A Survey of Health Care Models that Encompass Multiple Departments Peter Vanberkel, PhD Candidate University of Twente

Outline Part 1: Literature Overview Part 2: ORchestra – online bibliography

Introduction Background: Our Intention: Although there is an abundance of models for health care processes, few consider multiple units or departments. – Jun et al. 1999 Our Intention: What relationships were being accounted for? (i.e. What areas of the hospital?) How were they being modelled? (i.e. What techniques?) Identify examples of multi-department models. What factors are holding modellers back?

Search Method Other papers found via citations Jun, J., Jacobson, S., and Swisher, J. (1999). Application of Discrete-Event Simulation in Health Care Clinics: A Survey. Journal of the Operational Research Society, 50(2):109–123. Cited by over 70 papers 21.4% Tutorial or Instructional 10% Surveys 40% Applications / Case Studies of a Single Department 28.6% Applications / Case Studies of a Multiple Department Other papers found via citations In Total: Identified 78 papers which we considered to be of “Multiple Department”

What relationships were being accounted for. (i. e What relationships were being accounted for? (i.e. What areas of the hospital?) How were they being modelled? (i.e. What techniques?) Identify examples of multi-department models. What factors are holding modellers back?

What relationships were being accounted for. (i. e What relationships were being accounted for? (i.e. What areas of the hospital?)

Our Idealized Hospital Diagnostics (Lab / Pharmacy / X-Ray) Outpatient Clinics Operating Room Inpatient Wards Emergency Department Diagnostics (Lab / Pharmacy / X-Ray)

Emergency Department (12) OR(1) ICU(1) Ward(10) Emergency Department Referrals(1) Ambulances(1) Lab/DI(5)

Chart depicting the successive loss of French Army soldiers during Napoleon’s Russian Campaign (1812-13) Charles Joseph Minard

Surgical Care (36) DI(2) PACU(10) Operating Ward(22) Room ICU(9) Operating Room Waiting List(11) Emergency(0)

Inpatient Wards(20) Lab/DI(0) ICU(9) Inpatient Community Wards Care(1) OR(8) Emergency Dept (9)

Outpatient Clinics (4) DI/Lab(2) Pharmacy(1) Outpatient Operating Room(0) Emergency Dept (0) Primary Care(0) (3)

Diagnostics (3) DI / Lab Pharmacy OR(1) Ward(2)

OR in Health Care Campaign Diagnostics (Lab / Pharmacy / X-Ray) Outpatient Clinics Operating Room Inpatient Wards Emergency Department OR is the engine that drives the hospital… clearly modelling believe this Inpatient Beds are the most expensive Resources (surgery wards are studied more, medical wards less) Emergency Room Congestion is caused by inability to admit patients Diagnostics is studied much less Looking downstream is more common Diagnostics (Lab / Pharmacy / X-Ray)

Simulation(36) Other(17) Mathematical Programming(16) How were they being modelled? (i.e. What techniques?) Systems Dynamics(6) Simulation(36) Queueing Theory(7) Mathematical Programming(16) Other(17)

Department by Department

Two Dept. (38) Three Dept. (34) Departments is Scope Four Dept. (5) Five Dept. (1) Six Dept. (1)

Identify examples of multi-department models.

Notable References Brailsford, S. et al (2004). Emergency and on-demand health care: modelling a large complex system. Journal of the Operational Research Society, 55(1):34– 42. Scope: Referral, Ambulances, ED, Lab/DI, ICU, Ward Technique: Systems Dynamics Dexter, F. (2009). Bibliography of Operating Room Management Articles. Retrieved October 10,2008 from http://www.franklindexter.net. Scope: Surgical Services System dynamics is an approach to understanding the behaviour of complex systems over time. It deals with internal feedback loops and time delays that affect the behaviour of the entire system.[1] What makes using system dynamics different from other approaches to studying complex systems is the use of feedback loops and stocks and flows. These elements help describe how even seemingly simple systems display baffling nonlinearity.

Belien, J., et al. (2006). Visualizing the Demand for Various Resources as a Function of the Master Surgery Schedule: A Case Study. Journal of Medical Systems, 30(5):343–350. Scope: OR, Lab/DI Technique: Software Cochran, J. and Bharti, A. (2006a). A multi-stage stochastic methodology for whole hospital bed planning under peak loading. International Journal of Industrial and Systems Engineering, 1(1):8–36. Scope: OR, ICU, Ward Technique: Queueing Theory & Simulation System dynamics is an approach to understanding the behaviour of complex systems over time. It deals with internal feedback loops and time delays that affect the behaviour of the entire system.[1] What makes using system dynamics different from other approaches to studying complex systems is the use of feedback loops and stocks and flows. These elements help describe how even seemingly simple systems display baffling nonlinearity.

Fletcher, A. and Worthington, D. (2007) Fletcher, A. and Worthington, D. (2007). What is a ‘generic’ hospital model? Retrieved October 13, 2008: http://eprints.lancs.ac.uk/7051/1/004583.pdf System dynamics is an approach to understanding the behaviour of complex systems over time. It deals with internal feedback loops and time delays that affect the behaviour of the entire system.[1] What makes using system dynamics different from other approaches to studying complex systems is the use of feedback loops and stocks and flows. These elements help describe how even seemingly simple systems display baffling nonlinearity.

What factors are holding modellers back?

Factors Ambiguous Care Paths Complexity & Variability Hospital Culture Sorry… I have no scale for these factors

Problem 1: Ambiguous Care Paths “patient care plans for the individual patient are rarely formally recorded, as such, they tend to evolve with the patient stay, and exist in a piece-meal fashion in the minds of physicians, nurses, and discharge planners” (Kopach-Konrad et al., 2007).

Overcoming: Ambiguous Care Paths Discussions with managers and care providers Information system protocol HL7 Medical record audits Billing code audits Radio frequency identifiers Bar codes Patient tracking systems Clinical Pathways*

Problem 2: Complexity & Variability The complexity and variability that is inherent in health care either greatly limits the scope of models or forces modellers to take a more macro view. Either way, researchers loose a certain amount of perspective and perhaps draw conclusions on a model that does not incorporate the entire set of circumstances

Coping with: Complexity & Variability distinguish between those complicating factors that have the greatest influence and those factors which are simply attributes. To limit the amount of variability time should initially be spent eliminating the variability caused by the system itself. good protocols or work practices a clear understanding of the patient care trajectories.

Problem 3: Hospital Culture “management does not consider the total care chain from admission to discharge, but mainly focuses on the performance of individual units. Not surprisingly, this has often resulted in diminished patient access without any significant reduction in costs” (de Bruin et al., 2005). People working in the health care system are very knowledgeable about their own area but have relatively little understanding of what goes on in the next department. (Carter 2002)

Coping with: Hospital Culture From an Operational Research Perspective: Better Models Larger Scopes with a more sophisticated understanding of the requirements of the environment Practically Relevant Results which illustrate the benefits of coordination between departments

Part 2: ORchestra Bibliography

ORchestra Bibliography A comprehensive overview of scientific literature in the field of “Operations Research in Health Care” Can be accessed at: http://www.choir.utwente.nl/ORchestra. Is maintained by the Center for Health Care Operations Improvement and Research (CHOIR)

ORchestra Bibliography Categorized According to: Medical Category (MeSH terms) Model Category (Mathematics Subject Classification) Publication Type (MeSH terms) Multiple Departments? Interacting Patient Flows?

ORchestra Bibliography What’s Available Online? Detailed descriptions of the categorization method Sorted pdf’s of all articles in each category Free Text Searching of all Articles (Coming soon)

Discussion & Questions? http://beta.ieis.tue.nl/home (Literature Review) www.choir.utwente.nl/ORchestra/ (ORchestra)