1. Simulation Presentation to Design May 21, 2008

2. Agenda  Simulation  Process Redesign  Sample Emergency Project  Clients

3. Simulation – What is it?  Mathematical representation of real life  Model generation on simulation software  Queuing theory  Randomization and variation  Input process information  Outcome statistics  Scenario model to compare outcomes

4. Simulation – Project Steps  Collect data  Define current process  Develop model of current process  Compare model outcomes to real-life  Define changes  Develop scenario models  Compare scenario to model outcomes

5. Simulation - Data  Volumes  Average and Peak Daily Visits, Arrival by Hour  Types  Walk-In/Ambulance, Acuity, Discharge/Admit/Transfer  Activity Times  Triage, Evaluation, Tests, Disposition  Waiting Times  Test Results, Renege/Leave Without Being Seen  Locations  Triage, Beds  Staff Schedule  Physician, Nurse, Tech, Clerk, Registration

6. Simulation - Patient Volume  Daily average 157.8 visits in 2007  Monthly range from 147.0 to 163.6

7. Simulation - Patient Arrival  Pattern of arrival by hour

8. Simulation - Locations Current  3 Triage  5 Fast Track  30 Beds  12 Overflow beds

9. Emergency Process

10. Emergency Model

11. Current Model LOS Outcomes LOS HoursCurrent LOS Minimum1.21 Average3.98 75%ile4.84 90%ile6.14 Maximum14.24

12. Process Redesign  Insight Strategies, Inc. - Lean Method Current Redesign Color Key Process Wait Route Review Decision

13. Locations Redesign  1 Screening  3 Intake  2 Lab Draw  20 TREAD  Treat and Discharge  20 Acute Beds Current  3 Triage  5 Fast Track  30 Beds  12 Overflow beds

14. Scenario Model LOS Outcomes LOS HoursScenario LOSCurrent LOS Minimum0.651.21 Average3.233.98 75%ile4.044.84 90%ile5.626.14 Maximum17.7914.24

15. Clients – Real Outcomes Goals Achieved Pre - Implementation Jan – Jul 2005 Post - Implementation First 2 Weeks Length Of Stay5 Hours 18 Minutes3 Hours 3 Minutes Left Without Being Seen6.0 %0.45 % Goals Maintained Before Change May 2005 After Change May 2006 Daily Visits83.0115.1 Length Of Stay5 Hours 27 Minutes3 Hours 9 Minutes Left Without Being Seen15.2 %0.8 %

16. Clients - Experience  Kahn with Insight Strategies - Emergency Process Redesign (6)  CHW-East Valley Chandler Regional Medical Center, AZ  CHW-East Valley Mercy Gilbert Medical Center, AZ  University Health Center, UT  Banner Health Baywood Medical Center, AZ  Sun Health Webb Memorial Hospital, AZ  Sun Health Boswell Memorial Hospital, AZ  Kahn - Emergency Facility Planning (2)  Hospital Israelita Albert Einstein, Sao Paulo, Brasil  Foote Hospital, Jackson, MI  SJHS Process Improvement (5)  St. John Hospital and Medical Center  Cancer Center, Birthing Center, Registration, Surgery  Detroit Riverview Hospital  Birthing Center