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P R O F E S S O R , O P E R A T I O N S M A N A G E M E N TE D I T O R - I N - C H I E F , S O C I O - E C O N O M I C P L A N N I N G S C I E N C E S

D I R E C T O R , N S E R C C R E A T E P R O G R A M I N H E A L T H C A R E O P E R A T I O N S                                                                                                                                       & I N F O R M A T I O N M A N A G E M E N T

C O - D I R E C T O R , M C G I L L M D - M B A P R O G R A M

Healthcare Operations Management

Health Sector in Canada

Among the top three sectors that contribute to Canada’s GDP for the past five years,

Total spending in healthcare has outpaced both inflation and population growth for the tenth consecutive year,

Identified as one of the four priority areas in the most recent federal science & technology strategy

Canada’s Healthcare System

A Single Payer System …

Public insuranceEveryone in Canada is insured

through their provincial governmentHealth care is financed by federal

and provincial taxes (general revenues)

Federal government provides funding through cash payments and tax transfers to the provinces and territories

… & Supplementary Insurance

Almost 30 % of health care spending in Canada is through out-of-pocket payment and supplementary private insurance

Prescription drugs, dental care, and vision services are not covered in most provinces

The Canadian System – Pros

Costs are controlled: provincial health budgets, supplemented by federal funds

Canada’s per capita costs are 60% of US per capita costs

Administrative overhead remains low

Everyone is covered

Access is based on need, not ability to pay

The Canadian System – Challenges

Healthcare fundingPatient waiting timesMedical technologiesPersonnel shortageInclusion of pharmaceutical, home care

and long term care costs in the public health insurance

Canadian Healthcare Association

Health Spending in Canada

Total health spending accounted for 10.4% of GDP in Canada in 2008.

Total health spending per capita is 4,079 US$ in Canada in 2008 (adjusted for purchasing power parity).

OECD – Total Health Spending

Emergency Department Management

Research Team

Marc Afilalo, MDAntoinette Colacone, CCRA Alex Guttman, MDEli Segal, MD

Montreal Jewish General Hospital ED

A tertiary care ED triage area in Montreal with ~66,000 visits/year.

Arguably, one of the best ED in Montreal in terms of patient wait times and LOS

Montreal Tertiary Care Hospitals

Hospital ED LOS (hours)

acute care patients

CUSM Hôpital Général de Montréal 14.8 24556Hôpital général Juif 17.5 34482Hôpital St-Luc du CHUM 19.5 17905Hôpital du Sacré-Coeur de Montréal 19.5 24238CUSM Hôpital Royal Victoria 21.7 17048Hôtel-Dieu du CHUM 26.4 14231Hôpital Notre-Dame du CHUM 27.8 20269

Maximum LOS in the JGH ED (hours)

2007/08 2008/09 2009/10 2010/11 2011/120

50

100

150

200

250

300

350

The Research Program in ED

ED crowding is a serious problem facing hospitals nationwide.

The objectives are two-fold: Identify the external versus internal

causes of crowding in the EDEvaluate possible interventions to

reduce patient wait timesDesign a detailed intervention plan to

achieve lean ED processes

The Acute Care Unit in the JGH ED

Detailed ED Process FlowStart

Arrival through ambulance?

Ambulatory or Stretcher?

Arrival by Other Means

Triage (See detailed flow chart)

Yes

No

Registration (See detailed flow chart)

Ambulatory

Cubicle Available?

Nurse Available?

YesYes

No

No

Initial Nursing Assessment

Stretcher

Resuscitation Monitored Un-monitored

Physician Available?

Initial Physician Assessment

Yes

Extremely Critically-ill

patients waiting?

Other ambulance

patient waiting?

Yes

No

No

Yes

Patient in the process of

Triage?

No

Ambulance Patient waiting? Yes

Yes No

Needs immediate

intervention? Yes

No

Cubicle Type?

1

Does others need cubicle

more?

Hallway

Yes

Previously assessed by

nurse?

Patient placed in designated

cubicle

Nurse Available?

Initial Nursing Assessment

Is cubicle critical to assessment?

Does attending physician check

patients in hallway?

Is patient nursing chart

available?

Is patient chart (nursing sheet)

available?

No

Yes

Yes

Yes

No

No

No

No

YesYes

Yes

No

No

No

Yes

Is patient chart (doctor sheet)

available?

End

Yes

No

Flow Chart from the Time Patient Enters ED to First Physician Assessment (JGH)

Reducing Patient Wait Times in ED Triage

Triage Goals (CAEP)

1. To rapidly identify patients with urgent, life threatening conditions.

2. To determine the most appropriate treatment area for patients

3. To decrease congestion in ED.4. To provide ongoing assessment of

patients.5. To provide information to patients and

families regarding services, expected care and waiting times.

6. To contribute information that helps to define departmental acuity.

Emergency Department Triage

Triage functions as a priority system where ambulance patients have (often preemptive) priority over walk-in patients.

During the data collection period (Baseline), triage was staffed by one full-time triage nurse (RN) and a second RN being available for about 5 hours throughout the day.

Canadian Triage Acuity Standards

CAEP (1999)

Re-assess

U.S. Emergency Severity Index

No expected time intervals to physician evaluation

Data Collection at ED Triage

ED triage was observed over a 15 week period during weekday shifts (8:00 to 16:00) for an average of 8 hrs/day

537 ambulance and 3205 walk-in patients were observed

Data collected through observation: time to arrival, triage start time, triage end time and staffing resources in place.

Data extracted from the ED administrative database: socio-demographic, patient arrival patterns and triage severity.

Patient Arrival and Triage Service Times

Simulation Model Validation

Triage Wait Times

Triage Improvement Scenarios

Dedicated RNs + Regular triage: RN1 services only ambulance patients RN2 services only walk-in patients Regular triage on all patients

Dedicated RNs + Pre-triage: RN1 services only ambulance patients RN2 services only walk-in patients Quick pre-triage (0.5 to 1 min) to screen for

patients requiring ambulatory care

Triage Improvement Scenarios

Pooled RNs + Pre-triage Both RNs simultaneously responsible for

ambulance and walk-in patients Quick pre-triage (0.5 to 1 min) to screen for

patients requiring ambulatory care

Comparative Analysis of Wait Times & Nurse Utilization

Scenario Ambulance N=537

Walk-in N=3205

Nurse Utilization

Baseline (1.5 Pooled RNs)

3.6 + 5.9 18 + 29 71%

2 Dedicated RNs + Regular Triage 1.5 + 3.8 68 + 108

Walk in 90%Ambulance 25%

2 Dedicated RNs + Pre-triage 1.4 + 3.7 9 + 13

Walk in 53%Ambulance 25%

2 Pooled RNs + Pre-triage 0.68 + 1.66 2.25 + 3.7 39%

Comparative Analysis ofBaseline & “2 Pooled RN + Pre-

triage”

Wait Time Distibutions

0 5 10 15 20 25 30 35 40 45 50 55 60 65 70 75 80 85 90 95 100

105

110

115

120

125

0

500

1000

1500

2000

2500

3000

3500

4000

Wait Time Frequency Distribution For Ambulance Patients

Minutes0 5 10 15 20 25 30 35 40 45 50 55 60 65 70 75 80 85 90 95 10

0105

110

115

120

125

0

2000

4000

6000

8000

10000

12000

Wait Time Frequency Distribution For Walk Patients

Minutes

Baseline

Baseline

0 5 10 15 20 25 30 35 40 45 50 55 60 65 70 75 80 85 90 95 100

105

110

115

120

125

0

1000

2000

3000

4000

5000

6000

Wait Time Frequency Distribution For Ambulance Patients

Minutes

Pooled + Pre-triage

0 5 10 15 20 25 30 35 40 45 50 55 60 65 70 75 80 85 90 95 100

105

110

115

120

125

0

2000

4000

6000

8000

10000

12000

14000

16000

18000

Wait Time Frequency Distribution For Walk Patients

Minutes

Pooled + Pre-triage

Wait Times during the day

8:00 8:30 9:00 9:30 10:00

10:30

11:00

11:30

12:00

12:30

13:00

13:30

14:00

14:30

15:00

15:30

0.000.501.001.502.002.503.003.504.004.505.00

Average Wait Time For Ambulance Patients

Intervals

Min

utes

8:00 8:30 9:00 9:30 10:00

10:30

11:00

11:30

12:00

12:30

13:00

13:30

14:00

14:30

15:00

15:30

0.00

5.00

10.00

15.00

20.00

25.00

30.00

Average Wait Time For Walk Patients

Intervals

Min

utes

Baseline

Baseline

8:00 8:30 9:00 9:30 10:00

10:30

11:00

11:30

12:00

12:30

13:00

13:30

14:00

14:30

15:00

15:30

0.00

0.10

0.20

0.30

0.40

0.50

0.60

0.70

0.80

0.90

Average Wait Time For Ambulance Patients

Intervals

Min

utes

Pooled + Pre-triage

8:00 8:30 9:00 9:30 10:00

10:30

11:00

11:30

12:00

12:30

13:00

13:30

14:00

14:30

15:00

15:30

0.00

0.50

1.00

1.50

2.00

2.50

3.00

Average Wait Time For Walk Patients

Intervals

Min

utes

Pooled + Pre-triage

Nurse Utilization

8.00 9.00 10.00 11.00 12.00 13.00 14.00 15.00 16.000%

10%20%30%40%50%60%70%80%90%

100%

Nurses Hourly Utilization

Hours

% o

f Util

izat

ion

Baseline

8.00 9.00 10.00 11.00 12.00 13.00 14.00 15.00 16.000%

10%

20%

30%

40%

50%

60%

Nurses Hourly Utilization

Hours

% o

f Util

izat

ion

Pooled + Pre-triage

Triage Improvement Scenarios

Static Triage Nurse Staffing Hourly plan of RN capacity

Dynamic Triage Nurse Staffing An additional RN is called in when the triage

waiting line reaches a predetermined threshold level.

Dynamic staffing does not pay off on the basis of an hourly plan.

Questions & Comments ?