1. July 27, 2006ORAHS 2006: Poland1 A Case Study of a Simulation-Based Decision Support Tool Michael Carter Healthcare Modeling Lab, Mechanical & Industrial Engineering, University of Toronto

2. July 27, 2006ORAHS 2006: Poland2 Organizations Involved University of Toronto  The Health Care Resource Modelling Lab Hamilton Health Sciences Centre (HHS)  Perioperative Services  Clinical Appropriateness and Efficiency Program (CARE) Institute of Clinical Evaluative Sciences

3. July 27, 2006ORAHS 2006: Poland3 Primary Team Members University of Toronto  Jean Yong – MASc candidate  Michael Carter – Director, Healthcare Resource Lab  Carolyn Busby – Doctoral Candidate & Modeller Hamilton Health Sciences  Kelly Campbell – Director of Perioperative Services  Steve Metham – CARE Facilitator  Dr. Kevin Teoh – Head of Cardiac Surgery ICES  Dr. Jack Tu – Senior Scientist

4. July 27, 2006ORAHS 2006: Poland4 Background Background:  Expansion of operating room activity  Determine new surgical booking policy Objective:  Facilitate strategic planning of cardiac surgical resource allocation Determine OR schedule Determine number of beds required in ICU and ward

5. July 27, 2006ORAHS 2006: Poland5 Surgery Grouping Cardiac Surgery 2002-2004 N>4000 Redo/ Combined No Redo/ Combined CABG VALVE COTHR CONGD CAVLV AORTA CABG 1,2,3 TVR,AVR CONGD COTHR CABG 4,5,6,7 MVR CABG VALVE AORTA CAVLV COTHR

6. July 27, 2006ORAHS 2006: Poland6 Surgery Grouping Cardiac Surgery 2002-2004 Intermediate 322 mins n=281 359 In-btwn 284 mins n=890 313 Minor 244 mins n=1016 266 Major 1 353 mins n=116 Major 2 431 mins n=60

7. July 27, 2006ORAHS 2006: Poland7 Surgery Duration Distribution Minor 246 mins n=1530 In-btwn 285 mins n=1789 Intermediate 337 mins n=499 Major 461 mins n=220

8. July 27, 2006ORAHS 2006: Poland8 Conceptual Model Waiting List Cardiac Surgical Unit Operating Room ICU Cardiac Surgical Unit Same Day Surgery Ward Queue by surgeon Surgery duration – by procedure Prioritized by acuity Discharge

9. July 27, 2006ORAHS 2006: Poland9 Performance Indicators  Number of cases completed/year  Cancellation rates Lack of ICU/ ward bed Out of scheduled time More urgent case took precedent  Operating room utilization Under-utilization (hours/week) Overtime (hours/week)  Ward bed utilization (ICU & CSU)

10. July 27, 2006ORAHS 2006: Poland10 Model Validation 50 replications of 1 year each Imitate current scheduling rules Run the model with 2002, 2003, 2004 data Compare output from the 3 models with historical data Experts’ opinions  Meeting with clinicians

11. July 27, 2006ORAHS 2006: Poland11 Results 2004 HistoricalModel Avg Std. Deviation No. of cases/ year 1355127533.5 Cancellations due to more urgent replacement /year 776228.7 Cancellation due to lack of ICU beds /year 583528.3 Cancellation due to out-of-time /year 487311.2 Average overtime Hour/week 6.15.30.443 Average undertime Hour/week 16.630.61.84

12. July 27, 2006ORAHS 2006: Poland12 Applications Simulated what-if scenarios for 4 operating rooms to answer stakeholders’ questions Encouraged clinicians to propose new ideas of how the system could be run differently for higher efficiency Tested over 10 scenarios Can we meet provincial target with 4 ORs varying room length Do we have enough ICU/ ward capacity? What if we pool all the surgeons’ urgent slots together? Can we book surgery differently?

13. July 27, 2006ORAHS 2006: Poland13 Key issues from surgery Ability to achieve priority funded volumes Organization of block time – length and placement Available beds – ICU/ward Minimizing cancellation rate Booking rules Pooling of referrals System for urgent/emergent cases

14. July 27, 2006ORAHS 2006: Poland14 Modifying Cancellation Rule

15. July 27, 2006ORAHS 2006: Poland15 Can we book surgery differently?

16. July 27, 2006ORAHS 2006: Poland16 Scenarios – OR schedule Scenario AScenario B OR1OR2OR3OR4 Mon 1210 9 Tues 1210 9 Wed 11999 Thu N/A1210 Fri N/A1210 OR1OR2OR3OR4 Mon 10 9 Tues 10 9 Wed 11 99 Thu N/A12 10 Fri N/A12 10

17. July 27, 2006ORAHS 2006: Poland17 Model Results AB Seen / year 1430 ±251487 ±26 Cancellations /year Total 188 ±42221 ±47 More Urgent 83 ±22102 ±24 ICU/ ward 32 ±2241 ±27 Overtime 72 ±978 ±10 Overtime (hour/week) 5.6 ±0.66.0 ±0.7 Undertime (hour/week) 26.7 ±1.325.3 ±1.3

18. July 27, 2006ORAHS 2006: Poland18 Planning ICU and Ward Capacity

19. July 27, 2006ORAHS 2006: Poland19 Questions?