Operational Modeling: Informed solutions for complex problems

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1 Operational Modeling: Informed solutions for complex problems 16 th LCI Congress October 7-10, 2014

2 Our Big Idea Adapting standard practices from the semiconductor industry enables new techniques in design and construction to maximize value and eliminate waste

3 Today s Agenda Overview Dave Higgins, Jr What is OM? - Sandeep Desai ED Case Study Lynda Moyer, RN MBA

4 Parallels to Semi Conductors Electronic Design Automation Tools are on 9 th generation Tools were developed to achieve Moore s Law Semi conductor designs have to be perfect before fabrication 70% of their compute time is spent on validation

5 Operational Modeling Operational modeling is a tool to gain insight into existing operations and explore new scenarios virtually

6 Operational Modeling Helps diverse Owner groups separate needs from wants using a data driven approach

7 Building the Right Project Right With the extended validation of the program, there can be a marked improvement in the elimination of waste.

Facilities Equipment People Lease Buy Hire Construct Commission Source Business Objectives (Metrics) Your

8 An Optimized Process Business Environment Your Organizations Asset Data Fixed; People Asset Class Decision (Outcome) Build Remodel Implementation (Action) Plan Design Post Implementation Monitor Decision Engine Facilities Equipment People Lease Buy Hire Construct Commission Source Business Objectives (Metrics) Your Customer Data Contract Outsource Manage Training Maintain Validation, Insights and Feedback of Performance Data & Metrics

9 What is Operational Modeling? Software that models the behavior of a system over time, given resource constraints and caseload Four types of information are needed to construct a model: Flows: The sequence of tasks performed in a process Resources: What s needed in order to perform a task Durations: How long each step takes Caseload: Profiles and volume

10 Simplified Model Emergency Room patient generator ambulance walk-in waiting room Patient flow acquire Resources capacity schedule nurses waiting room seats triage release beds treatment doctors triage seats discharge admit

11 Simplified Model Emergency Room triage treatment 1. acquire resources acquire bed nurse doctor 2. perform task 3. determine next task 4. release resources release doctor nurse bed discharge admit

12 Why Build a Model? Discovery tool Virtual Identify data collection deficiencies Enable accurate analysis of resource utilization Understand the source of desirable or undesirable operating outcomes Rapidly explore what-if scenarios without changing actual operations Leverage computing power to explore variations on current and future operations Employ optimization techniques to reveal best operational tradeoffs Data-driven Avoid human bias in analysis and decision making process Extensive and detailed metrics are derived from simulation runs Perform sensitivity analysis

13 Operational Modeling Process DATA COLLECTION MODEL BUILD and VALIDATION SCENARIO EXPLORATION PHASE 1 S Stakeholder goals Questionnaires / Tours EMR data mining Operational flow descriptions PHASE 2 Create initial model Validate against reality SSS Collect additional data and refine as necessary PHASE 3 Collaborate to define what-if scenarios Iterate through scenarios 1. and S optimize Deliver detailed report with quantifiable options Project constraints

14 Operational Modeling: Building the foundation for success Data-driven approach to understanding health care operations

15 Challenges of Right-Sizing a Hospital

16 Healthcare is Complex Quantitative Metrics Qualitative Metrics Metrics Stakeholders Healthcare Providers Consumers Insurance Payers Accreditation Orgs. Values Stakeholders Patient Care Provider Family Community Financial Performance Quality Patient Safety Regulatory Collaboration Communication Engagement Affordability Satisfaction Innovation

17 Emergency Departments are Especially Complex

American College of Emergency Physicians Survey o

patients in your ED has: o Is your ED adequately

Source: American College of Emergency Physicians

18 American College of Emergency Physicians Survey o Since 1 st Jan 2014, the volume of emergency patients in your ED has: o Is your ED adequately prepared for significant increases in patient volume? Note: Figures may not total 100 due to rounding. Source: American College of Emergency Physicians survey of 1,845 ACEP members conducted April 4-14; margin of error +/-2.3 pct. Pts. The Wall Street Journal.

19 Case Study: Rightsizing ED Situation: ED with Capacity Problem Fixed physical space until 2021 Not meeting efficiency standards Issues with wait times, ambulance diversion & increased length of stay Different stakeholders with conflicting perspectives

20 Process: Define the Problem Traditional sizing formulas projected current deficit of 5 bays & deficit 9 bays by : Can anything be done to reduce overcrowding now? 2021: How should the ED be built & operated in the future to achieve lowest cost while still meeting performance targets

21 Building the Model Gathered Data o o o o o Electronic medical record (EMR) Staffing plans Pay rates Interviews Observations

22 Building the Model Paired EMR timestamps to workflow Created statistical probabilities of events occurring & durations Validated the model

23 Simulation & Optimization Test various what if scenarios with current volumes Extended urgent care hours Observation Care Unit Fast Track Direct Bedding 4 Hallway Beds Wait Room Triage & Wait Room Sub- Wait First selection had 192 combinations of work flows

24 Simulation Results with Current Patient Volumes UC-H UC-M IB SW TCU Median: Total Length of Stay (Min) 95 th Percentile: Total Length of Stay (Min) Median: Min Waiting on ED Resources 95 th Percentile: Min Waiting on ED Resources Median: Time to Provider (Min) 95 th Percentile: Time to Provider (Min) Baseline Opt Opt Opt Opt Opt Opt Opt Opt Opt Opt Opt

25 Simulation Results Time to Provider Urgent Care Extended Hours Moderate Decantation Baseline UC-M, TCU UC-M Time to Provider UC-M, IB, SW, TCU UC-M, IB, SW Ranked patients by T2P from longest to shortest UC-H: Urgent Care High Decantation UC-M: Urgent Care Moderate Decantation IB: Immediate Bedding FT: Fast Track SW: Results Sub-Wait Area TCU: Transitional are Unit

26 Optimization Lowest cost & best outcomes for 2021 patient load UC-H UC-M IB FT SW TCU Treatment Bays Sub-Wait Chairs NPV of Lifecycle Cost Savings Traditionally sized 45 0 $0 M Option Option $21 M Option Option UC-H: Urgent Care High Decantation UC-M: Urgent Care Moderate Decantation IB: Immediate Bedding FT: Fast Track SW: Results Sub-Wait Area TCU: Transitional Care Unit

27 Conclusion Developed a decision support system Allowed stakeholders to understand the tradeoffs of the many options Enabled discussion between the stakeholders in a data driven way Model showed a smaller Emergency Department was feasible by implementing certain operational strategies

28 How Target Value Design Influences Architecture and Design

29 What is TARGET VALUE DESIGN?

30 Target Value Design is a management practice that drives design to deliver value for the customer and develops design within project constraints.

31 Target Value Design allows the team to establish open levels of communication about the budget and collaborate to create value while reducing cost.

32 HOW YOU DO IT

33 Building Envelope MEP Production Interior Architecture and Design Innovation Team Leaders Landscape Site Improvements I.T. Structure

34 Turns current design practice upside-down: Design based on detailed estimate rather than estimate based on a detailed design Design what is constructible rather than evaluate constructability of a design Design in groups define issues and produce decisions Work in pairs or groups face-to-face

initial portion equally ICL Participants have remaining available Compensation and earn 85% of the amount based on Measures of

35 Contingency spent leaves Project a given amount below Target Cost ICL Participants earn the entire Profit-at-Risk amount Contingency Pool Incentive Compensation Contingency Pool Actual Used Target Cost Actual Cost Owner and ICL Participants Split initial portion equally ICL Participants have remaining available Compensation and earn 85% of the amount based on Measures of Success Scorecard Profit-at-Risk Reimbursable Costs Profit at-risk Reimbursable Costs Measures of Success Score: 85% Incentive Compensation Earned

36 Nine Foundational Practices: Engage deeply with the client to establish the target-value. Lead the design effort for learning and innovation. Design to a detailed estimate. Collaboratively plan and re-plan the project. Concurrently design the product and the process in design sets. Design and detail in the sequence of the customer who will use it. Work in small and diverse groups. Work in a Big Room. Common Understanding Build Trust Collocate Conduct Retrospectives throughout the process.

37 REPORT OUTS Report to the whole group each team week on the progress Ask questions Be accountable

38 INNOVATION TEAMS AND SPEED DATING Bringing more team members to the Big Room may be a higher upfront cost but it will help you in the end A new perspective can help solve a design problem

40 SET BASED DESIGN Carry solution sets far into the design process rather than narrow choices early

41 KEY TAKEAWAYS Assemble your team with all the right people Leverage full potential of your Innovation Team Every idea should be proposed and vetted out by the Team Tension can be a good thing push each other to the best design for the best price

42 CASE STUDY

43 NICU CHARTING STATIONS ORIGINAL DESIGN GOALS Maximize visibility to the Patient Maintain Patient and Family Privacy Workspace for two people Reduce Cost

44 (JCAHO)

45 NICU CHARTING STATIONS MOCK-UP

46 NICU CHARTING STATIONS FINAL DESIGN OUTCOMES Line of sight is clear Height of window and worksurface improves visibility Cubicle curtain will not block view unless pulled closed Second curtain in family area gives them controlled privacy

47 NICU CHARTING STATIONS - FINAL

48 LEVEL 5 DRYWALL FINISH HIGHLIGHTED PLANS Begin to balance design and cost before design is finished Base estimate off of more accurate representation than a design narrative

49 CEILING DESIGN

55 LESSONS LEARNED Definition of Value can be different between Owner and Design Team Open Dialogue is Imperative Build Trust We re all in this together! Involve estimators in key design presentations to Leadership Structure team weeks so Innovation Meetings and Design Meetings do not overlap Balance time and resources to brainstorm innovation and work through details

56 QUESTIONS

8/19/2015. Using Your Data and Metrics to Improve Care and Performance. Objectives. Agenda

8/19/2015. Using Your Data and Metrics to Improve Care and Performance. Objectives. Agenda Using Your Data and Metrics to Improve Care and Performance The Carolinas Center 39th Annual Hospice & Palliative Care Conference September 29, 2015 Tom Gualtieri-Reed, MBA Healthcare Consultant Spragens