Skip to main content
SpringerLink
Log in

Integrating systems engineering practice with health-care delivery

  • Original Article
  • Published:
Health Systems

Abstract

Health-care delivery is a complex and fragmented system with work-around culture. Improving health-care delivery requires innovating system interventions that redesign processes for consistent implementation of evidence-based practices (EBPs). Systems engineering is an approach that involves anticipating ineffective processes that jeopardize quality, and designing interventions to overcome such shortcomings. This approach is based on systems teaching about reflexivity, which when addressed can support consistent EBP and assesses how the newly designed system meets this consistency. Integrating a systems engineering approach to implementing EBP may effectively address complex issues such as hospital-acquired pressure ulcer prevention, which has an EBP protocol that is not consistently implemented without system redesign. Engineering approaches and methods including Plan-Do-Study-Act (PDSA), Situation-Background-Assessment-Recommendations (SBAR), stochastic modeling, House of Quality, and statistical process control charts with lean six sigma provide a structured approach to identifying points of successful implementation for EBPs that can subvert work-around culture. This perspective piece reviews successful approaches of systems engineering to solve the problem of clinical work-arounds and puts forward the case for its wider application to health-care delivery systems that could benefit from standardized EBPs.

This is a preview of subscription content, log in via an institution to check access.

Access this article

Log in via an institution

Price excludes VAT (USA)
Tax calculation will be finalised during checkout.

Instant access to the full article PDF.

Institutional subscriptions

Similar content being viewed by others

References

  • Azzolini J (1995) Essential systems engineering: a life-cycle process. 5th Annual International Symposium. International Council of Systems Engineering. St. Louis, MS.

  • Benneyan JC, Lloyd RC and Plsek PE (2003) Statistical process control as a tool for research and healthcare improvement. Quality and Safety in Health Care 12 (6), 458–464.

    Article  Google Scholar 

  • Berwick DM (2002) A user’s manual for the IOM’s ‘quality chasm’ report. Health Affairs (Millwood) 21 (3), 80–90.

    Article  Google Scholar 

  • Berwick DM (2007) Foreword: the clinical microsystem. In Quality by Design (Nelson EC, Batalden PB and Godfrey MM, Eds), Jossey-Bass, San Francisco, CA.

    Google Scholar 

  • Berwick DM (2009) What ‘patient-centered’ should mean: confessions of an extremist. Health Affairs (Millwood) 28 (4), w555–w565.

    Article  Google Scholar 

  • Bosk CL (1979) Forgive and Remember: Managing Medical Failure. University of Chicago Press, Chicago.

    Google Scholar 

  • Carey RG (2003) Improving Healthcare with Control Charts: Basic and Advanced SPC Methods and Case Studies. ASQ Quality Press, Milwaukee, WI.

    Google Scholar 

  • Comfort E (2008) Reducing pressure ulcer incidence through Braden scale risk assessment and support surface use. Advances in Skin and Wound Care 21 (7), 330–334.

    Article  Google Scholar 

  • Deming WE (1986) Out of Crisis. MIT Center for Advanced Engineering Study, Cambridge, MA.

    Google Scholar 

  • Desneves KJ, Todorovic BE, Cassar A and Crowe TC (2005) Treatment with supplementary arginine, vitamin C, and zinc in patients with pressure ulcers: a randomised controlled trial. Clinical Nutrition 24 (6), 979–987.

    Article  Google Scholar 

  • Donahue M, Miller M, Smith L, Dykes P and Fitzpatrick JJ (2011) A leadership initiative to improve communication and enhance safety. American Journal of Medical Qualilty 26 (3), 206–211.

    Article  Google Scholar 

  • Edmondson AC (2004) Learning from failure in health care: frequent opportunities, pervasive barriers. Quality and Safety in Health Care 13 (6), 3–9.

    Google Scholar 

  • Espin S, Lingard L, Baker GR and Regehr G (2006) Persistence of unsafe practice in everyday work: an exploration of organization and psychological constraining safety in the operating room. Quality and Safety in Health Care 15 (3), 165–170.

    Article  Google Scholar 

  • Frye E (2007) Knowledge with Know-How: Thayer School of Engineering at Dartmouth. University Press of New England, Hanover, NH.

    Google Scholar 

  • Gay SB, Sobel AH, Young LQ and Dwyer SJ (2002) Processes involved in reading imaging studies: workflow analysis and implications for workstation development. Journal of Digital Imaging 15 (3), 171–177.

    Article  Google Scholar 

  • George ML, Rowlands D, Price M and Maxey J (2005) The Lean Six Sigma Pocket Toolbook. McGraw-Hill, New York.

    Google Scholar 

  • Glouberman S and Zimmerman B (2002) Complicated and complex systems: the reform of medicare in Canada: Discussion Paper no. 8. The Commission on the Future of Health Care in Canada.

  • Godfrey MM, Melin CN, Muething SE, Batalden PB and Nelson EC (2008) Clinical microsystems, part 3: transformation of two hospitals using microsystem, mesosystem, and macrosystem strategies. Joint Commission Journal on Quality & Patient Safety 34 (10), 591–603.

    Article  Google Scholar 

  • Gonzales R, Handley MA, Ackerman S and O’sullivan PS (2012) A framework for training health professionals in implementation and dissemination science. Academic Medicine 87 (3), 271–278.

    Google Scholar 

  • Graves SC, Leff HS, Natkins J and Senger M (1983) A simple stochastic model for facility planning in a mental health care system. Interfaces 13 (5), 101–110.

    Article  Google Scholar 

  • Hauser JR (1993) How Puritan-Bennet used the house of quality. Sloan Management Review 34 (3), 61–70.

    Google Scholar 

  • Haynes A et al (2009) A surgical safety checklist to reduce morbidity and mortality in a global population. New England Journal of Medicine 360 (5), 491–499.

    Article  Google Scholar 

  • Kuo MH, Borycki EM, Kushniruk AW and Lee TS (2009) Integrating A3 reports and the house of quality: improving workflow in the recovery room using information technology. In Medical Informatics in a United and Healthy Europe 2009 (Adlassnig KP, Ed), European Federation for Medical Informatics, Copenhagen, pp 409–420.

    Google Scholar 

  • Kurtzman E and Buerhaus PI (2008) New medicare payment rules: danger or opportunity for nursing? American Journal of Nursing 108 (6), 30–35.

    Article  Google Scholar 

  • Leonard M, Bonacum D and Graham S (2011) SBAR technique for communication: a situational briefing model. [WWW document] http://www.ihi.org, (accessed 8 February 2011).

  • Llewellyn-Thomas HA (1997) Investigating patients’ preferences for different treatment options. The Canadian Journal of Nursing Research 23 (3), 45–64.

    Google Scholar 

  • Lyder CH, Grady J, Mathur D, Petrillo MK and Meehan TP (2004) Preventing pressure ulcers in Connecticut hospitals by using the plan-do-study-act model of quality improvement. Joint Commission Journal on Quality & Patient Safety 30 (4), 205–214.

    Article  Google Scholar 

  • Lyder CH et al (1998) Braden scale for the prediction of pressure ulcer risk in blacks and Latino/Hispanic elders: a pilot study. Ostomy Wound Manage 44 (3A Suppl), 42S–49S, discussion 50S.

    Google Scholar 

  • Makic MB, Vonreuden KT, Rauen CA and Chadwick J (2011) Evidence-based practice habits: putting more sacred cows out to pasture. Critical Care Nursing 31 (2), 38–61.

    Article  Google Scholar 

  • Merrill CT, Stocks C and Stranges E (2009) Trends in Uninsured Hospital Stays, 1997–2006. Healthcare Cost and Utilization Project. Agency for Healthcare Research and Quality. Bethesda, MD, USA.

    Google Scholar 

  • Morton A, Mengersen K, Waterhouse M and Steiner S (2010) Analysis of aggregated hospital infection data for accountability. Journal of Hospital Infection 76 (4), 287–291.

    Article  Google Scholar 

  • National Aeronautics and Space Administration. (2007) NASA Systems Engineering Handbook. NASA, Washington DC, Scientific and Technical Information.

  • Nelson EC, Batalden PB and Godfrey MM (2007) Quality by Design. Jossey-Bass, San Francisco, CA.

    Google Scholar 

  • Nelson EC, Batalden PB, Godfrey MM and Lazar JS (2011) Value by Design. Jossey-Bass, San Francisco.

    Google Scholar 

  • Nelson WA, Gardent PB, Shulman E and Splaine ME (2010) Preventing ethics conflicts and improving healthcare quality through system redesign. Quality and Safety in Health Care 19 (6), 526–530.

    Google Scholar 

  • Padula WV and Breteler MJM (2013) Sharing perspectives on HTA from both sides of the pond – lessons learned by graduate students at ISPOR’s 15th annual European congress. ISPOR Connections 19 (1), 15.

    Google Scholar 

  • Padula WV, Mishra MK, Makic MB and Sullivan PW (2011) Improving the quality of pressure ulcer care with prevention: a cost-effectiveness analysis. Medical Care 49 (4), 385–392.

    Article  Google Scholar 

  • Padula WV, Mishra MK, Weaver CD, Yilmaz T and Splaine ME (2012) Building information for systematic improvement of the prevention of hospital-acquired pressure ulcers with statistical process control charts and regression. BMJ Quality & Safety 21 (6), 473–480.

    Article  Google Scholar 

  • Ratliff CR et al (2003) Guideline for prevention and management of pressure ulcers. In WOCN Clinical Practice Guideline; No. 2. Wound, Ostomy, and Continence Nurses Society (WOCN), Glenview, IL, p. 52.

    Google Scholar 

  • Sadiq S, Orlowska M, Sadiq W and Foulger C (2003) Data Flow and Validation in Workflow Modelling. Australian Computer Society 2004. (Schewe KD and Dunedin WH, Eds), Conferences in Research and Practice in Information Technology. 27, New Zealand.

  • Schaffer A (2008) Fighting bedsores with a team approach. The New York Times.

  • Sedlack JD (2010) The utilization of six-sigma and statistical process control techniques in surgical quality improvement. Journal of Healthcare Quality 32 (6), 18–26.

    Article  Google Scholar 

  • Tucker AL (2004) The impact of operational failures on hospital nurses and their patients. Journal of Operations Management 22 (2), 151–157.

    Article  Google Scholar 

  • Tucker AL (2010) Harvard Business School Faculty Research Symposium. In (Edmondson AC, Ed), The Work-Around Culture: Unintended Consequences of Organizational Heroes. President & Fellows of Harvard College, Boston, MA.

    Google Scholar 

  • Tucker AL and Edmondson AC (2003) Why hospitals don’t learn from failures: organizational and psychological dynamics that inhibit system change. California Management Review 45 (2), 55–72.

    Article  Google Scholar 

  • Tucker AL, Nembhard IM and Edmondson AC (2007) Implementing new practices: an empirical study of organizational learning in hospital intensive care units. Management Science 53 (6), 894–907.

    Article  Google Scholar 

  • Tucker AL and Spear SJ (2006) Operational failures and interruptions in hospital nursing. Health Services Research 41 (3), 642–662.

    Google Scholar 

  • van Loon E and Zuiderent-Jerak T (2012) Framing reflexivity in quality improvement devices in the care for older people. Health Care Analysis 20 (2), 119–138.

    Article  Google Scholar 

  • Wald HL and Kramer AM (2007) Nonpayment for harms resulting from medical care: catheter-associated urinary tract infections. Journal of the American Medical Association 298 (23), 2782–2784.

    Article  Google Scholar 

  • Weeks WB and Bagian JP (2000) Developing a culture of safety in the veterans health administration. Effective Clinical Practice 3 (6), 270–276.

    Google Scholar 

  • Weinstein MC and Skinner JA (2010) Comparative effectiveness and health care spending – implications for reform. New England Journal of Medicine 362 (5), 460–465.

    Article  Google Scholar 

  • Welton JM (2008) Implications of medicare reimbursement changes related to inpatient nursing care quality. Journal of Nursing Administration 38 (7–8), 325–330.

    Article  Google Scholar 

  • Yarnoff C et al (2003) EDC glossary. In EDC 2003: An Introduction to Engineering Design and Communication. p 223, Northwestern University Press, Evanston, IL.

    Google Scholar 

  • Zimmerman B, Lindberg C and Plsek P (2001) A complexity science primer. In Edgeware, Insights from Complexity Science for Health Care Leaders (Zimmerman B, Lindberg C and Pisek P, Eds), pp 3–20, VHA, Irving, TX.

    Google Scholar 

Download references

Acknowledgements

The authors wish to acknowledge Dr. Jim Yong Kim for his inspirational call on systems engineering to improve health-care delivery, as well as the editor and two anonymous reviewers who helped prepare this manuscript.

Author information

Authors and Affiliations

  1. Department of Medicine, University of Chicago, Chicago, U.S.A.

    William V Padula

  2. Department of Orthopaedic Surgery, Technology Implementation Research Center, Massachusetts General Hospital, Boston, U.S.A.

    Michael P Duffy

  3. Visual Services Department, Harvard Vanguard Medical Associates, Boston, U.S.A.

    Taygan Yilmaz

  4. Department of Psychiatry, Dartmouth-Hitchcock Medical Center, Lebanon, U.S.A.

    Manish K Mishra

Authors
  1. William V Padula
    View author publications

    You can also search for this author in PubMed Google Scholar

  2. Michael P Duffy
    View author publications

    You can also search for this author in PubMed Google Scholar

  3. Taygan Yilmaz
    View author publications

    You can also search for this author in PubMed Google Scholar

  4. Manish K Mishra
    View author publications

    You can also search for this author in PubMed Google Scholar

Corresponding author

Correspondence to William V Padula.

Additional information

All authors made significant contributions to the manuscript in accordance with ICMJE Guidelines: article conception and design; drafting and revisions of article content; and final approval of the submitted version. William Padula, Michael Duffy, Taygan Yilmaz, and Dr. Manish Mishra made equal contributions to the conceptual framework and writing of this manuscript.

Rights and permissions

Reprints and permissions

About this article

Cite this article

Padula, W., Duffy, M., Yilmaz, T. et al. Integrating systems engineering practice with health-care delivery. Health Syst 3, 159–164 (2014). https://doi.org/10.1057/hs.2014.3

Download citation

  • Received:

  • Revised:

  • Accepted:

  • Published:

  • Issue Date:

  • DOI: https://doi.org/10.1057/hs.2014.3

Keywords

Search

Navigation