Resources

Operation management of healthcare delivery
Professor Xiaolan Xie
Center for Biomedical and Healthcare Engineering
1
Chapter 1. Healthcare delivery and its operation
2
Goal
present quantitative techniques from the
perspective of health care organisations’ delivery of
care, rather than their traditional manufacturing
applications.
3
Context and trends
Rising health expenditures (17.6% in USA, 11.6% in France for 2009)
Health expenditure as %GDP of 30 OECD countries
Average
Medium
Maximum
1995
7,8
3,4
13,3
1996
7,9
3,9
13,2
1997
7,7
4,2
13
1998
7,8
4,8
13
1999
8
5
13
2000
7,9
5,1
13,1
2001
8,2
5,6
13,9
2002
8,6
5,7
14,6
4
Context and trends
• Increasing demand due to demographic change and aging
population.
• Shift from offer-driven to patient-centered health care
with more active role of patients in health care and better
informed patients
• Growing concern of health care safety and quality ->
Need of traceability of health care delivery
• Arrivals of new ICT technologies (delivery robots, RFID,
telemedicine, HIS, PDA, e-prescription, POS, EDI, online
appointment, eVisit, …)
• Hospitals are bigger and bigger and more complex
(CHU-StE 2000 beds – 7259 employes, Ruijin Hospital –
2000 beds + 12000 outpatients/day, Huaxi hospital – 4000+
beds, Zhengzuo hospital 10000+ beds
5
French situations
•
Mostly public hospitals
•
Culture change on going. Words (clients, productivity, efficiency,
service level, competition) better understood.
•
Government responses:
•
New healthcare financing: T2A, new governance, referee physician
•
New health Info. Syst: carte vitale, personal health record
•
Diversification of healthcare organizations to meet the diversity of
healthcare demand (CHU, mid-size hospitals, clinics, home care, …)
•
Better regional regulation by ARS
•
Hospital responses :
•
merging, reorganization,
•
lean health care,
•
Integrated Hospital Information Systems everywhere
6
French situations
•
Many obstacles to change.
•
Healthcare costs hardly known,
•
Increasing bigger hospitals with people used to work in isolated isles
•
Lack of system thinking and spaghetti-like organization
•
poor management skills and incentives of health professionals
•
A labor-intensive industry facing quality human resources
shortage
•
about 10% of jobs in France and 40% in hospitals,
•
feminisation and aging health professionals,
•
working time regulation,
•
Increasing importance of working conditions, …
7
Context and trends
The bad side
Wild demand fluctuation
• large waiting list,
• large overtime,
• poor resource
utilization,
• ...
Poor demand-supply match
Extra-beds at ED, 2013.07
Poor quality of services
Outpatient queue, 6h AM,11/15/2011
8
Perspectives and evolution of French hospitals
• Montaigne report (2004),
l’hôpital de demain sera polymorphe et il n’y aura pas un modèle
unique d’hôpital mais une variété d’établissements, recouvrant des
organisations diversifiées, assurant des missions variées en fonction
du contexte dans lequel ils se situent:
• des établissements parties prenantes de réseaux, en liaison étroite
avec la médecine de ville,
• des hôpitaux sans murs ou quasiment, pour gérer l’hospitalisation à
domicile,
• des établissements organisés autour d’un plateau technique très
spécialisé,
• d’autres centrés sur l’hébergement et la dispensation de soins à des
personnes âgées dépendantes,
• des établissements privilégiant l’urgence et les soins de premiers
recours.
9
Perspectives and evolution of French hospitals
Six important trends:
•
Health expenditure regulation and healthcare cost transparency
•
Increasing productivity by optimization of healthcare delivery
organization and management.
•
Developing better relations with upstream and downstream parties in
the healthcare value chain
•
Adapting the healthcare offers
•
Transforming healthcare delivery and hospital organization by new
medical, technological and scientific progresses (new healthcare
modes: HAD, SAD, ...)
•
Increasing regional control of healthcare offers.
But also, informatization of hospitals and the importance of ICT as
drivers for healthcare delivery improvement.
10
Distinctive characteristics of health care services
•Patient participation : interaction between the health care organisation
and patient throughout the delivery of care
•Simultaneous production and consumption : product cannot be
inspected and challenge for quality control
•Perisable capacity : operating rooms, physicians, ...
•Intangible nature of health care outputs : cannot be tested or
handled before deciding on it.
•High levels of judgement and heterogeneous nature of health care
: However, standardization (diagnosis and treatment process, T2A) is in
process.
11
A Four-level model of health care system
12
A healthcare delivery system: function
Healthcare services
or modes
evironnement
regulation, insurance,
competition
• Medical cares
•Elective surgery
•Emergency surgery
•Day surgery
•Surgery at home
Patients
Healthcare
delivery system
Cured
patients
•Hospitalisation at
home
•Rehabilitation
•...
resources
13
A healthcare delivery system: human resources
A hospital is a lot of highly skilled human resources :
Surgeons
Anaesthetists
Nurses - Infirmier Anesthésiste Diplômé d’Etat (IADE)
Nurses - Infirmier de Bloc Opératoire Diplômé d’Etat (IBODE)
Nurses - Infirmier diplômé d’état (IDE)
Caregivers - Aides soignants
Stretchers - Brancardiers
Hospital attendants - Agents de Service Hospitalier (ASH)
Also: radiologists, biologists, technicians, secretaries, ...
CHU-St Etienne = 7000+ employees
14
A healthcare delivery system: material resources
• Expensive technical facilities (Plateaux Techniques Medicaux):
• Operating theatres (operating rooms, induction rooms,
recovery rooms)
• ICU, NICU (Intensive Care Units)
• Imaging equipment (MRI, CT scan, X-rays, …)
• Biology laboratories
• Pharmacies
• Sterilization facilities
• Hospitalization beds
• Consultation rooms
• ...
15
A healthcare delivery system: material resources
16
A healthcare delivery system: organisation
• Wards
• Medical services or units
• Specialties (Medecine, Surgery, Obstetrics)
• Clusters of competencies
• Hospitals
• Healthcare networks
• Logistic units
• Technical centers
• Administration
Usually with a funtional organisation.
17
French health authorities
•Haute autorité de la santé (HAS)
Elle est chargée d’évaluer l'utilité médicale de l'ensemble des actes,
prestations et produits de santé pris en charge par l'assurance maladie,
de mettre en oeuvre la certification des établissements de santé et de
promouvoir les bonnes pratiques et le bon usage des soins auprès des
professionnels de la santé et du grand public.
• La Direction de l’Hospitalisation et de l’Organisation des Soins
(DHOS), exerce une mission générale d’organisation de l’offre de soins
à la fois en ville et en établissement. Son rôle est principalement de
décliner les priorités de santé publique en les traduisant en priorités pour
le secteur hospitalier.
•Les Agences Régionales de l’Hospitalisation (ARH), traduisent
ensuite les priorités nationales données par la DHOS pour le secteur
hospitalier au niveau régional. L’ARH dispose du Programme de
Médicalisation du Système d’Information (PMSI) et des Schémas
Régionaux d’Organisation Sanitaire (SROS).
18
French healthcare performance improvement agency
MeaH: Mission Nationale d’Expertise et d’Audits Hospitaliers
www.meah.sante.gouv.fr (devenu ANAP)
• Une des trois missions opérationnelles créées dans le cadre de la Loi de
financement de la sécurité sociale de 2003 et du plan hôpital 2007
• Objectifs :
– Faire émerger une meilleure organisation des activités hospitalières
en conciliant :
• Service rendu au patient
• Efficience économique
• Conditions de travail satisfaisantes pour le personnel
• Exemples de chantier menés par la MEAH
Gestion des organisation des blocs opératoires, Circuit du
médicament, Radiothérapie, Restauration, Temps médical
19
Six Quality Aims for the 21st Century Health Care System
• Safe—avoiding injuries to patients from the care that is intended to help
them.
• Effective—providing services based on scientific knowledge to all who
could benefit and refraining from providing services to those not likely to
benefit (avoiding underuse and overuse, respectively).
• Patient-centered—providing care that is respectful of and responsive
to individual patient preferences, needs, and values and ensuring that
patient values guide all clinical decisions.
• Timely—reducing waits and sometimes harmful delays for both those
who receive and those who give care.
• Efficient—avoiding waste, including waste of equipment, supplies,
ideas, and energy.
• Equitable—providing care that does not vary in quality because of
personal characteristics such as gender, ethnicity, eographic location,
and socioeconomic status.
20
Six key healthcare performance dimensions OMS Europe- projet PATH
Clinical effectivenes
Qualité technique, organisation et pratiques basées sur la preuve, gain en
santé, résultat (individuel et global)
Patient centeredness
Réactivité envers les patients: orientation du patient (rapidité de prise en
charge, accès aux moyens d’aide sociale, qualité de l’accueil), satisfaction
du patient
Efficiency
Ressources, financière (syst. Financiers, continuité, gaspillage de
ressources), taux d’encadrement, expérience (dignité, confidentialité,
autonomie, communication)
safety
Patient et soignants, environnement, structure, utilisation des technologies
nécessaires à l’éfficience clinique
staff orientation
Santé, bien être, satisfaction, développement (taux de renouvellement,
emploi, absentéisme)
responsive governance
Orientation vers la communauté (réponse au besoins et demandes),
accessiblité, continuité des soins, promotion de la santé, équité, capacité
d’adaptation à l’évolution de la demande de la population
21
Health Operation Management
General OM decision:
The planning and control of the processes that transform inputs into
outputs
Example
(Individual doctor/patient consultation. Input = a patient with a
request for healthcare, output = patient diagnosed or cared or
cured. Resource to be managed: their time, diagnositic or
therapeutic services needed
Extensions:
Individual doctor -> individual provider (a hospital dept, a hospital, a
network of hospitals, …)
Scale and scope of the resources to be planned increase and the
complexity of OM
22
Health Operation Management
A meta-model of healthcare delivery system
INPUTS
PATIENT
DEMAND
(perceived need)
•
•
•
•
Number
Specialty
Teaching
reputation
PURCHASERS
(finances)
• Treatment modality
• Treatment protocol
• Provider-patient
encounters
MANAGEMENT
PROCESSES
• Infrastructure
• Structure
• Provider-patient
encounters
OUTPUTS
HEALTH
STATUS
CLINICAL
PROCESSES
ANCILARY
PROCESSES
Other hospi &
providers
TRANSFORMATION
PROCESSES
CLIENT
PERCEPTION
USE OF
RESOURCES
SUPPLIERS
23
Health Operation Management
Health OM can be defined as the analysis, design, planning
and control of the steps necessary to provide a service for a
client.
24
Decision Layers
Strategic decisions:
Decisions having long term impacts on the hospital
Horizon: year or multiple years
Made by top management
On hospital-wide long-term vision, types of services and directions
on material and human resources investments (hospital strategic plan projet d’établissement, contrat d’objectif et de moyens, organisation de
l’établissement, ...)
Major decisions:
Services: catchment areas, target groups/markets, specialities & product ranges
Investment: new hospital construction, new specialties, expansion
Partnership: shared resources, outsourcing, collaboration
Organisaton: units merging, mutualisation, polyvalence, working time regulation
25
Decision Layers
Tactical decisions:
Decisions taken at mid term
Horizon: trimestre or year
Ensure the right match between available resources and activities
of the strategic plan
Without profound changes of the structure and organisation
Examples:
Surgery time allocation to specialties,
Bed allocations
Case-mix
26
Decision Layers
Operational decisions:
Short term decisions
Horizon: day, week or month
Made by each operational unit.
Ensure the smooth execution of the all activities
Examples:
Surgery planning/scheduling, Admission/discharging control, nurse
scheduling, inventory control, supplier relation management, …
27
Decision framework
Vissers, Bertrand, De Vries (2001). A framework for production control in health care organizations.
STRATEGIC PLANNING
(range of services, long-term resource requirement, shared resources, annual patient volumes, service & efficiency levels)
2-5 years
patient flows
restrictions
resources
restrictions
PATIENT VOLUME PLANNING AND CONTROL
(available annual capacity per specialty, resource use regulation)
1-2 years
patient flows
resources
RESOURCE PLANNING AND CONTROL
(time-phased resource allocation (specialist time, # of patients per period)
3 months - 1 year
resources
patient flows
PATIENT GROUP PLANNING AND CONTROL
patient
(service requirement and planning guidelines per patient group))
Weeks – 3 months
resources
flows
PATIENT PLANNING AND CONTROL
patient flows
(scheduling individual patients)
Days - weeks
resources
Decision framework
Key resources
• Operating rooms
• Beds
• Diagnostic equipments
• Specialist time
• ICU
Patient groups
• By specialty (orthopaedic patients, general surgery,
trauma, oncology, internal medicine, diabetics)
• By ages (services for older people, …)
• By DRG (diagnostic related groups)
• By health resources groups
• …
29
STRATEGIC PLANNING
patient flows
Specialties & production range
Patient groups as business units
2-5 years
Restrictions on types of patients
patient flows
Volume contracts (insurance)
# patients per patient group
Service levels
PATIENT VOLUME
PLANNING & CONTROL
1-2 years
Restrictions on total patient vol
patient flows
Expected patient # per group
Capacity requirement per group
RESOURCE
PLANNING & CONTROL
3 months - 1 year
Restrictions on detailed patient vol
patient flows
Project patient # per period
PATIENT GROUP
PLANNING & CONTROL
Weeks – 3 months
Restrictions on timing of patient flows
patient flows
Scheduling of patients for visits,
admission, exam
PATIENT
PLANNING & CONTROL
Days - weeks
Resources
Collaboration & outsourcing
Shared resources
Restrictions on types of resources
Resources
Rough-cut capacity check
Target occupancy levels
Restrictions on amount of resources
Resources
Allocation of leading resources
Batching rules for shared resources
Restrictions on resource availability
Resources
Availability of specialist capacity
Restrictions on timing of resources
Resources
Allocation of capacity to individual
patients
A Wider Decision framework
Hans, Van Houdenhoven, Hulshof, A Framework for Health Care Planning and Control, 2012
31
Major operation management issues
Demand forecast (care types – geography – time)
Facility location
Facility layout
Planning / scheduling
Capacity planning
Supply chain and inventory management
Quality control
Project management
32
Major operation management issues
Modeling
Tools: enterprise modelling, SADT, IDEF, Petri nets,
Performance assessment and diagnostic
Tools: simulation, queueing theory, Markov chains, statistics,
Excel, ...
Design or re-engineering
Tools: simulation, optimisation, ...
Planning and control
Tools: planning, scheduling, optimisation, linear programing,
heuristics, statistics,...
33
Major operation management issues
34