1. VEDAT VERTER PROFESSOR, OPERATIONS MANAGEMENT EDITOR-IN-CHIEF, SOCIO-ECONOMIC PLANNING SCIENCES DIRECTOR, NSERC CREATE PROGRAM IN HEALTHCARE OPERATIONS & INFORMATION MANAGEMENT CO-DIRECTOR, MCGILL MD-MBA PROGRAM Healthcare Operations Management

2. Health Sector in Canada Among the top three sectors that contribute to Canadas 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

3. Canadas Healthcare System

4. A Single Payer System … Public insurance Everyone in Canada is insured through their provincial government Health 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

5. … & 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

6. The Canadian System – Pros Costs are controlled: provincial health budgets, supplemented by federal funds Canadas 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

7. The Canadian System – Challenges Healthcare funding Patient waiting times Medical technologies Personnel shortage Inclusion of pharmaceutical, home care and long term care costs in the public health insurance Canadian Healthcare Association

8. 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).

9. OECD – Total Health Spending

10. Emergency Department Management

11. Research Team Marc Afilalo, MD Antoinette Colacone, CCRA Alex Guttman, MD Eli Segal, MD

12. 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

13. Montreal Tertiary Care Hospitals HospitalED LOS (hours) acute care patients CUSM Hôpital Général de Montréal14.824556 Hôpital général Juif17.534482 Hôpital St-Luc du CHUM19.517905 Hôpital du Sacré-Coeur de Montréal19.524238 CUSM Hôpital Royal Victoria21.717048 Hôtel-Dieu du CHUM26.414231 Hôpital Notre-Dame du CHUM27.820269

14. Maximum LOS in the JGH ED (hours)

15. 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 ED Evaluate possible interventions to reduce patient wait times Design a detailed intervention plan to achieve lean ED processes

16. The Acute Care Unit in the JGH ED

17. Detailed ED Process Flow

18. Reducing Patient Wait Times in ED Triage

19. 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.

20. 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.

21. Canadian Triage Acuity Standards CAEP (1999) Re-assess

22. U.S. Emergency Severity Index No expected time intervals to physician evaluation

23. 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.

24. Patient Arrival and Triage Service Times

25. Simulation Model Validation Triage Wait Times

26. 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

27. 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

28. Comparative Analysis of Wait Times & Nurse Utilization Scenario Ambulance N=537 Walk-in N=3205 Nurse Utilization Baseline (1.5 Pooled RNs) 3.6 + 5.918 + 29 71% 2 Dedicated RNs + Regular Triage1.5 + 3.868 + 108 Walk in 90% Ambulance 25% 2 Dedicated RNs + Pre-triage1.4 + 3.79 + 13 Walk in 53% Ambulance 25% 2 Pooled RNs + Pre-triage0.68 + 1.662.25 + 3.7 39%

29. Comparative Analysis of Baseline & 2 Pooled RN + Pre-triage

30. Wait Time Distibutions Baseline

31. Wait Times during the day Baseline

32. Nurse Utilization Baseline Pooled + Pre-triage

33. 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.

34. Questions & Comments ?