Improvements in the Emergency Dept.:
Understanding and Managing Computer Simulations
Click here to download a PDF version of this white paper

Changes to any emergency department- large or small, rural or urban, busy or, well, busy-cause numerous and sometimes unforeseen consequences to healthcare delivery. Whether change is deliberate or is visited upon a provider from outside forces, it will impact patients, staff and the community. Computer simulations offer a safe and cost-effective way to experiment with changes to processes, staffing and even the footprint of a department or entire hospital. In this way, simulations guide administrators in making the best decisions for their facilities.

Computer modeling and simulation allows one to evaluate a number of scenarios for delivery of emergency care, over time and with any number of variables. Software can create a "virtual ED" of an existing or planned ED, with scaled-to-size walls, equipment, moving staff and patients on gurneys.

Common goals for using computer simulation for emergent care are to:

• compare an existing emergency department (ED) floor plan to a proposed renovation
  
• study emergency room design for new construction
  
• contrast one workflow with another to increase throughput and/or patient satisfaction
  
• analyze changes in staffing, square footage and/or number of beds
  
• predict the impact of demographic shifts in the patient population over time
  
• examine the effects of increased or decreased competition
  
• anticipate the impact of internal changes such as increasing or decreasing inpatient beds, laboratory staff or equipment, ED physicians, etc.
  

Computer simulation software can be either customized or off-the-shelf. However, because the data collection required for a thorough simulation is labor intensive, analysis of important human variables demands specialized expertise and creating actionable outcomes requires experience. Healthcare providers typically rely on an outside consultant to guide them through the process, to run simulations from start to finish, or both.

Why is computer simulation better than other methodologies?

Of course, real-time, on-site experiments to improve delivery of care would have extreme consequences in an Emergency Room. As an alternative, almost any paper and pen analysis of such experiments would be preferred. Like computer simulations, such analyses could capture on some level changes to workflow, for example, with little impact on staff, no impact on patient safety or satisfaction, and comparably little cost.

Computer simulations offer these advantages, plus other important benefits.

Charting complex human interactions

For many years, hospitals and other organizations in the service industry adopted the factory-based models to evaluate processes. But patients are not widgets, and factory workers do not typically need the same complex problem-solving skills of clinicians. So the familiar clock-watch evaluation of factory workflow does not account well for the complexities of patient-family-clinician interactions, the role of ancillary departments or the multi-tasking required of nurses and doctors in the emergency room setting.

The numerous factors that impact busy EDs are best captured by computer models. Once data is collected, administrators can test and view quickly and easily the impact of any number of variables, even those related to productivity based on the experience level of clinicians.

Change happens before their eyes

The benefit of a computer simulation continues with a deliverable such as the three-dimensional (3-D) on-screen visualization of patient throughput, for example. With computer-aided design software, both the administrative decision-makers and the front-line staff see, most literally, the impact of changes to the ED workflow and throughput.

Instead of data-heavy charts and statistics, stakeholders watch their own virtual ED transform and improve based on changes to the model. Since any changes to actual workflow will impact both caregiver and patients-often with reduced productivity at first-computer simulation goes a long way to creating advocates vs. detractors during the transition period of implementation.


What types of changes can ED simulations capture?

Computer simulation can help decision-makers to experiment with changes, compare options and simply to evaluate limitations in:

1. Existing Emergency Departments that are experiencing long wait-times or unsatisfactory throughput because of an increase in patient populations or bottlenecks in other areas of a healthcare facility, for example.
   
2. Planned renovations and entirely new EDs, to identify problem-areas months before the first construction vehicle arrives on the scene.
   
3. How workflow and floor plans will function over time relative to macroenvironmental factors such as population shifts and competitors' market share and microenvironmental factors such as changes in staffing or addition of faster diagnostic equipment

In the U.S., we're in good company in looking to computer simulation to improve ED care or avoid ED overcrowding. Tidewater Consulting shares here examples of practical ED simulations in Finland and the United Kingdom as well as in the U.S.

Case Study 1: Anticipating the impact of internal systemic or external changes

Researchers at the Massachusetts Institute of Technology in Cambridge used computer simulations to evaluate how availability of inpatient beds impacts the ED. This type of simulation might be relevant for hospitals planning to close inpatient units permanently or temporarily due to renovations, for example, or to discover ways to approach high census periods, during flu season for example. In some U.S. states, simulation results might also be part of a certificate of need application either for ED expansion, construction of a satellite center or request for new inpatient beds.

MIT researchers performed initial data collection (a process discussed in general terms later in this paper) at an urban hospital and then ran 300 simulations of different scenarios. Among the variables were patient and staffing data for various times of day and different days of the week.

Their studies provided interesting results. First, the simulation showed that when the inpatient unit is crowded, the ED is more likely to be crowded as well. That was to be expected. Second, however, it also showed that the ED is sometimes crowded when the inpatient unit is not. This information gives stakeholders direction for improving operations in the ED and increasing resource utilization in areas that are unrelated to inpatient bed availability.

Case Study 2: Improving an existing ED

The goal of a Finnish computer simulation was to provide direction to a hospital with 34,000 ED patients annually whose stated goal was to reduce wait times to less than two hours for 80 percent of its patients.

Using off-the-shelf software, the initial computer simulation of existing ED patterns identified back-ups caused by delays in ordering of x-rays and other tests. Consultants worked with staff to develop a team-triage system for testing. In a new computer simulation, a team comprised of a receptionist, nurse and physician initially evaluate the patient and determine which diagnostic tests he needs. Clinicians then leave the patient to provide basic information to a receptionist, who then gets the patient underway for testing.

Taking advantage of one of the greatest benefits of computer simulation, the Finnish researchers ran multiple simulations, using eight different scenarios for patient acuity. Of special note, these simulations incorporated staff input and experience and had no direct impact on actual ED workflow.

The results of the simulation: the triage-team approach predicts a 26 percent reduction in patient throughput. The simulations also accounted for human variables such as staff's increasing familiarity with a new system. By running the model with these variables, the simulation also predicts that staff would eventually be able to decrease wait times to less than 12-14 minutes, compared to the initial goal of under two hours.

Case Study 3: Responding to renovations and new construction

Healthcare planners at one California system looked to computer simulation to analyze and predict the impact of a major and important move: the merging of six different EDs, into a shared (though quadrupled) floor space. Simulations were important for obvious reasons, but also because the EDs had a combined total 160,000 patient visits annually, and each was already overcrowded.

Computer simulation allowed the hospital system "to experiment with many scenarios without impacting the existing quality of patient care, . . . to mitigate risks and . . . solve issues months before transition to the new facility."

The computer model revealed how ED-specific and system-wide changes could (or even would not) maximize resources. Plus, because it was performed well before the bricks and mortar stage, the consultant-hospital staff team was able to run simulations with varying floor plans.

The results of various computer simulations were:

• Discharging patients five hours earlier would reduce length of stay (LOS) by one-third.
  
• Adding 30 more inpatient beds would cut ED LOS in half. Related, inpatient units were 10 percent undersized.
  
• Reducing lab test turnaround would not impact LOS in a significant way.
  
• The number of ED beds planned could be reduced by one-third.
  
• The new ED could handle up to 65,000 patients yearly before LOS would be unacceptable.
  

Consultants and stakeholders evaluated these results to focus further simulations on bedside triage and registration, changes to the time of day inpatients were discharged, reducing inpatient LOS and increasing the inpatient occupancy rate.

What's the process? What are the deliverables?

Like any large project, preparing for a computer simulation of an ED first involves determining objectives and ways to measure success in meeting those objectives. The case studies discussed above provide examples of realistic outcomes. An experienced consultant can assist you with defining reasonable goals and actionable conclusions for your facility.

The next, and one of the most time-consuming steps in computer simulation is data collection. Relevant raw data includes detailed floor plans, staffing levels by job category, numbers and job classifications of ancillary departments in the ED, average patient visits, level of trauma or illness, etc. Data at this stage could also include the number of and volume for entry points for patients, number of ambulance companies using the facility and any other number of factors.

Data collection often includes "shadowing" of patients and of all levels of staff by experienced recorders. Recorders capture as much information as possible to provide an accurate depiction of what happens in the ED, why certain steps are taken, how long they take, and what factors external to the ED impact these events.

Initial deliverables include reports created from the raw data and relevant to pre-defined goals. Examples include reports on average patient throughput, average number of patients seen per physicians, averages for specific physicians, and busiest times of day or week. For computer simulations using three-dimensional software, decision-makers can get a birds-eye, dynamic and time-stamped view of staff-patient flow throughout the ED. This allows them to identify visually where and when bottlenecks occur throughout the day or during a defined period of time.

With a good data set, a facility can run predictive simulations to evaluate the impact of both internal and external changes in patient numbers, staffing, physical plant design, workflow, etc.

Conclusion: The role of vendors and consultants in creating actionable results

Though computer simulations offer opportunities to analyze ED function in ways not otherwise desirable or even possible (as with predictive modeling), obtaining actionable results takes forethought, planning and experience. Qualified vendors and consultants, working closely with administrative and clinical staff throughout the process, lead to the best outcomes.

As demonstrated with the following hospital simulation project, lack of communication and buy-in wastes time and money. An unfortunate computer simulation experiment in a hospital in England offers lessons to avoid.

Case Study 4: Unintended consequences

The goal of one U.K. computer simulation was to evaluate how changes in patient throughput might impact ED wait times. Researchers ran two simulations: 1. using existing processes, where all patients are registered and seen first by a doctor; and 2. using a predictive model to test a new triage system, whereby certain patients with minor illnesses receive care from a nurse first, and then by a doctor before discharge. The computer simulation concluded that the second option would reduce wait time and decrease costs (because of reallocation of time of the more highly paid physicians).

However, upon actual implementation of the new system in the ED, nursing staff adopted the new system, but physicians did not. This lack of adoption required a second live experiment, where again key personnel created unintended (and un-simulated) workflow patterns. Researchers concluded that lack of staff buy-in did indeed hinder both data collection and implementation of a workable new process.

Computer Simulation: "A tremendous opportunity"

Simulations can capture complex human interactions in a way not possible with other tools. However, as the U.K. researchers learned, the integral role of professionals experienced in healthcare, in computer modeling and in change management are not to be underestimated.

Even with the unintended outcomes discussed above, the academic researchers in England called computer simulation "a tremendous opportunity" for evaluating emergency department processes. As illustrated by the case studies, computer simulations identify critical issues, point to opportunities and pitfalls, and provide direction to address problems. Compared to other approaches, simulations offer these benefits quickly, easily, safely and with minimal negative impact on staff or patients. Even with such an imposing event as the merging of six EDs in California, computer simulations provided decision-makers with new directions about issues they had never experienced and which was not something they could easily intuit due to the sheer magnitude of the process.

When applying computer simulations to your emergency department, you hold the keys to avoid extra expense and maximize patient care:

1. Make your own staff, including clinical and ancillary staff at all levels of patient care, integral to the project team from start to finish. Their experience and expertise will be important to the entire process, not just to the outcome.
   
2. Research your options for vendors and consultants. Again, include key staff in assembling these players, to give them confidence that the external experts understand the complexities of the ED.
   Assembling a qualified team is integral to the success of every step of computer simulations. The bottom line: all team members should be as committed to the project as you are.
   
   

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Kolb E.M., Lee T. and Peck J. "Effect of coupling between ED and inpatient unit on the overcrowding in ED. MIT Park Center for Complex Systems, Mass. MIT, Cambridge. Proceedings of the 2007 Winter Simulation Conference.
Ruohonen T., Neittaanmaki, P. "Simulation model for improving he operation of the ED of Special Health Care." University of Jyvaskyla, Finland. Proceedings of the 2007 Winter Simulation Conference.
Miller M., Ferrin D, Ashby M., & Flynn T. "Merging six emergency departments into one: a simulation approach."
Davies R. "'See and treat' or 'see' and 'treat' in an emergency department. Warwick Business School, Coventry, U.K. Proceedings of the 2007 Winter Simulation Conference. Proceedings of the 2007 Winter Simulation Conference.




Understanding the Total Cost of Ownership (TCO) analysis for IS in the healthcare setting
2006 Jul-Aug;59(7):30.
Click here to download a PDF version of this white paper

In an industry with slimming margins and increasing demands for quantifiable results in every business and clinical area, it is increasingly important for healthcare organizations-and the internal "owners" of budget line items-to identify in a compelling way:

• the total cost of ownership of specific investments and
• the benefits expected over the life of the application.
  

Healthcare IS investments deserve such detailed analysis. Healthcare organizations are currently embarking upon multi-year technology investments, often exceeding the $100 million mark. However, the "out of the box" cost of IS investments does not reflect the true cost of any system.

The TCO process: an overview

TCO has become an industry standard for measuring and managing project-related costs over time. It looks beyond a one-year budget cycle. Based on the experiences of Tidewater Consulting, the report is a fluid, or living document that changes as an organization finalizes purchasing contracts, determines feasibility of various components of the project, and adapts to new opportunities (in products or technologies that become available, for example).  The “final” TCO therefore evolves as planning and discussions progress.

A thorough TCO analysis engages all stakeholders, not only to gain their support and perspectives concerning the IS product, but also to ensure that the final TCO report accurately reflects all costs, benefits, goals and expectations. For example, the finance team is a key player in determining where costs reside. (See sidebar, “Capital or Operating.”) Clinicians not only contribute to determining functionalities required for an IS system, but their level of experience with IS systems will also drive the level of training required for a hospital to optimize expected benefits of any specific system.  Human Resources staff, in turn, can inform these “soft” expenses.

Components of a TCO report

The TCO attempts to estimate all costs related to the ownership, management, support and usage of the components comprising the IS project.  Indirect costs are a key component of the TCO because, as mentioned, many costs cross organizational boundaries and reside outside of the budget of the project sponsor. 

Direct and indirect costs might include:

• initial hardware
• initial software
• implementation, including system downtime
• management
• research of vendors & contracts
• service
• support & training
• administration
• upgrades & related re-training
• capital purchases
• direct and indirect labor
• subscriptions
• system integration
• maintenance

Of special note, Tidewater Consulting finds that licensed software, licensed software support and professional services are the three top drivers of costs in IS TCO expense analyses.

In reviewing the cross-organizational scope of this analysis, it becomes clear that the TCO is driven by processes, people, technology and tools and comprises all costs expected in a defined timeframe. The timeframe might cover three, five, seven or even 10 years for some projects. It bears repeating that many related costs will be found outside of the IS department.

Five steps for creating a Total Cost of Ownership analysis for an IS project:

Step 1: Project Initiation. This is a very important phase in the project, because during this phase we determine:

• the scope of the project
• client expectations
• basic facts and a foundational context concerning the client environment

Ultimately, the project objective is defined at this stage.

Step 2: Cost Modeling. This major step in the TCO analysis will be used throughout the TCO project and will continue to be refined as new information is obtained.  In this stage, we work to define costs to be included in the model and to classify the costs according to the client’s financial policies and procedures.

As discussed previously, licensed software, licensed software support and professional services are three of the top cost drivers in this project.  Therefore, it is imperative to define at this point the scope of applications included in the project.

Step 5: Ongoing Refinement of the TCO Model.  Of course, not all contract negotiations required for a large project can be finalized at one time, nor is a rollout or implementation plan usually  determined concurrent with or even immediately after delivery of the Final Report.  Therefore, the TCO model acts as an estimate of project costs based on data and decisions available as of the date of the report deliverable.  As contract negotiations progress and key decisions regarding rollout and implementation strategy are reached, the TCO model should be refined to include the most current project cost estimates.

The organization should maintain an up-to-date TCO at all times so that the impact of any deviations from initial projections can be captured and evaluated for cause. 

A Benefits Assessment:

maximizing the TCO report

In order to capture enhancements in productivity and business returns related to any IS project, organizations should also consider conducting a Benefits Assessment as a companion to the TCO process.  This type of assessment reveals otherwise hidden benefits that fall into one of two categories:  quantitative financial benefits and softer value benefits. 

Quantifying all benefits through such a tool can lead to a substantial decrease in the total cost of ownership, because the assessment can reveal benefits that reside in areas such as cost reduction, quality improvement, risk mitigation, worker productivity, etc.  A team of Six Sigma practitioners are often valuable assets in accomplishing the benefits assessment.

Conclusions

The Total Cost of Ownership analysis helps to make IT costs transparent across the organization, create hard data for pricing and accounting purposes, and reveal opportunities for increased savings and efficiencies.  The TCO report identifies a starting point for areas of improvements, and a measuring stick for analysis of strategies for priority areas.

Personnel who have a background in healthcare operations, are familiar with internal and external stakeholders, are experienced in financial areas and have hands-on TCO experience can help a single hospital or an entire system to maximize efficiencies, improve the bottom line and provide better and more efficient healthcare for the patients they serve.

About Tidewater Consulting Group

Founded by a team of IBM consulting veterans, Tidewater Consulting Group is a national health care consulting firm focused solely on the business of hospitals and other healthcare providers. We provide advisory, interim management, revenue cycle management, project management, and modeling and simulation services to help improve patients’ lives.

We are committed to:

• Providing Thought Leadership
• Providing Exceptional Value for our Services
• Facilitating Knowledge Transfer
• Improving Client Satisfaction

The IT Professional and Change Leadership - Colin Konschak, RPh, MBA, FHIMSS, FACHE
2006 Jul-Aug;59(7):30.

More often, IT leaders are being put at the forefront of change in their organizations. I have seen this as both an outside healthcare consultant and as a technologically inclined health system pharmacy leader. The reason is simple: the revolution needed in health care today requires a unique mix of information technology knowledge and strong leadership.

To survive, healthcare organizations must compete in specific diseases and conditions, and they must meet ever-growing patient expectations of care. They also must satisfy their healthcare professionals-prized resources from a shrinking pool. Looking at the foregoing challenges, it is clear this is a huge career opportunity for healthcare IT leaders. However, they must be able to lead change.

The ability to successfully lead change is a highly valued skill. IT professionals who demonstrate change leadership abilities are seen as having great promise. To successfully lead change, leaders must excel at influencing the overall culture of their organizations and at effectively developing and communicating a vision for the "new" organization.

Leaders must exert influence over the culture of the organization, because the culture of most healthcare organizations must radically change if the necessary level of transformation is to occur. Culture helps employees understand their environment and how to respond to it. Employees develop solutions to everyday problems, these solutions are passed on to new hires and eventually they become institutionalized.

Organizational development authority Edgar H. Schein has identified five mechanisms for successfully influencing corporate culture: attention leaders give to issues, how leaders react to crises, role modeling, allocation of rewards, and criteria for selection or dismissal.

The attention leaders give to issues or problems is critical. If you are implementing an organization-wide electronic health record, all of the implementation team leaders must communicate the initiative every day, and ensure the top leaders keep the message out front. With continuous emphasis, everyone in the organization will understand this is a main concern and they will prioritize their projects accordingly.

Next, consider how you react to crises. Crises create high emotion. How you react to them will send a strong message. In any intensive IT implementation, there will be setbacks. Always ensure that if things go wrong, you are the one who is seen proposing the next step to turn this temporary setback into an opportunity.

Role modeling is next. Employees watch the behaviors of their leaders, listen to their words and act accordingly. You've seen the CEO who pushes adoption of technology as a critical success factor, yet refuses to carry a Blackberry or use the intranet to communicate. Leaders must embody their vision for the organization, or that vision will not be taken seriously. IT leaders can excel in this area.

The fourth mechanism is allocation of rewards. Rewards express clearly what the organization values. Therefore, incentive plans should be directly aligned with organizational goals.

The criteria for selection and dismissal a leader puts into practice is also critical. Your success will depend on hiring and retaining people who embrace change, accept the vision for the future and are proactive in operationalizing change. These are the only people who should be working for you.

To successfully lead change you must also effectively develop and communicate a vision for the "new" organization. When drastic change is required, the leader's vision provides a clear picture of the future and instills faith in the employees that it will be achieved.

A successful vision describes the future organization, focusing on the big picture. When developing a vision, successful leaders evaluate the old vision of the organization and determine which elements are still relevant. This shows employees that past work and success have enabled the organization to embark upon this new change, and diminishes the impression that the entire world has changed overnight.

Most importantly, successful leaders must develop a vision that is both credible and stretches the organization's capabilities. After leaders have developed a vision for the future, they must turn toward communicating that vision to the rest of the organization. The strongest chance of successfully communicating a vision to a large organization will depend on how often it is communicated. A leader should use multiple communication media and every opportunity.

Health care must learn a fundamental lesson from other industries-that quality must be improved while costs are simultaneously decreased. Only when leaders influence the overall culture of the organization and then effectively develop and communicate the vision will employees be empowered to make decisions necessary for achieving the leader's vision.

The Value of Project Management - Philip Felt, CPHIMS, MBA
http://www.vahimss.org/links/TheValueofProjectManagement.doc

There is no question that organizations find value in sound project management practices. In fact, the larger the project is, the more project management rigors become a requirement for success.

A lack of common processes results in stakeholders, project managers and team members being required to learn new processes as they move from project to project. In addition, no one has any idea whether the company is successfully delivering projects, and no one understands what others in the organization are doing. In this environment, a PMO makes sense to ensure that the organization has a core set of project management skills, common processes and templates. The PMO also acts as the owner of the project management methodology, and the PMO acts as a support organization that project managers and team members can utilize for assistance. In addition, the PMO can serve as a place for providing an organization-wide view of the status projects and can report on the improvements being made to project delivery capabilities over time.

In today's environment of million dollar projects, a PMO is increasingly being viewed as an essential component that enables the success of organizational objectives and efficiencies. All in all, the value provided by a PMO is summarized below.

• The PMO establishes and deploys a common set of project management processes and templates, which saves the organization from having to create these on each project. These reusable project management components help projects start-up more quickly and with much less effort.
• The PMO builds the methodology and updates it as needed to account for improvements and best practices. Therefore, as new or revised processes and templates are made available, the PMO deploys them consistently to the organization.
• The PMO facilitates improved project team communication by having common processes, deliverables, and terminology. There is less misunderstanding and confusion within the organization if everyone uses the same language and terminology for project related work.
• The PMO sets up and supports a common repository so that prior project management deliverables can be reused by similar projects, reducing project start-up time.
• The PMO provides training to build core project management competencies and a common set of experiences.
• The PMO delivers project management coaching services to keep projects from getting into trouble. Projects at risk can also be coached to ensure that they do not get any worse.
• The PMO tracks basic information on the current status of all projects in the organization and provides project visibility to management in a common and consistent manner.
• The PMO tracks organization-wide metrics on the state of project management, and project delivery.

Of course, not all organizations need a PMO. Each organization should look at the number of projects attempted and determine if the project was completed and the anticipated benefits were realized. This analysis starts with an understanding of how you measure and execute projects today, and how you would like to execute and measure success in the future. If your organization has repeatable processes, meets stakeholder's expectations and completes project on time and within budget, there may not be a reason to make any changes. However, if you are not where you want to be with your projects today, a PMO may be the best way for your organization to obtain its desired results.