Building a Smarter Healthcare System The IE s Role Kristin H. Goin Service Consultant Children s Healthcare of Atlanta 2 1
Background 3 Industrial Engineering The 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 2
Discussion Current State Healthcare Industry Opportunities for Improvement Applying IE Solutions Case Studies 5 Healthcare Industry 6 3
Healthcare Industry Access Cost Quality Long Wait Times and Delays Nosocomial Infections Medication Errors Misaligned Capacity and Demand Poor Patient Flow Inefficient Care Delivery Staffing Issues Administrative Waste Ineffective Revenue Cycle 7 Limited Data Processing Healthcare Opportunities Institute of Medicine 6 Healthcare Aims 8 4
Healthcare Opportunities Systems Thinking IE Tools Waste Reduction Data Driven Forecasting Modeling / Simulation Transparency Measurement Lean Six Sigma Operations Research Simulation Control Charts Dashboards 9 Children s Healthcare of Atlanta Located in Metro Atlanta 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 121 intensive care beds 37,538 annual surgical procedures 10 5
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 Improving Supply Chain Optimizing Operating Room Scheduling 11 Case Studies Urgent Care Patient Forecasting & Staffing Optimization Pharmacy Waste Reduction and Process Improvement Critical Care Medicine Physician Workflow Project Lifecycle Situation Analysis Future State Current Capabilities Options Implement & Change 12 6
Immediate Care Background Four urgent care facilities throughout metro Atlanta Majority of service is walk-in (variable demand) Neighborhood locations important in extending service to community Key Focus Areas Market Share Customer Service Wait Times Staffing Costs 13 Immediate Care Situation Analysis Inaccurate Patient Misaligned Increased Arrival Forecasting Provider Staffing Wait Times 14 7
Immediate Care Situation Analysis 15 Immediate Care Desired Future State Balance waits and delays with staffing cost Reduce Wait Times Reduce LWBS (left without being seen) Improve Customer Service Increase Market Share Optimize Provider Staff Improve Provider Productivity Improve Resource Utilization Reduce Staffing Cost 16 8
Immediate Care IE Tools Forecasting Predict Patient Arrivals Winter s Method seasonal forecasting Optimization Determine Ideal Provider Schedule Linear Programming objective fnct & constraints Simulation Test Impact to Waits and Delays Arena Simulation Software 17 Immediate Care Current Capabilities 18 9
Immediate Care Options and Recommendations 19 Immediate Care Options and Recommendations 20 10
Immediate Care Implementation & Results Access Cost Quality Improved accuracy in forecasting Improved staff productivity Significantly reduced wait times Improved patient satisfaction Cost savings $110,000 annually 21 Pharmacy Background Main pharmacy at Egleston Children s Hospital Produce IV and Oral medications for Med/Surg & ICU Hospital has 240 beds and average census >200 Support three additional satellite pharmacies Key Focus Areas Waste Reduction Lean Production Process Profit Margin Quality and Safety 22 11
Pharmacy Situation Analysis IV Batch Production System 3 2 1 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 23 Batch Production = Waste Pharmacy Situation Analysis Summary Statistics I1 I2 I3 Total Daily Doses per Batch 104 154 148 406 Production Time (run to deliver) 4 5 5 Average Doses / Hour 26 31 30 Weekly Waste 122 153 88 409 Avg. Daily Waste per Batch 24.4 30.6 17.6 Over 15% of all medications produced were returned or wasted = $250,000 per year for IV medications 24 12
Pharmacy Situation 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% Dialysis Acct 8 2% Cancelled Entry 1 0.2% Grand Total 409 100% 25 Pharmacy Desired Future State Lean IV Medication Process Reduce Waste Create Medications Just-In-Time Efficiently / Accurately Meet Patient Demand Optimize Resources Increase Access to Patient Information Create Method to Track Waste 26 13
Pharmacy IE Tools Lean Methodologies - Identify and Eliminate Waste Visual management, standard work, pull systems Scenario Analysis and Modeling Test process changes and measure potential success Operations Research Determine probability distributions and future state outcomes 27 Pharmacy Current Capabilities Disharges 16% 14% 12% 10% 8% 6% 4% 2% 0% Returned Doses Patient Discharge Hourly Distribution 48% 21% 22% 0 1 2 3 4 5 6 7 8 9 1011121314151617181920212223 Batch Patient Discharge Hour Distribution 50% 45% 40% 35% 30% 25% 20% 15% 10% 5% 0% Batch 28 14
Pharmacy Current Capabilities Med D/C 14% 12% 10% 8% 6% 4% 2% 0% 42% Returned Doses Percent of Medication D/C 30% 17% 0 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 22 Batch Percent of Medication D/C 45% 40% 35% 30% 25% 20% 15% 10% 5% 0% Batch 29 Pharmacy Options and Recommendations Recommended IV Production Process * * * * * * 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 30 15
Pharmacy Options and Recommendations Simulated Results: 70% Reduction in Wasted Medications IV Medication Run Time to Administration Percent of Daily Doses 45% 40% 35% 30% 25% 20% 15% 10% 5% 0% Current IV Process Recommended Process <=3 hrs. 3-5 hrs. 5-7 hrs. 7-9 hrs. 9-11 hrs. >11 hrs. Duration / Lead Time 31 Pharmacy Implementing Change Staffing Constraints Annual Census Distribution Productivity and Lead Time New Delivery Process Pharmacy Workflow Communication 32 16
Pharmacy Results Access Cost Quality Created Lean process Reduced 70% of waste Improved resource utilization Created pull system Reduced Pharmacy medication cost by $175,000 annually 33 CCM Physicians Problem 30 bed Pediatric Intensive Care Unit Treat highest acuity patients Teaching hospital with Attending, Fellow, and Resident physician team Focus Areas: Rounding Process and Duration Provider Resource Utilization Efficiency of Care Delivery Transfers of Care Teaching and Research 34 17
CCM Physicians Background 1 2 3, 4, and 5 6 7 8 9 14 and 15 10 21 16 13 12 11 35 20 19 17 18 11,000 square feet Max Daily Census 18-21 4 attendings 4 5 residents 2 3 fellows CCM Physicians Background 13 12 11 10 9 8 7 6 5 4 3 2 36 1 14 15 16 17 18 19 20 21 22 23 24 25 33,000 square feet Max Daily Census 27-30 9 attendings 4 5 residents 6 fellows 26 27 28 29 30 18
CCM Physicians Situation Analysis Pe ercent of Patients 30% 25% 20% 15% 10% 5% 2% Current PICU Plan of Care Completion 23% 21% 18% 18% 10% Percent of Patients 5% 3% 0% Before 9:00 9:00-9:30 9:30-10:00 10:00-10:30 10:30-11:00 11:00-11:30 11:30-12:00 After 12:00 Hour a Patient's Rounds are Completed 37 CCM Physicians Situation Analysis Radiology Rounds Teaching Patient Update Rounding Process Time per Patient Travel Patient Issues Delays Patient Report Discussion Plan of Care 38 Essential Non-Essential Non Value Added 19
CCM Physicians Situation Analysis Increased Resources Up to 10 physicians during rounds with multiple transfers Poor Communication Zoomerang Results: Inefficient and Ineffective teamwork 39 CCM Physicians IE Tools Lean Methodology - Identify and Eliminate Waste Human Factors Conduct observational studies Scenario and Simulation Analysis Test future state results and metrics Statistics and Hypothesis Testing Verify change in process 40 20
CCM Physicians Desired Future State Reduce time to round on patients Complete patient plan of care by 10:00 a.m. Create formalized, didactic lectures Reduce non-billable physician hours Improve communication with care team Maintain service and quality of care!!! 41 CCM Physicians Current Capabilities Rounding Process Process Metric Min Max Mean Median Total Time 1:38:00 3:43:00 2:37:00 2:30:00 End Hour 10:11 12:20 11:13 11:02 Average Patients / Team 9 15 12 12 Time per Patient 0:02:00 0:42:00 0:10:35 0:09:00 Time per Patient Variation Number of Patients 42 Patient Acuity 21
CCM Physicians Current Capabilities Non-Essential Process 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 Physician preference / style Variation 43 CCM Physicians Current Capabilities Non-Value Added Process 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 0:06:30 Delays 0:01:41 0:25:00 0:09:33 0:05:00 Waste 25 30 minutes per rounding team 44 22
CCM Physicians Current Capabilities Essential Process 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 0:20:00 Plan of Care 0:07:00 0:56:00 0:22:43 0:11:00 Total Essential time per patient Variation 45 CCM Physicians Options and Recommendations Process Re-Design Patient-Centric model (Customer at Center) Only essential components (Waste Reduction) Consistency in methods (Standard Work) Patient acuity tool (Visual Management) Structure Re-Design Two rounding teams Fellow replaces Attending as Resource Doctor 46 23
CCM Physicians Implementing Change 100% Pe ercent of Patients 120% 80% 60% 40% 20% 0% 23% Before 9:00 2% EG PICU Plan of Care Completion 56% 20% 9:00-9:30 80% 41% 9:30-10:00 95% 64% 10:00-10:30 99% 100% 100% 100% 82% 10:30-11:00 92% Scenario 3 11:00-11:30 97% 100% Current 11:30-12:00 After 12:00 47 CCM Physicians Implementing Change 48 13 ECMO 12 14 15 16 17 18 19 20 21 22 23 24 25 11 10 9 8 7 6 5 4 3 2 1 26 27 28 29 30 24
CCM Physician Results Access Cost Quality 97% rounding completion by 10:0000 1 hour reduction rounding duration Decreased from 3 to 2 Attendings Significant improvement in teamwork and communications Earlier patient discharges by 58 mins Timelier clinical decisions 49 Improved patient satisfaction Academic to Corporate World Gathering Data Shadowing Process Current State Case for Change Verifying and Validating Communication Change Management Hardwiring and Sustaining Situation Analysis Future State Current Capabilities Options Implement & Change 50 25
Kristin H. Goin 404-785-6691 kristin.goin@choa.org We are what we consistently do. Then, excellence is not an act but a habit -Aristotle 51 26