Building a Better Delivery System A New Engineering/Health Care Partnership (2005) / Chapter Skim
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Engineering Tools and Procedures for Meeting the Challenges
Engineering Tools and Procedures for Meeting the Challenges
Pages 139-188
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Engineering Tools and Procedures for Meeting the Challenges
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We use tools from psychology, computer science, broad categories: service and cost. Service can be measured operations research, management and economics, and by a variety of criteria, such as availability, reliability, qual- mathematics.
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A good deal of literature is now available on research in State and federal governments are involved, as well as a va- this area. Operations research tools and systems engineering riety of other organizations.
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Like industrial supply chains, the health care "supply chain" consists of multiple indepen FROM UNIT PROCESSES TO SUPPLY CHAINS dent agents, such as insurance companies, hospitals, doctors, employers, and regulatory agencies, whose economic If we examine how industrial operations, particularly structures, and hence objectives, differ and in many cases manufacturing operations, have evolved since the beginning conflict with each other. Both supply and demand for ser- of the nineteenth century, we can see that many efforts were vices are uncertain in different ways, making it very difficult motivated by a desire to understand and optimize individual to match supply to demand.
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Software companies that provide supply-chain planning software for multilocation In the domain of industrial supply chains, it is probably companies is another strong indicator of the advantages com- safe to say that we have developed a fairly good understandpanies perceive will accrue to them by the effective manage- ing of the operation and economics of individual unit proment of the various elements of their supply chains. The cesses, including functions such as transportation, distribustrong trend in industry to outsource noncritical functions tion, warehousing, and information processing.
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1991. Simulation Modeling and Analysis, 2nd supply-chain research is weakest (the effective coordination edition.
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Adverse drug events and adverse events in general in lack of respect for human nature in the design of health care medicine are severely underreported -- roughly only 1.2 to systems causes injuries and deaths, but it also costs money. 7.7 percent are reported (Vicente et al., 2003)
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With the know how to design technology that works for people becommercially available design, there were eight program- cause we know a lot about people at many levels -- physical, ming errors for drug concentration, three of which were un- psychological, team, organizational, and political. We do not detected.
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The operations research community has been involved with the biggest payoffs before implementation. with HCD enterprises for more than 40 years working on a HCD enterprises are very large, complex operational sys- wide range of problems, such as inventory for perishables; tems comprised of large numbers of people and machine ele- management of intensive care units; laboratory and radiolments.
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code. These and other macrosystem issues can be addressed Patients can enter the enterprise at a clinic, a hospital, or a quantitatively using enterprise-level simulation models that medical center.
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, it did viral hepatitis, low back pain, etc.) and more than 1,500 clini- show that simulation models can represent the complex cal tasks/procedures (e.g., preoperative anesthesia, computer dynamics of health care enterprise operations and can genertomography for staging/radiation, EEG, interpretation of ate useful information and insights for enterprise managers.
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Health operations research practitioners most marginal improvement to the enterprise are added until must become integral partners with senior enterprise managers an acceptable level of service is reached. (Mathematical pro- in their business planning.
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In Methodist Hospital, a large time-and-motion video Nearly three-fifths of hospital expense goes to the wages and study of patient care processes and the patient care team, benefits of caregivers and others. Furthermore, labor costs with Ann Hendrich as the principal investigator, was done to accounted for 38.8 percent of the increase in spending on determine how improvements could be made (Hendrich and hospital care between 1997 and 2001.
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The decrease in errors and charged from the same room. The unit was called the com- adverse events was a direct result of the changes in design prehensive coronary critical care unit (Hendrich et al., 2003)
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TRANSFORMING CURRENT HOSPITAL DESIGN 155 FIGURE 1 Typical critical-care patient room. FIGURE 2 Comprehensive cardiac critical care: acuity-adaptable room for single stay.
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2003c. The Cost of Current Hospital Patient Thus, patients who are between the critical care and medical Flow: A Simulation Model.
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Simulation modeling can be used to explore Traditional clinical research designs can address the effi- the implications and consequences of alternative processes cacy and effectiveness of treatment and the sensitivity and of care. Simulation modeling can also generate new insights specificity of diagnostic tests, but cannot easily address many into underlying systems of care and identify new approaches important clinical management questions.
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shows, modeling can not only lead to insights into the effec tiveness and efficiency of alternative strategies of care, but can also inform the basic biomedical sciences and generate Disease-Based Simulation Model hypotheses regarding the pathophysiology of disease. Colorectal cancer is currently the second leading cause of The main study results revealed that, among men who death from cancer in the United States (Jemal et al., 2003)
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feasible and, in addition, can also examine other features of Resident work scheduling remains an ongoing problem for these strategies of care, such as differential risk patterns academic health centers. among subgroups for the formation of adenomas or the speed In 1989, simulation modeling was used to examine resiof transformation from adenoma to cancer.
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The predictive CONCLUSION validation study was conducted on 18 house staff days and 6 house staff nights during which house staff were followed As the colorectal cancer and house staff scheduling modand their tasks recorded. We then programmed the simula- els demonstrate, discrete-event network simulation modeltion model to reflect the change in call schedules and repli- ing can be used to analyze and improve the content, procated the timing and number of admissions to the hospital to cesses, and structures of health care.
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2003. Colorectal cancer screening and surveillance: clinical American Journal of Gastroenterology 95(7)
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proposed this definition: The Health Care Financing Administration and the Na tional Committee on Quality Assurance are using the SF-36 The best measure of quality is not how well or how fre- to study the health outcomes of Medicare beneficiaries in quently a medical care service is given but how closely the Medicare HMOs. This Medicare Health Outcomes Survey is result approaches the fundamental objectives of prolonging the first to follow data on patients' health longitudinally.
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the definitions of the Institute of Medicine Committee on the Future of Primary Care (IOM, 1996) : Primary care is the provision of integrated, accessible health care services by clinicians who are accountable for addressin the United States who needed information about health plans ing a large majority of personal health care needs, developfor themselves and their employees.
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To engensatisfaction and physician morale had also declined, espe- der a true team culture, we will have to change the way phycially in terms of professional autonomy, time spent with sicians and other caregivers are educated. patients, and time for family and personal life (Murphy et al., 2001; Safran et al., 2001)
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The full Archimedes model is applied in a specific ity requires good information about the effects of different health care setting defined by specific care processes and courses of action on health, logistic, and economic outcomes. specific system resources.
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symptoms of a disease, without affecting its progression. The Examples in the current Archimedes model are systolic and other type of intervention, "care processes," determines how diastolic blood pressures, patency of a coronary artery, cartests and treatments are delivered.
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The deep level of tically significant difference between the model's results and physiological detail coupled with the care processes in the the real results. Archimedes model provide a rigorous way to test this.
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Using these methods, the Archimedes diabetes model has been validated against 17 epidemiologi USES OF AN ARCHIMEDES MODEL cal studies and 18 clinical trials thus far. The example shown in Figure 1 compares the model results with the trial results Archimedes is meant to create a virtual world at the level for the Heart Protection Study (2002)
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, the Archimedes diabetes model biological details to the care processes, logistics, resources, should be a useful tool for sharpening our understanding of and costs of health care systems. It is written at a deep level diseases and their management.
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Traditional engineers typically take on profes- counting standards, the code of standards that requires insursional responsibility; they are personally liable if harm re- ance companies operating in the United States to evaluate sults from a failure. Financial engineers have little personal their assets and liabilities according to regulatory standards.
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The factors that in the area of catastrophic risk. This reinsurance company determine risk are related to the work of both the life insurer takes in money by selling reinsurance to insurance companies and the health insurer.
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employees to set aside up to $5,000 a year before taxes in a health care expense account; unspent monies are lost at the IMPLICATIONS FOR THE HEALTH CARE INDUSTRY end of each year. We have observed that many Princeton faculty and staff, despite their greater than average intelli- Two primary challenges relate to financial engineering gence, rarely make the best decision relative to the costs of and the U.S.
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Nevertheless, well managed insurance companies can for Managing Corporate Risks.
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. One estimate is that more mean less toxic and more targeted interventions, but they than half of children younger than 15 are in clinical trials and may also mean that patients will have to take pills for a very that findings are quickly translated into pediatric oncology long time, perhaps even for a lifetime.
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Ensuring Quality Cancer Care, a report by the patient care. Such conferences, which may be held Institute of Medicine National Cancer Policy Board, states emphatically, "There is no national cancer program, care program or system of care in the United States" (IOM, 1999)
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The knowledge base for records of these patients and talking to the surgeons, the the science of cancer care has undergone a radical transfor- study found that the surgeons simply did not know what had mation, but little attention has been paid to ensuring the con- happened to these patients, they had simply "fallen through sistent translation of this knowledge to the health care set- the cracks." ting -- not just for patients in cancer centers on protocols, but Another serious problem is failure to use the evidence for all cancer patients all the time. Indeed, the assumption base.
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1998. Delivery of comprehensive cancer care at Kaiser Permanente.
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1999. Ensuring the Quality of Cancer Care, Sagebiel, R.W.
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is caused by error as defined by the "five rights." A great We must look at the performance/risk trajectories of com- number of errors do not cause harm, and more importantly a mon patient treatment process paths and examine the con- number of adverse drug events that cause death, disability, tributive impact to enterprise wide performance. Hospital or require treatment would not normally be counted using administrators must step back from their traditional vertical the classical "5 rights" framework.
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In this case, the potential for recogcauses of adverse drug events including transition zones nition of the risk for adverse events would have been picked between care teams and high impact intravenous infusion up by a computerized physician order entry (CPOE) , which events.
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health care. If we had continuity of information with pattern recognition support we could examine the risk trajectory of patients REFERENCE with very complex disorders and create scenarios and real time forecasts, as we do in aviation.
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Timing is an essential component of health care. The IDCOP practice is not a fixed, solved system; it is a When things happen is almost as important as what happens.
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Develop a repetitive master schedule to optimize the patient's initial appointment in a behavioral health practice. use of resources relative to the needs of the population.
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