Strategic Partnership of Healthcare and SE v.2.5.1

Strategic Partnership of Healthcare
and Systems Engineering
in Turbulent Times
International Council on Systems Engineering (INCOSE)
Healthcare Working Group
March 28, 2015
1

Quotes from the Report
• …”Systems Engineering know‐how
must 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.”
2

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 well
known systems engineering techniques such as queuing theory, Lean, Six Sigma, mathematical and computer simulations
and models, supply‐chain management techniques, and optimization techniques.   A recent Presidential  Council of Advisors
on Science and Technology agreed with these finding in their report, Better Health Care and Lower Costs: Accelerating
Improvement 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
3

Outline
1. The Current (Imperfect) State
2. Systems Engineering to the Rescue
3. What is Systems Engineering?
4. Added Value from Systems Engineering in Healthcare
5. Follow up and Contacts
4
Bohdan W. Oppenheim, bohdan.oppenheim@lmu.edu

1. The Current (Imperfect) State
5

Desired Characteristics of Healthcare
• Affordable & Accessible
• Safe
• Effective
• Patient centered
• Timely
• Efficient
• Inclusive of Latest Science
• Well integrated
6

• $8,508 per capita (UK: $3,406)
• Millions still without medical insurance
• Medicines unaffordable to a hundred million
people
• Over 30% of U.S. adults skip a recommended
test or treatment because of cost
• U.S. ranked #70 in wellness (mostly due to
obesity)
• U.S. ranked last among 11 countries in
preventable deaths
The Present Imperfect State
7

• 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 and
management methods fail to fix the dynamic hyper‐system of healthcare – needing more advanced
approaches!
8

2. Systems Engineering to the Rescue
9

Super
System
1
Super
System
3
Super
System
2
Super
System
4
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
10

3. What is Systems Engineering?
11

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

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
13
Serving Healthcare Professionals with Systems
Engineering Knowledge

• Complex systems almost always fail at
the interdisciplinary interfaces‐
• or at the interfaces with externalities
(environment)
• or interfaces with humans
• Medical professionals, managers, even
specialty engineers are not trained in
dealing with such problems
14
• 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.

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, and
other stakeholders, thousands of cooperating system elements,
hospitals, clinics, laboratories, pharmacies, equipment makers
and users, devices, specimen, procedures, laws and
regulations, in hundreds of cooperating organizations ...neither
traditional medicine nor traditional management are sufficient.
J.Thomas, INCOSE
N(N‐1)/2
15

Systems Engineering
An engineering discipline whose responsibility is creating and
executing an interdisciplinary process to ensure that the customer
and stakeholder's needs are satisfied in a high quality, trustworthy,
cost efficient and schedule compliant manner throughout a
system's entire life cycle.
INCOSE
16

4. Added Value from Systems Engineering in
Healthcare
17

• 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,
stable
patients
Patient
mortality
More care
needed
Budgets Stakeholders
Patients
Regulations Culture 18

• 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 to
subsystems, and provides
effective system
integration and verification
• Computer simulators of
operations (like flight
simulator)
www.123RF
www.flickr.com
Washington Post
campar.in.tum.de
19

Example of Stochastic Modeling of Emergency Department
20
• Great for Monte Carlo
studies of capacity, cost and
throughput
• Resource values are input
• Random factors are
modeled probabilistically
Tonya Premsrirath, KP

Powerful Studies Using Huge Databases of Patients’ Records
Number of potential medical records:
• Kaiser Permanente:
• U.S.
• World
10,000,000
300,000,000
7,000,000,000
21
Huge data „mining” now permits powerful
studies of simultaneous effects of numerous
factors and complex interations. We are no
longer constrained to simplistic clinical
studies that filter out confounding and
interaction effects. This yields rich medical
knowledge and potent treatments.

Streamlining operations and removing waste using Lean
Lean does not tell MDs how to
treat patients – it frees the
MDs to do it more and better
Lean Principles
22

Lean Improvements in Automated
Chemistry Laboratory
Current
State
Ideal
State
Future
State
Throughput
Time (Olympus)
733.5
minutes
36
minutes
140.5
minutes
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
↑ ↓
Provider
Complaints
↑ ↓
Employee
Morale
↓ ↑
Lean Improvements in
Microbiology Lab
Current Future State
State
All examples from Kaiser Permanente
Value Stream Mapping
Streamlining operations in Clinical Laboratories using Lean
23

Powerful Identification, Management and Mitigation of Risks in Healthcare, and Probabilistic Decision Making
https://www.google.com/?gws_rd=ssl#q=risk+matrix
https://www.google.com/?gws_rd=ssl#q=normal+curve
Regulations and compliance
24

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
25

Preventing “Incidents” – HealthCare.gov
Good Systems Engineering would prevent the imperfect rollout.
26

Finding the order in the chaos
• Systems Engineers are experts in finding patterns in what other people see as
chaos. They analyze the chaos by seeing patterns of processes or procedures
or 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 it
down into the details at multiple levels and points of view without losing track
of the big picture. They are experts at breaking things down from the top
level picture into the smallest details at the lowest levels where other
disciplines can address the problems in their area of expertise.
27

Management of Life‐cycle System Properties (“–ilities”)
• Safety
• Quality
• Interoperability
• Sustainability
• Reliability
• Survivability
• Maintainability
• Testability
• Resilience
• Robustness
• Reparability
• Flexibility/Adaptability
• Modularity
• Scalability
• Durability
• Evolvability
• Manufacturability
• Agility
28

Everyone wants a positive outcome for the patient. The problem lies with picking the best
way to facilitate this in a high value way.
The field of Systems Engineering offers a wide array of proven methods and scalable
approaches that foster a holistic way of examining and solving complex problems in
repeatable ways.
As the leading professional society and global promoter of Systems
Engineering, the International Council on Systems Engineering
(INCOSE) is in the best position to help your organization provide this
value today.
29

5. INCOSE is eager to partner with
Healthcare Professionals
39

• 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 make
your life quality better!
31

Technical Events and Contacts in INCOSE Healthcare Working Group (HWG)
Technical Events
January
International Workshop
http://www.incose.org
July
International Symposium
http://www.incose.org
Monthly or Bi‐Monthly
Informal web conferences
https://new.incose.org/wg/biomedical/content/event
Throughout the Year
Healthcare events at regional INCOSE
meetings
HWG Leadership
Overall Working Group Leads
Chris Unger Christopher.Unger@med.ge.com
Bob Malins rjmalins@eaglesummittech.com
Plus Regional leads for Europe, Australia, and East/Midwest/West coasts
Healthcare SE Applications
Chris Unger Christopher.Unger@med.ge.com
Healthcare MBSE Challenge
Ajay Thukral ajay.thukral@cientivegroup.com
http://omgwiki.org/MBSE/doku.php?id=mbse:drugdelivery
Healthcare Problem/Solution Database
Mike Celentano mike.celentano@roche.com
Healthcare Education Strategy
Rachel Leblanc rbowers@WPI.EDU
Jack Stein jstein@me.com,
Ajay Thukral ajay.thukral@cientivegroup.com
Lean
Bo Oppenheim boppenheim@lmu.edu
http://www.lean‐systems‐engineering.org/
Safety
32

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