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Improving Healthcare
Workshop
Brittany Hagedorn
SIMUL8 Corporation | SIMUL8.com | info@SIMUL8.com
Introductions
Brittany Hagedorn is SIMUL8’s new Healthcare Lead for Nort...
SIMUL8 Corporation | SIMUL8.com | info@SIMUL8.com
Clinical Quality and
Patient Safety
Management
Consulting
Introductions
...
SIMUL8 Corporation | SIMUL8.com | info@SIMUL8.com
Agenda
I. Project Overview
II. Results
III. Recommendations
IV. Discussi...
SIMUL8 Corporation | SIMUL8.com | info@SIMUL8.com
Project Overview – Goals
A local hospital was constructing a new bed tow...
SIMUL8 Corporation | SIMUL8.com | info@SIMUL8.com
Project Overview – Process
The process to be modeled was fairly simple, ...
SIMUL8 Corporation | SIMUL8.com | info@SIMUL8.com
Project Overview – Model Building
This process translated into a SIMUL8 ...
SIMUL8 Corporation | SIMUL8.com | info@SIMUL8.com
Project Overview – Excel Interface
By utilizing a unique identifier for ...
SIMUL8 Corporation | SIMUL8.com | info@SIMUL8.com
-
0.50
1.00
1.50
2.00
2.50
3.00
Monday Tuesday Wednesday Thursday Friday...
SIMUL8 Corporation | SIMUL8.com | info@SIMUL8.com
Results – Unexpected Findings
However, by using a simulation, we were ab...
SIMUL8 Corporation | SIMUL8.com | info@SIMUL8.com
Results – Operational Implications
Delayed surgeries are caused by a bed...
SIMUL8 Corporation | SIMUL8.com | info@SIMUL8.com
Recommendations – Alternatives
Given this information, the natural quest...
SIMUL8 Corporation | SIMUL8.com | info@SIMUL8.com
Recommendations – Voting Results
Please Vote – Which alternative was the...
SIMUL8 Corporation | SIMUL8.com | info@SIMUL8.com
Recommendations – Best Technical
Modifying the family waiting policy was...
SIMUL8 Corporation | SIMUL8.com | info@SIMUL8.com
Recommendations – Voting Results
Due to other factors, this alternative ...
SIMUL8 Corporation | SIMUL8.com | info@SIMUL8.com
Recommendations – Trade-Offs
Ultimately, it was institutional concern ab...
SIMUL8 Corporation | SIMUL8.com | info@SIMUL8.com
Lessons Learned
OVERALL PROJECT
• Unexpected findings – On several occas...
SIMUL8 Corporation | SIMUL8.com | info@SIMUL8.com
Discussion and Questions
“ Great ideas need landing gear as well as wing...
SIMUL8 Corporation | SIMUL8.com | info@SIMUL8.com
Next Steps
If you enjoyed today’s discussion, please join us in
Septembe...
SIMUL8 Corporation | SIMUL8.com | info@SIMUL8.com
Appendix – Additional Analysis
SIMUL8 Corporation | SIMUL8.com | info@SIMUL8.com
Alternative 1 Impacts
77%
70%
65%
58%
49%
43%
35%
29%
22%
17%
12%
7% 6% ...
SIMUL8 Corporation | SIMUL8.com | info@SIMUL8.com
Patient Delay Durations
4
18
5
8
15
26
44
30 32
33
0
5
10
15
20
25
30
35...
SIMUL8 Corporation | SIMUL8.com | info@SIMUL8.com
Block Time Utilization
66%
70%
73% 75% 76%
80%
87%
-
1.00
2.00
3.00
4.00...
SIMUL8 Corporation | SIMUL8.com | info@SIMUL8.com
Block Time Utilization
77% 77% 74%
69%
76%
0%
10%
20%
30%
40%
50%
60%
70...
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SIMUL8 Healthcare: Designing New Spaces and Processes with simulation

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In this workshop, Brittany discussed how simulation can be used to design new spaces and processes, not just improve the status quo.

Calling on her experience as an ASQ-certified Six Sigma Black Belt and her work on a wide variety of performance improvement projects – many of which incorporated simulation - Brittany presented a case study that demonstrates the interconnected nature of pre/post surgery operating processes and inpatient census.

We also looked at the project's unexpected findings, as well as shared insights into using simulation as a change management and leadership communication tool.

Published in: Technology, Business
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SIMUL8 Healthcare: Designing New Spaces and Processes with simulation

  1. 1. Improving Healthcare Workshop Brittany Hagedorn
  2. 2. SIMUL8 Corporation | SIMUL8.com | info@SIMUL8.com Introductions Brittany Hagedorn is SIMUL8’s new Healthcare Lead for North America. Brittany’s 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.
  3. 3. SIMUL8 Corporation | SIMUL8.com | info@SIMUL8.com Clinical Quality and Patient Safety Management Consulting 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. Lean and Six Sigma (Process Improvement) 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.
  4. 4. SIMUL8 Corporation | SIMUL8.com | info@SIMUL8.com Agenda I. Project Overview II. Results III. Recommendations IV. Discussion & Next Steps
  5. 5. SIMUL8 Corporation | SIMUL8.com | info@SIMUL8.com 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. We recommended a simulation. The executive team’s request was for an Excel analysis that would produce: • An average number of patients. • An average number of beds. 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.
  6. 6. SIMUL8 Corporation | SIMUL8.com | info@SIMUL8.com 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. Inpatients Outpatients Add-ons Pre-Surgery Prep Surgery Post- Surgery Recovery Home Observation Return to Unit Entry Points Post-Surgical Routing
  7. 7. SIMUL8 Corporation | SIMUL8.com | info@SIMUL8.com 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 Post- surgical routing
  8. 8. SIMUL8 Corporation | SIMUL8.com | info@SIMUL8.com 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. Patient MRN Characteristics Scheduled Actual Time Stamps
  9. 9. SIMUL8 Corporation | SIMUL8.com | info@SIMUL8.com - 0.50 1.00 1.50 2.00 2.50 3.00 Monday Tuesday Wednesday Thursday Friday PatientsperDay 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 • 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.
  10. 10. SIMUL8 Corporation | SIMUL8.com | info@SIMUL8.com 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. FY 2013 FY 2018 Maximum Schedule Annual Patient Volume 14,000 15,000 16,000 Days with Delayed Surgeries 67% 77% 82% Number of Delayed Surgeries 6 daily 9 daily 10 daily Number of Observation Patients to Floor 1.3 daily 1.5 daily 2.1 daily Additional Performance Metrics • 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. In addition, the frequency and duration of delays will increase if the growth target is reached.
  11. 11. SIMUL8 Corporation | SIMUL8.com | info@SIMUL8.com 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. 0 5 10 15 20 25 30 35 40 45 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 NumberinUse Hour of the Day Note: The second surge in O.R. volumes depicts delayed patients finally getting through pre-op into surgery. 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 Example Day – Effect of Bed Shortage Pre/Post Beds O.R. Rooms Maximum Bed Capacity
  12. 12. SIMUL8 Corporation | SIMUL8.com | info@SIMUL8.com 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 patient’s 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.
  13. 13. SIMUL8 Corporation | SIMUL8.com | info@SIMUL8.com 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.
  14. 14. SIMUL8 Corporation | SIMUL8.com | info@SIMUL8.com 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 Family Moves to Another Location during Surgery % Days with Delays 77% 45% # of Patients Delayed 10 daily / 2,647 annual 1 daily / 287 annual # Observation Patients to Floor 2 daily / 417 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.
  15. 15. SIMUL8 Corporation | SIMUL8.com | info@SIMUL8.com 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.
  16. 16. SIMUL8 Corporation | SIMUL8.com | info@SIMUL8.com 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. 1.5 3.4 4.3 5.4 6.7 9.3 10.3 77% 45% 32% 20% 13% 5% 2% 0% 10% 20% 30% 40% 50% 60% 70% 80% 90% 0.0 2.0 4.0 6.0 8.0 10.0 12.0 No Limit 42 hours 40 hours 38 hours 36 hours 30 hours 24 hours %ofDayswithDelays NumberofPatientstoFloor Policy Cut-Off Point Daily Obs to Floor % Days with Shortage The Ultimate Trade-Off • 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.
  17. 17. SIMUL8 Corporation | SIMUL8.com | info@SIMUL8.com Lessons Learned 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. A few last thoughts…
  18. 18. SIMUL8 Corporation | SIMUL8.com | info@SIMUL8.com Discussion and Questions “ Great ideas need landing gear as well as wings.” – C. D. Jackson
  19. 19. SIMUL8 Corporation | SIMUL8.com | info@SIMUL8.com Next Steps If you enjoyed today’s 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!
  20. 20. SIMUL8 Corporation | SIMUL8.com | info@SIMUL8.com Appendix – Additional Analysis
  21. 21. SIMUL8 Corporation | SIMUL8.com | info@SIMUL8.com Alternative 1 Impacts 77% 70% 65% 58% 49% 43% 35% 29% 22% 17% 12% 7% 6% 4% 3%2%0% 10% 20% 30% 40% 50% 60% 70% 80% 90% 40 41 42 43 44 45 46 47 48 49 50 51 52 53 54 55 %DayswithShortage Number of Pre/Post Beds
  22. 22. SIMUL8 Corporation | SIMUL8.com | info@SIMUL8.com Patient Delay Durations 4 18 5 8 15 26 44 30 32 33 0 5 10 15 20 25 30 35 40 45 50 0 5 10 15 20 25 Monday Tuesday Wednesday Thursday Friday AverageTimeinQueue(min) PatientsthatWaitedforPrep
  23. 23. SIMUL8 Corporation | SIMUL8.com | info@SIMUL8.com Block Time Utilization 66% 70% 73% 75% 76% 80% 87% - 1.00 2.00 3.00 4.00 5.00 6.00 7.00 0% 10% 20% 30% 40% 50% 60% 70% 80% 90% 100% CVS Other Uro Gyn Gen NOS ENT RatioBlockvs.AverageDuration BlockTimeUtilization
  24. 24. SIMUL8 Corporation | SIMUL8.com | info@SIMUL8.com Block Time Utilization 77% 77% 74% 69% 76% 0% 10% 20% 30% 40% 50% 60% 70% 80% 90% Utilization Min Avg Max 66% 70% 73% 75% 76% 80% 87% 0% 10% 20% 30% 40% 50% 60% 70% 80% 90% 100% CVS Other Uro Gyn Gen NOS ENT Utilization Min Avg Max

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