Healthcare Operations Management VEDAT VERTER PROFESSOR, OPERATIONS MANAGEMENT EDITOR-IN-CHIEF, SOCIO-ECONOMIC PLANNING SCIENCES DIRECTOR, NSERC CREATE PROGRAM IN HEALTHCARE OPERATIONS & INFORMATION MANAGEMENT CO-DIRECTOR, MCGILL MD-MBA PROGRAM
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
A Single Payer System … • Public insurance • Everyone in Canada is insured through their provincial government • Health 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 funding • Patient waiting times • Medical technologies • Personnel shortage • Inclusion 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).
Research Team • Marc Afilalo, MD • Antoinette Colacone, CCRA • Alex Guttman, MD • Eli 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
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 ED • Evaluate possible interventions to reduce patient wait times • Design a detailed intervention plan to achieve lean ED processes
Start End No Yes Patient in the process of Triage? Yes Yes No Yes No No Yes Yes Is patient chart (doctor sheet) available? Arrival through ambulance? Yes No No No Extremely Critically-ill patients waiting? Yes Other ambulance patient waiting? Yes Arrival by Other Means Physician Available? No No No Yes Resuscitation Ambulatory or Stretcher? Monitored Un-monitored No Nurse Available? Nurse Available? Is cubicle critical to assessment? Does attending physician check patients in hallway? Previously assessed by nurse? Initial Physician Assessment Initial Nursing Assessment Initial Nursing Assessment Is patient nursing chart available? Does others need cubicle more? Ambulance Patient waiting? Yes Yes Yes Cubicle Available? Yes No Yes No No Yes Triage (See detailed flow chart) Is patient chart (nursing sheet) available? Yes No Stretcher Yes No Needs immediate intervention? Cubicle Type? No Ambulatory Registration (See detailed flow chart) 1 Hallway Patient placed in designated cubicle Flow Chart from the Time Patient Enters ED to First Physician Assessment (JGH) Detailed ED Process Flow
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.
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 ofBaseline & “2 Pooled RN + Pre-triage”
Wait Time Distibutions Baseline Baseline
Wait Times during the day Baseline Baseline
Nurse Utilization Pooled + Pre-triage Baseline
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.