BAHC 510

1. BAHC 510 Class 1 October 22, 2012 Professor Martin L. Puterman

2. Intro • Course objectives • About me • About you • News, mailing lists, websites

3. Background and Setting

4. Canada Health Act - Principles Public Administration Health care insurance plans are to be administered and operated on a non-profit basis by a public authority. Comprehensiveness The health insurance plans of the provinces and territories must insure allhospital, physician and surgical-dental health services. Universality One hundred percent of the insured residents of a province or territory must be entitled to the insured health services on uniform terms and conditions. Portability Residents moving from one province or territory to another must continue to be covered for insured health care services for up to three months. Accessibility Insured persons have reasonable access to hospital, medical and surgical dental services unimpeded by charges or discrimination on the basis of age, health status or financial circumstances.

5. National Health Care Expenditure Trends 1975-2010 CIHI In 2008, Canada spent $171 billion on health care or $5,154 per person Average annual growth in expenditures is about 4.6% This represents approximately 10.7% of Canada’s GDP Public sector spending is about 70% of total 92% of this is by provincial governments. 50% of private sector spending is out of pocket; 40% by insurance companies 1.5 million people work in health care 1 out of 10 Canadians work in health care Nurses and Physicians are the largest groups The workforce is rapidly aging

6. Canadiian Health Care Expenditures - 2008

7. Canadian Age Distribution and Hospital Expenditures by Age

8. Time Trend - Health Care Expenditures in Canada

9. International ComparisonsOECD - 2009 Source: Stats.oecd.org

10. International Comparisons –HC Expenditures as a percent of GDP -2008

11. International Comparison of Public vs. Private Expenditures as Percent of GDP Private Public

12. Health System Challenges Reducing wait times for services Meeting the increased health care demands of an aging population Delivering quality care in the face of an aging and diminishing workforce Using costly new technologies and therapies appropriately Delivering high quality and safe care HC expenditures have become an increasing portion of GDP

13. Five questions • How do we know whether patients are flowing well? • Why does it matter? • How can we improve flow? • How do we know that what we did improved flow? • How do we maintain our improvements?

14. What is operations management? • Operations management (OM) concerns the acquisition of resources and the organization and control of processes that produce goods or services • Focus can be either strategic or operational • Why is health care OM different than OM in other organizations?

15. “If you’re not keeping score, you’re just practicing” Vince Lombardi

16. Performance Metrics • Queue lengths • Waiting times • Percent who meet target • Patient Satisfaction scores • Staff Satisfaction scores

17. Key Levers • Decrease demand • Increase capacity • Use existing capacity more efficiently

18. VGH CT Scanning Study 18

19. VGH CT Scanner Questions Determine whether an additional scanner was needed and if so, where should it be located? Define and measure current waiting times for CT scans at VGH Identify system bottlenecks and inefficiencies Identify strategies for eliminating current backlogs and compare the short term and long term costs and benefits of each Propose ways to expand analyses to other sites and explore improvements in booking and centralized planning 19

20. Analyzing the appointment system 20 • The appointment booking process • Requisition arrives • Patient info – scan type • Radiologist specifies urgency level • Clerk assigns date • Clerk contacts patient • Clerk records date • Collect and analyze relevant data • We will investigate how to better manage such a system next class.

21. Data Challenges 21 • How do we determine if the system is performing well? • System Level Performance Metrics • Urgency Level Performance Metrics • What data is required? • Time stamps • Requisition received • Scan completed • Upstream wait time measures • Where do we get it? • Databases • Appointment systems • Observation (as a key first step and last resort for getting data)

22. More on Data 22 • Perspective vs. Retrospective data • Perspective – from now going forward • Based on appointment data • Retrospective – from now going back • Based on scan date • Historical • Complete records • What are the strengths and weakness of each type of data? • What we did - Obtained booked requisitions at the end of each day • Copy them • What are the shortcomings of the approach we used?

23. Sample Wait Time Data from a different study Clients Jul-04 Jul-05 Jul-06 Mar-04 Mar-05 Mar-06 Mar-07 Jan-04 Nov-04 Nov-05 Nov-06 Jan-07 Nov-03 Jan-05 Jan-06 May-04 May-05 May-06 Sep-04 Sep-05 Sep-06 Calendar Time 23

24. Data Summary - Outpatient Waiting Time Outpatient Categories OP1 OP2 OP3 Recommended WT < 1 wk < 2 wks < 4 wks (RWT) Actual WT 1.6 3.6 6.3 Average (wks) 6.6 10.4 13.9 Max 0.0 0.0 0.1 Min 42 86 103 Sample Size % scanned after 50.0% 68.6% 74.8% RWT CT Wait Times for Outpatients at VGH (Priority OP1: < 1 week) 20 Scheduled after 1 week: 50.0% 15 Frequency 10 5 0 0 1 2 3 4 5 6 7 Weeks CT Wait Times for Outpatients at VGH CT Wait Times for Outpatients at VGH (Priority OP2: < 2 weeks) (Priority OP3: < 4 weeks) 20 20 Scheduled after 2 weeks: 68.6% Scheduled after 4 weeks: 74.8% 15 15 Frequency Frequency 10 10 5 5 0 0 0 1 2 3 4 5 6 7 8 9 10 11 0 1 2 3 4 5 6 7 8 9 10 11 12 13 14 Weeks Weeks 24

25. Step 2: the scanning process 25 • Key steps for outpatient • Patient checks in • Patient waits • Prepare patient (set up) • Enter room • Scan • Check scan • Out of room • How do we assess its performance? • What data do we need? • How do we get data?

26. On Site Observations - VGH Scanners are not being used efficiently; capacity is wasted 26

27. Possible impediments to flow obtained from process analysi • System starved • No patient available • Why? • Porter delays • No exams scheduled during tech lunch breaks • Excessive time scheduled for an exam • Outpatients arrive late • Outpatients do not arrive (no shows) • System congested • Exam times too short • Patients not picked up • Reformatting of images • Maintenance • Difficult IVs 27

28. Outcomes of study Added dedicated porter to CT area Management accepted idea of overbooking Hired lunch time technologist Commissioned in-depth study of porter services at VGH VCHA hired several grads Generated further research Jonathan Patrick’s PhD Dissertation on scheduling Antoine Saure’sPhd Dissertation on RT scheduling 28

29. Improving Porter Operationsat VGH

30. The Porter Study

31. Secondary services: Overarching questions • How do non-medical activities impact patient flow? • How much attention do they receive in planning? • How do we measure their performance?

32. Porter Study Approach • Project Plan • Set Scope • System Observation • Process Analysis (Diagnosis) • Data Collection • Compute Performance Metrics and Measurement • Simulation Model and Scenario • Optimization Model • Scenario Analysis • Development of Recommendations • Implementation Plan

33. Process Map (In Patient on ward) Porters Nurse on Ward Doctor on Ward Dispatcher Diagnostic Area www.chcm.ubc.ca

34. Questions on Process • Who does the system serve? • Who is its client? • What are process steps? • Who is involved in each? • What information do they need? • What are potential bottlenecks? • Are all jobs the same? • When is information about jobs known? • How should this be used? • How do we obtain data?

35. What do porters do? • Move patients • Move samples • Move material and information

36. Resource & Dispatching Communication Operation Timeline Clear Dispatch Travel Pickup Travel Porter arrives Porter dispatched Begins move Request received Completes move Porter clears Who knows what and when? What are appropriate performance metrics to assess system performance? How could we obtain them?

37. Proposed Metric Porter arrives Porter dispatched Begins move Request received Completes move Porter clears Response Targets STAT (15 min), ASAP (30 min), Routine (45 min) Performance Measurement % of jobs dispatched within response target per priority Performance Standard Hospital established minimum level of performance Measuring Performance “Current Metric” Performance Metric: Time between “Request Received” until “Porter Dispatched”

38. Porter arrives Porter dispatched Begins move Request received Completes move Porter clears Historical Performance (Oct 2003 - June 2004)VGH Unscheduled Jobs – Centralized Porters Metric is based on this time

39. Discrete Event Simulation • What is it? • Why do we do it? • How do we use it? • Scenario analysis • How do we create one? • Using an OR staff • Software – Arena, Simul8, .. • How do we know if it represents reality?

40. System Structure Demand Data Simulation Model Service Level by Job Priority Resources & Shift Schedules Dispatching Rules Porter Simulation Model Overview Example: 90% of STAT trips are dispatched within 15 minutes

41. Simulation Screen Shot

42. Porter Simulation www.chcm.ubc.ca

43. System Structure Changes Optimize Staffing Schedules Resources Allocation Sensitivity Analysis Totally Centralize Decentralize Heavy Users Reallocate Decentralized Porters Decrease Delay Increase Average Demand Decentralize Emergency Decentralize OR Reallocate Porter to PAR Reallocate Porter to X-Ray & CT Shorten Dispatch Delay Shorten Delay At Wards Scenario Analysis Adjust the Response Targets Scenarios What do you think the impact of these changes would be? Why? By how much?

44. As Is Totally Centralize Conclusion: A totally centralized system would not improve service. (why not?) Scenario Analysis Results:Centralize All Operations System Performance : Percentage of jobs achieving target 100% 95% 90% 85% 80% 75% Percentage 70% 65% 60% 55% 50% STAT ASAP Routine Prescheduled Job Type

45. Conclusion: Improved communication and upgraded hardware would be very beneficial. Scenario Analysis Results:Remove system inefficiencies 100% 95% 90% 85% 80% As Is Percentage Scenario #1 75% Scenario #2 70% Scenario #3 65% 60% 55% 50% STAT ASAP Routine Prescheduled Job Type Scenario #1: Shorten average time from “Arrive” to “Begin Move” from 3 minutes to 2 minutes. Scenario #2: Shorten average dispatching delay (machine delay) is shortened from 2.7 minutes to 0.5 minutes Scenario #3: Combine scenarios #1 and #2

46. Hourly Capacity and DemandWhat does this show? Assumption: Porters handle 3.3 trips/hour

47. Matching capacity with demand • How do we determine demand? • What is the result of not matching these? • What if there are too few porters? • What if there are too many porters? • Why is this hard? • What levers do we have to meet demand? • Shift scheduling and optimization • We’ll come back to this in future

48. Conclusion: Optimal staffing schedule significantly improves the performance without changing the current shifts and total number of porters. Scenario Analysis Results: Optimized Staffing Schedule 100% 95% 90% 85% 80% 75% As Is Percentage 70% Optimal Staffing Schedule 65% 60% 55% 50% Routine STAT ASAP Prescheduled Job Category Scenario: Total number of porters and shifts remain unchanged, only the allocation of porters to shifts is adjusted. www.chcm.ubc.ca

49. Study Recommendations -VGH • Use optimized staff schedule and review shift schedules • Improve communication between dispatchers and units • Allocate a porter to OR during peak hours • Upgrade dispatching hardware • Establish performance standards and discuss response targets with users • Share performance measurements and obtain feedback in regular user meetings • Measure end-to-end porter time as seen from users’ point of view • Improve the management and organization of decentralized porters www.chcm.ubc.ca

50. www.chcm.ubc.ca