ จะสงผลกระทบกับคุณภาพ
ทำงาน ฝกอบรม และจัดหาเครื่องมือ
เพื่อพัฒนากระบวนการทำงาน 28
Pix source: facebook.com/history; en.wikipedia.org; marcoantonioadministracao.blogspot.com; cqetraining.com
29. มาตรฐานคุณภาพโรงพยาบาล
• 1990S: The concepts of TQM/CQI were adopted by hospitals
worldwide, but lost popularity later. (Why?)
• Late 1990-2000s: Emerging quality standards:
– ISO, HA Thailand, JCI, MBNQA, TQA, etc.
• 2000s: Re-emerging concepts of TQM/CQI in different names:
– Lean Thinking/Lean Management
– Six Sigma
– Theory of Constrains (TOC)/Constraints Management
29
Pix
source:
facebook.com/history
34. เครื่องมือการบริหารจัดการทั่วไป
(General Management Tools)
• Strategic level: SWOT analysis, strategic HRM,
the Balance Scorecard (BSC), road-mapping, etc.
• Operational level: queuing model, business process
redesign, pay-for-performance (P4P), benchmarking, etc.
• Group level: the six thinking hats of de Bono,
the Delphi method, affinity diagram, etc.
34
35. จากการประกันคุณภาพสูการพัฒนาคุณภาพอยางตอเนื่อง
Quality Assurance (QA) Quality Improvement (QI)
• Professional training • Guidance (e.g. Practice guidelines,
• Professional licensing Protocols & Care pathways)
• Specialty board certification • Data analyses (e.g. Administrative
• Continuing professional data vs. Clinical data, Process vs.
education (e.g. CME, CNE) Outcome indicators)
• Peer review of records with • Feedback (e.g. Confidential vs.
feedback Public reporting, with financial
• Regulation of hospitals & clinics implications vs. without)
(e.g. MOPH, NHSO, CSMBS) • Institutionalized systems change
• Tort system (e.g. lawsuit) • Collaborative systems change
35
36. Food for Thought I
“Management is doing things right;
leadership is doing the right things.”
--Peter F. Drucker
36
Pix
source:
leadershipdynamics.wordpress.com
42. Food for Thought II
“All improvement is change,
but not all change is improvement”.
--Louise Stoll
42
Pix source: louisestoll.com
43. Food for Thought III
“We can’t solve the problems using the same
kinds of thinking we used when we created them.”
“Insanity is doing the same thing over and over
again but expecting different results.”
--Albert Eistein
43
Pix source: teachermoloneyking.com
53. the rooms were increased. The team also
increased the amount of space designated as the
patient area, hypothesizing that the additional
space would lead patients to feel more involved
in their care.
“The day after we set up the exam rooms, I
Patient Care Process Innovation
was seeing patients in one of them and getting
case study
immediate feedback about what worked,”says
Alan Duncan, M.D., SPARC’s medical director.
Mayo Clinic SPARC
“One thing patients responded well to was the Innovation Program
room’s rounded table. Sitting next to me at a
table, rather than across from me at a desk,
made patients feel like a partner in their own
• Prototyping: Rough, Right, Rapid
health care.”
s Decision aids
Physicians often wrestle with the problem of
patient compliance, wondering why patients fail
to adhere to the treatment plans they are given.
“We’ve found that being ‘given’ a treatment
plan is a big part of the adherence problem,”
says Victor Montori, M.D., SPARC’s director
of research and education.“When patients are
simply handed a prescription or told to make
lifestyle changes to improve a condition, they may
not fully comprehend the importance of the
recommendation. Furthermore, they may not get
to express concerns and challenges they may face
in implementing the recommendation. Indeed,
the recommendation, while optimal for most, may
not be the right one for this patient.”
Rapid prototyping is used to explore and refine ideas generated
by the SPARC team’s research.
3
53
Source: Mayo Clinic (2007) SPARC presents a significant opportunity
to make a difference in how we provide
54. skill of a surgeon or the diagnostic ability of a
radiologist may be difficult for most people,
nearly everyone recognizes quality service.
“When people come to Mayo Clinic, they
expect to receive world-class medical care,”
Patient Care Process Innovation
says Dr. Duncan.“ What sometimes surprises
them is the level of service they receive here.
Patients write to tell us about a physician who
treated them as more than just a number, a
custodian who put down her broom to help them
find an appointment or a desk attendant whose
• Mayo Clinic’s Center for Innovation: smile and demeanor put a nervous child at
ease.You can bet that if people are taking time
The SPARC Innovation Program at Mayo Clinic See
(Formerly SPARC program) Plan
to tell us those stories, they are telling them
to their families and friends as well.”
Act
Refine
“If I asked my customers
what they wanted,
Communicate
they would have said
a faster horse.”
— Henry Ford
The SPARC Innovation Program at Mayo Clinic
SPARCing advances in clinical care
SPARC inspires novel thinking about the best “By observing people, you uncover needs that
ways to deliver health care. As part of the effort, would never come out if you asked directly,
industrial engineers observe physicians and ‘What could we be doing better,’”says Ryan
patients interacting, and then develop ways to Armbruster, SPARC’s director of operations and
improve not just efficiency, but the overall design.“Observing situations allows us to get at
patient experience. needs people are unable to articulate because
Many SPARC activities take place in specially they aren’t even aware they exist.”
designed and constructed practice spaces in the “We’re looking to identify better ways of
Mayo Building. There consenting patients are delivering care through hypothesis-driven
observed as they interact with physicians. The research, which is similar to the scientific method
focus of the observation varies and has included used to unlock the mysteries of human diseases
how a redesigned exam room affects the patient- and formulate effective treatments,”says 54
Source: Mayo Clinic (2007)
physician relationship; how a new educational
tool impacts a patient’s understanding of his or
Dr. Brennan.“ In the process, we’ve created
Brainstorming sessions yield many innovative ideas in the SPARC offices.
something novel: a clinical laboratory where
her condition; and how a self-service check-in we can study the how of health care delivery.”
Nicholas LaRusso, M.D., chair, Department gratifying to be able to have an impact on patient
system influences patient satisfaction. in Rochester, believes
of Medicine at Mayo Clinic care over the period of a few weeks or months
that SPARC has the potential to elevate both instead of a few decades. We get the satisfaction
55. Patient Care Process Innovation
• Typical patient care process Innovation at LLUAHSC
(Loma Linda University Adventist Health Sciences Center)
Innova8on
Vision
&
Valida8on,
Future
State
Implementa8on
Insight
&
guiding
Customiza8on,
Design
&
Monitoring
Foresight
Principle
Prototype
Months
1-‐3
Months
4
Months
4-‐7
Months
8-‐10
Months
11-‐18
Educa8on
Communica8on
Change
Management
Project
Management
Cross-‐Func8onal
Team
55
Source: Adapted from Fike & Mengwasser (2007)
56. Six Sigma
• The DMAIC project methodology:
Define-Measure-Analyze-Improve-Control
• Systems to verify individuals’ relevant skill level
(Green Belt, Black Belt, etc.)
56
Pix
source:
leantransformaCon.com;
orielstat.com
59. ขอจำกัดของ Six Sigma
• Six Sigma มีทั้งการใชเครื่องมือทางสถิติที่ซับซอน และโครงสรางของการ
สรางทีมพัฒนาคุณภาพเปนลำดับขั้นชัดเจน อาจจำเปนนำตองปรับใชใหถูก
บริบทของบุคลากรประเภทตางๆขององคกร
• มีแนวโนมที่อาจจะควบคุมความเสถียรของกระบวนการยอย (stabilizing
processes) โดยที่อาจจะไมชวยยกระดับสมรรถภาพ (performance) ของ
ระบบใหญ่หรือขององคกร (inherent risk of “local optimization”)
59
Pix
source:
www.aafp.org/fpm;
individunificaCon.com
60. Constraint Management
• “หวงโซแตละเสนแข็งแรงไดเทากับขอตอ
ที่ออนแอที่สุดในโซเสนนั้นเทานั้น
(A chain is no stronger than its
weakest link)”
• The Theory of Constraints (TOC)
เปนปรัชญาทางการบริหารที่เสนอโดย
Eliyahu M. Goldratt (1984) มองการ
พัฒนาคุณภาพองคกรแบบองครวม
(big-picture, holistic view)
60
Souce:
Goldrab
(1984):
Pix
source:
prowessandpearls.blogspot.com
61. Constraint Management
• 5-step process to reach the “goal” of organization:
1) Identify: คนหาและระบุ “ขอจำกัด (constraints)” ของระบบในปจจุบัน
2) Exploit: ตัดสินใจวาจะจัดการกับขอจำกัดของระบบอยางไร
3) Subordinate: ประสานทรัพยากรทั้งองคกรเพื่อจัดการกับขอจำกัดนั้น
4) Elevate: เปลี่ยนแปลงระบบเพื่อทำลายขอจำกัด (break the constraints)
5) Go back to step 1: โดยระวังไมใหขอจำกัดนั้นกลับมาอีก
61
Source: Inuzu et al. (2012)
64.
การบูรณาการแนวคิดการพัฒนาคุณภาพ
“The Constraints Management window is like looking
at the forest from a hot air balloon and selecting the
best tree from which to pick fruit. The Lean window
shows the simplest way to pick the low-hanging fruits
as well as the fruit on the floor with very little effort.
And the Six Sigma window shows how to consistently
pick the bulk of the sweeter fruits, without bruising
them, at higher, difficult-to-reach
branches of the tree.”
64
Source: Inuzu et al. (2012); Pix source: magic-mural-factory.com