TRIZ and Patient Safety John Gosbee, MD, MS Human Factors

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TRIZ and Patient Safety

• John Gosbee, MD, MS
• Human Factors Engineering and Healthcare
  Specialist
• VA NCPS
• John.Gosbee_at_med.va.gov
• Adapted from Jack Hipple Innovation-TRIZ

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BASIC CONCEPTS OF TRIZ

• Systems (through inventions) evolve toward
  IDEALITY
• It is key to use RESOURCES within the system or
  easily convertible
• Resolving CONTRADICTIONS as they evolve
• Inventive principles are recognized and used
• Gathered from bottom-up aggregation of patents
• but, from mechanical and non-computer era in
  Russia (1900-1950)

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WHAT IS TRIZ ?

• A Russian acronym
• Theoria Resheneyva Isobretatelskehuh Zadach
• (Theory of Solving Problems Inventively)

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WHAT IS TRIZ ?

• A way of thinking
• A family of tools, tool kits, and software
• The way of thinking can ALWAYS be used, but the
  tools in the tool kit can be selected depending
  the nature of the problem, time available, etc.

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THE HISTORY OF TRIZ

• A discovery of a talented patent examiner for the
  Russian navy, Genrich Altshuller, 1950s
• Originated from the study of several hundred
  thousand of the worlds most inventive
  patents--now in the millions
• He recognized that the development of
  technological systems follows predictable
  patterns that cut across ALL areas of
  technology--the speed of technical evolution can
  be accelerated
• Also recognized that problem solving principles
  are also predictable and repeatable--anyone can
  invent!
• Established schools to teach after a Stalin 7 yr.
  prison term--deceased in 1999 at age 71

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BASIC CONCEPTS

• Systems evolve toward IDEALITY irreversibly
• Using RESOURCES within the system or easily
  convertible
• Resolving CONTRADICTIONS as they evolve
• PATTERNS OF INVENTIONS/OPERATORS are constantly
  recognized and used

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CONCEPT OF IDEALITYOR IDEAL FINAL RESULT

• Seems simple, but difficult to state clearly
• Get the task accomplished with few or no
  resources
• Examples

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I HAVE TO REMOVE CORES FROM A MILLION GREEN
PEPPERS.

• How would I do this?

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RESOURCE CHECKLIST (e.g., shoe)

• We use these to get to Ideality
• Substances (laces, sole, eyelets)
• Fields (static electricity)
• Space (inside, on top, inside eyelets)
• Time (N/A)
• Information (smell or not, dirty or not)
• System functionality (foot wear, pounding on
  table)

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WHATS A RESOURCE?

• A resource
• is any substance (including waste) available in
  the system or its environment
• has the functional and technological ability to
  jointly perform additional functions
• is an energy reserve, free time, unoccupied
  space, information, etc.

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Electricity through a wire - RESOURCES
Copper Contaminates Type Amount Diameter Lengt
h Shape of wire Amount Form of excitation signal
(A/C) Frequency Amount Form of excitation signal
(A/C) Frequency Hydrogen Oxygen Nitrogen Carbon Te
mperature, Pressure, Velocity, Speed
Wire Current Voltage Air
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EXAMPLES OF CONTRADICTIONS

• Weight vs. strength
• Speed and weight vs. fuel economy
• Vision accuracy vs. distance
• Organizational structure vs. entrepreneurial
  climate
• Food that tastes good vs. good for you
• Open office space vs. quiet
• Accessibility vs. security and safety
• Voice of the customer vs. radical innovation
• Security vs. easy access

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PHYSICAL CONTRADICTION

• A characteristic must be higher and lower
  (self-opposing)
• Example A pen tip should be sharp to draw fine
  lines, but blunt to avoid tearing the paper
• A characteristic must be present and absent
• Example For sandblasting the abrasive must be
  present (to abrade) but is not wanted on (or in)
  the product
• Example Aircraft landing gear are needed for
  landing but undesired in flight

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Resolving Not Compromising - Contradictions

• After thousands of suggestions to compromise ? we
  all do it reflexively
• Study of nurses at Harvard teaching hospital
• Dozens of primary problem-solvings/day
• Few or zero secondary problem solvings observed
• Example
• I want every employee to bring exercise weights
  on travel (via airplane)
• They need 20 to exercise fully but they only
  want to carry 2

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SEPARATION PRINCIPLESFOR PHYSICAL
CONTRADICTIONS(cars on roads that meet)

• Separation in time (stop lights)
• Separation in space (overpass)
• Separation between parts and the whole (rotary)
• Separation upon condition (Drawbridge)

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SEPARATION BETWEEN PARTS AND THE WHOLE

• A characteristic exists at the system level but
  not at the component level (or vice versa)
• Example A bicycle chain is rigid at the
  micro-level for strength, and flexible at the
  macro-level.
• Example Epoxy resin and hardener are liquid
  until mixed, then they solidify.

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PATTERNS OF INVENTION

• Removing stems from bell peppers
• Removing shells form sunflower seeds
• Cleaning filters
• Unpacking parts wrapped in protective paper
• Splitting diamonds along micro-cracks
• Producing sugar powder from sugar crystals
• Explosive depulping

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With Certain Ideality or Contradiction Statements

• Fall into the 40x40 matrix
• Numbers in each cell point to pre-existing
  solutions (patents)
• Unfortunately most columns/rows are
  manufacturing/mechanical
• Slightly unfortunately, most solution types do
  not easily translate to medical contradictions

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Design Contradictions in Healthcare

• Use existing holes in people without using them
  (feeding tubes)
• Make holes in people with no trauma (lowest gauge
  needle possible)
• Clearly identify patients while making them as
  anonymous as possible

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RESOURCES

• www.innovation-triz.com , newsletter (free)
• TRIZ Journal, on line at www.triz-journal.com
  (free)
• Books
• And Suddenly the Inventor Appeared, Altshuller
• Hands on Systematic Innovation, Mann, CREAX
  Press
• TRIZ The Right Solution at the Right Time,
  Salamatov
• The Engineering of Creativity, Savransky, CRC
  Press
• Simplified TRIZ, Rantanen and Domb, CRC Press
• Note All available from Altshuller Institute