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Using Advanced Process Simulation
  Methodology to Plan for a Major
 Facility Renovation of the Surgical
 Suite at The Children’s Hospital of
          Wisconsin (CHW)




        Submitted by Alexander Kolker, PhD,
       Outcomes Operations Project Manager,
          Children’s Hospital of Wisconsin
A case study presentation from
 the ASQ Healthcare Division:
      www.asq.org/health.
       Copyright © 2009, Alexander Kolker.
             Used with permission.

     Submit your own case study
      to be considered for publication.

  What other content would you like to see
on the Healthcare Division site? Let us know!
About Children’s Hospital of Wisconsin (CHW)
• Member of Children’s Hospital and Health System (CHHS)
• Private, independent, not-for-profit, 296-bed, Magnet
  designated teaching hospital
• Surgical services consist of 12 operating rooms, 2 special
  procedure rooms, and a full complement of support services
• Performed a total of 14,628 surgical procedures in 2008
• Mission is our children (and it spells “care”):
   – Caregiving - offering some of the nation's best medical
     care
   – Advocacy - speaking up and protecting children
   – Research - finding cures to the illnesses that affect
     children
   – Education - sharing what we learn and teaching
     others to care for kids
The Project Team
  • Alexander Kolker, PhD, outcomes operations
    project manager (leader)
  • Mary O’Connor, RN, MSN, MBA, director,
    surgical services
  • Brett Norell, MHA/MPH, FACHE, business
    manager, surgical services
  • Keith Oldham, MD, surgeon in chief
  • George Hoffman, MD, chief of anesthesia
The Problem
• Children’s Hospital of Wisconsin (CHW) has maximized
  the capacity of its current operating rooms and special
  procedure rooms.
• In addition, surgical services is spread geographically in
  the facility, requiring a majority of patients to arrive to one
  floor for preoperative preparation and then transport to
  another floor for their surgical procedures.
• As a result, the organization is in the planning stages for a
  major facility renovation of its surgical suite to increase
  capacity; patient, physician, and staff satisfaction; and
  efficiency of surgical services.
• The expansion will also allow for the streamlining of
  patient flow both in preoperative services and within
  the operating room areas.
The Problem
The practically important issues that arise with a renovation
  for capacity expansion are:
• Is the designed number of general and specialized
  operating rooms and prep/post-operative beds adequate
  to meet the projected patient flow and volume increases
  through 2013?
• If the design does not meet the need, how many
  operating rooms and/or prep/post-operative beds would
  be needed?
• Ensure that the renovation cost is under control and
  maintain a high level of quality and satisfaction standards
  for surgical services, using answers from management
  science to determine that the number of operating
  rooms and prep/post-operative beds is not
  excessive.
Project Goal
Performance criteria established for the management science
  model:
• Delay for patient to be admitted to a preoperative surgical bed
  should not exceed 15 minutes.
• Delay to enter operating room from a preoperative surgical bed
  should not exceed the following:
     General OR – 2 hours            Neurosurgery OR – 3 hours
     Urgent OR – 3 hours             Orthopedic OR – 2 hours
     Cardiovascular OR – 5 hours     Cardiac Cath Lab – 2 hours
• Percent of patients waiting longer than acceptable delay to
  enter operating room from a preoperative surgical bed should
  not exceed 5%.
• Delay to enter post anesthesia care beds from an operating
  room should not exceed 5 minutes.

  Average annual utilization of operating rooms should be
  in the range of 60% to 90%.
Root Cause Analysis
• Principles of management science and operations
  research helped address the issue of capacity analysis
  and patient flow in the complex surgical facility.
• Discrete events simulation methodology is the most
  powerful scientific and engineering methodology for
  analyzing and managing a proper balance of patient flow.
• The proper balance includes:
   – Number of patients entering the system at the given point of
     time
   – Number of patients leaving the system after spending the
     appropriate time in it
   – Capacity constraint of the system that limits its ability to
     handle the required number of patients in a safe way
     that meets the high quality standards of our hospital
Root Cause Analysis
• Discrete events computer simulation
  methodology helped predict if the current number
  of beds and operating rooms and their allocation
  for the various surgical services would be enough
  to meet the projected patient flow demand from
  2009 to 2013.
• Using computer simulation of a number of
  feasible scenarios, we determined the best
  possible allocation of available resources
  (operating rooms and beds) to meet the accepted
  criteria and estimated the implementation
  cost of different options.
Addressing Root Causes
The following computer simulation models (tools) were
  developed and analyzed:
• Model 1: Baseline operations - all surgical services
  function as currently specified between two floors.
  Construct two general operating rooms onto upper-level
  floor to serve otolaryngology, gastroenterology, and
  pulmonary patient volume from lower-level floor.
• Model 2: Move gastroenterology and pulmonary patient
  volume from upper level to a separate service area.
• Model 3: Separate service area for gastroenterology and
  pulmonary patient volume that includes 2 to 3 special
  procedure rooms and 8 to 11 prep/post beds and PACU
  (post-anesthesia care unit) beds.

  Total annual patient volume included in the simula-
  tion models is in the range from 15,000 to 17,000.
Addressing Root Causes
Decision variables were:
• The number of pre-operative beds and PACU beds
• The number of operating rooms and special procedure
  rooms (SPR)
• Their allocation for surgical services

Project personnel included:
• Healthcare management science expert-computer
  simulation specialist and project manager-leader
• Data analyst
• Director of surgical services
• Upper hospital management and physicians who partici-
  pated in review of simulation results and conclusions

Time requirement for project: approximately one month
Addressing Root Causes
Obstacles encountered included:
• Building complex computer models of real-world
  patient flow surgical operations
• Extracting and combining needed data from
  several different databases
• Meeting the tight project timeframe and
  modification of input data and model after review
  of previous simulation runs

  These obstacles were overcome because of the
  understanding by upper management that multi-
  million dollar management decisions require
  quantitative analysis based on management
  science/engineering.
Return on Investment
• Projected investment for OR renovation is
  approximately $10.75 M.
• Projected return on investment is 7% over a
  15-year period, and positive cash flow in
  year one.
• Patient/family satisfaction survey results
  projection for rating of care as “excellent” (based
  on the scale of poor, fair, good, very good and
  excellent) is greater than 65%.
Monitoring and Evaluating Over Time
• The director of facilities development oversees
  renovation progress, budget, construction time,
  quality, etc.
• Surgical services and medical leadership are
  engaged in the final design and occupation
  planning of new surgical space.
• A simulation model similar to the one developed
  to determine the appropriate number of pre- and
  post-operative beds and operating rooms will be
  used to evaluate the progress of the new
  process over time.
Simulation Model Layout
For More Information
• Learn more about Children’s Hospital of
  Wisconsin: www.chw.org.
• More case study presentations are available from
  the ASQ Healthcare Division:
  www.asq.org/health/quality-information/library.
• Read healthcare case study articles from ASQ:
  www.asq.org/healthcare-use/why-quality/case-
  studies.html.
• To find articles, books, courses, and other
  resources on healthcare quality, search the ASQ
  Knowledge Center:
  www.asq.org/knowledge-center/search.

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Advanced Process Simulation Methodology To Plan Facility Renovation

  • 1. Using Advanced Process Simulation Methodology to Plan for a Major Facility Renovation of the Surgical Suite at The Children’s Hospital of Wisconsin (CHW) Submitted by Alexander Kolker, PhD, Outcomes Operations Project Manager, Children’s Hospital of Wisconsin
  • 2. A case study presentation from the ASQ Healthcare Division: www.asq.org/health. Copyright © 2009, Alexander Kolker. Used with permission. Submit your own case study to be considered for publication. What other content would you like to see on the Healthcare Division site? Let us know!
  • 3. About Children’s Hospital of Wisconsin (CHW) • Member of Children’s Hospital and Health System (CHHS) • Private, independent, not-for-profit, 296-bed, Magnet designated teaching hospital • Surgical services consist of 12 operating rooms, 2 special procedure rooms, and a full complement of support services • Performed a total of 14,628 surgical procedures in 2008 • Mission is our children (and it spells “care”): – Caregiving - offering some of the nation's best medical care – Advocacy - speaking up and protecting children – Research - finding cures to the illnesses that affect children – Education - sharing what we learn and teaching others to care for kids
  • 4. The Project Team • Alexander Kolker, PhD, outcomes operations project manager (leader) • Mary O’Connor, RN, MSN, MBA, director, surgical services • Brett Norell, MHA/MPH, FACHE, business manager, surgical services • Keith Oldham, MD, surgeon in chief • George Hoffman, MD, chief of anesthesia
  • 5. The Problem • Children’s Hospital of Wisconsin (CHW) has maximized the capacity of its current operating rooms and special procedure rooms. • In addition, surgical services is spread geographically in the facility, requiring a majority of patients to arrive to one floor for preoperative preparation and then transport to another floor for their surgical procedures. • As a result, the organization is in the planning stages for a major facility renovation of its surgical suite to increase capacity; patient, physician, and staff satisfaction; and efficiency of surgical services. • The expansion will also allow for the streamlining of patient flow both in preoperative services and within the operating room areas.
  • 6. The Problem The practically important issues that arise with a renovation for capacity expansion are: • Is the designed number of general and specialized operating rooms and prep/post-operative beds adequate to meet the projected patient flow and volume increases through 2013? • If the design does not meet the need, how many operating rooms and/or prep/post-operative beds would be needed? • Ensure that the renovation cost is under control and maintain a high level of quality and satisfaction standards for surgical services, using answers from management science to determine that the number of operating rooms and prep/post-operative beds is not excessive.
  • 7. Project Goal Performance criteria established for the management science model: • Delay for patient to be admitted to a preoperative surgical bed should not exceed 15 minutes. • Delay to enter operating room from a preoperative surgical bed should not exceed the following: General OR – 2 hours Neurosurgery OR – 3 hours Urgent OR – 3 hours Orthopedic OR – 2 hours Cardiovascular OR – 5 hours Cardiac Cath Lab – 2 hours • Percent of patients waiting longer than acceptable delay to enter operating room from a preoperative surgical bed should not exceed 5%. • Delay to enter post anesthesia care beds from an operating room should not exceed 5 minutes. Average annual utilization of operating rooms should be in the range of 60% to 90%.
  • 8. Root Cause Analysis • Principles of management science and operations research helped address the issue of capacity analysis and patient flow in the complex surgical facility. • Discrete events simulation methodology is the most powerful scientific and engineering methodology for analyzing and managing a proper balance of patient flow. • The proper balance includes: – Number of patients entering the system at the given point of time – Number of patients leaving the system after spending the appropriate time in it – Capacity constraint of the system that limits its ability to handle the required number of patients in a safe way that meets the high quality standards of our hospital
  • 9. Root Cause Analysis • Discrete events computer simulation methodology helped predict if the current number of beds and operating rooms and their allocation for the various surgical services would be enough to meet the projected patient flow demand from 2009 to 2013. • Using computer simulation of a number of feasible scenarios, we determined the best possible allocation of available resources (operating rooms and beds) to meet the accepted criteria and estimated the implementation cost of different options.
  • 10. Addressing Root Causes The following computer simulation models (tools) were developed and analyzed: • Model 1: Baseline operations - all surgical services function as currently specified between two floors. Construct two general operating rooms onto upper-level floor to serve otolaryngology, gastroenterology, and pulmonary patient volume from lower-level floor. • Model 2: Move gastroenterology and pulmonary patient volume from upper level to a separate service area. • Model 3: Separate service area for gastroenterology and pulmonary patient volume that includes 2 to 3 special procedure rooms and 8 to 11 prep/post beds and PACU (post-anesthesia care unit) beds. Total annual patient volume included in the simula- tion models is in the range from 15,000 to 17,000.
  • 11. Addressing Root Causes Decision variables were: • The number of pre-operative beds and PACU beds • The number of operating rooms and special procedure rooms (SPR) • Their allocation for surgical services Project personnel included: • Healthcare management science expert-computer simulation specialist and project manager-leader • Data analyst • Director of surgical services • Upper hospital management and physicians who partici- pated in review of simulation results and conclusions Time requirement for project: approximately one month
  • 12. Addressing Root Causes Obstacles encountered included: • Building complex computer models of real-world patient flow surgical operations • Extracting and combining needed data from several different databases • Meeting the tight project timeframe and modification of input data and model after review of previous simulation runs These obstacles were overcome because of the understanding by upper management that multi- million dollar management decisions require quantitative analysis based on management science/engineering.
  • 13. Return on Investment • Projected investment for OR renovation is approximately $10.75 M. • Projected return on investment is 7% over a 15-year period, and positive cash flow in year one. • Patient/family satisfaction survey results projection for rating of care as “excellent” (based on the scale of poor, fair, good, very good and excellent) is greater than 65%.
  • 14. Monitoring and Evaluating Over Time • The director of facilities development oversees renovation progress, budget, construction time, quality, etc. • Surgical services and medical leadership are engaged in the final design and occupation planning of new surgical space. • A simulation model similar to the one developed to determine the appropriate number of pre- and post-operative beds and operating rooms will be used to evaluate the progress of the new process over time.
  • 16. For More Information • Learn more about Children’s Hospital of Wisconsin: www.chw.org. • More case study presentations are available from the ASQ Healthcare Division: www.asq.org/health/quality-information/library. • Read healthcare case study articles from ASQ: www.asq.org/healthcare-use/why-quality/case- studies.html. • To find articles, books, courses, and other resources on healthcare quality, search the ASQ Knowledge Center: www.asq.org/knowledge-center/search.