Improving Healthcare Workshop

Brittany Hagedorn

Introductions
Brittany Hagedorn is SIMUL8s new Healthcare Lead for North America.

Brittanys mission is to promote the use of process simulation and related tools within healthcare. The role will include: 1. Supporting existing users. 2. Publicizing the great work already being done. 3. Fostering growth of the simulation community. 4. Pioneering new applications within healthcare. 5. Developing tools and training.

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Introductions
My experience has been in project-oriented roles, first as a Six Sigma Black Belt within a hospital system, then as an external consultant. Through these roles, I have had the privilege to work on a wide variety of challenges. My favorite projects include: Reducing the lead time for pediatric sedated procedures from six weeks to seven days. Addressing bottlenecks in nursing workflows. Eliminating 70% of duplicative double checks for physician documentation. Constructing a clinical quality scorecard that could be easily managed and integrated into executive compensation. Developing a primary care compensation plan for 150+ physicians to incentivize their transition toward a value-based, accountable clinical care model. Creating an integration strategy for a newly formed cardiology medical group. Building a business case for post-acute care services. Supporting preventable harm interventions.

Lean and Six Sigma (Process Improvement)

Clinical Quality and Patient Safety

Management Consulting

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Agenda I. Project Overview II. Results III. Recommendations IV. Discussion & Next Steps

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Project Overview Goals

A local hospital was constructing a new bed tower. They wanted to know often they would need a medical/surgical bed for post-surgical observation patients.

The executive teams request was for an Excel analysis that would produce: An average number of patients. An average number of beds. We recommended a simulation.

After discussions, we recommended a project charter for a simulation that would produce: The range for the expected number of beds. Identification of any downstream effects.

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Project Overview Process

The process to be modeled was fairly simple, with a few routing decisions. Each step had a variable time duration, which included both random variation and patient-specific factors such as specialty and acuity.

Entry Points

Post-Surgical Routing

Inpatients PostSurgery Recovery

Home

Outpatients

Pre-Surgery Prep

Surgery

Observation

Add-ons

Return to Unit

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Project Overview Model Building

This process translated into a SIMUL8 model quickly, but there was some additional work to build the OR schedule into the simulation.

Entry Points

Resources

Postsurgical routing

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Project Overview Excel Interface

By utilizing a unique identifier for each patient entering the simulation, we obtained individual-level data and results that were like-real-life.

Characteristics Patient MRN

Scheduled

Actual Time Stamps

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Results Patient Volumes

The model assumed a continuation of current policy, which meant that observation patients would remain in the pre/post surgical suite until discharged or the end of the day. At the end of the day, all remaining patients were transferred to an inpatient unit, which results in longer stays and increased costs. Observation Patients to Floor per Day
3.00 2.50

Patients per Day

2.00 1.50 1.00 0.50 Monday Tuesday Wednesday Thursday Friday

With current policies, there would be fewer than two patients per day needing placement at the end of the day. As a result, additional inpatient beds dedicated to observation patients would not be needed.

Note: The variability by day of the week was due to the surgeon specialty mix.

Excel analysis resulted in 1.3 beds per day, without insight into daily variation or downstream effects.

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Results Unexpected Findings

However, by using a simulation, we were able to capture additional performance metrics, which suggested that there may be other potential issues. Additional Performance Metrics
FY 2013
Annual Patient Volume Days with Delayed Surgeries Number of Delayed Surgeries 14,000

FY 2018
15,000

Maximum Schedule
16,000

67%

77%

82%

The simulation queues showed that many patients were seeing delayed surgery starts. With current state processes and policies, this would happen on over 65% of days. When delays did occur, it would affect on average 6 patients per day.

6 daily

9 daily

10 daily

Number of Observation Patients to Floor

1.3 daily

1.5 daily

2.1 daily

In addition, the frequency and duration of delays will increase if the growth target is reached.

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Results Operational Implications

Delayed surgeries are caused by a bed shortage, which prevents patients from being prepped for their procedure on time. This directly affect profitability, either in foregone revenue or increased staffing costs.

Example Day Effect of Bed Shortage

Observation patients remain in Pre/Post Unit Not enough bed capacity for arriving patients Delayed prep causes delayed surgery start times Patients are cancelled or staff must work overtime
Number in Use 45 40 35 30 25 20 15

Maximum Bed Capacity

10
5 0 5 6 7 8

Pre/Post Beds O.R. Rooms

9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 Hour of the Day

Note: The second surge in O.R. volumes depicts delayed patients finally getting through pre-op into surgery.

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Recommendations Alternatives
Given this information, the natural question is how do we fix it?

There were three alternative solutions that were simulated, in order to measure the real impact that implementation would have.

1. Pre-Admission Testing Rooms Repurpose the four pre-admission testing rooms that were adjacent to the pre/post suite. These could be retrofitted before construction was complete as recovery spaces. 2. Family Waiting Policy The plan for the new unit was to allow patients families to remain in their patients prep room during the surgery, and return the patient to the same location for recovery. 3. Observation Patient Policy Modify the policy to indicate that observation patients should be moved to an inpatient unit if they will be staying for longer than a pre-determined threshold.

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Recommendations Voting Results

Please Vote Which alternative was the most effective? A. Reclaim 4 pre-admission testing rooms. B. Ask families to move to the waiting room during surgery. C. Move observation patients to inpatient beds after surgery.

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Recommendations Best Technical

Modifying the family waiting policy was the most effective at balancing the needs of the inpatient units and operating rooms.

Family Remains in Pre/Post Room during Surgery % Days with Delays 77%

Family Moves to Another Location during Surgery 45%

# of Patients Delayed
# Observation Patients to Floor

10 daily / 2,647 annual

2 daily / 417 annual

1 daily / 287 annual

0 annual

The change in policy would minimize the number of delayed cases and eliminate the need for inpatient beds to house observation patients, releasing bed capacity for other uses. Additional improvement could be made by modifying the O.R. block schedule to distribute observation patients more evenly throughout the week.

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Recommendations Voting Results

Due to other factors, this alternative was not implemented.

Please Vote Which was the primary barrier?

A. The solution was too technically complex to implement. B. We did not have the right executives in the room to be able to make the policy decision. C. There were other programs being implemented that were perceived to be in conflict. D. Political divisions created barriers to buy-in.

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Recommendations Trade-Offs
Ultimately, it was institutional concern about Value Based Purchasing (which rewards hospitals for patient satisfaction scores) that drove the decision to modify the observation patient policy instead.

The Ultimate Trade-Off

12.0 Number of Patients to Floor 10.0 8.0 6.0 4.0 2.0 1.5 0.0 No Limit 42 hours 40 hours 38 hours 36 hours 30 hours 24 hours Policy Cut-Off Point Daily Obs to Floor % Days with Shortage 3.4 45% 6.7 32% 4.3 77% 10.3 9.3 90% 80% % of Days with Delays 70% 60% 50% 40% 30% 13% 5% 2% 0%

5.4
20%

20%
10%

The trade-off was a decision for the executive team. As more observation patients were moved to inpatient units, the number of delays dropped dramatically. Ultimately, the policy was modified so that every observation patient was moved to an inpatient unit after surgery.

The other factor to consider is the impact on E.R. throughput.

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Lessons Learned
A few last thoughts

OVERALL PROJECT
Unexpected findings On several occasions, the analysis results did not turn out as expected. Eventually, we discovered that the simulation was operating correctly but the process was not operating as it had been described. Scope creep The scope of the project grew several times, as we uncovered additional questions that needed to be answered. Stakeholder buy-in Changing policy presents challenges, depending on the stakeholders and their entrenched beliefs. The best technical solution will not always be implemented. RELATED TO DESIGN Rules of Thumb Architecture and construction teams often rely on industry standards when designing physical spaces, such as four beds per OR. But every situation is unique and this approach results in over/under-built spaces. Earlier is Better Simulation is helpful at any stage of the process, but to reduce costs, earlier is always better. If we had completed this analysis a few months earlier, we would not have needed to redo several rounds of architectural plans, which prevented us from considering several alternatives.
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Discussion and Questions

Great ideas need landing gear as well as wings. C. D. Jackson

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Next Steps
If you enjoyed todays discussion, please join us in September for the next workshop! Are you facing complex processes and an overwhelming amount of work to do? Suggest a future topic! Join the simulation community by connecting with us on LinkedIn, Twitter, or on our website at SIMUL8.com!

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Appendix Additional Analysis

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Alternative 1 Impacts
90% 80% % Days with Shortage 77% 70% 65% 58% 49% 43% 35% 29% 22% 17% 12% 7% 6% 4% 3%2% 40 41 42 43 44 45 46 47 48 49 50 51 52 53 54 55 Number of Pre/Post Beds

70%
60% 50% 40% 30% 20% 10% 0%

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Patient Delay Durations

25 44 Patients that Waited for Prep 50 45 Average Time in Queue (min)

20 30
15 26 18 15 32 33

40
35 30 25

10

20
15

5 4 0 Monday Tuesday Wednesday 5

10 5 0

Thursday

Friday

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Block Time Utilization

100% 90% Block Time Utilization 80% 70% 60% 50% 40% 30% 20% 10% 1.00 3.00 2.00 66% 70% 73% 75% 76% 80% 5.00 4.00 7.00 87% 6.00 Ratio Block vs. Average Duration

0%
CVS Other Uro Gyn Gen NOS ENT

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Block Time Utilization

100% 90% 80% 70% Utilization 60% 50% 66% 70% 73% 75% 76% 80% 87%

Min Avg Max

40%
30% 20% 10% 0% CVS Other Uro Gyn Gen NOS ENT

90% 80% 70% Utilization 60% 50% 40% 30% 20% 10% 0% Min Avg Max 77% 77% 74% 76% 69%

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