Modeling Patient Flow as a System

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Modeling Patient Flow as a System

• Presentation to Institute for Healthcare
  Improvement (IHI), November 1, 2005
• Randolph W. Hall
• Epstein Department of Industrial and Systems
  Engineering
• University of Southern California

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System Engineering

• Bounds and scope what it encompasses
• Components entities that comprise system
• Interaction of components
• Flow of information
• Flow of people (patients, staff, )
• Flow of objects (records, specimens, )
• Goals, objectives, outcome measurement
• Re-engineer to improve performance

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Patient Flows

• Movement of patients through a healthcare system
• When the system works well, patients flow like a
  river
• When it fails, patients flow like a reservoir
• Unless patient needs to remain in the system for
  health reasons, reservoirs are bad, rivers are
  good
• A queue represents the accumulation of patients
  awaiting service (examination, test, treatment,
  etc.)
• A queue could also be a specimen awaiting
• analysis, a request awaiting a file transfer,
  etc,

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Healthcare Systems

• Macro
• Regional
• Center
• Department

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The Macro System

• Components
• States of personal health
• Presence within the health care system
• Birth and death
• Objectives
• Maximize the years from birth to death (length of
  life).
• Maximize the proportion of ones life spent in
  the well state.
• Maximize the quality of life when not in the well
  state.

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Regional System

• Components
• Primary Care, Secondary Care, Tertiary Care
• Specialized services dialysis, MRI,
• Continuing care
• Ancillary services, such as pharmacies
• Objectives
• Minimizing the cost of providing desired
  services.
• Maximizing convenience and access to services
  that individuals need.
• Maximizing the likelihood of a positive health
  outcome from service.

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Center as a System

• Components
• Medical departments
• Surgery
• Admissions, registration, financial services
• Radiology, testing centers
• Pharmacy, records, housekeeping, other support
  services
• Allied clinics
• Patient Flow Objectives
• Minimizing waits as patients transition from
  department to department.
• Achieving a high level of synchronization among
  patients, employees and resources, so that
  services begin promptly on patient arrival and
  are provided with high efficiency.
• Identifying and resolving system level
  bottlenecks that impede the flow of patients.

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Patient Activities

•        Information collection as part of
  admission
•        Diagnostics and examinations
•        Procedures, surgeries and therapies
•        Education
•        Rehabilitation and recuperation
•        Transportation between departments
•        Discharge processes 

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Background Activities

• Transfer of medical records
• Transfer and analysis of laboratory specimens
• Filling prescriptions
• Housekeeping to prepare rooms for new patients
• Communication among departments, scheduling and
  decision-making in preparation for patient
  arrivals
• Movement and availability of wheel chairs,
  gurneys, and other portable equipment
• Completion of required paperwork for internal or
  governmental use.

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Department as a System

• Components
• People staffing and patients
• Information, Scheduling, Appointment Systems
• Equipment and Supplies
• Physical Space (Rooms)
• Patient Flow Objectives
• Effective coordination, do not create delay
  within, nor impose elsewhere (e.g., delays in
  accepting patients, or failing to prepare a
  patient for transfer)
• Prompt and appropriate service
• Proper staffing and scheduling, matching supply
  to demand

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Alter Service Process

• Scheduling
• Coordination
• Process changes,
• Communication,
• Automation,
• Increase the capacity for serving customers, and
  increase the synchronization between capacity and
  customer arrival patterns.

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Alter Arrival Process

• Appointments,
• Pricing,
• Patient information,
• Education programs,
• Quality and Preventive Care
• Influence the patterns by which patients present
  for service, improving the alignment between
  capacity and demand.

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Alter Queueing Process

• Triage,
• Move waiting from the health care facility to the
  home,
• Redesign waiting areas,
• Changes in prioritization, etc.,
• Ensure that the adverse consequences of waiting
  are minimized. (But dont build to the queue)
•  

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Case Study LA County/USC Hospital (With Dr.
David Belson, Dr. Maged Dessouky)
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Characteristics

• 35 Hospital Departments (all visited,
  interviewed)
• 85 ward admissions come through he ED
• Major trauma center, central LA, public hospital
• Large residency program with USC
• Numerous languages spoken Spanish most common
• Older facility, soon to be replaced (new facility
  will have fewer beds)
• Long length of stay 6.5 days on average
• 40,000 inpatient visits per year 205,000 ED,
  522,000 outpatient

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Steps

• Interview and focus groups throughout the center
• Collect and analyze data samples
• Process map the hospital, both at center level
  and department level
• Simulation studies
• Identify opportunities for improvement
• Follow up implementation projects in radiology
  and surgery

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Patient Flow Through ED
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Flow Through 1050 Area
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Data Challenges

• Relevant data not recorded
• Recorded data not accurate (retrospective,
  transcription errors, etc.)
• Data not used to manage system, either
  operational or strategic
• For special study, who is the patient?
• Difficult to extract available data

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Creation of From/To Table
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Time of Day Patterns
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Queue Sizes
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Challenges at the Interface

• Scheduling/assigning patient for next step
• Preparing patient for transfer
• Communicating with receiving unit
• Transporting patient
• Receiving patient at next unit
• Why cant they accept our patient, were backed
  up?
• Why do they send a patient when we are not
  ready?
• This patient belongs in a different unit?

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Symptoms

• Significant delay in ED, large number of boarders
• 15 leave without being seen
• Delays for needed tests, access to radiology
• Delays for surgery after admission
• Inappropriate admits, just waiting for a test
• Very long waits for scheduled services
• Long length of stay
• Significant denied days
• Gridlock

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Problems

• Lack of awareness of how I affect problems
  elsewhere
• Too much idle time in key processes surgery and
  radiology in particular
• Basic resources needed to deliver more
  housekeeping and transportation
• Insufficient information to guide actions
• Chronic queueing

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Change

• Special data collection needed to make the point,
  to demonstrate how things are and how they could
  be
• Must be a team approach open the lines of
  communication so the departments understand each
  other
• In an environment where there are no financial
  incentives, let the patients be the driving force

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Chronic Queueing System (CQS)

• Emergency Departments
• Public Housing
• Motor Vehicle Departments
• Immigration/Naturalization Services
• Courts
• To lesser degree roadways

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PATIENT FLOWS
IN JURIES
ILLNESSES
RENEGE/BALK
WAITING
TREATMENT
TREATMENT
TREAT ELSEWHERE OR FOREGO
SPILLBACK
DISCHARGE
HOSPITAL
DISCHARGE
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Concluding Remarks

• Potential demand for service can be huge
• Effect on staff, particularly at the ED, is very
  important.
• Difficult to solve patient flow in a public
  health center in isolation of the regional
  system, and in isolation of the macro system