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Ramathibodi Quality Conference lecture 2012.9.20

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Borwornsom Leerapan
Borwornsom Leerapan

Lecturing "common pitfalls" in healthcare quality management at Ramathibodi Quality Conference'55.

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??????????????????????????????? ????? ?????????, ?.?., PhD, SM? ???????????????????? 19: ?????????????? ????? ??????????? ??????????????????????????????? ?.?????? 20 ??????? 2555? 1 ? Pix source: bbc.co.uk/bitesize/standard/biology?
Presentation Outlines? ?? ???????? (pitfall) ????????????? ???????????????? ?????????????????????????? ? ?? ???????????????????????????? (????????????????) ? ?? ?????????????????????????????????????????????? 2 ? Pix source: online.wsj.com?
Pitfall #1: ¡°Just Be Professional?¡±? ¡°?????????????????????????????????????????????????¡±? 3 ? Pix source: kevin.lexblog.com?
¡°??????????????????????????????????¡±? 4 ? Pix ?source: ?devastatecharlie.blogspot.com; ?uboat.net; ?strangecosmos.com; ?historylink101.com ? ?
¡°??????????????????????????????????¡±? 5 ? Pix ?source: ?devastatecharlie.blogspot.com; ?uboat.net; ?warbirdinformaConexchange.org; ?pwencycl.kgbudge.com ? ? ?
???????? (????????)? 6 ? Pix ?source: ?airportjournal.com; ?pwencycl.kgbudge.com ? ? ?
???????????????????? (???????)? 7 ? Pix ?source: ?virtualphalcon.blogspot.com; ?canitbesaturdaynow.com; ?science.howstu?works.com ? ? ?
8 ? Source: www.youtube.com/watch?v=vJG698U2Mvo?
9 ? Source: Leap (1994)?
?????????????????????? 10 ? Source: ?AmalberC ?et ?al. ?(2005): ?Pix ?source: ?focusedehs.com; ?alexhibbert.com ?
???????????????????????????????? (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? ?? Con?rmation bias? generate known causes ?? Anxiety? ?? Overcon?dence? of errors? ?? Boredom? ?? Coning of attention? ?? Poorly design & ?? Fear? ?? Reversion under stress? maintenance of ? equipment ? ?? Inadequate training? 11 ? Modi?ed from: Leap (1994)?
??????????????????????? (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 ? Modi?ed 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
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 ? Modi?ed ?from: ?James ?Reason ?(1993): ?Pix ?source: ?simulaCon.londondeanery.ac.uk ? ?
¡°Swiss Cheese Model¡±? 14 ? Modi?ed from: Reason (1993); Pix source: webmm.ahrq.gov?
15 ? Figure ?Source: ?medicexchange.com ? ? ?
16 ? Figure ?Source: ?ascribe.com ?
???????? #1: ????????????????????????? ????????????????? (Individual competency)? ????????????? #1: ?????????????????????????¡°???????¡± ? ??????????????????? (sharp end) ??????????? (blunt end) ? ??????????????????????????????????????????????????? 17 ? Pix source: docblogs.wordpress.com; gearjunkie.com?
18 ? ?????????????????????????????? 20 ?.?.2555 ?????????? 00.30 ?. ?
Pitfall #2: ¡°Just Another Buzzword?¡±? ¡°???????????????????????????? ????????????????????????¡±? 19 ? Pix source: mobilecollective.wordpress.com?
??????????????????????????????????? ?? The Institute of Medicine (IOM) de?nition 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? ? Ef?cient? 20 ? Pix ?source: ?nap.edu ? ? Equitable?
?? Hospital Accreditation Standards (HA Thailand) ? ?? Joint Commission International Accreditation Standards for Hospital (JCI) ? ?? Malcolm Baldrige National Quality Award (MBNQA) ? ?? Thailand Quality Award (TQA) ? ¡°????????????????????????????????????¡±? 21 ? Pix source: patentspostgrant.com?
?? 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 ? ?? Modi?ed Deming (FOCUS-PDCA)? ?? Clinical Microsystems ? ?? Kaizen-Gemba? ?? Routine to Research (R2R) ? ¡°???????? concepts ?????????¡±? 22 ? Pix source: sinai.edublogs.org?
?? 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) ? ¡°????????????????? ????????????????¡±? 23 ? Pix source: psychsurvivor2.wordpress.com/tools?
? ? ? ¡°?????????????????????????????¡±? ?? Late 1800s: Frederick W. Taylor (Scienti?c Management)? ¨C?Frank & Lillian Gilbreth ? (the concept of Time, Motion & Fatigue study)? ¨C?Henry Gantt (Project Management)? 24 ? Pix source: facebook.com/history; shadetreemechanic.com; en.wikipedia.org; buckmanb.wordpress.com?
? ? ? ?????????????? (Manufacturing)? ?? Early 1900s: Henry Ford vs. Alfred P. Sloan? ¨C? Ford¡¯s Model T 1913: 1st assembly line for mass production? (¡°You can have any color so long as it is black.¡±)? ¨C? Sloan¡¯s General Motor (GM) operated autonomous ? divisions coordinated through a general of?ce (GMC, ? Chevrolet, Cadillac, Buick, Pontiac, etc.) ? ¨C? ¡°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 ?
?????????????????????????? ?? 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 ? ?
? ??????????????????????? ?? 1950S: Small and fragmented Japanese Auto Market, required a more ?exible & ef?cient manufacturing system.? ?? 1960s: Ohno Taiichi, Toyota Production Engineer? developed the ¡°Just-In-Time (JIT) production¡±, or? the "Toyota Production System (TPS)¡±.? ¨C? Mapping the work ?ow & eliminating the unnecessary steps (¡°lean thinking¡±)? ¨C? Using teamwork to identify and ?x problems as and where they occurred (¡°Kaizen-Gemba¡±, ¡°integrated socio-technical system¡±).? 27 ? Pix ?source: ?facebook.com/history; ?starnostar.com ?
? ? TQM/CQI? ?? 1980s: Total Quality Management: ? ¨C? 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? ?? ??????????????????????????????? ? ?? ?????????????????????????? (???? ??????????????????) ? ?? ??????????? (empowered) ????? ?? ???????????????????????????? ???????????????????????????????? ??????????? ??????????????? ?????????????????????? ????? ??????? ?????????????????? ???????????????????????? ? 28 ? Pix source: facebook.com/history; en.wikipedia.org; marcoantonioadministracao.blogspot.com; cqetraining.com?
? ??????????????????????? ?? 1990S: The concepts of TQM/CQI were adopted by hospitals worldwide, but lost popularity later. (Why?)? ?? Late 1990-2000s: Emerging quality standards: ? ¨C? ISO, HA Thailand, JCI, MBNQA, TQA, etc.? ?? 2000s: Re-emerging concepts of TQM/CQI in different names:? ¨C? Lean Thinking/Lean Management ? ¨C? Six Sigma? ¨C? Theory of Constrains (TOC)/Constraints Management ? 29 ? Pix ?source: ?facebook.com/history ?
? ??????????????????????? ¡°???????????????????????/??????¡± >>> ¡°????????????????????????????¡±? Thailand Quality Award (TQA) Framework? 30 ? Pix ?source: apo-?©\tokyo.org ?
?????????? 1.0? Phase 1: QC? ¨C????????????? (quality control) ???????????? ?????????? (defects) ????????????????????? ? ¨C????????????????? (producer) ?????????????? (consumer) ? ??????????????????????? (sampling) ?????????????????? ? ¨C???????????????????? (statistical errors)? ?????????????????????????????????? ???????????????????????????? ?????????????????????????????? ? 31 ? Pix ?source: ?en.wikipedia.org ?
?????????? 2.0 ? Phase 2: QA (with tools) & QA? ¨C???? Statistical Process Control (SPC) ?????????????????? ¨C??????????????????????????????????????????? ?????????????? ????????????????????????????????? ¨C?????????????????????????????????????? (operational level) ? 32 ? Pix ?source: ?en.wikipedia.org ?
?????????? 3.0 ? ?? Phase 3: TQM/CQI? ¨C???????????????????????????????????? ????????????????????????????????? ???????????????????????????? ? ¨C????????????????? ???? ?????????????? (system approach) ????????????????? ?????????????????????? ????????? ?????????????????????????????? ???????????? 33 ? Pix source: tpabooks.?les.wordpress.com?
???????????????????????????????? (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, af?nity diagram, etc. ? 34 ?
?????????????????????????????????????????????????? Quality Assurance (QA)? Quality Improvement (QI)? ?? Professional training ? ?? Guidance (e.g. Practice guidelines, ?? Professional licensing ? Protocols & Care pathways)? ?? Specialty board certi?cation ? ?? 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. Con?dential vs. feedback ? Public reporting, with ?nancial ?? Regulation of hospitals & clinics implications vs. without)? (e.g. MOPH, NHSO, CSMBS) ? ?? Institutionalized systems change? ?? Tort system (e.g. lawsuit) ? ?? Collaborative systems change? 35 ?
Food for Thought I? ? ¡°Management is doing things right; ? leadership is doing the right things.¡±? ? ? ? ? ? ? ? ? ? ? ? ? ? ? ? ? ? ? ? ? ?--Peter F. Drucker ? ? ? ? ? ? ? ? ? 36 ? Pix ?source: ?leadershipdynamics.wordpress.com ?
???????? #2: ????????????????????????????? ?????????????????? (Management Fads & Fashions)? ???????????????????????? ????????????????????????????? (QC) ? ???????????? (QA) ????????????????????????????????????????? (TQM/CQI)? ????????????? #2: ¡°??????????????????? ????????????????? ????????????????????????????? ?????? ?????????????¡±? 37 ? Pix source: praphansarn.com; school.discoveryeducation.com/?
Pitfall #3: ¡°Adhere to a Frame?¡±? ¡°??????????????????????????????????????????????????¡±? 38 ? Pix source: creativedreamincubator.com?
Deming Cycle? ?? PDCA: Plan-Do-Check-Act? (PDSA: Plan-Do-Study-Act)? ? ?? FOCUS-PDCA: Find-Organize-Clarify-Understand-Select? (Modi?ed PDCA by Hospital Corporation of America)? 39 ? Pix ?source: ?www.aafp.org/fpm; ?individuni?caCon.com ?
??????????? Deming Cycle? ?? PDCA ???????????????????????????????????????? (performance) ????????????????????????? ?? PDCA ??????????? ???????????????????????????? ?????????????????? ????????????????????????????????????????? (???? Benchmarking ??????? ???????, ?????????? ¡°NIH syndrome¡±)? ?? PDCA ???????????????????????????????????????? ¡°???????¡± ????? ?????????? (???? ?????????????????????????????????????????????????? ??????????????????????????????????????????????????????????????? Routine-to-Research or ¡°R2R¡± ???????)? 40 ? Pix ?source: ?www.aafp.org/fpm; ?individuni?caCon.com ?
??????????? Deming Cycle? ??????????????????? ¡°PDCA¡± & ¡°R2R¡± ? 41 ? Pix ?source: ?courtesy ?of ?Akarin ?Nimmamit, ?MD ?
Food for Thought II? ¡°All improvement is change,? but not all change is improvement¡±.? ? --Louise Stoll? 42 ? Pix source: louisestoll.com?
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?
Lean Management? 44 ? Pix source: joevaughan.com?
Kaizen/Gemba? ?? Kaizen (¸ÄÉÆ) ???????????? ¡°??????? (kai)¡± ??????????? ¡°?? (zen)¡±? ?? Genba (¬Fˆö) ???????????? ¡°???????????¡± ( e.g. the crime scene, the place where value is created)? ?? ???????????? Muda/waste, ??????????????????????????????????????? ??????? ¡°5?.¡± (5-S¡± method):? ¨C? Seiri (ÕûÀí), tidiness, ?????? ¨C? Seiton (ÕûîD), orderliness, ?????? ¨C? Seiso (Çå’ß), cleanliness,?????? ¨C? Sieketsu (Çå), standardize clean-up, ?????????? ¨C? Shisuke (Üz), discipline, ??????????? ? Pix source: van Assen (2009)?
Spaghetti Diagramming? 46 ? Pix source: sprickgroup.com?
Value Stream Mapping (VSM)? 47 ? Pix source: cfmc.org?
Value Stream Mapping (VSM)? 48 ? Pix ?source: ????????????????? ??????????????????????? Stat ?? ????????????? (2552), ?retrieved ? ?from ?gotoknow.org ? ? ?
49 ? Source: ? ?Ext. ??????? ?????????????, ?Ext. ?????? ??????????????, ?Ext. ?????? ?????????????, ?Ext. ????????? ??????? ?(2555) ? ?
50 ? Source: ? ?Ext. ??????? ?????????????, ?Ext. ?????? ??????????????, ?Ext. ?????? ?????????????, ?Ext. ????????? ??????? ?(2555) ? ?
patient screening OPD ? Home registration PROCESS pharmac y Screening ? Vital ?signs+BW ? prescription Refer ? Admit ? appointmen t Treatment History taking room! Exit ?Care ? ER ? age ?0-?©\14 ?yrs age ?15-?©\59 ?yrs waiting ? OPD ?8 ?room age ?>60 ?yrs Lab ? 51 ? Source: ? ?Ext. ??????? ?????????????, ?Ext. ?????? ??????????????, ?Ext. ?????? ?????????????, ?Ext. ????????? ??????? ?(2555) ? ?
??????????? Lean Management? ?? ???????? waste ??????????????????????????????????????????? ??????????????????? (performance) ????????????????????????? ?? Work?ow redesign ??????????? ???????????????????? ???????? ?????????????????????????? 52 ? Pix ?source: ?thelodownny.com ?
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
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 ? Re?ne ? ¡°If I asked my customers what they wanted, Communicate ? they would have said a faster horse.¡± ¡ª 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
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)?
Six Sigma? ?? The DMAIC project methodology: ? De?ne-Measure-Analyze-Improve-Control? ?? Systems to verify individuals¡¯ relevant skill level (Green Belt, Black Belt, etc.)? 56 ? Pix ?source: ?leantransformaCon.com; ?orielstat.com ?
Statistical Process Control (SPC)? 57 ? Source: qualitysafety.bmj.com?
58 ? Pix ?source: ?facebook.com/medicalhumour ?
??????????? Six Sigma? ?? Six Sigma ???????????????????????????????????????? ?????????????????? ?????????????????????????????????????? ???????????????????????????? ???????????????????????????????????? ?? ????????????????????????????????????????????????? (stabilizing processes) ????????????????????????????????? (performance) ??? ????????????????????? (inherent risk of ¡°local optimization¡±)? 59 ? Pix ?source: ?www.aafp.org/fpm; ?individuni?caCon.com ?
Constraint Management? ?? ¡°??????????????????????????????????????? ???????????????????????????????????? ? (A chain is no stronger than its weakest link)¡±? ?? The Theory of Constraints (TOC) ???????????????????????????????? Eliyahu M. Goldratt (1984) ?????? ??????????????????????????? ? (big-picture, holistic view) ? 60 ? Souce: ?Goldrab ?(1984): ?Pix ?source: ?prowessandpearls.blogspot.com ?
Constraint Management? ?? 5-step process to reach the ¡°goal¡± of organization:? 1)? Identify: ???????????? ¡°???????? (constraints)¡± ?????????????????? 2)? Exploit: ????????????????????????????????????????????? 3)? Subordinate: ??????????????????????????????????????????????????? 4)? Elevate: ????????????????????????????????? (break the constraints)? 5)? Go back to step 1: ????????????????????????????????????? 61 ? Source: Inuzu et al. (2012) ?
??????????? Constraints Management? ?? ?????? TOC/Constraints Management ?????? ??????????????? ¡°Goal¡± ???????????????????? ????????????????????????????????????????? ???????? ??????????????????????????????????????? ¡°????????¡± ?????????????????? ¡°???????¡± ???? ? ¡°???????????????????¡± ???????????????????????? 62 ? Pix source: amazon.com?
???????? #3: ???????????????????????????????????? ????????????????????????????????????????? ????????????? #3: ¡°????? ?????????? ????????????????? ?????????????????????????????? ??????????????????????? ???????? ????? ????????????? ???????????????????????????????????¡± 63 ? Pix source: xn--l3c2a5a7a3cwa.com?
? ????????????????????????????????? ¡°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 ?oor 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, dif?cult-to-reach? branches of the tree.¡±? 64 ? Source: Inuzu et al. (2012); Pix source: magic-mural-factory.com?
?????????????? ????? ??????????? ?? ?????????????????????????????? ?????????????????????????????????? ??????????????? ? ?? ????????????? ???????????????? ??? ????????????????????????????? ???????????????????????????????? ?????????????????????????? ?? ??????????????????????????? ?????? ???????????????????? ??? ????????? ?????????????????? ???????????? ??? ?????????????????????? ? ? Pix source: facebook.com/pathtopeachandhappiness? 65 ?
Presentation Outlines? ?? ???????? (pitfall) ????????????? ???????????????? ?????????????????????????? ? ?? ???????????????????????????? (????????????????) ? ?? ?????????????????????????????????????????????? ¡°??????????? ?????????????????? ???????????????????????????¡±? 66 ? Pix source: online.wsj.com?
????????????????????????????? ??????????????????????? ?????????????????????????????????????????????????? TQM/CQI ??????????? (People) ???????????? (Process) ????????????????? (Performance)? 67 ? Pix source: facebook.com/medicalhoumour?

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Ramathibodi Quality Conference lecture 2012.9.20

  • 1. ??????????????????????????????? ????? ?????????, ?.?., PhD, SM? ???????????????????? 19: ?????????????? ????? ??????????? ??????????????????????????????? ?.?????? 20 ??????? 2555? 1 ? Pix source: bbc.co.uk/bitesize/standard/biology?
  • 2. Presentation Outlines? ?? ???????? (pitfall) ????????????? ???????????????? ?????????????????????????? ? ?? ???????????????????????????? (????????????????) ? ?? ?????????????????????????????????????????????? 2 ? Pix source: online.wsj.com?
  • 3. Pitfall #1: ¡°Just Be Professional?¡±? ¡°?????????????????????????????????????????????????¡±? 3 ? Pix source: kevin.lexblog.com?
  • 4. ¡°??????????????????????????????????¡±? 4 ? Pix ?source: ?devastatecharlie.blogspot.com; ?uboat.net; ?strangecosmos.com; ?historylink101.com ? ?
  • 5. ¡°??????????????????????????????????¡±? 5 ? Pix ?source: ?devastatecharlie.blogspot.com; ?uboat.net; ?warbirdinformaConexchange.org; ?pwencycl.kgbudge.com ? ? ?
  • 6. ???????? (????????)? 6 ? Pix ?source: ?airportjournal.com; ?pwencycl.kgbudge.com ? ? ?
  • 7. ???????????????????? (???????)? 7 ? Pix ?source: ?virtualphalcon.blogspot.com; ?canitbesaturdaynow.com; ?science.howstu?works.com ? ? ?
  • 10. ?????????????????????? 10 ? Source: ?AmalberC ?et ?al. ?(2005): ?Pix ?source: ?focusedehs.com; ?alexhibbert.com ?
  • 11. ???????????????????????????????? (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? ?? Con?rmation bias? generate known causes ?? Anxiety? ?? Overcon?dence? of errors? ?? Boredom? ?? Coning of attention? ?? Poorly design & ?? Fear? ?? Reversion under stress? maintenance of ? equipment ? ?? Inadequate training? 11 ? Modi?ed from: Leap (1994)?
  • 12. ??????????????????????? (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 ? Modi?ed 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 ? Modi?ed ?from: ?James ?Reason ?(1993): ?Pix ?source: ?simulaCon.londondeanery.ac.uk ? ?
  • 14. ¡°Swiss Cheese Model¡±? 14 ? Modi?ed from: Reason (1993); Pix source: webmm.ahrq.gov?
  • 15. 15 ? Figure ?Source: ?medicexchange.com ? ? ?
  • 16. 16 ? Figure ?Source: ?ascribe.com ?
  • 17. ???????? #1: ????????????????????????? ????????????????? (Individual competency)? ????????????? #1: ?????????????????????????¡°???????¡± ? ??????????????????? (sharp end) ??????????? (blunt end) ? ??????????????????????????????????????????????????? 17 ? Pix source: docblogs.wordpress.com; gearjunkie.com?
  • 18. 18 ? ?????????????????????????????? 20 ?.?.2555 ?????????? 00.30 ?. ?
  • 19. Pitfall #2: ¡°Just Another Buzzword?¡±? ¡°???????????????????????????? ????????????????????????¡±? 19 ? Pix source: mobilecollective.wordpress.com?
  • 20. ??????????????????????????????????? ?? The Institute of Medicine (IOM) de?nition 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? ? Ef?cient? 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) ? ¡°????????????????????????????????????¡±? 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 ? ?? Modi?ed Deming (FOCUS-PDCA)? ?? Clinical Microsystems ? ?? Kaizen-Gemba? ?? Routine to Research (R2R) ? ¡°???????? concepts ?????????¡±? 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) ? ¡°????????????????? ????????????????¡±? 23 ? Pix source: psychsurvivor2.wordpress.com/tools?
  • 24. ? ? ? ¡°?????????????????????????????¡±? ?? Late 1800s: Frederick W. Taylor (Scienti?c Management)? ¨C?Frank & Lillian Gilbreth ? (the concept of Time, Motion & Fatigue study)? ¨C?Henry Gantt (Project Management)? 24 ? Pix source: facebook.com/history; shadetreemechanic.com; en.wikipedia.org; buckmanb.wordpress.com?
  • 25. ? ? ? ?????????????? (Manufacturing)? ?? Early 1900s: Henry Ford vs. Alfred P. Sloan? ¨C? Ford¡¯s Model T 1913: 1st assembly line for mass production? (¡°You can have any color so long as it is black.¡±)? ¨C? Sloan¡¯s General Motor (GM) operated autonomous ? divisions coordinated through a general of?ce (GMC, ? Chevrolet, Cadillac, Buick, Pontiac, etc.) ? ¨C? ¡°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. ?????????????????????????? ?? 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. ? ??????????????????????? ?? 1950S: Small and fragmented Japanese Auto Market, required a more ?exible & ef?cient manufacturing system.? ?? 1960s: Ohno Taiichi, Toyota Production Engineer? developed the ¡°Just-In-Time (JIT) production¡±, or? the "Toyota Production System (TPS)¡±.? ¨C? Mapping the work ?ow & eliminating the unnecessary steps (¡°lean thinking¡±)? ¨C? Using teamwork to identify and ?x 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: ? ¨C? 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? ?? ??????????????????????????????? ? ?? ?????????????????????????? (???? ??????????????????) ? ?? ??????????? (empowered) ????? ?? ???????????????????????????? ???????????????????????????????? ??????????? ??????????????? ?????????????????????? ????? ??????? ?????????????????? ???????????????????????? ? 28 ? Pix source: facebook.com/history; en.wikipedia.org; marcoantonioadministracao.blogspot.com; cqetraining.com?
  • 29. ? ??????????????????????? ?? 1990S: The concepts of TQM/CQI were adopted by hospitals worldwide, but lost popularity later. (Why?)? ?? Late 1990-2000s: Emerging quality standards: ? ¨C? ISO, HA Thailand, JCI, MBNQA, TQA, etc.? ?? 2000s: Re-emerging concepts of TQM/CQI in different names:? ¨C? Lean Thinking/Lean Management ? ¨C? Six Sigma? ¨C? Theory of Constrains (TOC)/Constraints Management ? 29 ? Pix ?source: ?facebook.com/history ?
  • 30. ? ??????????????????????? ¡°???????????????????????/??????¡± >>> ¡°????????????????????????????¡±? Thailand Quality Award (TQA) Framework? 30 ? Pix ?source: apo-?©\tokyo.org ?
  • 31. ?????????? 1.0? Phase 1: QC? ¨C????????????? (quality control) ???????????? ?????????? (defects) ????????????????????? ? ¨C????????????????? (producer) ?????????????? (consumer) ? ??????????????????????? (sampling) ?????????????????? ? ¨C???????????????????? (statistical errors)? ?????????????????????????????????? ???????????????????????????? ?????????????????????????????? ? 31 ? Pix ?source: ?en.wikipedia.org ?
  • 32. ?????????? 2.0 ? Phase 2: QA (with tools) & QA? ¨C???? Statistical Process Control (SPC) ?????????????????? ¨C??????????????????????????????????????????? ?????????????? ????????????????????????????????? ¨C?????????????????????????????????????? (operational level) ? 32 ? Pix ?source: ?en.wikipedia.org ?
  • 33. ?????????? 3.0 ? ?? Phase 3: TQM/CQI? ¨C???????????????????????????????????? ????????????????????????????????? ???????????????????????????? ? ¨C????????????????? ???? ?????????????? (system approach) ????????????????? ?????????????????????? ????????? ?????????????????????????????? ???????????? 33 ? Pix source: tpabooks.?les.wordpress.com?
  • 34. ???????????????????????????????? (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, af?nity diagram, etc. ? 34 ?
  • 35. ?????????????????????????????????????????????????? Quality Assurance (QA)? Quality Improvement (QI)? ?? Professional training ? ?? Guidance (e.g. Practice guidelines, ?? Professional licensing ? Protocols & Care pathways)? ?? Specialty board certi?cation ? ?? 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. Con?dential vs. feedback ? Public reporting, with ?nancial ?? 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 ?
  • 37. ???????? #2: ????????????????????????????? ?????????????????? (Management Fads & Fashions)? ???????????????????????? ????????????????????????????? (QC) ? ???????????? (QA) ????????????????????????????????????????? (TQM/CQI)? ????????????? #2: ¡°??????????????????? ????????????????? ????????????????????????????? ?????? ?????????????¡±? 37 ? Pix source: praphansarn.com; school.discoveryeducation.com/?
  • 38. Pitfall #3: ¡°Adhere to a Frame?¡±? ¡°??????????????????????????????????????????????????¡±? 38 ? Pix source: creativedreamincubator.com?
  • 39. Deming Cycle? ?? PDCA: Plan-Do-Check-Act? (PDSA: Plan-Do-Study-Act)? ? ?? FOCUS-PDCA: Find-Organize-Clarify-Understand-Select? (Modi?ed PDCA by Hospital Corporation of America)? 39 ? Pix ?source: ?www.aafp.org/fpm; ?individuni?caCon.com ?
  • 40. ??????????? Deming Cycle? ?? PDCA ???????????????????????????????????????? (performance) ????????????????????????? ?? PDCA ??????????? ???????????????????????????? ?????????????????? ????????????????????????????????????????? (???? Benchmarking ??????? ???????, ?????????? ¡°NIH syndrome¡±)? ?? PDCA ???????????????????????????????????????? ¡°???????¡± ????? ?????????? (???? ?????????????????????????????????????????????????? ??????????????????????????????????????????????????????????????? Routine-to-Research or ¡°R2R¡± ???????)? 40 ? Pix ?source: ?www.aafp.org/fpm; ?individuni?caCon.com ?
  • 41. ??????????? Deming Cycle? ??????????????????? ¡°PDCA¡± & ¡°R2R¡± ? 41 ? Pix ?source: ?courtesy ?of ?Akarin ?Nimmamit, ?MD ?
  • 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?
  • 44. Lean Management? 44 ? Pix source: joevaughan.com?
  • 45. Kaizen/Gemba? ?? Kaizen (¸ÄÉÆ) ???????????? ¡°??????? (kai)¡± ??????????? ¡°?? (zen)¡±? ?? Genba (¬Fˆö) ???????????? ¡°???????????¡± ( e.g. the crime scene, the place where value is created)? ?? ???????????? Muda/waste, ??????????????????????????????????????? ??????? ¡°5?.¡± (5-S¡± method):? ¨C? Seiri (ÕûÀí), tidiness, ?????? ¨C? Seiton (ÕûîD), orderliness, ?????? ¨C? Seiso (Çå’ß), cleanliness,?????? ¨C? Sieketsu (Çå), standardize clean-up, ?????????? ¨C? Shisuke (Üz), discipline, ??????????? ? Pix source: van Assen (2009)?
  • 46. Spaghetti Diagramming? 46 ? Pix source: sprickgroup.com?
  • 47. Value Stream Mapping (VSM)? 47 ? Pix source: cfmc.org?
  • 48. Value Stream Mapping (VSM)? 48 ? Pix ?source: ????????????????? ??????????????????????? Stat ?? ????????????? (2552), ?retrieved ? ?from ?gotoknow.org ? ? ?
  • 49. 49 ? Source: ? ?Ext. ??????? ?????????????, ?Ext. ?????? ??????????????, ?Ext. ?????? ?????????????, ?Ext. ????????? ??????? ?(2555) ? ?
  • 50. 50 ? Source: ? ?Ext. ??????? ?????????????, ?Ext. ?????? ??????????????, ?Ext. ?????? ?????????????, ?Ext. ????????? ??????? ?(2555) ? ?
  • 51. patient screening OPD ? Home registration PROCESS pharmac y Screening ? Vital ?signs+BW ? prescription Refer ? Admit ? appointmen t Treatment History taking room! Exit ?Care ? ER ? age ?0-?©\14 ?yrs age ?15-?©\59 ?yrs waiting ? OPD ?8 ?room age ?>60 ?yrs Lab ? 51 ? Source: ? ?Ext. ??????? ?????????????, ?Ext. ?????? ??????????????, ?Ext. ?????? ?????????????, ?Ext. ????????? ??????? ?(2555) ? ?
  • 52. ??????????? Lean Management? ?? ???????? waste ??????????????????????????????????????????? ??????????????????? (performance) ????????????????????????? ?? Work?ow redesign ??????????? ???????????????????? ???????? ?????????????????????????? 52 ? Pix ?source: ?thelodownny.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 ? Re?ne ? ¡°If I asked my customers what they wanted, Communicate ? they would have said a faster horse.¡± ¡ª 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: ? De?ne-Measure-Analyze-Improve-Control? ?? Systems to verify individuals¡¯ relevant skill level (Green Belt, Black Belt, etc.)? 56 ? Pix ?source: ?leantransformaCon.com; ?orielstat.com ?
  • 57. Statistical Process Control (SPC)? 57 ? Source: qualitysafety.bmj.com?
  • 58. 58 ? Pix ?source: ?facebook.com/medicalhumour ?
  • 59. ??????????? Six Sigma? ?? Six Sigma ???????????????????????????????????????? ?????????????????? ?????????????????????????????????????? ???????????????????????????? ???????????????????????????????????? ?? ????????????????????????????????????????????????? (stabilizing processes) ????????????????????????????????? (performance) ??? ????????????????????? (inherent risk of ¡°local optimization¡±)? 59 ? Pix ?source: ?www.aafp.org/fpm; ?individuni?caCon.com ?
  • 60. Constraint Management? ?? ¡°??????????????????????????????????????? ???????????????????????????????????? ? (A chain is no stronger than its weakest link)¡±? ?? The Theory of Constraints (TOC) ???????????????????????????????? Eliyahu M. Goldratt (1984) ?????? ??????????????????????????? ? (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: ???????????? ¡°???????? (constraints)¡± ?????????????????? 2)? Exploit: ????????????????????????????????????????????? 3)? Subordinate: ??????????????????????????????????????????????????? 4)? Elevate: ????????????????????????????????? (break the constraints)? 5)? Go back to step 1: ????????????????????????????????????? 61 ? Source: Inuzu et al. (2012) ?
  • 62. ??????????? Constraints Management? ?? ?????? TOC/Constraints Management ?????? ??????????????? ¡°Goal¡± ???????????????????? ????????????????????????????????????????? ???????? ??????????????????????????????????????? ¡°????????¡± ?????????????????? ¡°???????¡± ???? ? ¡°???????????????????¡± ???????????????????????? 62 ? Pix source: amazon.com?
  • 63. ???????? #3: ???????????????????????????????????? ????????????????????????????????????????? ????????????? #3: ¡°????? ?????????? ????????????????? ?????????????????????????????? ??????????????????????? ???????? ????? ????????????? ???????????????????????????????????¡± 63 ? Pix source: xn--l3c2a5a7a3cwa.com?
  • 64. ? ????????????????????????????????? ¡°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 ?oor 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, dif?cult-to-reach? branches of the tree.¡±? 64 ? Source: Inuzu et al. (2012); Pix source: magic-mural-factory.com?
  • 65. ?????????????? ????? ??????????? ?? ?????????????????????????????? ?????????????????????????????????? ??????????????? ? ?? ????????????? ???????????????? ??? ????????????????????????????? ???????????????????????????????? ?????????????????????????? ?? ??????????????????????????? ?????? ???????????????????? ??? ????????? ?????????????????? ???????????? ??? ?????????????????????? ? ? Pix source: facebook.com/pathtopeachandhappiness? 65 ?
  • 66. Presentation Outlines? ?? ???????? (pitfall) ????????????? ???????????????? ?????????????????????????? ? ?? ???????????????????????????? (????????????????) ? ?? ?????????????????????????????????????????????? ¡°??????????? ?????????????????? ???????????????????????????¡±? 66 ? Pix source: online.wsj.com?
  • 67. ????????????????????????????? ??????????????????????? ?????????????????????????????????????????????????? TQM/CQI ??????????? (People) ???????????? (Process) ????????????????? (Performance)? 67 ? Pix source: facebook.com/medicalhoumour?