Merging Cath Labs: Using simulation to design a solution and understand the impact
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Learn how Boston Scientific used simulation to test the impact of merging Cath Labs from two different sites in a Canadian hospital. In this live webinar session, Boston Scientific's Yixin Wang will discuss how simulation formed a key part of the change process, engaged clinicians and administrators in the redesign, and ensured consensus on the best solution. You'll learn how the teams worked together to understand the complexities of future demand from the local population, procedure types and timings, staffing, scheduling, as well as determining the optimum design for the combined unit.
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Merging Cath Labs: Using simulation to design a solution and understand the impact
- 1. 1 CORP-97406-AF NOV2014 Cath lab Workflow Webinar
- 2. 2 CORP-97406-AF NOV2014 House keeping Audio Q & A Recording will be available on SIMUL8Healthcare.com
- 3. 3 CORP-97406-AF NOV2014 Introduction Yixin Wang MBA, BEEE., PMP Sr. Marketing Manager Boston Scientific
- 4. 4 CORP-97406-AF NOV2014 Agenda • Introduction • Project Overview • Samples of Simulation-Based Scenario Analysis • Samples of Key Results • Summary • Q&As
- 5. 5 CORP-97406-AF NOV2014 Customer Background • Treats 55,000 patients per year • Largest inherited arrhythmia clinical and resource program in Canada • Leading more than 20 international trials, involving 30,000 patients and 400 physicians, scientist and researcher in 20 countries • Working closely with Mayo on a trial of genomics (coronary disease) • Partnering with the banting and best diabetes center • Progressive adoptions of 3D echocardiography to establish the first Canadian anesthesiology cardiovascular imaging center • 1M to “pioneers” through a ‘dragon’s den” innovation committee
- 6. 6 CORP-97406-AF NOV2014 Project Background Catheterization laboratory ( Cath lab) general info: – No. of Labs: 4. • 2 Percutaneous Coronary Intervention(PCIs) , 1 Structural Heart and 1 Electrophysiology Procedure(EP ) – No. of prep and recovery bay beds: 14 – Operating hours: • Bay : 7:00 to 18:00 • Labs: 8:00 to 17:30 – Resource ratio: • Labs: non congenital cases: 3:1 . Congenital cases: 4:1 • Prep: 4-5:1 and 1:1 the hour after procedure ( during recovery) • Attendants ( housekeeping and transportation): 3 Current State / Baseline model
- 7. CORP-256902-AA MAR2015 7 © Boston Scientific 2014. All Rights Reserved. Same day discharge pathway Performance management – operational metrics Management / Financial Structure Capacity and Demand Cultural Aspect / Team Spirit 5A,5B Scheduling Bed Management Bed/Bay Management Bed/Bay Management Cost /Procedure/ Physicians Standard Work Roles and Responsibilities Pt Categories: Urgent, Elective ( PCI/Cath, Congenital, EP) Process Scope
- 8. CORP-256902-AA MAR2015 8 © Boston Scientific 2014. All Rights Reserved. Simulation-Based Scenario Analysis
- 9. CORP-256902-AA MAR2015 9 © Boston Scientific 2014. All Rights Reserved. Key Questions Understand Current Performance Physical Space Add additional lab rooms (Business Expansion) Improvement ideas •Room utilization •Slot utilization •Current bay: Do we have enough •Options to support expansion •What type •How many •Focus on adjust physician schedule •Templates •Operating schedule
- 10. CORP-256902-AA MAR2015 10 © Boston Scientific 2015. All Rights Reserved. Simulation Design Population- Based Demand Day-Of Patient Process Schedule Resource Constraints Schedule Results
- 11. CORP-256902-AA MAR2015 11 © Boston Scientific 2014. All Rights Reserved. Data Requirements (Assumptions) • Process Details – Activity description – Who performs the activity (ex. pre-op nurse) – How long the activity takes (in minutes) – Where the activity is performed (ex. pre-op bed) – Delay or transportation times between each activity • Patient Demand – Daily patient schedule – Types of procedures – Level of patient demand, by procedure type and by status – How long each procedure type takes • Resource Constraints – Which clinical staff perform each procedure type – List of all staff involved in the Cath Lab operation – How many of each type of staff are available, by shift and/or day of week – Percentage of time each staff member spends on non-patient-touch activities
- 12. CORP-256902-AA MAR2015 12 © Boston Scientific 2015. All Rights Reserved. The Model • The simulation is built to reflect layout as well as process.
- 13. CORP-256902-AA MAR2015 13 © Boston Scientific 2014. All Rights Reserved. Simulation Results Many detailed results are collected, including: • Patient delays • Schedule backlog • Schedule/slot utilization • Resource utilization • Room and bay Occupancy
- 14. CORP-256902-AA MAR2015 14 © Boston Scientific 2015. All Rights Reserved. Demand Scenarios Scenario Themes: 1. Base Case – Current State 2. Additional Specialty Volume Growth 3. Transfer of some O.R.-based Cases 4. Add 2 rooms into the current state (Merge 2 sites into 1) Variables for scenarios • Demand level • No. of labs • Lab mix • Bay hours • Reschedule cut offs • Overnights
- 15. CORP-256902-AA MAR2015 15 © Boston Scientific 2015. All Rights Reserved. Scenario Examples Scenario 5 vs. Scenario 10 # Demand Level # Labs Labs Mix Lab Hours Bay Hours Reschedules Overnights Highlights 5 System funded + 2% for unfunded services + pacemaker from O.R. 4 Additional pacemaker volume from O.R. 6 cases per week added) and additional congenital cases 8:00- 18:00 7:00-18:00 16:30 No • Designed to accommodate the entire requested volume from O.R. without taking away any additional slots based on scenario 4 as physician engagement could become a concern • Overall performance was the best out of the last 5 scenarios. This model achieved an avg. 68% room utilization among lab 1,2 & 3. ( Max 76%, Min 60%) • Slot utilization shows the best performance among the last 5 simulations as well. ( benchmark slot utilization should be something approx. 70%, leave some space for urgent requests, reduce the waiting time etc.) • Added additional 6 pacemaker slots by expand/add cases/slots based on utilization • Still was able to add 2 congenital case per week • Redesigned the schedule base on best estimation 10 System funded + 2% for unfunded services + pacemaker from O.R. 4 More Expansion 8:00- 20:00 7:00-22:00 19:00 No Add even more new slots. The wait list is eliminated and slot utilization is reasonable across the board.
- 16. CORP-256902-AA MAR2015 16 © Boston Scientific 2014. All Rights Reserved. Primary Improvement Variables Scheduling Template Hours of Operation Overnight Stays Cancellation Policy Number of Rooms/Bays Demand Levels
- 17. CORP-256902-AA MAR2015 17 © Boston Scientific 2014. All Rights Reserved. Sample Results
- 18. CORP-256902-AA MAR2015 18 © Boston Scientific 2014. All Rights Reserved. Results: Slot Utilization by Type Understand Current State
- 19. CORP-256902-AA MAR2015 19 © Boston Scientific 2014. All Rights Reserved. Results: Bay Occupancy Understand Future State : bay capacity - 5 10 15 20 25 30 0:00 1:00 2:00 3:00 4:00 5:00 6:00 7:00 8:00 9:00 10:00 11:00 12:00 13:00 14:00 15:00 16:00 17:00 18:00 19:00 20:00 21:00 22:00 23:00 Monday Tuesday Wednesday Thursday Friday Weekly Max If run unconstrained, the simulation shows that we could expect to need up to 28 bays if all 6 rooms are experiencing peak demand at the same time. Bay occupancy drops quickly as the day progresses. There may be opportunity to reduce construction costs by reorganizing the schedule.
- 20. CORP-256902-AA MAR2015 20 © Boston Scientific 2014. All Rights Reserved. Results: Room Utilization per Week Improvement ideas
- 21. CORP-256902-AA MAR2015 21 © Boston Scientific 2014. All Rights Reserved. Recommendations
- 22. CORP-256902-AA MAR2015 22 © Boston Scientific 2014. All Rights Reserved. Baseline Highlights • Baseline model, current state, highlights – Room Utilization: • Average utilization among lab 1, lab 2 and lab 3 are only at 56%, lab 2 has the lowest annualized utilization 45% • Lab 4 is almost at capacity, running an annualized utilization at 97% – Slot Utilization • Biopsy needs to assign more slots • Elective PCI is well under utilized • Management team required to expand pacemaker and structural slots • Keep urgent PCI in order to manage the LOS expectation • Based on the baseline performance, 12 scenarios were generated to improve utilizations by adjust physician schedules and lab/bay schedules, best option: Scenario 5. 63% 45% 61% 93% EP Elective PCI Biopsy Structural Pacemaker Urgent PCI STEMI BiV Monday 100.00% 31.15% N/A N/A 92.63% 66.92% N/A N/A Tuesday 100.00% 21.47% N/A N/A N/A 46.43% N/A 82.69% Wednesday 100.00% 37.98% N/A 93.59% N/A 78.85% N/A 37.50% Thursday 100.00% 31.73% 100.48% N/A 98.08% 71.15% N/A N/A Friday 100.00% 34.23% N/A 70.39% N/A 67.69% N/A N/A Total 100.00% 30.61% 100.48% 79.09% 95.35% 63.30% N/A 55.45% Under utilized slots Need to assign more slots Require to expand slots Don’t change due to the need to meet LOS expectations
- 23. CORP-256902-AA MAR2015 23 © Boston Scientific 2014. All Rights Reserved. Summary Scheduling Template Case schedule example before vs. after Best recommendation for case schedule template: Room 1 Monday Tuesday WednesdayThursday Friday EP 1 2 5 2 3 2 Elective PCI 2 2 5 2 3 2 Biopsy 3 6 6 6 3 6 Structral 4 6 6 6 3 6 Pacemaker 5 6 6 6 2 6 Urgent PCI 6 2 STEMI 7 6 Biv 8 Room 2 Monday Tuesday WednesdayThursday Friday 3 6 4 5 4 3 6 4 5 4 3 6 4 6 4 3 6 4 6 4 3 6 4 6 4 6 Room 3 Monday Tuesday WednesdayThursday Friday 5 5 8 5 6 5 5 8 5 6 5 5 8 5 2 5 5 8 5 2 5 5 8 5 2 8 5 Room 4 Monday Tuesday WednesdayThursday Friday 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 Room 1 Monday Tuesday WednesdayThursday Friday 2 2 2 3 2 6 6 6 3 6 2 2 2 3 2 6 6 6 3 6 6 6 6 2 6 2 6 Room 2 Monday Tuesday WednesdayThursday Friday 2 2 2 2 4 6 6 2 6 4 2 2 4 2 4 2 6 4 6 4 6 6 4 6 4 Room 3 Monday Tuesday WednesdayThursday Friday 5 8 8 5 2 5 8 8 5 6 5 2 8 5 2 5 2 8 5 2 5 6 5 6 5 5 Room 4 Monday Tuesday WednesdayThursday Friday 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 Baseline Best Solution (Scenario 5) • Added 6 pacemaker slots. Per Week • Added 2 congenital slots per week • Took away some slots from Elective PCI
- 24. CORP-256902-AA MAR2015 24 © Boston Scientific 2014. All Rights Reserved. Room Utilization comparison between base model (current state) vs. suggestion Scenario 5 Summary Slot Utilization Room Utilization before vs. after
- 25. CORP-256902-AA MAR2015 25 © Boston Scientific 2014. All Rights Reserved. Lesson Learned • Ask the right questions • Understand the variables • Walk/see the process • Collect Voice of Customer/Hospital • Manage the scope closely • Regular use of the software package
- 26. CORP-256902-AA MAR2015 26 © Boston Scientific 2014. All Rights Reserved.
- 27. CORP-256902-AA MAR2015 27 © Boston Scientific 2014. All Rights Reserved. SIMUL8 in Health Continue the discussion A recording of today’s session will be available on SIMUL8Healthcare.com
Editor's Notes
- Yixin Wang is a Senior Marketing Manager for Boston Scientific where she leads the effort in developing value strategies and CVSL solutions that address the rapidly changing competitive economic needs of Interventional Cardiology customers. Yixin has over 10 years’ experience in process and organizational performance improvement in healthcare, business functions, IS and service industries across U.S., Europe and Asia. Yixin started her career as an R&D engineer, she then gained her black belt qualifications with Dell Inc. Yixin also holds her Project Management Profession Certification with vast experience in managing international assignments. She has trained 100+ participants per year on process improvement. Yixin holds a master degree of business from Institute of Technology, Cork and a bachelor degree of Electrical and Electronic Engineering from University College Cork, Ireland.
- Welcome to this webinar, my name is Yixin, I am a senior marketing manager with Boston scientific. I was the program lead for this engagement. Let me introduce you about our customer first. This project was executed in a Canadian customer site. ( read the bullet points), overall, this is a highly motivated customer with very engaged personnel, inducing physicians.
- Let’s take a closer look at the cath lab space. For the audiences who are not familiar with those terms, A catheterization laboratory or cath lab is an examination room in a hospital or clinic with diagnostic imaging equipment used to visualize the arteries of the heart and the chambers of the heart and treat any stenosis or abnormality found. The current state was the original setup we encountered at this customer site. They had 4 rooms ( read out the bullet points). PCI stands for percutaneous coronary intervention (angioplasty or stent placement), Electrophysiology proceudre room. Boston Scientific team has performed an end to end diagnostic in their cardiology department. We have found this account has very resilient, experienced team, usually has low staff turnover rate, physicians were quite engaged with the frontline staff, there was the circle of trust for front line staff to be willing acknowledge the needs for change or improvements. However, we also observed a very high touch scheduling system, low ability to accommodate additional volume/referrals, their operating hours were somewhat restricted. You usually see a much longer working hours in the U.S system. and most importantly, the operating hours were inflexible. Staffs could refuse to stay longer to care for patients and they often requested for hard stop at 18:00. their communication methods were very manual and inefficient. Often causing duplicate work. They have a lot of variations in the process which caused inefficient lab turnover time. Daily management system was almost non existing. Lastly, their physical space ( especially the bay) is restricted. Also, as you may expect. A lot of variations in all processes. Some basic info on resource ratio : some what expensive model, used to be all nurses in the room, all nurses also rotate between rooms and the bay area one of the improvement was to add in MRT roles from last year. They added 4 MRT and 1 in each room. They can perform some of the patient care but not admin meds Let’s move onto next slide to check out the end to end process
- Boston scientific team has performance end to end process evaluation. A lot of aspects have been considered in the diagnostic phase. However, the simulation mode scope is from patient admission to discharge) Like any other cath lab, the patient flow is very similar. Patient can enter the cath lab directly or come from a ward. Get prepped for procedure and wait at the same area. Then go through cath lab, recovery, depends on the patient type it may be discharged directly or transfer into a ward for recovery). There are 3 types of patients: Elective ( procedure scheduled in advance), Urgent ( patient come from the inpatient unit with urgent need – but not always same day ). STEMI ( emergent cases) Now, we all have a good understanding of current state. Let’s take a look at the simulation base scenario analysis.
- First set of questions we received were: what is our team’s current performance? Could you tell us the average utilization among all labs, do I have any capacity left Which procedure is the busiest? Which one is under or over utilized – management seeks a good understanding of utilization in order to expand pacemaker and structural hearts program as well as keep urgent PCI in order to manage the LOS expectation from higher up. Based on the baseline performance, we ended up presenting12 scenarios to improve utilizations by adjust physician schedules and lab/bay schedules Key takeaways ( which I will also mention later is), during this process, the leadership team also got better at asking questions, their scope became narrower and more specific
- There are a few key variables that Simul8 required for building a model that we need, there were: Demand, (current, projected and business needs) Schedule ( lab schedule, patient schedule and physician schedule) Day of patient process Resource constraints I included some examples in the next slide
- Now, we can look at the final model. On the left hand, you can see 4 blue boxes that is where key variables can be adjusted or modified. Let’s click them open and take a look so you can get a sense of the parameters behind this model. On the right hand side, you can also see a clock, this represents the length of the simulation you want it to run. The software allows you to simulate scenarios for a day, a week up to year(s) in a few minutes – confirm with Claire . Let’s try to run this for a week while I talk a few more details. While the simulation is running, you can see on top of the area is where the bay ( prep and recovery) area is at, the beds reprints the layout there. On the bottom, you can see the 4 labs. The new one will open next to them ( point out in the layout) This graphic was done based on the layout map hospital provided to us. So the model is basically embedded into the actual hospital layout. This was a nice feature our customers liked when we present to them, so they can “see” and “ feel” how the process is running. You may see a few dots in an area, this usually represents bottom necks in the process.
- This is a list of results each scenario generated. ( read through bullet points)
- Like I mentioned earlier, there were 12 scenarios selected for this project. 12 of them were categorized into 4 themes. Don’t focus on growth but enhance the current performance Add additional specifically volume that business needs Transfer some existing OR cases into current setting Add 2 rooms or merge the 2 locations into 1 We don’t have a lot of time to look into each scenario, but I have picked 2 as example to show you here in the next slide.
- Here is a detail of Scenario 5 ( best scenario based on leadership preferences) vs. a random selected scenario ( 10) , you can see the demand level is the same however, the lab mix changed quite bit which S 10 allows more expansion, lab hours changes from existing hours to longer ones. The reschedule cut off time is expanded. Of course the results were different, S10 would have generate even better results and eliminated wait list, however, leadership team has decided not to be too aggressive and wanted to implement S5 first to realize some results.
- Again, to summarize, the area of improvements from simulation are the ones presented here. These are also the area we looked at for improvement projects.
- Another nice feature of simlu8 is the ability to build charts and reports for repeat use. For example, the 12 scenarios have generated tons of graphs but we had set a standard report, so all of them produced charts in the same way as we want which helped us to build presentations. Let’s take a look at some of the results. What I will be showing is just a highlights not the entire package.
- One slot utilization slide to help the leadership understand their current performance. Look at the procedures that is over utilized and the ones has potential to “donate” some case time. Understanding this was a big culture change for this organization to embark. But luckily they had very engaging physician group. We completed a project that specifically looked at physician schedule and was able to work out some solutions to level load lab hours.
- Here showing a result from the bay capacity section. The chart presented opportunities and challenges in the bay area. With expansion, bay will have bigger space and the CVSL administration needed an answer on how many bed they would need to accommodate business growth. Here we were able to provide visibility for them.
- An example of working on some improvement ideas. How we compare results from scenarios. Charts make it visual and easy to understand. These were a big win for the physician team.
- Example of a few slides from the final package. Base slot utilization indicator 60%-70% If utilization is too high, it will cause patient delay, waiting and difficulties to add on urgent requests If utilization is too low, room utilization will be impacted If utilization is over 100%, it indicates a need to add additional slots. E.g. baseline model with Biopsy slots Urgent PCI stays the same to ensure LOS is under control
- Compare the schedule template and use it as an input for improvement workshop.
- Clients enjoy the dynamic view of final product Understand data, results and need to have a “good story” to link between the data and simul8 model PDCA – Plan- Do- Check-Adjust