pathways to the future improving health system performance the role of stochastic simulation in...
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Improving Health System PerformanceImproving Health System Performance
The role of Stochastic simulation in The role of Stochastic simulation in predicting the utility of investmentspredicting the utility of investments
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Amid the entangled complexities of health Amid the entangled complexities of health services all aspects of performance are services all aspects of performance are
inter-dependentinter-dependent
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• Mike Ardagh, National Clinical Director of Emergency Department Services
• Stuart Powell and Emmanuel Jo, Service Analysis, National Health Board Business Unit, Ministry of Health
email; [email protected]• Joy Farley and Warwick Gilchrist, Taranaki
District Health Board
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Shorter stays in the Emergency Department
95% will be admitted, discharged or transferred within 6 hours
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Shorter stays in the ED
• About the whole of system
• Overlaps with;
• Elective aspirations
• Primary care considerations
• Cost containment endeavors
• Quality concerns
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Patients
1. 43 year old man with pneumonia, waiting for the medical registrar to assess.
2. 60 year old lady with a compound ankle fracture awaiting surgery.
3. A 73 year old woman with chest pain, waiting for a free ED cubicle
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Patients
1. 43 year old man with pneumonia, waiting for the medical registrar to assess.
• What if we had a separate medical assessment unit?
• Or a second medical registrar?
• Or IV antibiotics in primary care?
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Patients
2. 60 year old lady with a compound ankle fracture awaiting surgery.
• What if we had a dedicated acute theatre?
• Or another orthopaedic registrar?
• Or if elective orthopaedic activity was at another site?
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Patients
3. A 73 year old woman with chest pain, waiting for a free ED cubicle.
• Should we have more monitored cubicles?
• Or a bigger Coronary Care Unit?
• Or a low risk chest pain pathway run through the ED observation unit?
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Seeking answers
• Value stream mapping and other lean thinking techniques
• Breach analysis and other measures of variance• Street wisdom• Turning data until it catches the light• Modelling of present state compared to present
state plus an intervention
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Advantages of using simulation
•Real life experiments without implementing in the real world
•Identify how changes to variables within the system can impact other parts of the system
•Easy identification of bottle necks
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Disadvantages of using simulation
•If the data doesn’t reflect reality, the results won’t be real
•There may be unknown/unpredicted confounders the data has not taken into account
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The Simulation Tool
• Witness Simulation Software
• Used with success in a variety of industries
• 3 examples of use in Health Care and Hospitals on website (2 UK, 1 USA)
www.lanner.com
• Trialled with ADHB data*, and TDHB underway.
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Patient flow simulation for Taranaki DHB
•Aim:
To investigate the influence on patient flow, of a short stay unit next to ED.
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Model structure
Community(home)
Primary Care(9am-8pm, Mon-Fri)split into ED or home
ED(24x7)
split intoMED,SURG, PAEDS, MH,
Mat or home
Hospital inpatient serviceElective-MED
Elective-SURGAcute Inpatient-MED
Acute Paeds SurgAcute Paeds medicalAcute Inpatient-SURG
MENTALHEALTHMATERNITY
Primary queueArrival
9am-5pm, Mon-Fripull
Elective queue
ED queue-triaged
Time differential arrival24x7
(Undefined Patients)
Push to home
QueueWating in ED
Pull
Push to homePull
priority1
Pullpriority 3
Push for ASMED,ASSURGAIMED,AISURG
if there is a space in inpatient service
Push for MED, SURG, PAEDS, MH, MAT
Push to home
Push to ED queue
Short Stay Unit (23 hours)
Pullpriority2
Push MATERNITY, MENTALHEALTH
Elective-SURG stay time
Acute SURG stay time
Maternity stay time
Taranaki-Base HospitalED pathway simulaiton
1Elective referral, (Elective-Med, Elective-Surg) 3
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Timeline for a process optimisation using simulation for a DHB
Step Task Time
Required
1 Plan and identify what to optimise 1 day
2 Draw up a model structure and flow diagrams 1 week
3 Check the structure by the MOH team 1 day
4 Data gathering for the model 2-3 weeks
5 Building the model using special simulation software
2-4 weeks
6 Validate and calibrate the model for Business as Usual Scenario
1 week
7 Test different policy options in the complex virtual life environment to identify better outcome
1 week
Approximately 10 weeks !!!!
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Summary
• Achieving the Shorter Stays in the Emergency Department Target requires whole of system reforms
• Health systems are complex and interactive
• Interventions will influence many parts of the system
• Simulation has the potential to predict the influence of interventions
• The Shorter Stays Target is not competing with other priorities.