Pay close attention to the next three words: health care system. The fact that a team of Binghamton University systems scientists did just that could trim between 20- and 60-minutes off your next visit to the emergency room.
By applying the principles of industrial and systems engineering and working with quality improvement teams at United Health Services, the BU researchers–including a master’s student, a doctoral student, a program assistant and an industrial engineering and systems science professor–are looking to expedite patient care in local emergency departments. Their treatment plan? An extensive review of critical literature followed by ample doses of data collection and analysis, the acute application of process-mapping and, finally, the development of a serious case of simulation.
According to Laura Kushner, quality management nurse coordinator at Wilson Memorial Hospital, it’s a prescription that’s right on target. Patient turnaround time in the UHS emergency departments is already at or near the industry standard-about two hours for emergent patients and close to three hours for urgent and non-urgent patients. But UHS is committed to continuous quality improvement, and initial indicators suggest that implementation of the BU team’s suggestions will lead to “dramatic reductions” in patient turnaround time, with no compromises in quality of care and without the need for additional staff or resources, Kushner said.
Patient turnaround time is defined as the time between a patient’s arrival in the emergency department and when she or he is either released or admitted to the hospital. A host of studies show that patient turnaround time is one of the prime factors in overall patient satisfaction. That’s why hospital representatives-from administrators to ED staff–were quick to agree to collaborate with BU researchers who offered to help optimize the delivery of emergency room services, Kushner said.
The project was the brainchild of K. Hari Srihari, professor of systems science and industrial engineering, and director of BU’s Electronics Manufacturing Research and Services. He proposed the challenge to graduate student Tejas Gandhi as a possible master’s thesis project about a year ago. Srihari, who for the past decade has built an international reputation as an electronics packaging researcher, said sorting out health care issues through the perspectives of industrial engineering and systems science isn’t as incongruous as it might seem. Industrial and systems engineering is being widely applied across the United States to the service sector, most particularly hospitals and airlines, he said.
“Within the health care arena, concepts such as optimization and simulation can be and are being used to increase the effectiveness and efficiency of the delivery of care to the patient or customer,” Srihari said. “The fundamentals of Industrial and Systems Engineering are usually as applicable to healthcare management and delivery systems as they are, for example, to manufacturing systems.”
With one big difference, that is.
“We have bottlenecks in the manufacturing arena and we have them in the health care system, Gandhi said. “The difference is when it comes to health care, we have the human issues. We have to keep in mind and respect the clinical aspects. I cannot compromise on the quality of care. If the objective is to reduce the patient turnaround time, I cannot do that by reducing the patient treatment time. I cannot change the doctors’ protocol.”
What Gandhi and his team instead did was to collect and review thousands of hospital records. He then spent untold hours each week in the emergency department of Wilson Memorial Hospital, tracking and timing the processes involved in patient care. But the work didn’t stop there. Gandhi developed an accurate and realistic simulation program that clearly demonstrates the expected affect of any recommended change in current processes on patient wait times.
“The simulation was to run throughout the day. We had to model even the smallest detail, how much time the nurse would spend charting, how much time to examine, so that in the end we would end up with the most accurate model as we could,” he said.
The simulation uses digital images Gandhi characterizes as “PAC-people” to represent patients in various stages of treatment in the emergency department. It even takes into account the real-life “reneger” phenomenon. That means it is programmed to randomly ensure that a predetermined percentage of “patients” tire of the wait and walk out of the emergency department before being treated or before they are officially released. While others around the nation have developed simulation programs to visualize issues and possible solutions within emergency departments, Gandhi’s might be the most accurate and realistic. That’s because while most simulations characterize patient care only by level of acuity of illness or injury or by particular categories of care, such as trauma, pediatric or cardiac, Gandhi’s simulation is based on the major 50 ailments actually used by ED staff in triaging patients, as well as on levels of acuity of illness or injury.
UHS administrators and staff are definitely impressed with how closely the simulation mirrors the realities of the emergency department, Kushner said.
“This outside objective review has validated what we knew both anecdotally and through our own data-based research,” she said. “But what the BU team brought to us was the ability to visually simulate the outcome of proposed changes.”
Because change can be a difficult thing for people to embrace, particularly when the outcomes of that change are unknown, both Kushner and Gandhi think the simulation will help hospital officials and workers to feel confident about positive outcomes from the changes suggested by the BU research team. Probably the two most important suggested changes involve moves that could pare significant “wait” times by making better use of existing hospital staff through rescheduling or retraining.
Data shows 4 p.m. to 6 p.m., for instance, as the busiest time period in the emergency department. Simply rescheduling work hours to maximize coverage during those hours could enhance patient turnaround time. Another even more dramatic reduction in turnaround time could come from having ER nurses do the blood draws for lab work. Most blood draws are currently done by phlebotomists who must often be paged to the emergency department from elsewhere in the hospital, Gandhi said.
“Slowly, if we were to train the ED staff to draw blood, we could achieve a much higher reduction in turnaround time. To begin with 15 percent is drawn by the ED staff. Increase that to 30 percent, then to 50 percent, and eventually to 100 percent and you could see reductions of up to one hour in turnaround time. If only 30 percent of blood is drawn by ED staff, almost 20 minutes reduction can be achieved.” Srihari said Gandhi brought to the project the kind of skills and dedication that was needed for it to succeed.
“Tejas brought diligence, patience, and attention to detail. He has the ability to skillfully work with a variety of professionals while keeping his ‘eye on ball,’ Srihari said. “Tejas was able to successfully utilize the theory and concepts he had learned on campus to solve a real life problem. He was equally at home observing the workings of the Emergency Department and mapping its activities or using the concepts that pertain to modeling and simulation. He was critical to the success of this project.” Although it did not quicken in him any interest in becoming a doctor or nurse, Gandhi said the project will likely be critical to his future.
“During my time in the ED, I’ve seen patients show up with throat pain and headache, and at the same time I have seen trauma patients. The worst has been when a patient passed away,” he said. “I’m good from the system point of view. Being a doctor would be too close.”
Gandhi does, however, hope to make a career out of the application of industrial engineering and systems science principles in the health care arena. “I think health care has enormous depth and many places where industrial engineering principles can be applied,” he said.
UHS, for instance, has already expressed interest in looking at its radiology operations, and Gandhi is also considering the development of a centralized monitoring and control system that would provide instantaneous information on available hospital beds, he said.
“Right now,if an ED patient needs to be admitted, most of the times a nurse has to physically go and check to see if the bed is available.” Whatever the future holds for him, Gandhi and his team know for certain that one reality of the manufacturing arena is just as likely to apply in the health care arena.
“If you are eliminating a bottleneck at one point, chances are good that you have created one somewhere else. So then you must turn your attention there. It’s a process of continuous improvement.”