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Operation management of healthcare delivery

Professor Xiaolan Xie

Center for Biomedical and Healthcare Engineering

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Chapter 1. Healthcare delivery and its operation

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Goal

present quantitative techniques from the perspective of health care organisations’ delivery of care, rather than their traditional manufacturing applications.

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Context and trends

Rising health expenditures Rising health expenditures (17.6% in USA, 11.6% in France for 2009)(17.6% in USA, 11.6% in France for 2009)

1995 1996 1997 1998 1999 2000 2001 2002Average 7,8 7,9 7,7 7,8 8 7,9 8,2 8,6Medium 3,4 3,9 4,2 4,8 5 5,1 5,6 5,7

Maximum 13,3 13,2 13 13 13 13,1 13,9 14,6

Health expenditure as %GDP of 30 OECD countries

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Context and trends

• Increasing demand Increasing demand due to demographic change and aging due to demographic change and aging population.population.

• Shift from offer-driven to patient-centered health care Shift from offer-driven to patient-centered health care with more active role of patients in health care and better with more active role of patients in health care and better informed patientsinformed patients

• Growing concern of health care safety and quality Growing concern of health care safety and quality -> -> Need of traceability of health care delivery Need of traceability of health care delivery

• Arrivals of new ICT technologiesArrivals of new ICT technologies (delivery robots, RFID, (delivery robots, RFID, telemedicine, HIS, telemedicine, HIS, PDA, e-prescription, POS, EDI, online PDA, e-prescription, POS, EDI, online appointment, eVisit, …)appointment, eVisit, …)

• Hospitals are bigger and bigger and more complex Hospitals are bigger and bigger and more complex (CHU-StE 2000 beds – 7259 employes, Ruijin Hospital – (CHU-StE 2000 beds – 7259 employes, Ruijin Hospital – 2000 beds + 12000 outpatients/day, Huaxi hospital – 4000+ 2000 beds + 12000 outpatients/day, Huaxi hospital – 4000+ beds, Zhengzuo hospital 10000+ bedsbeds, Zhengzuo hospital 10000+ beds

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French situations

• Mostly public hospitalsMostly public hospitals

• Culture change on goingCulture change on going. Words (clients, productivity, efficiency, . Words (clients, productivity, efficiency, service level, competition) better understood.service level, competition) better understood.

• Government responsesGovernment responses: :

• New healthcare financing: T2A, new governance, referee physician New healthcare financing: T2A, new governance, referee physician

• New health Info. Syst: carte vitale, personal health recordNew health Info. Syst: carte vitale, personal health record

• Diversification of healthcare organizations to meet the diversity of Diversification of healthcare organizations to meet the diversity of healthcare demand (CHU, mid-size hospitals, clinics, home care, …) healthcare demand (CHU, mid-size hospitals, clinics, home care, …)

• Better regional regulation by ARS Better regional regulation by ARS

• Hospital responses Hospital responses : :

• merging, reorganizationmerging, reorganization, ,

• lean health care, lean health care,

• Integrated Hospital Information Systems everywhereIntegrated Hospital Information Systems everywhere

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French situations

• Many obstacles to changeMany obstacles to change. .

• Healthcare costs hardly known,Healthcare costs hardly known,

• Increasing bigger hospitals with people used to work in isolated islesIncreasing bigger hospitals with people used to work in isolated isles

• Lack of system thinking and spaghetti-like organizationLack of system thinking and spaghetti-like organization

• poor management skills and incentives of health professionalspoor management skills and incentives of health professionals

• A labor-intensive industry facing quality human resources A labor-intensive industry facing quality human resources shortage shortage

• about 10% of jobs in France and 40% in hospitals,about 10% of jobs in France and 40% in hospitals,

• feminisation and aging health professionals, feminisation and aging health professionals,

• working time regulation,working time regulation,

• Increasing importance of working conditions, …Increasing importance of working conditions, …

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Context and trends

The bad side The bad side •large waiting list,

•large overtime,

•poor resource utilization,

•...

Wild demand fluctuationWild demand fluctuation

Extra-beds at ED, 2013.07Extra-beds at ED, 2013.07 Outpatient queue, 6h AM,11/15/2011Outpatient queue, 6h AM,11/15/2011

Poor demand-supply matchPoor demand-supply match Poor quality of servicesPoor quality of services

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Perspectives and evolution of French hospitals

• Montaigne report (2004), Montaigne report (2004),

l’hôpital de demain sera l’hôpital de demain sera polymorphepolymorphe et il n’y aura pas un modèle et il n’y aura pas un modèle unique d’hôpital mais une variété d’établissements, recouvrant des unique d’hôpital mais une variété d’établissements, recouvrant des organisations diversifiéesorganisations diversifiées, assurant des , assurant des missions variées missions variées en fonction en fonction du contexte dans lequel ils se situent: du contexte dans lequel ils se situent:

•des établissements parties prenantes de réseaux, en liaison étroite des établissements parties prenantes de réseaux, en liaison étroite avec la médecine de ville, avec la médecine de ville,

•des hôpitaux sans murs ou quasiment, pour gérer l’hospitalisation à des hôpitaux sans murs ou quasiment, pour gérer l’hospitalisation à domicile, domicile,

•des établissements organisés autour d’un plateau technique très des établissements organisés autour d’un plateau technique très spécialisé, spécialisé,

•d’autres centrés sur l’hébergement et la dispensation de soins à des d’autres centrés sur l’hébergement et la dispensation de soins à des personnes âgées dépendantes, personnes âgées dépendantes,

•des établissements privilégiant l’urgence et les soins de premiers des établissements privilégiant l’urgence et les soins de premiers recours.recours.

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Perspectives and evolution of French hospitals

Six important trends:Six important trends:

•Health expenditure regulation and healthcare cost transparencyHealth expenditure regulation and healthcare cost transparency

•Increasing productivity by optimization of healthcare delivery Increasing productivity by optimization of healthcare delivery organization and management.organization and management.

•Developing better relations with upstream and downstream parties in Developing better relations with upstream and downstream parties in the healthcare value chainthe healthcare value chain

•Adapting the healthcare offersAdapting the healthcare offers

•Transforming healthcare delivery and hospital organization by new Transforming healthcare delivery and hospital organization by new medical, technological and scientific progresses (new healthcare modes: medical, technological and scientific progresses (new healthcare modes: HAD, SAD, ...)HAD, SAD, ...)

•Increasing regional control of healthcare offers.Increasing regional control of healthcare offers.

But also, informatization of hospitals and the importance of ICT as But also, informatization of hospitals and the importance of ICT as drivers for healthcare delivery improvement.drivers for healthcare delivery improvement.

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Distinctive characteristics of health care services

•Patient participationPatient participation : : interaction between the health care organisation and patient throughout the delivery of care

•Simultaneous production and consumptionSimultaneous production and consumption : : product cannot be inspected and challenge for quality control

•Perisable capacityPerisable capacity : : operating rooms, physicians, ...

•Intangible nature of health care outputsIntangible nature of health care outputs : : cannot be tested or handled before deciding on it.

•High levels of judgement and heterogeneous nature of health High levels of judgement and heterogeneous nature of health carecare : : However, standardization (diagnosis and treatment process, T2A) is in process.

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A Four-level model of health care systemA Four-level model of health care system

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A healthcare delivery system: function

Healthcare services Healthcare services or modesor modes

• Medical caresMedical cares

•Elective surgeryElective surgery

•Emergency surgeryEmergency surgery

•Day surgeryDay surgery

•Surgery at homeSurgery at home

•Hospitalisation at Hospitalisation at homehome

•RehabilitationRehabilitation

•......

Healthcare Healthcare delivery systemdelivery system

PatientsPatients Cured Cured patientspatients

evironnementevironnementregulation, insurance,regulation, insurance,

competitioncompetition

resourcesresources

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A healthcare delivery system: human resources

A hospital is a lot of highly skilled 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

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A healthcare delivery system: material resources

• Expensive technical facilities (Plateaux Techniques Medicaux):Expensive technical facilities (Plateaux Techniques Medicaux):

• Operating theatres (operating rooms, induction rooms, Operating theatres (operating rooms, induction rooms, recovery rooms)recovery rooms)

• ICU, NICU (Intensive Care Units)ICU, NICU (Intensive Care Units)

• Imaging equipment (MRI, CT scan, X-rays, …)Imaging equipment (MRI, CT scan, X-rays, …)

• Biology laboratoriesBiology laboratories

• PharmaciesPharmacies

• Sterilization facilities Sterilization facilities

• Hospitalization bedsHospitalization beds

• Consultation roomsConsultation rooms

• ......

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A healthcare delivery system: material resources

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A healthcare delivery system: organisation

• Wards Wards

• Medical services or unitsMedical services or units

• Specialties (Medecine, Surgery, Obstetrics)Specialties (Medecine, Surgery, Obstetrics)

• Clusters of competenciesClusters of competencies

• HospitalsHospitals

• Healthcare networksHealthcare networks

• Logistic unitsLogistic units

• Technical centersTechnical centers

• AdministrationAdministration

Usually with a funtional organisation.Usually with a funtional organisation.

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French health authorities

•Haute autorité de la santé (HAS)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 deMédicalisation du Système d’Information (PMSI) et des Schémas Régionaux d’Organisation Sanitaire (SROS).

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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 MEAHGestion des organisation des blocs opératoires, Circuit du

médicament, Radiothérapie, Restauration, Temps médical

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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.

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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

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Health Operation ManagementHealth Operation Management

General OM decision:General OM decision:

The planning and control of the processes that transform inputs The planning and control of the processes that transform inputs into outputsinto outputs

ExampleExample

(Individual doctor/patient consultation. Input = a patient with a (Individual doctor/patient consultation. Input = a patient with a request for healthcare, output = patient diagnosed or cared or request for healthcare, output = patient diagnosed or cared or cured. Resource to be managed: their time, diagnositic or cured. Resource to be managed: their time, diagnositic or therapeutic services neededtherapeutic services needed

Extensions:Extensions:

Individual doctor -> individual provider (a hospital dept, a hospital, Individual doctor -> individual provider (a hospital dept, a hospital, a network of hospitals, …)a network of hospitals, …)

Scale and scope of the resources to be planned increase and the Scale and scope of the resources to be planned increase and the complexity of OMcomplexity of OM

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Health Operation ManagementHealth Operation Management

A meta-model of healthcare delivery systemA meta-model of healthcare delivery system

INPUTSINPUTS

PATIENT PATIENT DEMANDDEMAND(perceived need)

Other hospi & Other hospi & providersproviders•Number•Specialty•Teaching•reputation

PURCHASERSPURCHASERS(finances)(finances)

SUPPLIERSSUPPLIERS

TRANSFORMATIONTRANSFORMATION PROCESSESPROCESSES

CLINICAL CLINICAL PROCESSESPROCESSES•Treatment modalityTreatment modality•Treatment protocolTreatment protocol•Provider-patient Provider-patient encountersencounters

MANAGEMENT MANAGEMENT PROCESSESPROCESSES•InfrastructureInfrastructure•StructureStructure•Provider-patient Provider-patient encountersencounters

AN

CILA

RY

A

NC

ILAR

Y

PR

OC

ES

SE

SP

RO

CE

SS

ES

OUTPUTSOUTPUTS

HEALTH HEALTH STATUSSTATUS

CLIENT CLIENT PERCEPTIONPERCEPTION

USE OF USE OF RESOURCESRESOURCES

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Health Operation ManagementHealth Operation Management

Health OM can be defined as the analysis, design, planning Health OM can be defined as the analysis, design, planning

and control of the steps necessary to provide a service for a and control of the steps necessary to provide a service for a

client.client.

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Decision LayersDecision Layers

Strategic decisions:Strategic decisions:

Decisions having long term impacts on the hospitalDecisions having long term impacts on the hospital

Horizon: year or multiple years Horizon: year or multiple years

Made by top managementMade by top management

On hospital-wide long-term vision, types of services and directions On hospital-wide long-term vision, types of services and directions on material and human resources investmentson material and human resources investments (hospital strategic plan (hospital strategic plan - projet d’établissement, contrat d’objectif et de moyens, organisation de - projet d’établissement, contrat d’objectif et de moyens, organisation de l’établissement, ...)l’établissement, ...)

Major decisions: Major decisions:

ServicesServices: : catchment areas, target groups/markets, specialities & product rangescatchment areas, target groups/markets, specialities & product ranges

InvestmentInvestment: new hospital construction, new specialties, expansion: new hospital construction, new specialties, expansion

PartnershipPartnership: shared resources, outsourcing, collaboration: shared resources, outsourcing, collaboration

OrganisatonOrganisaton: : units merging, mutualisation, polyvalence, working time regulationunits merging, mutualisation, polyvalence, working time regulation

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Decision LayersDecision Layers

Tactical decisions:Tactical decisions:

Decisions taken at mid termDecisions taken at mid term

Horizon: trimestre or yearHorizon: trimestre or year

Ensure the right match between available resources and activities Ensure the right match between available resources and activities of the strategic planof the strategic plan

Without profound changes of the structure and organisationWithout profound changes of the structure and organisation

Examples: Examples:

Surgery time allocation to specialties,Surgery time allocation to specialties,

Bed allocationsBed allocations

Case-mixCase-mix

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Decision LayersDecision Layers

Operational decisions:Operational decisions:

Short term decisionsShort term decisions

Horizon: day, week or monthHorizon: day, week or month

Made by each operational unit.Made by each operational unit.

Ensure the smooth execution of the all activities Ensure the smooth execution of the all activities

Examples: Examples:

Surgery planning/scheduling, Admission/discharging control, nurse Surgery planning/scheduling, Admission/discharging control, nurse scheduling, inventory control, supplier relation management, …scheduling, inventory control, supplier relation management, …

Decision frameworkDecision frameworkVissers, 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)

patient flows resources2-5 years2-5 years

PATIENT VOLUME PLANNING AND CONTROL(available annual capacity per specialty, resource use regulation)

patient flows resources1-2 years1-2 years

RESOURCE PLANNING AND CONTROL(time-phased resource allocation (specialist time, # of patients per period)

patient flows resources3 months - 1 year3 months - 1 year

PATIENT GROUP PLANNING AND CONTROL(service requirement and planning guidelines per patient group))

patient flows resourcesWeeks – 3 monthsWeeks – 3 months

PATIENT PLANNING AND CONTROL(scheduling individual patients)

patient flows resourcesDays - weeksDays - weeks

restrictions restrictions

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Decision frameworkDecision 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•…

STRATEGIC PLANNINGpatient flowsSpecialties & production range

Patient groups as business units

ResourcesCollaboration & outsourcing

Shared resources2-5 years2-5 years

PATIENT VOLUME PLANNING & CONTROL

patient flowsVolume contracts (insurance)# patients per patient group

Service levels

ResourcesRough-cut capacity checkTarget occupancy levels1-2 years1-2 years

RESOURCE PLANNING & CONTROL

3 months - 1 year3 months - 1 year

PATIENT GROUPPLANNING & CONTROL

Weeks – 3 monthsWeeks – 3 months

PATIENTPLANNING & CONTROL

Days - weeksDays - weeks

Restrictions on types of patients Restrictions on types of resources

patient flowsExpected patient # per group

Capacity requirement per group

ResourcesAllocation of leading resources

Batching rules for shared resources

patient flowsProject patient # per period

ResourcesAvailability of specialist capacity

patient flowsScheduling of patients for visits,

admission, exam

ResourcesAllocation of capacity to individual

patients

Restrictions on total patient vol Restrictions on amount of resources

Restrictions on detailed patient vol Restrictions on resource availability

Restrictions on timing of patient flows Restrictions on timing of resources

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A Wider Decision frameworkA Wider Decision framework

Hans, Van Houdenhoven, Hulshof, A Framework for Health Care Planning and Control, 2012

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Major operation management issuesMajor operation management issues

Demand forecast (care types – geography – time)Demand forecast (care types – geography – time)

Facility locationFacility location

Facility layoutFacility layout

Planning / schedulingPlanning / scheduling

Capacity planningCapacity planning

Supply chain and inventory managementSupply chain and inventory management

Quality controlQuality control

Project managementProject management

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Major operation management issuesMajor operation management issues

ModelingModeling

Tools: enterprise modelling, SADT, IDEF, Petri nets, Tools: enterprise modelling, SADT, IDEF, Petri nets,

Performance assessment and diagnosticPerformance assessment and diagnostic

Tools: simulation, queueing theory, Markov chains, statistics, Tools: simulation, queueing theory, Markov chains, statistics, Excel, ...Excel, ...

Design or re-engineeringDesign or re-engineering

Tools: simulation, optimisation, ...Tools: simulation, optimisation, ...

Planning and controlPlanning and control

Tools: planning, scheduling, optimisation, linear programing, Tools: planning, scheduling, optimisation, linear programing, heuristics, statistics,...heuristics, statistics,...

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Major operation management issuesMajor operation management issues