Going "lean" in Healthcare with simulation modeling

1. Navigant Consulting, Inc.
Tools in Your Toolbox
Using Lean Concepts & Tools to Provide
an Optimized Care Delivery System and
Inform Healthcare Facility Design
Debbie Hoffman
April 8, 2009
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2. Today’s Topics
Why Change?
Laying the Foundation for Process
Change
Tool Box
Current State to Future State
Questions
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3. Can we afford to continue doing business as usual?
• US Health care spending represents 18 % Plus of GDP in 2008 and has been forecasted
to be 20 % by the year 2017. This is Two times more than any other country. * Source:
NIH, 2008
• Over the last 35 years, while the nation’s spending on all goods and services has risen
at an average annual rate of 7.2 % the amount spent on healthcare as grown at a rate of
9.8 %..as a consequence, Americans simply cannot afford adequate care. 1
• If Federal government spending remains relatively constant % of GDP, the rising cost
of Medicare within that budget will crowd out all other spending.1
• If governmental financial statements reported the liabilities they face from contractual
commitments to provide healthcare for retired employees, every city and town in the
US would be bankrupt. There is no way for them to pay except by denying funding to
other projects or raise taxes to extremely levels. 1
1 The Innovator’s Prescription – A Disruptive Solution for Health Care, Christensen,Clayton 2008
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4. Planning for Optimized Care Delivery
There are two types of costs that need to be considered in the optimization of
health care delivery‐ first time building cost & continuing operational costs.
Staffing
Efficiency
Physician /
Quality of Staff
Care Optimized Satisfaction
Health Care
Delivery
Adaptability /
Patient
Flexibility/
Satisfaction
Sustainable
Operational Process
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5. Laying the Foundation for Process Change
What does LEAN bring to the table?
Predictability of
workflow‐
Decrease cycle standardization
times = of processes
decrease ALOS
Adaptability of
space allowing
Space flexibility –
requirements increasing
reduced‐ utilization and
elimination of LEAN
decrease
duplicity obsolescence
Balancing
spaces needs
versus utilization Less process
steps = less
Development of handoffs = less
a “future state” errors
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6. Creating a New Level of Collaborative Design
Environment
Key elements for success
• Guiding Principles‐ WHAT DO THEY VALUE?
• What does the client want to solve?
• Everyone having a seat at the table
• Consensus building
• Sharing of all documents
• Value analysis throughout design
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7. Tools in the Tools Box
Project Flow – Key Elements
Value Stream Modeling / Narravtive
Simulation Modeling
“What if’s” – Case Study
Application of Metric
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8. Project Flow
Changing the typical project flow will result in dividends by reducing first time building
cost and continuing of operations
Functional /
Strategic Delivery Care Simulation Schematic Design &
Space
Planning Models Modeling Design Construction
Program
› Identify key › Identify service › Draw flow charts › Balance # of › Blocking and › Project oversight
trends and line › Data collection rooms versus stacking › Risk assessment
growth patterns configurations utilization diagrams
› Pilot program
› Define program & › Prepare workload › Define functional › Internal and
› Test “what-if” adjacencies
facility priorities projections external
scenarios
› Feasibility Study › Quantify staffing Simultaneously Determine
› department flows
› Optimize optimal
needs
adjacencies departmental
› Value Stream based on care
Modeling area allocations
delivery efficient
› Detail room-by-
room / needs
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9. Areas to Consider for Modeling Key Flows
Defining Key Elements of Patient Encounter
Encounter Post‐
Pre‐Encounter Arrival Encounter Check‐Out Encounter
Scheduling Building Rooming Schedule follow‐ Chart completion
Pre‐registration Prep or assessment up: Billing
Drop off/greeting
Pre‐certification Chaperoning Visits Results reporting
Way finding
Financial counseling Clinician Patient referrals Referring physician
Orientation/
Clinical information directions notification Testing or communication
capture Care delivery procedures Patient
Building amenities
Patient instruction Clinical Urgent communication
Elevator protocols
transmission documentation consultations Patient monitoring
Appointment Destination Ordering/ Sub‐acute care or Prescription
confirmation Registration/ prescribing therapies management
Chart preparation check‐in Education & Patient satisfaction
Financial/business research survey
services Patient tracking
Patient & family
waiting
Consent for service
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10. Value Streaming Patient Flow
Operational Benefits
• Eliminates waste Current State ‐ From this…..
• Decreases handoffs
• Reduces steps and cycle times
• Increases predictability of workflow
• Decrease staffing requirements
• Improves quality of outcomes
• Defines constraints and enablers
• Reduce errors
Facility Impacts
• Space requirements reduced
• Fewer dedicated spaces Future State‐ to this!
• Removes walls that create silos
• Minimizes patient movements
• Increases opportunity to “Broadband”
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11. Overall VSM‐ Patient Access to Treatment Mall‐ Future
State
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12. VSM‐ Single Clinic Visit
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13. VSM to Design Implications
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14. Recommendations
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15. Inside Simulation Modeling
• A tool to measure operating performance
What it is… • Most effective when focused on defined and specific issues
• Most useful in addressing complex, interactive systems
What it isn’t… • A “virtual reality” that will mimic all operating conditions
• Creating, testing and refining operating models
Principal benefits…
• Provides factual basis for setting performance objectives –
human resources, capital resources, patient and staff satisfaction
• Trade off room utilization versus room needs
• Travel distances per staff, patient, supplies for various scenarios
• Avg. & Max waiting times
Key Questions • Space needs of facility by the time of day and day of week
• Test optimal scenarios given constraints of space, schedule, &
staffing
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16. Simulation Model ‐ Example
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17. Simulation Model ‐ Example
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18. Case Study Benefit and Value
The principal value of the simulation modeling proved to be in three areas:
Testing alternative Participation of service line
Testing of physical capacity operational configurations directors and key staff in
at peak demand conditions and concepts for the modeling to obtain informed
prep/recovery function buy‐in
• Quantifying the number • Test program with changes • Involvement of key staff to
of rooms and resources in operational identify opportunity for
needed to staff the new assumptions (e.g. extended improving intra‐
hospital hours, increased volume) departmental and inter‐
departmental patient flow
• Identify amount of room • Identify prep/recovery
within space program for configuration that can • User participation to
future growth adequately support peri‐ improve project buy‐in
operative areas and staff morale
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19. Case Study – Children’s Memorial Hospital
Lincoln
Park
Lake Michigan
CMH Current Facility
Northwestern
University
Feinberg School
of Medicine
Navy Pier
New CMH Campus/
Medical School
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20. Questions Asked
How many trauma and Critical Care Facility Entrance
urgent care rooms are Point
needed? How often does
each room type reach What are the average wait
Emergency times for a machine? How
capacity? What are the
Dept. many prep and recovery
implications of a bi-level
ED? spaces are needed per
modality/floor?
Critical Care Diagnostic
NICU/PICU Imaging
What is the max number What prep/recovery
of rooms demanded? configuration is most
How often is the max Prep/ economical? How many
reached? Recovery/ spaces are required? What
Obs efficiencies are gained by
sharing prep and stage II
What is the max number of areas?
rooms demanded? How Procedure
Acute
often is the max reached? Suite
What happens to the ED What time will the OR’s
when the Acute IP is full? finish their cases at the end
What is the average and of the day? What
Psych operational issues arise from
max wait times for a
bed? a bi- or tri-level operating
room?
Medical Surgical
IP Units Patients Patients
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21. Questions Answered
Will the IP units reach capacity during peak What are the implications of adding another
months? How much space is there for machine or extending operating hours on wait
program growth? times?
Inpatient Max Utilization
Acute
Census
What is the impact of a full IP on the ED?
How late will ORs need to stay open to finish projected
caseloads?
What is the impact of reducing turnaround?
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22. Conclusions
Simulation modeling is a tool that has the potential of helping managers and planners
not only in functional and space programming and planning but also can play a
significant role in :
Ongoing Operational
Staffing & Budgeting Equipment Planning
Analysis
» Accurately account for » Effectively track equipment » Lean value stream mapping
variable costs by tracking utilization patterns across to understand which
usage rates and assigning time processes add value to a
cost information into the work flow
» Illustrate outcomes of
model
utilizing resources with » Identify opportunities in
» Printed reports of value different treatment times reducing turnaround times,
added, business value cost implications of
» Count the number of scans
added, and non‐value standardizing medical
machines in radiology will
added classifications instruments, ideal
incur in defined set of time
departmental adjacencies,
» Quantification of staff for capital planning
and recovery
required to maintain purposes
configurations
certain utilization rates and
to ensure proper staffing
resources
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23. Your Comments & Questions
For additional information or case studies please call
Debbie Hoffman
949 395‐1482
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