healthcare operations management
DESCRIPTION
Healthcare Operations Management. VEDAT VERTER PROFESSOR, OPERATIONS MANAGEMENT EDITOR-IN-CHIEF, SOCIO-ECONOMIC PLANNING SCIENCES DIRECTOR, NSERC CREATE PROGRAM IN HEALTHCARE OPERATIONS & INFORMATION MANAGEMENT - PowerPoint PPT PresentationTRANSCRIPT
VEDAT VERTER
P R O F E S S O R , O P E R A T I O N S M A N A G E M E N TE D I T O R - I N - C H I E F , S O C I O - E C O N O M I C P L A N N I N G S C I E N C E S
D I R E C T O R , N S E R C C R E A T E P R O G R A M I N H E A L T H C A R E O P E R A T I O N S & I N F O R M A T I O N M A N A G E M E N T
C O - D I R E C T O R , M C G I L L M D - M B A P R O G R A M
Healthcare Operations Management
Health Sector in Canada
Among the top three sectors that contribute to Canada’s GDP for the past five years,
Total spending in healthcare has outpaced both inflation and population growth for the tenth consecutive year,
Identified as one of the four priority areas in the most recent federal science & technology strategy
Canada’s Healthcare System
A Single Payer System …
Public insuranceEveryone in Canada is insured
through their provincial governmentHealth care is financed by federal
and provincial taxes (general revenues)
Federal government provides funding through cash payments and tax transfers to the provinces and territories
… & Supplementary Insurance
Almost 30 % of health care spending in Canada is through out-of-pocket payment and supplementary private insurance
Prescription drugs, dental care, and vision services are not covered in most provinces
The Canadian System – Pros
Costs are controlled: provincial health budgets, supplemented by federal funds
Canada’s per capita costs are 60% of US per capita costs
Administrative overhead remains low
Everyone is covered
Access is based on need, not ability to pay
The Canadian System – Challenges
Healthcare fundingPatient waiting timesMedical technologiesPersonnel shortageInclusion of pharmaceutical, home care
and long term care costs in the public health insurance
Canadian Healthcare Association
Health Spending in Canada
Total health spending accounted for 10.4% of GDP in Canada in 2008.
Total health spending per capita is 4,079 US$ in Canada in 2008 (adjusted for purchasing power parity).
OECD – Total Health Spending
Emergency Department Management
Research Team
Marc Afilalo, MDAntoinette Colacone, CCRA Alex Guttman, MDEli Segal, MD
Montreal Jewish General Hospital ED
A tertiary care ED triage area in Montreal with ~66,000 visits/year.
Arguably, one of the best ED in Montreal in terms of patient wait times and LOS
Montreal Tertiary Care Hospitals
Hospital ED LOS (hours)
acute care patients
CUSM Hôpital Général de Montréal 14.8 24556Hôpital général Juif 17.5 34482Hôpital St-Luc du CHUM 19.5 17905Hôpital du Sacré-Coeur de Montréal 19.5 24238CUSM Hôpital Royal Victoria 21.7 17048Hôtel-Dieu du CHUM 26.4 14231Hôpital Notre-Dame du CHUM 27.8 20269
Maximum LOS in the JGH ED (hours)
2007/08 2008/09 2009/10 2010/11 2011/120
50
100
150
200
250
300
350
The Research Program in ED
ED crowding is a serious problem facing hospitals nationwide.
The objectives are two-fold: Identify the external versus internal
causes of crowding in the EDEvaluate possible interventions to
reduce patient wait timesDesign a detailed intervention plan to
achieve lean ED processes
The Acute Care Unit in the JGH ED
Detailed ED Process FlowStart
Arrival through ambulance?
Ambulatory or Stretcher?
Arrival by Other Means
Triage (See detailed flow chart)
Yes
No
Registration (See detailed flow chart)
Ambulatory
Cubicle Available?
Nurse Available?
YesYes
No
No
Initial Nursing Assessment
Stretcher
Resuscitation Monitored Un-monitored
Physician Available?
Initial Physician Assessment
Yes
Extremely Critically-ill
patients waiting?
Other ambulance
patient waiting?
Yes
No
No
Yes
Patient in the process of
Triage?
No
Ambulance Patient waiting? Yes
Yes No
Needs immediate
intervention? Yes
No
Cubicle Type?
1
Does others need cubicle
more?
Hallway
Yes
Previously assessed by
nurse?
Patient placed in designated
cubicle
Nurse Available?
Initial Nursing Assessment
Is cubicle critical to assessment?
Does attending physician check
patients in hallway?
Is patient nursing chart
available?
Is patient chart (nursing sheet)
available?
No
Yes
Yes
Yes
No
No
No
No
YesYes
Yes
No
No
No
Yes
Is patient chart (doctor sheet)
available?
End
Yes
No
Flow Chart from the Time Patient Enters ED to First Physician Assessment (JGH)
Reducing Patient Wait Times in ED Triage
Triage Goals (CAEP)
1. To rapidly identify patients with urgent, life threatening conditions.
2. To determine the most appropriate treatment area for patients
3. To decrease congestion in ED.4. To provide ongoing assessment of
patients.5. To provide information to patients and
families regarding services, expected care and waiting times.
6. To contribute information that helps to define departmental acuity.
Emergency Department Triage
Triage functions as a priority system where ambulance patients have (often preemptive) priority over walk-in patients.
During the data collection period (Baseline), triage was staffed by one full-time triage nurse (RN) and a second RN being available for about 5 hours throughout the day.
Canadian Triage Acuity Standards
CAEP (1999)
Re-assess
U.S. Emergency Severity Index
No expected time intervals to physician evaluation
Data Collection at ED Triage
ED triage was observed over a 15 week period during weekday shifts (8:00 to 16:00) for an average of 8 hrs/day
537 ambulance and 3205 walk-in patients were observed
Data collected through observation: time to arrival, triage start time, triage end time and staffing resources in place.
Data extracted from the ED administrative database: socio-demographic, patient arrival patterns and triage severity.
Patient Arrival and Triage Service Times
Simulation Model Validation
Triage Wait Times
Triage Improvement Scenarios
Dedicated RNs + Regular triage: RN1 services only ambulance patients RN2 services only walk-in patients Regular triage on all patients
Dedicated RNs + Pre-triage: RN1 services only ambulance patients RN2 services only walk-in patients Quick pre-triage (0.5 to 1 min) to screen for
patients requiring ambulatory care
Triage Improvement Scenarios
Pooled RNs + Pre-triage Both RNs simultaneously responsible for
ambulance and walk-in patients Quick pre-triage (0.5 to 1 min) to screen for
patients requiring ambulatory care
Comparative Analysis of Wait Times & Nurse Utilization
Scenario Ambulance N=537
Walk-in N=3205
Nurse Utilization
Baseline (1.5 Pooled RNs)
3.6 + 5.9 18 + 29 71%
2 Dedicated RNs + Regular Triage 1.5 + 3.8 68 + 108
Walk in 90%Ambulance 25%
2 Dedicated RNs + Pre-triage 1.4 + 3.7 9 + 13
Walk in 53%Ambulance 25%
2 Pooled RNs + Pre-triage 0.68 + 1.66 2.25 + 3.7 39%
Comparative Analysis ofBaseline & “2 Pooled RN + Pre-
triage”
Wait Time Distibutions
0 5 10 15 20 25 30 35 40 45 50 55 60 65 70 75 80 85 90 95 100
105
110
115
120
125
0
500
1000
1500
2000
2500
3000
3500
4000
Wait Time Frequency Distribution For Ambulance Patients
Minutes0 5 10 15 20 25 30 35 40 45 50 55 60 65 70 75 80 85 90 95 10
0105
110
115
120
125
0
2000
4000
6000
8000
10000
12000
Wait Time Frequency Distribution For Walk Patients
Minutes
Baseline
Baseline
0 5 10 15 20 25 30 35 40 45 50 55 60 65 70 75 80 85 90 95 100
105
110
115
120
125
0
1000
2000
3000
4000
5000
6000
Wait Time Frequency Distribution For Ambulance Patients
Minutes
Pooled + Pre-triage
0 5 10 15 20 25 30 35 40 45 50 55 60 65 70 75 80 85 90 95 100
105
110
115
120
125
0
2000
4000
6000
8000
10000
12000
14000
16000
18000
Wait Time Frequency Distribution For Walk Patients
Minutes
Pooled + Pre-triage
Wait Times during the day
8:00 8:30 9:00 9:30 10:00
10:30
11:00
11:30
12:00
12:30
13:00
13:30
14:00
14:30
15:00
15:30
0.000.501.001.502.002.503.003.504.004.505.00
Average Wait Time For Ambulance Patients
Intervals
Min
utes
8:00 8:30 9:00 9:30 10:00
10:30
11:00
11:30
12:00
12:30
13:00
13:30
14:00
14:30
15:00
15:30
0.00
5.00
10.00
15.00
20.00
25.00
30.00
Average Wait Time For Walk Patients
Intervals
Min
utes
Baseline
Baseline
8:00 8:30 9:00 9:30 10:00
10:30
11:00
11:30
12:00
12:30
13:00
13:30
14:00
14:30
15:00
15:30
0.00
0.10
0.20
0.30
0.40
0.50
0.60
0.70
0.80
0.90
Average Wait Time For Ambulance Patients
Intervals
Min
utes
Pooled + Pre-triage
8:00 8:30 9:00 9:30 10:00
10:30
11:00
11:30
12:00
12:30
13:00
13:30
14:00
14:30
15:00
15:30
0.00
0.50
1.00
1.50
2.00
2.50
3.00
Average Wait Time For Walk Patients
Intervals
Min
utes
Pooled + Pre-triage
Nurse Utilization
8.00 9.00 10.00 11.00 12.00 13.00 14.00 15.00 16.000%
10%20%30%40%50%60%70%80%90%
100%
Nurses Hourly Utilization
Hours
% o
f Util
izat
ion
Baseline
8.00 9.00 10.00 11.00 12.00 13.00 14.00 15.00 16.000%
10%
20%
30%
40%
50%
60%
Nurses Hourly Utilization
Hours
% o
f Util
izat
ion
Pooled + Pre-triage
Triage Improvement Scenarios
Static Triage Nurse Staffing Hourly plan of RN capacity
Dynamic Triage Nurse Staffing An additional RN is called in when the triage
waiting line reaches a predetermined threshold level.
Dynamic staffing does not pay off on the basis of an hourly plan.
Questions & Comments ?