Date post: | 12-Jul-2015 |
Category: |
Healthcare |
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Using Simulation to Manage
Unscheduled Care
Guest Speaker:
Dr Paul Schmidt
Consultant Acute Physician, Portsmouth Hospitals NHS Trust
Powerful. Flexible. Fast.
SIMUL8 Corporation | SIMUL8.com | [email protected]
Presenters
Paul Schmidt
Consultant Acute Physician,
Portsmouth Hospitals NHS Trust
SIMUL8 Corporation | SIMUL8.com | [email protected]
Housekeeping
1. Audio
2. Q & A
Recording available on SIMUL8Healthcare.com
SIMUL8 Corporation | SIMUL8.com | [email protected]
Introduction to the case study
Overview of context and challenges for unscheduled care operations
Principles for a rational operational strategy
Use of Modelling and Simulation
Outcomes
Lessons learnt and next steps
ACUTE NHS TRUST
South Coast of England▪ 600,000 catchment
▪ 105, 000 ED attendances
▪ 40,000 inpatients
Emergency Clinical Service Centre (CSC)
▪ Emergency Department
▪ Acute Medicine Unit
▪ Single management structure since 2010
▪ Clinical directors for ED and AMU
Increasing and changing nature of demand Trauma & injuries
True new non-trauma emergencies
Chronic medical co-morbidities with acute deterioration
Frail elderly
Ambulant and exercising choice
Patients with chaotic lives
ED access block
Acute medicine Emergency Ambulatory Care (AEC)
(Dis)continuity of care?
Asplin et al (2002)
Functional divide designed for clinicians rather than patients
Operational inefficiencies
Not aligned to patients
Inefficient use of skills
Complex patient flow
Failure to meet targets
Cost overrunsLow morale
Staff turnoverFailure to recruit
Damage to reputation
Create focused Services around customers with similar requirements requiring similar processes
The greater the pooling of demand and processors, the more effective a given system will be in minimising queues. (Erlang queue theory)
Service time variation increases the length of the queue
Reduced service time variation increases resource utilisation
Very high utilisation levels increase risk that peaks in demand could cause exponential growth in queue length
Avoid cut-outs unless completely justified. Only use for unique processes/services
MedicalAcute Med UnitEDOutliersOutliers
MedicalAcute Med UnitED MedicalAcute Med UnitEDOutliers
Sorting (streaming)Prioritising (triage)ED Queues
Acute Med UnitED MedicalOutliers
GP
ED vs GP admissionsChoosing outliers
Inconsistent overburdening (mura) of staff at different times
Very high staff utilisation or process constraint (muri)
Non-value adding activities (muda)(waiting times, clinical rework, unnecessary transfers)
Inventory (patients for beds)
Batching and overproduction (consultant WRs)
Desynchronised flow (to specialist beds)
Unnecessary complexity
Add valueFeel valued
Use skillsWork in a good team
STAFF
PATIENTS
ContinuityGood communicationNo unnecessary waitsGood quality care Trust in staff
OPERATION
Fewer moves
Simpler processes
Good use of skills
Less work in progress
High staff utilisation
Patient-centred
Less variation
CORPORATE
Safety, avoid critical events
Impact on elective services
Financial constraints
Meet targets
Reputation
ALIGNMENT
Flow/ED access block/4-hour breaches Patient safety: direct and overnight
admissions Bed capacity allocation Staffing and staff utilisation Job content of consultants Staff buy-in and identification with new
organisation Cultures different in ED and AMU
Understand demand
SegmentationTime
Test designs
Simulation
models
Key performance
indicators
Coherent redesign
Simplify &
cut waste
Stream to skills
Patient access
Fewest transfers
Align
Co-production
Synchronise flow
86.7%
by 4 hrs 94.6%
96.7%
• 3-stage to 2-stage process
• All patients through ED (including GP
referrals and Ambulatory patients)
• Patients separated by their expected
total LOS
• ≤ 48 hrs – Short-Stay
• > 48 hrs – Medical Spec
• Assessment (and resources) bought
forward to ED
• MAU becomes Short-Stay ward – for
execution of care only
Alignment of Demand and Services in an Integrated Model
(All Emergency CSC Activity)
Injuries
Own Transport 20,919
999 calls 7,944
Trauma &
Orthopaedic CSC
Surgical Spec
Wards
4,957 cases
Gastro 2409
Uro/Vasc 215
Cardioresp 107
Neuro 79
Various 182
Acute Medicine
Short stay ward
13819 cases
Cardioresp 5028
Neuro 2316
Adverse reactions 1744
Unknown/misc 1414
Gastrointestinal 1026
Uro/Vasc 454
Multi-systems 452
Skin/soft tissue 443
Metabolic 288
Mental health 268
Skin/soft tissue trauma 194
Various 192
Trauma /Injury Unit
28,906 cases
Soft tissue injuries 21578
Multi-trauma
Orthopaedic problems 7328
Falls that needs injuries treated
or ruled out
Non Trauma Assessment Unit
29,603 cases
Cardioresp 9033
Gastrointestinal 6781
Neuro 6413
Adverse reactions 2326
Unknown/misc 2174
Urology/Vascular 1124
Metabolic 986
Multisystem 672
Mental health 94
Ambulatory Unit
29,916 cases
Skin/ soft tissue 8099
Unknown/misc 7265
Cardioresp 5300
ENT 1674
Eye 1549
Neuro 1476
Uro/Vasc 883
Adverse reactions 858
Obs/gynae 842
Dental 725
Multi-system 671
Mental health 574
Non-trauma:
Own transport
Own Transport 31,021
Non-Trauma
Ambulance Transport
999 calls 28,541
Urgent GP amb 1,827
Medical/DMOP
Spec Wards
12,186 cases
Cardioresp 3750
Neuro 2704
Gastro 1352
Metabolic 497
Multisystem 375
Uro/Vasc 354
Unknwn/Misc 347
Adv reactions 145
4324 1912
23,817 7,833 20,970
9256 1964 2663 2993 9523
Trauma Obs
ward 1902
210
210
239
GP Calls 10,000
Diverted 2,000
5500 3500
Patient access
Streaming into
focused services
Co-production by
ED and acute
physicians
Consultant decision
prior to admission
Assessment
Cells
Single transfer
OutliersMedicalAcute Med UnitED
OutliersMedicalAcute Med UnitED
00:00
01:12
02:24
03:36
04:48
06:00
0 24 48 72 96 120 144 168
Real
Sim
New
Average Std Dev Lower CI Upper CI
Real 02:38 0.01 02:36 02:40
Sim 02:38 0.04 02:30 02:45
New 02:29 0.02 02:23 02:34
Wed Thurs Fri Sat SunTuesMon
0
100
200
300
400
500
600Real Sim NEW
Difference = 4000 fewer breaches
4 hr target
00:00
00:28
00:57
01:26
01:55
02:24
02:52
0 24 48 72 96 120 144 168
Real
Sim
NEW
Average Std Dev Max Min
Real 01:16 00:20 02:07 00:36
Sim 00:57 00:35 02:32 00:18
NEW 00:32 00:19
0
200
400
600
800
1000
1200
1400
ED/AC to Home Home from MAU/ ShortStay
Non-MedicalAdmission*
Specialty
Min
ute
s
Existing
Merged
Desynchronised
flow
• Mean ED LOS reduced by 12 min/patient
• Time to nurse assessment reduced by 9 min/patient
• Time to doctor assessment almost halved
• Doctor workload reduced by 6.6% - equivalent
of having 2.5 extra doctors
• Queues reduced: ED and AMU
• Transfers of care reduced by 16.8%
• Time to end destination reduced for all destinations –
more than halved for medical specialties
Interaction with Specialties▪ Constraints imposed by specialty bed supply
▪ Impact of reduced transfers
▪ Synchronised flow
Staffing▪ Optimised rotas
▪ Staff utilisation
▪ Job content
Bed capacity▪ How many?
▪ Where?
Actual bed provisionAverage Bed Use
Utilisation
Existing Integrated Existing Integrated Existing Integrated
4 hour assessment cells 40 55 17.2 21.8 43% 39.70%
Short stay beds 67 50 41.3 31.83 61.60% 63.60%
Specialty bed provision (excl Rehab)
742 758 699.3 713.7 94.20% 94.20%
Total inpatient beds (excl Rehab) 809 808 757.8 767.33*
Gives confidence improvement is possible Requires whole hospital change, not tinkering
with parts
Simplify and redirect flow
Staffing models will have to changes
Change staff rotas before making capital investments
Right size the capacity at each stage.
South Central Strategy Health Authority for project funding
James Newbold, data analyst for untiring efforts creating and testing the SIMUL8 models
Questions?
Please forward any topics you would like to
see covered to: [email protected]
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