Applications of Complex Systems: Medical = Management

From: Subject: Applications of Complex Systems: Medical Management Date: Sun, 14 Sep 2003 14:46:42 +0300 MIME-Version: 1.0 Content-Type: multipart/related; boundary="----=_NextPart_000_0005_01C37ACF.0319B060"; type="text/html" X-MimeOLE: Produced By Microsoft MimeOLE V6.00.2800.1165 This is a multi-part message in MIME format. ------=_NextPart_000_0005_01C37ACF.0319B060 Content-Type: text/html; charset="iso-8859-1" Content-Transfer-Encoding: quoted-printable Content-Location: http://necsi.org/guide/examples/er.html Applications of Complex Systems: Medical = Management

Applications of Complex = Systems: Medical=20 Management

by Yaneer = Bar-Yam

An emergency department in a hospital provides = an=20 important example of a partially self-contained system that must = respond=20 effectively to a wide variety of circumstances due to the variety = of=20 individual problems, combinations of problems, and unscheduled = demand,=20 which fluctuates significantly over time. For a number of years, = Mark=20 Smith, MD, Chairman, and Craig Feied, MD, Director of Informatics = of the=20 Department of Emergency Medicine, Washington Hospital, Washington, = D.C.,=20 have been developing strategies for applying complex systems ideas = to the=20 design of processes, information flow, and physical layout in an = emergency=20 department.

Design of an emergency = department=20 process

by Mark Smith and Craig=20 Feied

A specific example of applying complex systems = ideas to=20 the emergency department is the redesign of the process of = obtaining blood=20 tests. The process of blood testing that originally existed in the = emergency department involved sending the blood samples to a = central=20 laboratory. The basic problem in this process was not just the = distance=20 over which the sample and test order had to be sent, but the = number of=20 people and communication steps that were involved. Specifically, = the=20 process involved eight steps.

The order for the test is written on the = chart, where=20 it is then noted by the nurse, and entered as an order into the = "order=20 entry" computer system by either the nurse or the clerk. A lab = request=20 slip is then generated on a nearby printer. The patient=92s blood = specimen=20 is then attached to this slip and the pair sent, via pneumatic = tube or=20 transporter, to the "accessioning" position of the laboratory. The = sample=20 is then distributed to the section of the laboratory that is = appropriate=20 for that particular test. Once completed, the test results are = transmitted=20 back to the ED, via telephone call or fax to the unit secretary, = who then=20 must relay the results back to the physician who ordered the test. = This=20 process involves at least 7 people, 8 steps, and takes 60=20 minutes.

In an effort to reduce patient throughput time, = a "point=20 of service" testing system was instituted, using a = "mini-laboratory"=20 situated in the middle of the emergency department and staffed = with a=20 laboratory technologist:

To obtain a blood test in this system, the = physician=20 marks the desired test on a sheet of paper and hands that paper = directly=20 to the point-of-service laboratory technologist. The technologist = locates=20 the blood sample that had already been placed onto a rack by the = patient=92s=20 nurse and then runs the test. Three minutes later, the = technologist=20 returns the sheet of paper complete with the test results to the=20 physician; three people, three steps.

This change reduced the time it takes for a = laboratory=20 result to be completed and also reduces the potential for error of = a=20 common and central process in the emergency room. When it is = possible,=20 complex systems, including organizations, work better when the = processes=20 are designed with fewer steps and fewer people. If processes are = kept=20 short and simple, fewer opportunities exist for something to go = wrong.=20 Less degradation of information occurs, because there are fewer = 'handoffs'=20 of information from one person to another. Fewer steps mean that = fewer=20 feedback loops need to be constructed in order to ensure that = errors or=20 faults in the process are detected and corrected.

Just as a few simple rules and a small number of = variables=20 can create a complex adaptive system, small reductions in the = number of=20 variables and rules can have dramatic and nonlinear impact in = reducing the=20 complexity of a system. In the more complicated version of the lab = process, the lab result time-to-physician was non-deterministic = because of=20 the complexity of the process. Results reporting sometimes took = many=20 hours; tests were sometimes lost completely and had to be = repeated; and=20 people sometimes simply forgot to see the results at all. Under = the=20 point-of-care process, the lab results time-to-physician is highly = predictable and the error rate in results delivery is very = low.

When changes are made, unintended side effects = can occur=20 that may be beneficial or detrimental. An unintended and = unanticipated=20 positive side effect occurred with the institution of point of = service=20 laboratory testing: the turnaround time for critical tests that = were being=20 sent to the main laboratory decreased. The reason was that the = emergency=20 department now had a laboratory technologist in its midst who in = effect=20 became an advocate for its interests. Whenever a test whose result = was=20 urgently needed had to be sent to the main laboratory for = processing, the=20 point-of -service laboratory technologist would convey the urgency = of=20 obtaining the result to her colleague in the main laboratory. That = colleague responded to a call from a fellow laboratory = technologist in a=20 manner different from a call from a nameless and faceless doctor, = nurse,=20 or clerk.

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