1

Building a Smarter Healthcare SystemThe IE’s Role

Kristin H. GoinService Consultant

Children’s Healthcare of Atlanta

2

2

Background

3

Industrial Engineering

The objective of Industrial Engineering is to promoteThe objective of Industrial Engineering is to promote quality, efficiency, and productivity by optimizing resources while concurrently minimizing costs.

The tools of industrial engineering are aimed at understanding, evaluating and optimizing dynamic systems

4

systems.

3

Discussion

Current State Healthcare Industry

Opportunities for Improvement

Applying IE Solutions

Case Studies

5

Healthcare Industry

6

4

Healthcare Industry

Long Wait Times and Delays

Access Cost Quality

X

Nosocomial Infections

Medication Errors

Misaligned Capacity and Demand

Poor Patient Flow

Inefficient Care Delivery

X X

X X

X X

X X

X X

7

Inefficient Care Delivery

Staffing Issues

Administrative Waste

Ineffective Revenue Cycle

Limited Data Processing

X

X X

X

X

X X

Healthcare Opportunities

Institute of Medicine6 Healthcare Aims

8

5

Healthcare Opportunities

Systems Thinking IE Tools

Waste Reduction

Data Driven

Forecasting

Modeling / Simulation

Lean

Six Sigma

Operations Research

Simulation

9

Transparency

Measurement

Control Charts

Dashboards

Children’s Healthcare of Atlanta

Located in Metro Atlanta• 474 staffed beds in 3 children’s hospitals• 474 staffed beds in 3 children s hospitals• 16 community locations• 572,722 annual patient visits

Level II trauma center• 171 830 annual ED visits

10

171,830 annual ED visits• 121 intensive care beds• 37,538 annual surgical procedures

6

Current Projects

Optimizing Provider Staffing in the Cardiac ICU

Centralizing Outpatient Scheduling

Developing Patient Placement Algorithms

Reducing Transfers of Care – Provider Scheduling

Enhancing Discharge Process and Efficiency

11

Improving Supply Chain

Optimizing Operating Room Scheduling

Case Studies

Urgent Care Patient Forecasting & Staffing Optimization

Pharmacy Waste Reduction and Process Improvement

Critical Care Medicine Physician Workflow

12

Future State

CurrentCapabilities

SituationAnalysis Options Implement

& Change

Project Lifecycle

7

Immediate CareBackground

Four urgent care facilities throughout metro AtlantaMajority of service is walk-in (variable demand)Majority of service is walk in (variable demand)Neighborhood locations important in extending service to community

Key Focus AreasMarket Share

13

Customer ServiceWait TimesStaffing Costs

Immediate CareSituation Analysis

Inaccurate Patient Misaligned IncreasedInaccurate Patient Arrival Forecasting

Misaligned Provider Staffing

Increased Wait Times

14

8

Immediate CareSituation Analysis

15

Immediate CareDesired Future State

Balance waits and delays with staffing cost• Reduce Wait TimesReduce Wait Times• Reduce LWBS (left without being seen)• Improve Customer Service• Increase Market Share

• Optimize Provider Staff

16

• Improve Provider Productivity• Improve Resource Utilization• Reduce Staffing Cost

9

Immediate CareIE Tools

Forecasting – Predict Patient Arrivals• Winter’s Method – seasonal forecastingWinter s Method seasonal forecasting

Optimization – Determine Ideal Provider Schedule• Linear Programming – objective fnct & constraints

Simulation – Test Impact to Waits and Delays

17

• Arena Simulation Software

Immediate CareCurrent Capabilities

18

10

Immediate Care Options and Recommendations

19

Immediate Care Options and Recommendations

20

11

Immediate CareImplementation & Results

I d i f ti

Access Cost Quality

Improved accuracy in forecasting

Improved staff productivity

Significantly reduced wait times

Improved patient satisfaction

X

X X

X

X

21

Cost savings $110,000 annually

Pharmacy Background

Main pharmacy at Egleston Children’s HospitalProduce IV and Oral medications for Med/Surg & ICUProduce IV and Oral medications for Med/Surg & ICUHospital has 240 beds and average census >200Support three additional satellite pharmacies

Key Focus AreasWaste Reduction

22

Lean Production ProcessProfit MarginQuality and Safety

12

PharmacySituation Analysis

3

IV Batch Production System

2

11 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24

23Batch Production = Waste

PharmacySituation Analysis

Summary Statistics I1 I2 I3 TotalSummary Statistics I1 I2 I3 TotalDaily Doses per Batch 104 154 148 406Production Time (run to deliver) 4 5 5Average Doses / Hour 26 31 30Weekly Waste 122 153 88 409Avg. Daily Waste per Batch 24.4 30.6 17.6

24

Over 15% of all medications produced were returned or wasted = $250,000 per year for IV medications

13

PharmacySituation Analysis

Reason Medication Returned

Count of Medications

Percent of Waste

Pt. DC 183 45%Med DC 195 48%Not Given 7 2%Registration Error 3 1%Redispense 12 3%

25

Redispense 12 3%Dialysis Acct 8 2%Cancelled Entry 1 0.2%Grand Total 409 100%

PharmacyDesired Future State

Lean IV Medication Process• Reduce WasteReduce Waste• Create Medications Just-In-Time• Efficiently / Accurately Meet Patient Demand• Optimize Resources• Increase Access to Patient Information• Create Method to Track Waste

26

14

Pharmacy IE Tools

Lean Methodologies - Identify and Eliminate Waste• Visual management, standard work, pull systemsVisual management, standard work, pull systems

Scenario Analysis and Modeling – Test process changes and measure potential success

Operations Research – Determine probability

27

distributions and future state outcomes

PharmacyCurrent Capabilities

Returned DosesPatient Discharge Hourly DistributionPatient Discharge Hourly Distribution

21% 22%

48%

4%

6%

8%

10%

12%

14%

16%

Dis

harg

es

10%15%20%25%30%35%40%45%50%

Bat

ch

28

0%

2%

0 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 230%5%10%

Batch Patient Discharge Hour Distribution

15

PharmacyCurrent Capabilities

Returned DosesP t f M di ti D/CPercent of Medication D/C

17%

30%

42%

4%

6%

8%

10%

12%

14%

Med

D/C

10%15%

20%25%

30%35%

40%45%

Bat

ch

29

0%

2%

0 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 220%5%

Batch Percent of Medication D/C

PharmacyOptions and Recommendations

Recommended IV Production Process

* **

*

**

30

*

1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24

16

PharmacyOptions and Recommendations

Simulated Results: 70% Reduction in Wasted Medications

IV Medication Run Time to Administration

20%

25%

30%

35%

40%

45%

of D

aily

Dos

es

Current IV Process Recommended Process

31

0%

5%

10%15%

<=3 hrs. 3 - 5 hrs. 5 - 7 hrs. 7 - 9 hrs. 9 - 11 hrs. >11 hrs.

Duration / Lead Time

Perc

ent

PharmacyImplementing Change

Staffing ConstraintsAnnual Census DistributionAnnual Census DistributionProductivity and Lead TimeNew Delivery ProcessPharmacy WorkflowCommunication

32

17

PharmacyResults

Access Cost Quality

Created Lean process

Reduced 70% of waste

Improved resource utilization

Created pull system

X

X

X

X

33

Created pull system

Reduced Pharmacy medication cost by $175,000 annually

X

CCM PhysiciansProblem

30 bed Pediatric Intensive Care UnitTreat highest acuity patientsg y pTeaching hospital with Attending, Fellow, and Resident physician team

Focus Areas:Rounding Process and Duration Provider Resource Utilization

34

Provider Resource UtilizationEfficiency of Care DeliveryTransfers of CareTeaching and Research

18

CCM PhysiciansBackground

2 3, 4, and 5 6 7 81

9

1014 and 15

35

16

17

1819

20

2113 12 11

• 11,000 square feet• Max Daily Census 18 - 21• 4 attendings• 4 – 5 residents• 2 – 3 fellows

11

1213

14 15 16 17 18 19 20 21 22 23 24 25

11

1213

14 15 16 17 18 19 20 21 22 23 24 25

CCM PhysiciansBackground

6

7

89

10

11

29

28

2726

6

7

89

10

11

29

28

2726

• 33,000 square feet

36 1

23

45

6

30

29

1

23

45

6

30

2933,000 square feet• Max Daily Census 27 - 30 • 9 attendings• 4 – 5 residents• 6 fellows

19

CCM PhysiciansSituation Analysis

Current PICU Plan of Care Completion30%

18%

23%

18%

10%

21%

10%

15%

20%

25%

30%er

cent

of P

atie

nts

Percent of Patients

37

2%5%

3%

0%

5%

Before9:00

9:00 -9:30

9:30 -10:00

10:00 -10:30

10:30 -11:00

11:00 -11:30

11:30 -12:00

After12:00

Hour a Patient's Rounds are Completed

Pe

CCM PhysiciansSituation Analysis

Rounding Process

Radiology Travel

Patient Issues

Delays

Time per Patient

Radiology Rounds

Teaching

Patient Update

38 Non Value Added

Patient Report Discussion Plan of

Care

Non-Essential Essential

Patient Update

20

CCM PhysiciansSituation Analysis

Increased Resources

Up to 10 physicians during rounds with

Poor Communication

Zoomerang Results:Inefficient and Ineffective

39

gmultiple transfers teamwork

CCM PhysiciansIE Tools

Lean Methodology - Identify and Eliminate Waste

Human Factors – Conduct observational studies

Scenario and Simulation Analysis – Test future state results and metrics

40

Statistics and Hypothesis Testing – Verify change in process

21

CCM PhysiciansDesired Future State

Reduce time to round on patientsComplete patient plan of care by 10:00 a.m.Complete patient plan of care by 10:00 a.m.Create formalized, didactic lecturesReduce non-billable physician hoursImprove communication with care team

Maintain service and quality of care!!!

41

CCM PhysiciansCurrent Capabilities

Process Metric Min Max Mean MedianRounding Process

Total Time 1:38:00 3:43:00 2:37:00 2:30:00End Hour 10:11 12:20 11:13 11:02Average Patients / Team 9 15 12 12Time per Patient 0:02:00 0:42:00 0:10:35 0:09:00

Variation

42

Time per Patient

Number of Patients

Patient Acuity

22

CCM PhysiciansCurrent Capabilities

Non EssentialProcess Metric Min Max Mean Median

Radiology Rounds 0:05:00 0:39:00 0:18:49 0:15:00

Teaching 0:03:00 1:04:00 0:20:34 0:15:47

Patient Assessment / Update 0:00:00 0:43:00 0:12:39 0:03:00

Non-Essential

43

Variation

Physician preference / style

CCM PhysiciansCurrent Capabilities

Non-Value AddedProcess Metric Min Max Mean Median

Travel 0:05:00 0:26:42 0:14:04 0:13:30

Patient Issues 0:02:00 0:09:00 0:05:49 0:06:30Delays 0:01:41 0:25:00 0:09:33 0:05:00

44

Waste 25 – 30 minutes per rounding team

23

CCM PhysiciansCurrent Capabilities

EssentialProcess Metric Min Max Mean Median

Patient Report 0:37:00 1:33:49 1:10:01 1:13:00

Discussion 0:06:00 0:24:00 0:17:40 0:20:00Plan of Care 0:07:00 0:56:00 0:22:43 0:11:00

Variation

45

Total “Essential” time per patient

Variation

CCM Physicians Options and Recommendations

Process Re-DesignProcess Re Design• Patient-Centric model (Customer at Center)• Only essential components (Waste Reduction)• Consistency in methods (Standard Work)• Patient acuity tool (Visual Management)

46

Structure Re-Design• Two rounding teams• Fellow replaces Attending as Resource Doctor

24

CCM PhysiciansImplementing Change

EG PICU Plan of Care Completion120%

23%

56%

80%

95%99% 100% 100% 100%

41%

64%

82%92%

97% 100%

40%

60%

80%

100%

erce

nt o

f Pat

ient

s

47

20%

41%

2%0%

20%

Before9:00

9:00 -9:30

9:30 -10:00

10:00 -10:30

10:30 -11:00

11:00 -11:30

11:30 -12:00

After12:00

Pe

Scenario 3 Current

CCM PhysiciansImplementing Change

12

13

14 15 16 17 18 19 20 21 22 23 24 25

ECMO

6

7

8

9

10

11

12 14 15 16 17 18 19 20 21 22 23 24 25

29

28

27

26

481

2

3

4

5

6

30

29

25

CCM PhysicianResults

97% ro nding completion b 10 00

Access Cost Quality

97% rounding completion by 10:00

1 hour reduction rounding duration

Decreased from 3 to 2 Attendings

Significant improvement in teamwork and communications

X

X

X

X

X

49

Earlier patient discharges by 58 mins

Timelier clinical decisions

Improved patient satisfaction

X

X X

X

X

XAcademic to Corporate World

Gathering DataShadowing ProcessShadowing ProcessCurrent StateCase for ChangeVerifying and ValidatingCommunicationChange Management

50

Hardwiring and Sustaining

Future State

CurrentCapabilities

SituationAnalysis Options Implement

& Change

26

Kristin H. Goin404-785-6691404 785 6691kristin.goin@choa.org

“We are what we consistently do. Then, ll i t t b t h bit”

51

excellence is not an act but a habit”- Aristotle