Chris DeFlitch, MD, FACEP Penn State Hershey Medical Center Connected (CIS) Physician Champion Founder, Penn State Partn

1. Healthcare Engineering with Physician Directed Queuing (PDQ)TM Success Stories-Triage and Process with EDIS Chris DeFlitch, MD, FACEPPenn State Hershey Medical CenterConnected (CIS) Physician ChampionFounder, Penn State Partners for Healthcare Engineering Director & Vice-Chair, Dept of Emergency Medicine

2. HEALTHCARE TODAY • BOARDERS • No Beds for ED Patients • HALLWAY Patients • Ambulance DIVERSION • Dissatisfied Providers • Dissatisfied Patients • Regulatory Issues • Define Capacity as Bed

3. Traditional Targets 37 patient stations (1350 visits/station) 44K sq ft 0 stations short <1% LWOTS 0 Hallway beds 0 Boarders Satisfied Providers Satisfied Patients Patients Safe Right Care, Right Location Reality Capacity for 28,500 20 open stations (2589 visits/station) 24K sq ft 17 stations short >7% LWOT Hallway care 10+ Boarders Dissatisfied Providers Dissatisfied Patients Safety, Regulatory? Some Care, Any Location Emergency Department (50,000)

4. Use EDIS for Success • Understand workflow, map processes • Critical Resources • Demand-Capacity • Interdependencies • Apply Queuing and IE science to flow • Define Value with EDIS DATA • Redefine & Expand Capacity to Care • Limited Resources • Limited Capital • Actually DO IT…..TRANSFORM

5. Add Operational DATA to Workflow • Arrival distributions • Critical Interval Processing Times • Resources data, number and type • Perspective Flows • Patient • Provider • Resources

6. Provider Perspective Flows

7. “Typical” Arrival Patterns

8. Define the ISSUE with Operational Data High Demand No Capacity

9. Understand Queuing Systems • Science of WAITING • All queuing systems possess the same basic elements: • Customer (Demand) • Resources (Capacity) • Queues • When analyzed, it is clear that queuing systems are ubiquitous in healthcare. “One mans WAIT is another mans WORK”

10. Must be performed to meet customer needs Adds form or feature to service Enhances service quality Customers willing to pay for this work If you STOP the activity, would your customer complain? If yes, then it’s likely Value-Added. Value-Added Activity George ML. Lean Six Sigma Pocket Toolbook. 2005

11. Handling beyond what is minimally required to move work Rework to fix errors Duplicative work Wait Idle time Delays Unnecessary motion Over processing (too many steps to complete the job) If you STOP activity, would any customer know the difference? If not, then it’s probably Non-Value-Added. WASTE (non-value added) George ML. Lean Six Sigma Pocket Toolbook. 2005

12. Clinical Value Analysis

13. Clinical Value Streaming - TRIAGE

14. Clinical Value Streaming- CP Triage

15. “Healthcare is the only industry I have ever heard of that actually has a name for a major category of waste. You have waiting rooms. Most organizations outside of healthcare would go bankrupt if they thought like this”. Page 33 Lean-Six Sigma for Healthcare Caldwell et al “Infuse care into the queue (waiting) ….define capacity to CARE not a bed” Penn State Healthcare Engineering Team DeFlitch et al

16. Critical to Healthcare Engineer • Burning Platform • Defined CRITICAL Resource(s) & interdependencies • Boarders • Ancillaries • Information • Providers • Minimal Space • WITHOUT Adding Resources

17. Physician (or MLP) Determines Queue passively Listens to RN traditional “triage” Delegates Procedures Initiates work-up when no beds Triage Nurse(s) Arrives patient Manage Minor Emergency Technician support Splint Transport Physician Directed Queuing (PDQ)TM

18. Baseline 5.6% 8h 6m 71 min 93 min 5h 34m 5h 51m Healthcare Engineered 2.7% 6h 16m 45 min 60 min 3h 9m 1h 23m PDQ Year-to-Year Results Comparison LWBS Length of Stay Door-Rm Door-Dr ESI 4 ESI 5 • 52% • 23% • 37% • 35% • 44% • 76%

19. Current Front-End Space TRIAGE Ambulance Walk-In “need” 20K sq ft …..you get 7k

20. Currently under Construction Technician Staffing Triage1 PDQ Check in Checkout Private Minor Dx Queues Private Complex Dx Queues Triage2 Visitors to Hospital

21. Minor Emergency, Walk In PDQ Full Reg & Checkout Triage Visitors to Hospital

22. Minor Emergency, Ambulance Triage PDQ Full Reg & Checkout Visitors to Hospital

23. Room Required & Available, Walk In Triage Visitors to Hospital

24. Room Required & Available, Ambulance Triage1 Mini Reg Visitors to Hospital

25. Room Not Available, Walk In FullReg PDQ Triage Private Complex Dx Queues Visitors to Hospital

26. Room Not Available, Ambulance Triage FullReg Private Complex Dx Queues PDQ Visitors to Hospital

27. Next Venues of Healthcare Engineering • Service Line Flow (Neurosurg) • Peri-Op Processing (Operative Suites) • Hospital Capacity Management • Other Interdependent ED flows • Informatics Project Management • Quality Outcomes (MRSA, Diabetes) • Process Simulation with OSGi

28. Future of HEALTHCARE ENGINEERING • Process simulation models • Explicitly represent variability • Predict interdependency • Manage complex systems in a computer • Predict system performance under varying inputs (loads) • Compare alternative system designs • Determine the effects of alternative policies on system performance