Tools For Problem Solving and Decision Making

Chapter 6.
Tools for Problem Solving and

Decision Making
An Integrated Approach to
Improving Quality and Efficiency
Daniel B. McLaughlin
Julie M. Hays
Healthcare Operations
Management
Copyright 2008 Health Administration Press. All rights reserved. 6-2
Chapter 6. Tools for Problem Solving
and Decision Making
Decision-making framework
Framing
Basic process improvement
Root cause analysis
Failure mode and effects analysis (FMEA)
Decision trees
Optimization
Theory of Constraints (TOC)
Force field analysis
Decision-Making Framework
Framing
- Identifying and framing the issue or problem
Gathering intelligence
- Generating or determining possible courses of action
and evaluating those alternatives
Coming to conclusions
- Choosing and implementing the best solution or
alternative
Learning from feedback
- Reviewing and reflecting on the above steps and
outcomes
Barriers to Good Decision
Making
Key Elements Barriers to Brilliant Decision
Making
Framing the question

Plunging in
Frame blindness
Lack of frame control
Gathering intelligence Overconfidence in your judgment
Shortsighted shortcuts
Coming to conclusions Shooting from the hip
Group failure
Learning/failing to learn from
feedback
Fooling yourself about feedback
Not keeping track
Failing to audit your decision
process
A Test of Your Problem-Solving
Abilities
4
If a doctor gave you
three pills and said to
take one every half
hour, how long would
they last?
1
Can a man living in Milwaukee,
Wisconsin, be buried west of the Mississippi?
2
If you had only one match and entered a room
where there was a lamp, an oil heater, and some
kindling wood, which would you light first?
3
How many animals of each
species did Moses take along
on the ark?
5
If you have two U.S. coins totaling 55 cents and one
of the coins is not a nickel, what are the two coins?
Mind Mapping
Diagram
created in
Inspiration
by
Inspiration
Software,
Inc.
Process Mapping/Flowcharting
Graphical depiction of a process showing
inputs, outputs, and steps in the process
Used to understand and optimize a process
Integral part of most improvement initiatives
including Six Sigma, Lean, Balanced
Scorecard, RCA, FMEA, and so forth
Process Mapping Steps
1. Assemble and train the team.
2. Determine process boundaries and
desired level of detail.
3. Determine and order major process tasks.
4. Draw a formal flowchart.
5. Check the accuracy of the formal
flowchart.
6. Collect more data and information as
needed.
Flowchart Standard Symbols
Microsoft Visio screen shots
reprinted with permission from
Microsoft Corporation.
A
rectangle
is used to
show a
task or
activity.
A diamond is used to
show those point in the
process where a choice
can be made or
alternate paths can be
followed.
Arrows show the
direction of flow of
the process.
End
Feedback
loop
D shapes are
used to show
delays.
Block arrows
are used to show
transports.
An oval is used to show
inputs/outputs to the
process or start/end of the
process.
Activity and Role Lane Mapping
Role
Activity Clerk Nurse Porter Doctor
Take insurance information x
Move patient x x
Record vital signs x x
Take history x x
Examine patient x
Write pathology request x
Deliver pathology request x
Service Blueprinting
Microsoft Visio screen shots reprinted with
permission from Microsoft Corporation.
Customer
gives
prescription
to clerk
Clerk enters
data
Clerk gives
prescription
to
pharmacist
Pharmacist
fills
prescription
Clerk gives
medicine to
customer
Clerk
retrieves
medicine
Pharmacist
gives
medicine to
clerk
Customer
receives
medicine
Line of interaction
Line of visibility
Customer
Actions
Onstage
Actions
Backstage
Actions
Root Cause Analysis
Structured, step-by-step techniques for
problem solving
Aimed at determining and correcting the
ultimate causes of a problem
What happened?
Why did it happen?
What can be done to prevent it from
happening again?
Five Whys Technique
Ask why the condition occurred.
Ask why for each answer (five times is a
good rule of thumb).

Cause and Effect Diagram
Waiting
Time
Waiting
Time
Methods
Machines Man
Mother Nature
(Environment)
Cause and Effect Diagram
Old inner-city
building
Lack of
treatment
rooms
Elevators
broken
Wheelchairs
unavailable
Transport arrives late
Process takes
too long
Excessive paperwork
Unexpected
patients
Wrong
patients
Staff not available
Corridor
blocked
Sick
Late
Files unorganized
Bureaucracy
Incorrect referrals
Lack of technology
Poor scheduling
Poor maintenance
HIPAA regulations
Waiting Time
Methods
Machines Man
Mother Nature
(Environment)
Original appointment missed
Failure Mode and Effects
Analysis (FMEA)
1
2
3
4
5
6
7
8
Total RPN (sum of all RPNs):
Failure Mode and Effects
Analysis (FMEA)
Failure mode: What could go wrong?
Failure causes: Why would the failure happen?
Failure effects: What would be the consequences of
failure?
Likelihood of occurrence: 110, 10 = very likely to occur
Likelihood of detection: 110, 10 = very unlikely to detect
Severity: 110, 10 = most severe effect
Risk priority number (RPN): Likelihood of occurrence
Likelihood of detection Severity
Theory of Constraints
The Goal (Goldratt and Cox 1986)
Every organization is subject to at least one
constraint, which limits it from moving
toward its goal.
Eliminating or alleviating the constraint can
enable the organization to come closer to its
goal.
Theory of Constraints
Five Steps
1. Identify the constraint (or bottleneck).
2. Exploit the constraint.
3. Subordinate everything else to the
constraint.
4. Elevate the constraint.
5. Repeat the process for the new constraint.
Optimization
A technique used to determine the optimal
allocation of limited resources, given a desired
goal

Resources
- People
- Money
- Equipment

Linear or nonlinear
Goal or objective
- Maximize profit or
revenue
- Minimize cost
Optimization
Optimization models have three basic
elements:
1. An objective function, which is the quantity
that needs to be minimized or maximized
2. The controllable inputs or decision variables
that affect the value of the objective function
3. Constraints that limit the values the decision
variables can take on
Decision Trees
70.0% 0.7
0 -7
Flu
-7 -7
30.0% 0.3 60.0% 0
0 -7 -6 -13
Costs
-7 -12.2
Vaccination 40.0% 0
Vaccination 70.0%
Vaccination
Program #2 -4 -11
program #1 0 -10.4 60.0% 0
-7 -12 -12
Costs
Flu -10.4
0 -7.28 0 40.0% 0
30.0% 0 -8 -8
0 0
HMO
vaccination
decision
Program
Flu
outbreak
No flu
outbreak
Flu
outbreak
No flu
outbreak
Program
No
program
C
D
A
B
Choose this
path because
expected
costs of $10.4
million are
Choose this
path because
expected
costs of $7
million are
less than
$7.28 million.
No
program
The tree diagram in this
figure was drawn with the
help of PrecisionTree,
a software product of
Palisade Corp., Ithaca,
NY; www.palisade.com.
Choose this
path because
expected costs
of $10.4 million
are less than
$12.2 million
Choose this
path because
expected costs
of $7 million
are less than
$7.28 million

Decision Tree
Risk Analysis
Initial Vaccination
Program
No Initial Vaccination
Program
# X P X P
1 7 1 12 0.42
2 8 0.28
3 0 0.30
Force Field Analysis
A technique for evaluating all the forces for
(driving) and against (restraining) a
proposed change
Used to decide whether a proposed change
can be implemented successfully
Used to develop strategies that will enable
successful implementation of a change
Force Field Analysis

Plan:
Change
to
bedside
shift
handover
Critical incidents
on the increase
Staff knowledgeable in
change management
Increase in discharge
against medical advice
Complaints from patients
and doctors increasing
Care given predominantly
biomedical in orientation
Ritualism and
tradition
Fear that this may lead
to more work
Fear of increased
accountability
Problems associated
with late arrivals
Possible disclosure of
confidential information
Total: 19
4
4
3
5
5
Total: 21
Driving Forces
Restraining Forces
4
5
3
3
4
Total: 19 Total: 21
Conclusion
The tools and techniques outlined in this
chapter are intended to help organizations
along the path of continuous improvement.
The choice of tool and when to use that tool
are dependent on the problem to be solved.
In many situations, several tools from this
and other chapters should be used to
ensure that the best possible solution has
been found.

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Chapter 6.

Tools for Problem Solving and

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