Improving Processes for Health Care Delivery : Lessons From Johns Hopkins Medicine

This work prepares current and future managers and consultants focused on health care delivery systems to improve the efficiency of processes that deliver care. This material will help you manage capacity, improve patient flow, estimate process costs, and conduct experiments that lead to process improvement. Essential tools covered include process mapping and measurement, data collection and analysis, and the use of discrete event simulation as a tool for virtual experimentation and improvement. Tools are introduced with no assumption of prior training. Many examples of settings, problems, and solutions are presented, along with a generalized approach to process improvement that is specifically tailored to health care settings. Readings, exercises, and cases suitable for discussion or end-course projects are also provided. Writing is based on a decade of experience teaching at the MBA and MS levels, managing dozens of improvement processes, and a host of our prior scholarly publications, book chapters, and case studies. Foreword Preface Organization of Content Background and Intended Audience Prologue 0.1 A Patient’s Journey Through the Eastern University Hospital System 0.1.1 Entry Through the ED 0.1.2 Specialty Outpatient Clinic 0.1.3 Procedure Capacity and Parallel Processing 0.1.4 Patient Flows and Transfers Between Units 0.1.5 Billing and the Cost of Care 0.2 Health Care Process Analytics Contents Acronyms Chapter 1 A Primer on Process Analysis for Health Care Delivery 1.1 Introduction 1.2 Basic Definitions 1.2.1 Process Management 1.2.2 Goals of Process Management 1.3 Key Process Measures: Throughput,Work in Process, and Cycle Time 1.3.1 Little’s Law 1.3.2 Example 1 1.3.3 Example 2 1.3.4 Example 3 1.3.5 Example 4 1.4 Putting the Pieces Together: Instrumentation Preparation 1.5 Key Take-Aways 1.6 Review Material and Prior Works 1.6.1 Process Analysis for ED 1.6.2 Process Analysis for Hernia Clinic Chapter 2 A Primer on Process Analysis for Health Care Delivery 2.1 Introduction 2.2 Data Collection 2.3 Gantt Charts: A Valuable Tool to Understand Health Care Delivery Processes 2.3.1 Creating Gantt Charts 2.4 Examples of Clinic Visits 2.5 Collected Comments on Gantt Charts 2.6 Makespan and the Critical Path Method 2.6.1 Earliest Start, Earliest Finish and the Forward Pass 2.6.2 Latest Finish, Latest Start, and the Backward Pass 2.7 Putting the Pieces Together: Appointment Scheduling at Eastern Hospital Outpatient Clinic 2.8 Key Take-Aways 2.9 Review Material and Prior Works 2.9.1 Surgeon Using Two Rooms: Normal Cases 2.9.2 Surgeon Using Two Rooms Double Cases Chapter 3 Special Issues in Process Analysis for Health Care: Shared Resources and Cycles 3.1 Introduction 3.2 Process Mapping 3.3 Parallel Processing 3.4 Combining Resources 3.5 Sharing Resources 3.6 Scheduling Jobs with Variable Activity Times 3.7 A Cyclic Approach to Appointment Scheduling 3.7.1 Problem Setting and Identification 3.7.2 Finding an Optimal Schedule 3.7.3 Composite Jobs 3.7.4 Application in the AMC 3.7.5 Heuristics for Appointment Scheduling 3.7.6 Gantt Chart of Simple Heuristic 3.8 Key Take-Aways 3.9 Review Material 3.9.1 Cyclic Scheduling Template with NEW and RETURN Patients 3.9.2 Cyclic Scheduling Template with only RETURN Patients Chapter 4 Management of Queues 4.1 Introduction 4.2 Problem Setting 4.3 Analysis of Waiting Times 4.3.1 Resource Utilization 4.4 Theoretical Foundations for the Study of Queues 4.4.1 Anatomy of a Queueing System 4.4.2 Exponential Time Distributions 4.4.3 Contributions of Markov 4.4.4 Little’s Law & Queues 4.4.5 M|M|1 Queues 4.4.6 M|M|s Queues 4.5 Examination of Vaccine Delivery Process 4.5.1 System Capacity 4.5.2 Average Cycle Time and Census 4.5.3 Average Waiting Time 4.5.4 Process B: Two Servers with a 50/50 Split 4.5.5 Process C: Two Less Experienced Servers with Reduced Speed 4.6 Key Take-Aways 4.7 Review Material 4.7.1 Large Scale Vaccination Site: Process A 4.7.2 Large Scale Vaccination Site: Process B Chapter 5 Cost Estimation and Process Improvement 5.1 Introduction 5.1.1 Cost are Just a Percentage of Charges - Right? 5.2 Cost Measurement at a Prototypical Outpatient Clinic: Process 1 5.3 Time-Driven, Activity-Based Costing 5.3.1 Cost Measurement at Eastern Hospital Outpatient Center: Process 2 5.3.2 Process Metrics Using Process 1 5.3.3 Process Metrics Using Process 2 5.4 Key Take Aways 5.5 Review Material & Prior Works 5.5.1 Cost for Blood Test with Attending Follow-Up 5.5.2 Cost for Blood Test with Nurse Follow-Up Chapter 6 A Process Improvement Process 6.1 Introduction 6.2 A Representative Clinic: Part I 6.3 How to Fix Health Care Processes 6.4 The Process Improvement Process 6.4.1 Step 1: Process Description 6.4.2 Step 2: Data Collection 6.4.3 Step 3: Create a DES of the System 6.4.4 Step 4: Metrics of Interest 6.4.5 Step 5: Propose Process Changes 6.4.6 Step 6: Predict Impact of Process Changes 6.5 Experiments, Simulations, and Results 6.5.1 Arrival Process 6.5.2 Physician Processing Times 6.5.3 Private Practice versus the AMC 6.5.4 Pre-processing 6.5.5 Cyclic Scheduling 6.6 Key Take-Aways 6.7 Review Material 6.7.1 Searching for a Better Appointment Schedule 6.7.2 Searching for a Better Appointment Schedule Chapter 7 Discrete Event Simulations: Concepts, Metrics, and Canonical Models 7.1 Introduction 7.2 Outpatient Clinics 7.2.1 Variability and System Performance 7.2.2 Pooling Resources 7.2.3 Mixing Patient Types 7.2.4 State Dependent Face Time 7.3 Emergency Departments 7.3.1 Downstream Resources and Blocking 7.3.2 Length of Stay from ED to Discharge 7.4 Key Take-Aways 7.5 Review Material & Prior Works 7.5.1 Patient Unpunctuality 7.5.2 An Academic Model with Distributions of Teaching Time 7.5.3 State Dependent Activity Times Chapter 8 Case Study: Miller Pain Treatment Center 8.1 Introduction 8.2 Eastern Hospital and E-HOC 8.3 Private Practice 8.4 Efficiency of Clinic Operations 8.5 Patient Tardiness and Waiting Times 8.6 Merging Clinics 8.7 Miller Pain Treatment Clinic 8.8 Issues in the AMC 8.9 Review Material Chapter 9 Case Study: Collecting Activity Times Using a Real Time Location System 9.1 Collecting Activity Time Data in Eastern Hospital 9.1.1 Kick-Off Meeting 9.1.2 Additional Issues 9.2 The GI Team 9.2.1 Processing AMS and RTLS Data 9.3 Review Material and Prior Works Chapter 10 Case Study: The RadOnc Clinic Expansion 10.1 Analyzing Flow Data 10.2 Visualizing Key Data 10.3 Review Material Chapter 11 Case Study: Safe Birth Clinic 11.1 Introduction 11.2 Process A: The Earlier Process (Followed by Patients Until December 2018 11.3 Process B: The Current Process (Being Followed by Patients Since January 2019) 11.4 A New Potential Addition: Genetic Counselling and Physical Therapy Session 11.5 Process Redesign: Separate Upfront Examinations by the Doctor 11.6 Discussion Questions Chapter 12 Epilogue 12.1 Introduction 12.2 Complications in Projects to Improve Health Care Processes 12.3 Searching for Improvement Ideas Using Prior Works 12.3.1 Finding Ideas 12.3.2 Screening Ideas 12.4 Closing Comments References Index