Strategic Partnership of Healthcare and Systems Engineering

in Turbulent Times

International Council on Systems Engineering (INCOSE) Healthcare Working Group

March 28, 2015

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Quotes from the Report• …”Systems Engineering know‐howmust be propagated at all levels [of healthcare]”

• “Implementation of [systems engineering] bears potential not only to improve the efficiency of [health]care delivery, but also to improve its quality.”

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What MDs are saying about Systems Engineering…• „It is surprising that many industries have used systems engineering to improve reliability, safety, efficiency, and 

effectiveness.  Health care, however,  has been late in embracing systems engineering despite the potential to help fix what is basically a non‐system of care.   Although health care can do some amazing things, anyone working in health care has  also seen examples of  suboptimal patient outcomes, unaddressed patient safety issues, poor reliability, and inefficiencies.  Traditional medical thinking is not well equipped to improve many of these problems.  Much of this,                          however, can be addressed if systems engineers, physicians, and health care professionals could better collaborate and use wellknown systems engineering  techniques such as queuing theory, Lean, Six Sigma, mathematical and computer simulationsand models, supply‐chain management techniques, and optimization techniques.   A recent Presidential  Council of Advisorson Science and Technology agreed with these finding in their report, Better Health Care and Lower Costs: AcceleratingImprovement through Systems Engineering. This really should create the burning platform for greater incorporation of systems engineering into medical care.” ‐ Michael Kanter, M.D., Regional Medical Director of Quality & Clinical Analysis, Southern California Permanente Medical Group

• „If we physicians are truly interested in improving medical care for our patients and in taking more control of our work, then it is vital for us to learn and apply the principles of systems engineering.  Physicians already think in terms of bodily systems so it is not a great intellectual leap for us.  I find it stimulating and rewarding to use my systems thinking skills and to work in teams with systems engineers who understand medical care.  Everything we do is a process inside a larger system.  If we want better outcomes, we need to roll up our sleeves and get to work using systems engineering principles as our indispensable tools." ‐ Stephen F. Tarzynski MD MPH FAAP, Pediatrics, Physician Director of Community Relations & Market Development, West Los Angeles Area, Kaiser Permanente Medical Care Program

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Outline

1. The Current (Imperfect) State2. Systems Engineering to the Rescue3. What is Systems Engineering?4. Added Value from Systems Engineering in Healthcare5. Follow up and Contacts

4Bohdan W. Oppenheim, bohdan.oppenheim@lmu.edu

1. The Current (Imperfect) State

5Bohdan W. Oppenheim, bohdan.oppenheim@lmu.edu

Desired Characteristics of Healthcare

• Affordable & Accessible• Safe• Effective• Patient centered• Timely• Efficient• Inclusive of Latest Science• Well integrated

6Bohdan W. Oppenheim, bohdan.oppenheim@lmu.edu

• $8,508 per capita (UK: $3,406)

• Millions still without medical insurance

• Medicines unaffordable to a hundred millionpeople

• Over 30% of U.S. adults skip a recommendedtest or treatment because of cost

• U.S. ranked #70 in wellness (mostly due to obesity)

• U.S. ranked last among 11 countries inpreventable deaths

The Present Imperfect State

7Bohdan W. Oppenheim, bohdan.oppenheim@lmu.edu

• Highly fragmented system, inefficient interfaces - in desperate need of integration in many dimensions

• Bureaucratic overhead robbing providers of useful time with patients• Wrong incentives (Cost curve still climbing, although much less with ACA)• Dramatic changes needed to accommodate the ACA shift from “pay per service” to “pay

per outcome”• Revolutions in big data mining and genetics open extraordinary evidence-based

opportunities for which knowledge of systems thinking, statistics and medicine must be integrated

• Huge progress in medical devices require solid engineering know-how and interoperability• Huge waste in all operations rob patients of quality care – needing Lean• Formerly routine operations such as Operating Room, Critical Care, Emergency

Department, Pharmacy – are becoming complex systems that exceed human management capability - requiring special simulators (like aircraft simulators for pilots)

• Shrinking budgets require exceptional efficiencies and streamlining – needing Lean• The growing complexity of the healthcare system – needing excellent risk analysis• Increasingly advanced medical devices and information technology needing greater

oversight• Unmanaged complexity leads to unpredictable results – needing special tools.

A Short list of Problems

In increasingly complex operations, with rapid change beyond our control ‐ traditional medicine andmanagement methods fail to fix the dynamic hyper‐system of healthcare – needing more advanced

approaches!8

Bohdan W. Oppenheim, bohdan.oppenheim@lmu.edu

2. Systems Engineering to the Rescue

9Bohdan W. Oppenheim, bohdan.oppenheim@lmu.edu

Super System

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Super System

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Super System

2

Super System

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Complex System 1

Complex System 2

U.S. Healthcare = Dynamic Hyper System

Help from Systems 

Engineering

Healthcare Stakeholders• Patients (300,000,000+ in U.S.)

• Medical professionals

• Medical facilities, hospitals, clinics, labs

• Medical Equipment

• Pharmaceuticals

• Researchers and academia

• Insurances

• Employers

• Federal & State Governments

• Military and Veterans Administration

• Fire Departments and Ambulances

• and more

Powerful Solution

10Bohdan W. Oppenheim, bohdan.oppenheim@lmu.edu

3. What is Systems Engineering?

11Bohdan W. Oppenheim, bohdan.oppenheim@lmu.edu

What is Systems Engineering?

• Beginnings in 1950s in the US Ballistic Missile Programs• It is about rigorous integration of highly complex pieces so that they work

together as a system, perfectly, as intended!• Technical management of complex systems, problems and projects

(healthcare, infrastructure, engineering, energy, education...)• Rigorous but mostly non-mathematical heuristic knowledge how to

analyze and construct complex systems.

12© 2014 Bohdan W. Oppenheim, bohdan.oppenheim@lmu.edu

Bohdan W. Oppenheim, bohdan.oppenheim@lmu.edu

Two Paths for Systems Engineers to Serve Healthcare

Traditional Systems Engineer• Typically B.S. in engineering, science, math• Graduate degree as above and/or or in Systems

Engineering, or equivalent experience• Often courses in statistics, management, modeling,

simulations• Exerienced in multidisciplinary design and

development of complex technical systems (spacecraft, rockets, ships, aircraft, weapon systems, nuclear plants, mega projects in infrastructure)

• Working as „coordinator” and „integrator” of millions of technical elements and interfaces, all of which must operate perfectly or the system fails.

• Fully prepared to assist healthcare professionals in addressing their complex challenges.

Healthcare Systems Engineer• Start with healthcare education (MD, nurse, pharmacist,

BS in bio or health sciences, healthcare management, administration, researcher…)

• MS degree in Healthcare Systems Engineering (HSE).g. LMU HSE curriculum:

• Systems Engineering• Project Management• Healthcare Delivery Systems• Lean Healthcare  & Advanced Lean Management of Healthcare• Systems Thinking in Healthcare• Systems Modeling and Simulations in Healthcare• Data Mining in Healthcare (statistics on huge databses)• Patient Safety and Quality Systems• Finances and Accounting in Healthcare• Medical Devices and Integrated Systems• Healthcare Enterprise Informatics and Electronic Records• Project, Internship

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Serving Healthcare Professionals with SystemsEngineering Knowledge

Bohdan W. Oppenheim, bohdan.oppenheim@lmu.edu

What is Systems Engineering?• Complex systems almost always fail atthe interdisciplinary interfaces‐

• or at the interfaces with externalities(environment)

• or interfaces with humans

• Medical professionals, managers, evenspecialty engineers are not trained in dealing with such problems

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• SE is a rigorous time-proven process of management and coordination of all relevant details, and strong focus on the system integration and life-cycle performance.

Bohdan W. Oppenheim, bohdan.oppenheim@lmu.edu

Simplest system: N = 2

1 connection

Slightly more complex system: N = 5

10 one-to-one connections

becomes

Why do we need Systems Engineering in Healthcare?

With millions of patients, doctors, nurses, administrators, andother stakeholders, thousands of cooperating system elements,hospitals, clinics, laboratories, pharmacies, equipment makers and users, devices, specimen, procedures, laws andregulations, in hundreds of cooperating organizations ...neither traditional medicine nor traditional management are sufficient.

J.Thomas, INCOSE

N(N‐1)/2

15Bohdan W. Oppenheim, bohdan.oppenheim@lmu.edu

Systems Engineering

An engineering discipline whose responsibility is creating and executing an interdisciplinary process to ensure that the customerand stakeholder's needs are satisfied in a high quality, trustworthy, cost efficient and schedule compliant manner throughout asystem's entire life cycle.

INCOSE

What is Systems Engineering?

16Bohdan W. Oppenheim, bohdan.oppenheim@lmu.edu

4. Added Value from Systems Engineering in Healthcare

17Bohdan W. Oppenheim, bohdan.oppenheim@lmu.edu

• Managing Complexity and Efficiently Navigating in Complex Problem Space

• Systemic approach using Systems Thinking (looking at problems in their context, seeing the big picture, understanding emerging properties and unintended consequences)

• Systems Architecting and Interoperability

• Interface Management

• Coordination with numerous stakeholders

Added Value from Systems Engineering in Healthcare

Cured,stablepatients

Patient mortality

More careneeded

Budgets Stakeholders

Patients

Regulations Culture 18Bohdan W. Oppenheim, bohdan.oppenheim@lmu.edu

• Powerful mathematical modeling of operations in Emergency Department, Operating Room, Pharmacy, Clinic, Clinical Laboratory, Medical Administration, Supply Chain…

• Stochastic (probabilistic) modeling of operations for studies of capacity, throughput, resources and costs

• Logical and functional modeling of complex operations, including state-of-the art “Model Based Systems Engineering” which captures, manages, and allocates requirements tosubsystems, and provides effective system integration and verification

• Computer simulators of operations (like flight simulator)

Added Value from Systems Engineering in Healthcare

www.123RF

www.flickr.com

Washington Post

campar.in.tum.de

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Example of Stochastic Modeling of Emergency Department

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Added Value from Systems Engineering in Healthcare

• Great for Monte Carlostudies of capacity, cost and throughput

• Resource values are input• Random factors are

modeled probabilistically

Bohdan W. Oppenheim, bohdan.oppenheim@lmu.edu

Tonya Premsrirath, KP

Powerful Studies Using Huge Databases of Patients’ Records

Number of potential medical records:• Kaiser Permanente:• U.S.• World

10,000,000300,000,0007,000,000,000

Added Value from Systems Engineering in Healthcare

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Huge data „mining” now permits powerfulstudies of simultaneous effects of numerousfactors and complex interations. We are nolonger constrained to simplistic clinicalstudies that filter out confounding andinteraction effects. This yields rich medical knowledge and potent treatments.

Bohdan W. Oppenheim, bohdan.oppenheim@lmu.edu

Streamlining operations and removing waste using LeanAdded Value from Systems Engineering in Healthcare

Lean does not tell MDs how totreat patients – it frees the

MDs to do it more and better

Lean Principles

22Bohdan W. Oppenheim, bohdan.oppenheim@lmu.edu

Added Value from Systems Engineering in Healthcare

Lean Improvements in AutomatedChemistry Laboratory

Current State

Ideal State

FutureState

Throughput Time (Olympus)

733.5minutes

36minutes

140.5minutes

Cost Savings Baseline$1,570,976  $994,876

.50 .50

Quality Mod High High

Frustration of Lab Staff HIGH Low Moderate

Frustration of MD Mod Low Mod

Frustration of Patient High Low Mod

Throughput Time (Virology)

57 hours 13.5 hours (76%)

Test Quality Optimal Optimal

Patient Complaints

↑ ↓

ProviderComplaints

↑ ↓

Employee Morale

↓ ↑

Lean Improvements inMicrobiology Lab

Current Future StateState

All examples from Kaiser Permanente

Value Stream Mapping

Streamlining operations in Clinical Laboratories using Lean

23Bohdan W. Oppenheim, bohdan.oppenheim@lmu.edu

Powerful Identification, Management and Mitigation of Risks in Healthcare, and Probabilistic Decision Making

Added Value from Systems Engineering in Healthcare

https://www.google.com/?gws_rd=ssl#q=risk+matrix

https://www.google.com/?gws_rd=ssl#q=normal+curve

Regulations and compliance

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Good Electronics Records Transform Medicine

• Bad Electronic Records cause numerous troubles:

• Increase risks to patients• Overwhelm with needless alerts• Poor workflows• Unfriendly user interface• Ineficient data entry

• Systems Engineering provides expertise for IT projects

• „Millions lines of code” is bread‐ and‐butter of Systems Engineering

Added Value from Systems Engineering in Healthcare

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Added Value from Systems Engineering in Healthcare

Preventing “Incidents” – HealthCare.gov

Good Systems Engineering would prevent the imperfect rollout.

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Added Value from Systems Engineering in Healthcare

Finding the order in the chaos• Systems Engineers are experts in finding patterns in what other people see aschaos. They analyze the chaos by seeing patterns of processes or proceduresor steps, group them, and quantify what success is for each of the steps.

Seeing the whole picture and narrowing down to the details• Systems Engineers are experts at looking at a complex system and breaking itdown into the details at multiple levels and points of view without losing trackof the big picture. They are experts at breaking things down from the toplevel picture into the smallest details at the lowest levels where other disciplines can address the problems in their area of expertise.

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Management of Life‐cycle System Properties (“–ilities”)

Added Value from Systems Engineering in Healthcare

• Safety• Quality

• Interoperability• Sustainability

• Reliability• Survivability

• Maintainability• Testability

• Resilience• Robustness• Reparability

• Flexibility/Adaptability• Modularity

• Scalability• Durability

• Evolvability• Manufacturability

• Agility28

Bohdan W. Oppenheim, bohdan.oppenheim@lmu.edu

Everyone wants a positive outcome for the patient. The problem lies with picking the bestway to facilitate this in a high value way.The field of Systems Engineering offers a wide array of proven methods and scalableapproaches that foster a holistic way of examining and solving complex problems in repeatable ways.

Added Value from Systems Engineering in Healthcare

As the leading professional society and global promoter of SystemsEngineering, the International Council on Systems Engineering(INCOSE) is in the best position to help your organization provide this value today.

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5. INCOSE is eager to partner withHealthcare Professionals

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• INCOSE lists 10,000 subject matter experts on systems engineering and hundreds on healthcare… who master integrating people, tools, and process.

• Over 60 years of practice

• We speak the language of Systems Engineering in the Context of Healthcare

• We handle both the hard and soft aspects of systems engineering and healthcare, leading to greater success rates

• We provide university‐level education in Healthcare Systems Engineering

• INCOSE enables cross‐industry sharing of best practices. We are a forum for meeting world class experts in Systems Engineering and Healthcare

INCOSE at service to Healthcare

We invite all Healthcare Professionals: physicians and nurses; hospital, clinic, laboratory and pharmacy employees; healthcare administrators and managers; medical researchers and scholars; and all others ‐ to contact us. We are ready to help you take better care of your patients and makeyour life quality better!

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Technical Events and Contacts in INCOSE Healthcare Working Group (HWG)

Technical EventsJanuary

International Workshophttp://www.incose.org

JulyInternational Symposiumhttp://www.incose.org

Monthly or Bi‐MonthlyInformal web conferenceshttps://new.incose.org/wg/biomedical/content/event

Throughout the YearHealthcare events at regional INCOSEmeetings

HWG LeadershipOverall Working Group Leads

Chris Unger Christopher.Unger@med.ge.comBob Malins rjmalins@eaglesummittech.comPlus Regional leads for Europe, Australia, and East/Midwest/West coasts

Healthcare SE ApplicationsChris Unger Christopher.Unger@med.ge.com

Healthcare MBSE ChallengeAjay Thukral ajay.thukral@cientivegroup.comhttp://omgwiki.org/MBSE/doku.php?id=mbse:drugdelivery

Healthcare Problem/Solution DatabaseMike Celentano mike.celentano@roche.com

Healthcare Education StrategyRachel Leblanc rbowers@WPI.EDU

Jack Stein jstein@me.com,Ajay Thukral  ajay.thukral@cientivegroup.com

LeanBo Oppenheim boppenheim@lmu.eduhttp://www.lean‐systems‐engineering.org/

Safety

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