- Email: [email protected]
Highlights of the 2011 Mayo Clinic Systems Engineering and Operations Research conference
Operations Research for Health Care 1 (2012) 16–19
Contents lists available at SciVerse ScienceDirect
Operations Research for Health Care journal homepage: www.elsevier.com/locate/orhc
Short communication
Highlights of the 2011 Mayo Clinic Systems Engineering and Operations Research conference Gene C. Dankbar a,∗ , Mark J. Hayward b a
Division of Systems and Procedures, Mayo Clinic, Rochester, MN 55905, USA
b
Center for the Science of Healthcare Delivery, Mayo Clinic, Rochester, MN 55905, USA
article
info
Article history: Received 16 January 2012 Accepted 19 January 2012 Available online 27 February 2012 Keywords: Health care Mayo Clinic Systems engineering
abstract In this report, we share highlights of the fourth annual Mayo Clinic Systems Engineering and Operations Research conference. The conference provided a forum for system engineers, operations researchers, clinicians, managers and administrators to share experiences, learning and success stories from their work in applying analytical and modeling tools to a range of problems. This report represents a snapshot of the challenges faced in acute health care, the techniques being deployed and the progress being made by engineers and operations researchers in helping to improve the quality and value of services. © 2012 Elsevier Ltd. All rights reserved.
1. Introduction The Fourth Annual Mayo Clinic Conference on Systems Engineering and Operations Research (SEOR) in Health Care was held in August 2011 in Rochester Minnesota, USA [1]. The conference was held in association with the Production and Operations Management Society (POMS) and the Society for Health Systems (SHS). The continuing mission of the conference is to gather a multidisciplinary group of systems engineers, clinicians, administrators, and academic professors to discuss the translation of systems engineering methods to more effective health care delivery [2]. The challenges outlined in the 2001 Institute of Medicine Report, Crossing the Quality Chasm, are still relevant today [3]. New to the 2011 Conference was the ability for attendees R to attend the conference through Second Life⃝ [4]. The conference concluded with a powerful story from a patient and their care team on the importance, and urgency, to use the tools of systems engineering and operations research to improve the health of all patients. 2. Conference workshops The conference started with a series of workshops. Dr. Franklin Dexter, University of Iowa, focused on decision-making on the day of surgery. As a practicing anesthesiologist with a long interest in operations research, Dr. Dexter brings a unique perspective to
∗
Corresponding author. Tel.: +1 507 266 1698; fax: +1 507 266 6806. E-mail addresses: [email protected] (G.C. Dankbar), [email protected] (M.J. Hayward). 2211-6923/$ – see front matter © 2012 Elsevier Ltd. All rights reserved. doi:10.1016/j.orhc.2012.01.003
the issues of effectively staffing the operating room. Dr. Dexter led participants through numerous scenarios for improving the safety and efficiency of the operating room. Continuing the theme of surgery, Dr. David Cook and Jeff Thompson, Mayo Clinic, discussed their work in cardiovascular surgery to reduce costs while simultaneously improving care for their patients. Using tools from six sigma to obtain baseline information and to identify the key variables, the project team used computer simulation modeling to evaluate different scenarios related to staffing models, number of operating rooms used, hours of operation, and the impact of reducing variation in case length to explore the influence on costs and efficiency. The insights from examination of the historical information along with the modeling led the team to develop new protocols, theater schedules, and streamlined methods to deliver better patient care. The workshop highlighted the importance of combining the traditional tools of quality improvement and systems engineering. The importance of applying OR tools to the issue of patient access in ambulatory care settings was highlighted in the workshop by Hari Balasubramanian, Ph.D., University of Massachusetts. Dr. Balasubramanian outlined the tradeoffs in ambulatory clinics on patient panel size [5], the mix of each clinician’s empaneled patients, length of appointments, patient satisfaction, continuity in seeing a familiar provider, and the flexibility of the ambulatory care staff in providing timely care to their patients. Probability and computer modeling showed the tradeoffs associated with the complexity of a problem faced by every ambulatory care clinic. The final two workshops revolved around computer simulation modeling. Mayo Clinic colleagues, Thomas Rohleder, Ph.D., Todd Huschka, and Brian Bailey, led participants through a tutorial on the basics and value of simulation. They stressed that success in simulation is only possible through a well-defined problem,
G.C. Dankbar, M.J. Hayward / Operations Research for Health Care 1 (2012) 16–19
knowledge in computer simulation modeling, and available expertise on the clinical processes concerned. Dr. Yue Dong, Fazi Amirahmadi, Chris Schieffer, and Ashish Gupta, all of Mayo Clinic, took computer simulation into the intensive care unit, applying the skills to sepsis resuscitation. Using discrete event simulation they were able to evaluate differing scenarios for patients with suspected sepsis in a cost effective manner to identify the options leading to optimal care and costs. 3. Opening keynotes Mark Hayward, conference co-chair, Mayo Clinic, opened the general conference and introduced Dr. John Noseworthy, Chief Executive Officer, Mayo Clinic. Dr. Noseworthy discussed the many different ways engineers have helped Mayo Clinic since its founding. From engineers helping build devices for Mayo Clinic physicians and scientists to the staff in the Division of Systems and Procedures, an internal consulting group at Mayo Clinic staffed by individuals with skills in industrial and process engineering. Dr. Noseworthy pointed to Mayo Clinic’s first system engineer, Dr. Henry Plummer, one of the partners with the Mayo brothers. In concluding his remarks, Dr. Noseworthy challenged conference participants to leverage their engineering skills to partner with clinicians to make connections to our patients, wherever they may be in the world. Dr. Albert Mulley, Director of the Dartmouth Center for Health Care Delivery Science, discussed his long research in the area of informed medical decision-making. Dr. Mulley’s research has focused on the use of decision theory and outcomes research to distinguish between warranted and unwarranted variations in clinical practice. Dr. Mulley encouraged participants to review the recent report from the Institute of Medicine, Engineering a Learning Healthcare System: A Look at the Future—Workshop Summary [6]. Dr. Mulley went on to describe the work of Dr. Jack Wennberg and his colleagues at the Dartmouth Atlas [7]. This work shows widespread variability in the amount of care and cost of care across the United States. An article by Dr. Atul Gawande, ‘‘The Cost Conundrum’’ [8] brought this variability to life by describing the differences between two communities in Texas. These are the challenges facing system engineers. Teamwork between clinicians, engineers, and other team members in the process will be critical. Dr. David Lane, London School of Economics (LSE), illustrated the use of system dynamics (SD) through two public health examples. The United Kingdom National Audit Office and LSE staff constructed a simulation model to understand and control clostridium difficile outbreaks [9]. Different contamination stages, various transmission mechanisms and bed, toilet and staff hand cleaning were represented. In the second example, SD qualitative systems mapping approach was used to structure child and family social workers’ understanding of the problems with the existing system. Dr. Lane highlighted the benefits of involving people in building SD models to establish understanding, and buy-in, of the system, better solutions, and a commitment to action. The first day of the conference concluded with a panel discussion describing Mayo Clinic’s methods for providing increasing value in health care. Dr. Veronique Roger, Dr. Robert Nesse, and Robert Chase pointed to Mayo Clinic’s commitment to continually explore new ways to bring higher value to patients. Dr. Roger, chair, Mayo Clinic Center for the Science of Health Care Delivery, pointed to numerous articles on methods to improve health care. Dr. Roger also stressed the need for rigor in our approaches, to ensure the solutions are generalizable [10]. Dr. Nesse, Chief Executive Office, Mayo Clinic Health System, described efforts by leading healthcare organizations to collaborate to improve care through the High Value Health Care Collaborative (HVHC) [11]. Nesse, Roger, and Chase emphasized the need for health care groups to move to new models of care, align research and measures, and focus on delivering value in a cost-effective manner.
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4. Improving care and patient safety in the operating rooms The second day of the conference featured a wide array of applications of SEOR tools in a variety of clinical settings. Dr. Robert Cima, Mayo Clinic, shared how the use of technology in the operating rooms has helped to reduce the number of retained foreign objects to near zero. Extensive data analysis from over 190,000 operations revealed the majority of those retained foreign objects were sponges. Through bar-coded technology, supporting hardware and process changes, Mayo Clinic in Rochester, Minnesota, has gone three years without a retained sponge in the operating room. Dr. Cima emphasized the multidisciplinary nature of the project team along with extensive data and financial analysis leading to project success [12]. Vikram Tiwari, Ph.D., University of Houston, and David Berger, MD, Baylor University, laid out of the case for real-time flow control of the operating room. Their project entailed a real-time location system for patients, personnel, critical equipment, and activities. Real-time visual displays are also an important part of the changes to help personnel track and react to the hourly changes. Improved operating room utilization, reductions in delays between cases and timeliness of first cases were just a few of the successes seen by the project. Dr. Brian Rothman, Vanderbilt University, shared work underway at his institution to provide real-time decision support in the operating rooms. The Vanderbilt Perioperative Information Management System (VPIMS) is an integrated electronic medical record with real-time anesthesia and nursing documentation and providing notification information to staff throughout the operating rooms via electronic in-room whiteboards, desktop computers, and conventional pagers. Rothman noted timely delivery of this information can provide clinical teams better opportunities for safe and effective care. 5. Data mining for making better decisions in health care The extensive use of data mining and analysis in health care was illustrated in a session hosted by three clinical practitioners from Vanderbilt University. Dr. Stephan Russ addressed the difficult problem of patient placement in the hospital setting. Through a switch to a centralized bed assignment system, the hospital was able to reduce the time it takes to assign a bed and increase inpatient occupancy without an adverse affect on the rate of patient transfers. Dr. Brian Rothman discussed the need for capacity planning for facilities through an illustration on the number of operating rooms needed in Obstetrics for handling unpredictable cases. The team looked at three years of historical data in the obstetrics suite and showed through statistical process control charts, the probability of needing an additional operating room. Use of the model helped decision-makers make an informed decision regarding an expensive resource. Dr. Jesse Ehrenfeld concluded the session by pointing to the usefulness of the extensive information available in the operating rooms. 6. Optimizing patient flow Craig Froehle, Ph.D., University of Cincinnati, addressed the complex issue of providing continuity of care for patients with complex health issues. These patients may see a different, customized subset of providers during their visit. Using mixed integer programming, the team was able to develop patient and provider schedules to minimize patient wait times, provider idle time, and the duration of the clinic. Implications for spreading the scheduling model to a larger facility were discussed during the session. Denise White, Ph.D., Cincinnati Children’s Hospital Medical Center, continued the discussion on clinic flow by exploring the
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G.C. Dankbar, M.J. Hayward / Operations Research for Health Care 1 (2012) 16–19
complexities involved in coordinating several patient visits along with ensuring good patient service. White and colleagues explored the problem through five scenarios in how patients are seen in an outpatient clinic. Dr. David Cook and Thomas Rohleder, Ph.D., Mayo Clinic, explored future bed needs in cardiovascular surgery through simulation modeling. The model explored differing scenarios and looked at seasonal effects, patient mix, and projected lengths of stay for both intensive care unit (ICU) beds and step down units. The model is being used by decision makers to help evaluate the tradeoffs between service levels and ICU bed utilization. 7. Health information systems The topic of electronic medical record (EMR) implementation garnered a large amount of interest during one of the largest attended breakout sessions. Dr. Brian Hinch, University of Toledo Medical Center, shared his long experience with EMR implementation and openly shared the lessons learned during their recent implementation. Visible physician support, listening to user needs for customizing certain aspects of the medical record, extensive staff training, and personal support during the EMR rollout were key. One hundred percent adoption of the EMR at all clinics and a positive return on investment, along with improved patient outcomes have ensued. In addition, the EMR provided a robust method for actively finding potentially harmful prescribing errors and correcting them before the medication was issued. Wesley Williams, Ph.D., Mental Health Center of Denver, showed how incorporation of the EMR into the workflow of the clinicians was key to effective implementation. Enabling clinicians to have their information in one system helped reduce errors at the source and led to high degrees of clinician satisfaction. Maryanne Mathiowetz shared Mayo Clinic’s long experience with the EMR and discussed the integration of internally developed applications with vendor supplied software. Phased implementation of the EMR and concentrating on clusters of patient care units ensured consistency and adequate education for staff affected by the changes. 8. Systems engineering tools to enhance lean and six sigma projects The complimentary nature of systems engineering and operations research tools lean and six sigma were on full display in this breakout session. Robert Furrey, Baptist Health Medical Systems, Little Rock, Arkansas, addressed the issue of capacity in their cardiovascular practice using lean and six sigma methods. Through identification of process bottlenecks, the team was able to produce a real-time information system to help the clinical staff determine which patients are waiting, who is ready for procedure, and schedule discharge time. The patient tracking system helped staff handle a 26% increase in volume with no constraints while using existing staff. Planning for the potential of a pandemic was the task faced by Amin Gupta, Ph.D., University of Louisville. The realities of a potential H1N1 or viral attack are remote, but possible. Gupta used computer simulation to build upon prior work on a drive-through mass vaccination clinic. Drive-through clinics have the advantage of higher throughput, less chance of spreading disease, and waiting inside the vehicle. Gupta’s model may have wide applicability in communities across the world. It is an ongoing challenge in hospital operating rooms: getting the first case started on time. Kevin Taafe, Ph.D., Clemson University, and colleagues took on this challenge. Balancing a need to start the operating rooms on time, improve room utilization, with patient, surgeon, and staff satisfaction, the multidisciplinary team utilized six sigma tools and computer simulation. Based on computer simulation, the team was able to demonstrate the potential to move to 88% on time performance.
9. Patient outcomes analysis The importance of examining and analyzing patient outcomes was the focus in this session. James Naessens, ScD, Mayo Clinic, reviewed the importance of risk adjustment in medical care. Riskadjustment is essential as researchers and front-line clinicians work to ensure valid comparisons across organizations. David Vanness, Ph.D., University of Wisconsin School of Medicine and Public Health, discussed the importance of recursive partitioning to segment patient groups into subgroups with similar outcomes. This important work helps investigators make better predictions of mortality and morbidity at specified levels of the economy. Predictive risk modeling is a rich area for research in SEOR and Dr. Erik Hess, Mayo Clinic, and colleagues discussed this challenge. The importance of keeping the patient in the center of risk assessment and subsequent decisions was front and center in Dr. Hess’ presentation. Predicting the need for treatment for patients who present with chest pain to the emergency room was illustrated [13]. 10. Storyboard session Another prominent piece of the conference is the extensive number of storyboards. Nearly forty storyboards were shared throughout the conference. Special recognition was awarded to two of the presenters: Takahiro Tanaka, Binghamton University, for their paper, ‘‘Infusion Chair Scheduling Optimization Applying Bin-Packing Heuristics’’ and Rema Padman, Carnegie Mellon University, for their paper, ‘‘Modeling and Analysis of Flows, Response Time and Variability in the eVisit Care Delivery Process’’. 11. Organizational change The final day of the conference started with Dr. Carl Clark, Chief Executive Officer, Mental Health Center of Denver. Dr. Clark has challenged his organization to become the best mental health services in the country. To meet the challenge, his team has worked to create meaningful measures. Dr. Clark reminded attendees mental health is the top health burden in the United States and patients carrying a mental health burden live, on average, 25 years less than all Americans. Dr. Clark has a firm belief every patient can recover. The demand for mental health outstrips the capacity to see all the patients. SEOR skills are needed to solve this vexing issue. In concluding his remarks, Dr. Clark reminded attendees of the need for soft skills along with our technical skills: ‘‘. . . people do not care how much you know; it is how much you care’’. Dr. Steve Hagedorn, Mayo Clinic, joined the conference to discuss the development of the Medical Home [14]. Dr. Hagedorn outlined five principles for creating a team-based, medical home model:
• • • • •
Standardize the processes to support the infrastructure. Develop the multidisciplinary team. Develop the metrics to support the changes. Think patient-centered. Leverage the power of teams.
12. Conclusion For the first time in the four years of the conference, a patient and family member were invited to participate in an open panel discussion regarding the care they received during a recent health experience. Members of the patient’s care team were in attendance to describe the systems in place to support the patient’s care in the outpatient and inpatient setting. Dr. Michael Rock, Mayo Clinic, and well known healthcare OR practitioner, Distinguished Professor Emeritus William Pierskalla, Ph.D., UCLA, co-facilitated the session.
G.C. Dankbar, M.J. Hayward / Operations Research for Health Care 1 (2012) 16–19
The opportunities for SEOR skills were highlighted throughout the session. Dr. Pierskalla told participants ‘‘. . . when SEOR is done well, it is largely invisible to the patient, clinician, and hospital employee’’. Pierskalla noted the following enablers to success in applying SEOR skills in healthcare: 1. 2. 3. 4. 5. 6.
Patient Centered Culture of the system. Information Technology/Information System availabilities. Teamwork from all involved parties. Salaried versus fee for service physicians. Capable, knowledgeable SEOR staff employees. A culture of always looking for ways to improve.
The patient’s story served as a powerful reminder of the challenges faced by health care. The collaboration between clinical practitioners and SEOR practitioners is critical in the next few years as the US healthcare system faces an aging population, growing chronic illness, and dwindling monetary resources. As engineering principles and models are gradually incorporated into the fabric of health care delivery systems, a deliberate commitment must be made by health care professionals and engineers alike to build nimble yet robust evaluation systems centered on patient choices and preference for care delivery and outcomes [15]. References [1] See the 2011 Mayo Clinic Conference on Systems Engineering and Operations Research in Health Care web site. http://www.mayo.edu/cme/special-topicsin-health-care-2011r092. Accessed December 23, 2011. [2] J. Kamath, J. Osborn, V. Roger, T. Rohleder, Highlights From the Third Annual Mayo Clinic Conference on Systems Engineering and Operations Research in Health Care, Mayo Clinic Proceedings, August 2011, p. 781. [3] Crossing the Quality Chasm: A New Health System for the 21st Century, National Academies Press, 2001.
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[4] Second life. http://secondlife.com. Accessed December 15, 2011. [5] Panel size is the number of patients assigned to a clinician for ongoing care, Mark Murray, Mike Davies, Barbara Boushon, Panel Size: How Many Patients Can One Doctor Manage?, Family Practice Management, April 2007, p. 44. [6] Engineering a learning healthcare system: a look at the future—workshop summary, Released: July 8, 2011. http://www.iom.edu/Reports/2011/ Engineering-a-Learning-Healthcare-System.aspx. Accessed December 6, 2011. [7] Dartmouth Atlas of Health Care. http://www.dartmouthatlas.org. [8] Atul Gawande, The cost conundrum, what a texas town can teach us about health care, The New Yorker, June 1, 2009. [9] Clostridium difficile, often called C. difficile or C. diff, is a bacterium that can cause symptoms ranging from diarrhea to life-threatening inflammation of the colon. Illness from C. difficile most commonly affects older adults in hospitals or in long term care facilities and typically occurs after use of antibiotic medications. http://www.mayoclinic.com/health/c-difficile/ DS00736. Accessed December 23, 2011. [10] Value in health care: key information for policymakers to assess efforts to improve quality while reducing costs, US General Accountability Office, GAO11-445, July 26, 2011. http://www.gao.gov/products/GAO-11-445, Accessed December 12, 2011. [11] High value health care collaborative expands, June 1, 2011. http://www. dartmouth-hitchcock.org/news/newsdetail/59724/. Accessed 12/11/2011. [12] R.R. Cima, A. Kollengode, J. Clark, S. Pool, C. Weisbrod, G.J. Amstutz, C. Deschamps, Using a data-matrix-coded sponge counting system across a surgical practice: impact after 18 months, Jt. Comm. J. Qual. Patient. Saf. 37 (2) (2011) 51–58. [13] E.P. Hess, R.J. Brison, J.J. Perry, L.A. Calder, V. Thiruganasambandamoorthy, D. Agarwal, A.T. Sadosty, M.L. Silvilotti, A.S. Jaffe, V.M. Montori, G.A. Wells, I.G. Stiell, Development of a clinical prediction rule for 30-day cardiac events in emergency department patients with chest pain and possible acute coronary syndrome, Ann. Emerg. Med. (2011). [14] The Patient Centered Medical Home is a health care setting that facilitates partnerships between individual patients, and their personal physicians, and when appropriate, the patient’s family. Source: National Committee on Quality Assurance. http://www.ncqa.org/tabid/631/default.aspx. Accessed December 23, 2011. [15] J. Kamath, J. Osborn, V. Roger, T. Rohleder, Highlights From the Third Annual Mayo Clinic Conference on Systems Engineering and Operations Research in Health Care, Mayo Clinic Proceedings, August 2011, p. 781.
Contents lists available at SciVerse ScienceDirect
Operations Research for Health Care journal homepage: www.elsevier.com/locate/orhc
Short communication
Highlights of the 2011 Mayo Clinic Systems Engineering and Operations Research conference Gene C. Dankbar a,∗ , Mark J. Hayward b a
Division of Systems and Procedures, Mayo Clinic, Rochester, MN 55905, USA
b
Center for the Science of Healthcare Delivery, Mayo Clinic, Rochester, MN 55905, USA
article
info
Article history: Received 16 January 2012 Accepted 19 January 2012 Available online 27 February 2012 Keywords: Health care Mayo Clinic Systems engineering
abstract In this report, we share highlights of the fourth annual Mayo Clinic Systems Engineering and Operations Research conference. The conference provided a forum for system engineers, operations researchers, clinicians, managers and administrators to share experiences, learning and success stories from their work in applying analytical and modeling tools to a range of problems. This report represents a snapshot of the challenges faced in acute health care, the techniques being deployed and the progress being made by engineers and operations researchers in helping to improve the quality and value of services. © 2012 Elsevier Ltd. All rights reserved.
1. Introduction The Fourth Annual Mayo Clinic Conference on Systems Engineering and Operations Research (SEOR) in Health Care was held in August 2011 in Rochester Minnesota, USA [1]. The conference was held in association with the Production and Operations Management Society (POMS) and the Society for Health Systems (SHS). The continuing mission of the conference is to gather a multidisciplinary group of systems engineers, clinicians, administrators, and academic professors to discuss the translation of systems engineering methods to more effective health care delivery [2]. The challenges outlined in the 2001 Institute of Medicine Report, Crossing the Quality Chasm, are still relevant today [3]. New to the 2011 Conference was the ability for attendees R to attend the conference through Second Life⃝ [4]. The conference concluded with a powerful story from a patient and their care team on the importance, and urgency, to use the tools of systems engineering and operations research to improve the health of all patients. 2. Conference workshops The conference started with a series of workshops. Dr. Franklin Dexter, University of Iowa, focused on decision-making on the day of surgery. As a practicing anesthesiologist with a long interest in operations research, Dr. Dexter brings a unique perspective to
∗
Corresponding author. Tel.: +1 507 266 1698; fax: +1 507 266 6806. E-mail addresses: [email protected] (G.C. Dankbar), [email protected] (M.J. Hayward). 2211-6923/$ – see front matter © 2012 Elsevier Ltd. All rights reserved. doi:10.1016/j.orhc.2012.01.003
the issues of effectively staffing the operating room. Dr. Dexter led participants through numerous scenarios for improving the safety and efficiency of the operating room. Continuing the theme of surgery, Dr. David Cook and Jeff Thompson, Mayo Clinic, discussed their work in cardiovascular surgery to reduce costs while simultaneously improving care for their patients. Using tools from six sigma to obtain baseline information and to identify the key variables, the project team used computer simulation modeling to evaluate different scenarios related to staffing models, number of operating rooms used, hours of operation, and the impact of reducing variation in case length to explore the influence on costs and efficiency. The insights from examination of the historical information along with the modeling led the team to develop new protocols, theater schedules, and streamlined methods to deliver better patient care. The workshop highlighted the importance of combining the traditional tools of quality improvement and systems engineering. The importance of applying OR tools to the issue of patient access in ambulatory care settings was highlighted in the workshop by Hari Balasubramanian, Ph.D., University of Massachusetts. Dr. Balasubramanian outlined the tradeoffs in ambulatory clinics on patient panel size [5], the mix of each clinician’s empaneled patients, length of appointments, patient satisfaction, continuity in seeing a familiar provider, and the flexibility of the ambulatory care staff in providing timely care to their patients. Probability and computer modeling showed the tradeoffs associated with the complexity of a problem faced by every ambulatory care clinic. The final two workshops revolved around computer simulation modeling. Mayo Clinic colleagues, Thomas Rohleder, Ph.D., Todd Huschka, and Brian Bailey, led participants through a tutorial on the basics and value of simulation. They stressed that success in simulation is only possible through a well-defined problem,
G.C. Dankbar, M.J. Hayward / Operations Research for Health Care 1 (2012) 16–19
knowledge in computer simulation modeling, and available expertise on the clinical processes concerned. Dr. Yue Dong, Fazi Amirahmadi, Chris Schieffer, and Ashish Gupta, all of Mayo Clinic, took computer simulation into the intensive care unit, applying the skills to sepsis resuscitation. Using discrete event simulation they were able to evaluate differing scenarios for patients with suspected sepsis in a cost effective manner to identify the options leading to optimal care and costs. 3. Opening keynotes Mark Hayward, conference co-chair, Mayo Clinic, opened the general conference and introduced Dr. John Noseworthy, Chief Executive Officer, Mayo Clinic. Dr. Noseworthy discussed the many different ways engineers have helped Mayo Clinic since its founding. From engineers helping build devices for Mayo Clinic physicians and scientists to the staff in the Division of Systems and Procedures, an internal consulting group at Mayo Clinic staffed by individuals with skills in industrial and process engineering. Dr. Noseworthy pointed to Mayo Clinic’s first system engineer, Dr. Henry Plummer, one of the partners with the Mayo brothers. In concluding his remarks, Dr. Noseworthy challenged conference participants to leverage their engineering skills to partner with clinicians to make connections to our patients, wherever they may be in the world. Dr. Albert Mulley, Director of the Dartmouth Center for Health Care Delivery Science, discussed his long research in the area of informed medical decision-making. Dr. Mulley’s research has focused on the use of decision theory and outcomes research to distinguish between warranted and unwarranted variations in clinical practice. Dr. Mulley encouraged participants to review the recent report from the Institute of Medicine, Engineering a Learning Healthcare System: A Look at the Future—Workshop Summary [6]. Dr. Mulley went on to describe the work of Dr. Jack Wennberg and his colleagues at the Dartmouth Atlas [7]. This work shows widespread variability in the amount of care and cost of care across the United States. An article by Dr. Atul Gawande, ‘‘The Cost Conundrum’’ [8] brought this variability to life by describing the differences between two communities in Texas. These are the challenges facing system engineers. Teamwork between clinicians, engineers, and other team members in the process will be critical. Dr. David Lane, London School of Economics (LSE), illustrated the use of system dynamics (SD) through two public health examples. The United Kingdom National Audit Office and LSE staff constructed a simulation model to understand and control clostridium difficile outbreaks [9]. Different contamination stages, various transmission mechanisms and bed, toilet and staff hand cleaning were represented. In the second example, SD qualitative systems mapping approach was used to structure child and family social workers’ understanding of the problems with the existing system. Dr. Lane highlighted the benefits of involving people in building SD models to establish understanding, and buy-in, of the system, better solutions, and a commitment to action. The first day of the conference concluded with a panel discussion describing Mayo Clinic’s methods for providing increasing value in health care. Dr. Veronique Roger, Dr. Robert Nesse, and Robert Chase pointed to Mayo Clinic’s commitment to continually explore new ways to bring higher value to patients. Dr. Roger, chair, Mayo Clinic Center for the Science of Health Care Delivery, pointed to numerous articles on methods to improve health care. Dr. Roger also stressed the need for rigor in our approaches, to ensure the solutions are generalizable [10]. Dr. Nesse, Chief Executive Office, Mayo Clinic Health System, described efforts by leading healthcare organizations to collaborate to improve care through the High Value Health Care Collaborative (HVHC) [11]. Nesse, Roger, and Chase emphasized the need for health care groups to move to new models of care, align research and measures, and focus on delivering value in a cost-effective manner.
17
4. Improving care and patient safety in the operating rooms The second day of the conference featured a wide array of applications of SEOR tools in a variety of clinical settings. Dr. Robert Cima, Mayo Clinic, shared how the use of technology in the operating rooms has helped to reduce the number of retained foreign objects to near zero. Extensive data analysis from over 190,000 operations revealed the majority of those retained foreign objects were sponges. Through bar-coded technology, supporting hardware and process changes, Mayo Clinic in Rochester, Minnesota, has gone three years without a retained sponge in the operating room. Dr. Cima emphasized the multidisciplinary nature of the project team along with extensive data and financial analysis leading to project success [12]. Vikram Tiwari, Ph.D., University of Houston, and David Berger, MD, Baylor University, laid out of the case for real-time flow control of the operating room. Their project entailed a real-time location system for patients, personnel, critical equipment, and activities. Real-time visual displays are also an important part of the changes to help personnel track and react to the hourly changes. Improved operating room utilization, reductions in delays between cases and timeliness of first cases were just a few of the successes seen by the project. Dr. Brian Rothman, Vanderbilt University, shared work underway at his institution to provide real-time decision support in the operating rooms. The Vanderbilt Perioperative Information Management System (VPIMS) is an integrated electronic medical record with real-time anesthesia and nursing documentation and providing notification information to staff throughout the operating rooms via electronic in-room whiteboards, desktop computers, and conventional pagers. Rothman noted timely delivery of this information can provide clinical teams better opportunities for safe and effective care. 5. Data mining for making better decisions in health care The extensive use of data mining and analysis in health care was illustrated in a session hosted by three clinical practitioners from Vanderbilt University. Dr. Stephan Russ addressed the difficult problem of patient placement in the hospital setting. Through a switch to a centralized bed assignment system, the hospital was able to reduce the time it takes to assign a bed and increase inpatient occupancy without an adverse affect on the rate of patient transfers. Dr. Brian Rothman discussed the need for capacity planning for facilities through an illustration on the number of operating rooms needed in Obstetrics for handling unpredictable cases. The team looked at three years of historical data in the obstetrics suite and showed through statistical process control charts, the probability of needing an additional operating room. Use of the model helped decision-makers make an informed decision regarding an expensive resource. Dr. Jesse Ehrenfeld concluded the session by pointing to the usefulness of the extensive information available in the operating rooms. 6. Optimizing patient flow Craig Froehle, Ph.D., University of Cincinnati, addressed the complex issue of providing continuity of care for patients with complex health issues. These patients may see a different, customized subset of providers during their visit. Using mixed integer programming, the team was able to develop patient and provider schedules to minimize patient wait times, provider idle time, and the duration of the clinic. Implications for spreading the scheduling model to a larger facility were discussed during the session. Denise White, Ph.D., Cincinnati Children’s Hospital Medical Center, continued the discussion on clinic flow by exploring the
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complexities involved in coordinating several patient visits along with ensuring good patient service. White and colleagues explored the problem through five scenarios in how patients are seen in an outpatient clinic. Dr. David Cook and Thomas Rohleder, Ph.D., Mayo Clinic, explored future bed needs in cardiovascular surgery through simulation modeling. The model explored differing scenarios and looked at seasonal effects, patient mix, and projected lengths of stay for both intensive care unit (ICU) beds and step down units. The model is being used by decision makers to help evaluate the tradeoffs between service levels and ICU bed utilization. 7. Health information systems The topic of electronic medical record (EMR) implementation garnered a large amount of interest during one of the largest attended breakout sessions. Dr. Brian Hinch, University of Toledo Medical Center, shared his long experience with EMR implementation and openly shared the lessons learned during their recent implementation. Visible physician support, listening to user needs for customizing certain aspects of the medical record, extensive staff training, and personal support during the EMR rollout were key. One hundred percent adoption of the EMR at all clinics and a positive return on investment, along with improved patient outcomes have ensued. In addition, the EMR provided a robust method for actively finding potentially harmful prescribing errors and correcting them before the medication was issued. Wesley Williams, Ph.D., Mental Health Center of Denver, showed how incorporation of the EMR into the workflow of the clinicians was key to effective implementation. Enabling clinicians to have their information in one system helped reduce errors at the source and led to high degrees of clinician satisfaction. Maryanne Mathiowetz shared Mayo Clinic’s long experience with the EMR and discussed the integration of internally developed applications with vendor supplied software. Phased implementation of the EMR and concentrating on clusters of patient care units ensured consistency and adequate education for staff affected by the changes. 8. Systems engineering tools to enhance lean and six sigma projects The complimentary nature of systems engineering and operations research tools lean and six sigma were on full display in this breakout session. Robert Furrey, Baptist Health Medical Systems, Little Rock, Arkansas, addressed the issue of capacity in their cardiovascular practice using lean and six sigma methods. Through identification of process bottlenecks, the team was able to produce a real-time information system to help the clinical staff determine which patients are waiting, who is ready for procedure, and schedule discharge time. The patient tracking system helped staff handle a 26% increase in volume with no constraints while using existing staff. Planning for the potential of a pandemic was the task faced by Amin Gupta, Ph.D., University of Louisville. The realities of a potential H1N1 or viral attack are remote, but possible. Gupta used computer simulation to build upon prior work on a drive-through mass vaccination clinic. Drive-through clinics have the advantage of higher throughput, less chance of spreading disease, and waiting inside the vehicle. Gupta’s model may have wide applicability in communities across the world. It is an ongoing challenge in hospital operating rooms: getting the first case started on time. Kevin Taafe, Ph.D., Clemson University, and colleagues took on this challenge. Balancing a need to start the operating rooms on time, improve room utilization, with patient, surgeon, and staff satisfaction, the multidisciplinary team utilized six sigma tools and computer simulation. Based on computer simulation, the team was able to demonstrate the potential to move to 88% on time performance.
9. Patient outcomes analysis The importance of examining and analyzing patient outcomes was the focus in this session. James Naessens, ScD, Mayo Clinic, reviewed the importance of risk adjustment in medical care. Riskadjustment is essential as researchers and front-line clinicians work to ensure valid comparisons across organizations. David Vanness, Ph.D., University of Wisconsin School of Medicine and Public Health, discussed the importance of recursive partitioning to segment patient groups into subgroups with similar outcomes. This important work helps investigators make better predictions of mortality and morbidity at specified levels of the economy. Predictive risk modeling is a rich area for research in SEOR and Dr. Erik Hess, Mayo Clinic, and colleagues discussed this challenge. The importance of keeping the patient in the center of risk assessment and subsequent decisions was front and center in Dr. Hess’ presentation. Predicting the need for treatment for patients who present with chest pain to the emergency room was illustrated [13]. 10. Storyboard session Another prominent piece of the conference is the extensive number of storyboards. Nearly forty storyboards were shared throughout the conference. Special recognition was awarded to two of the presenters: Takahiro Tanaka, Binghamton University, for their paper, ‘‘Infusion Chair Scheduling Optimization Applying Bin-Packing Heuristics’’ and Rema Padman, Carnegie Mellon University, for their paper, ‘‘Modeling and Analysis of Flows, Response Time and Variability in the eVisit Care Delivery Process’’. 11. Organizational change The final day of the conference started with Dr. Carl Clark, Chief Executive Officer, Mental Health Center of Denver. Dr. Clark has challenged his organization to become the best mental health services in the country. To meet the challenge, his team has worked to create meaningful measures. Dr. Clark reminded attendees mental health is the top health burden in the United States and patients carrying a mental health burden live, on average, 25 years less than all Americans. Dr. Clark has a firm belief every patient can recover. The demand for mental health outstrips the capacity to see all the patients. SEOR skills are needed to solve this vexing issue. In concluding his remarks, Dr. Clark reminded attendees of the need for soft skills along with our technical skills: ‘‘. . . people do not care how much you know; it is how much you care’’. Dr. Steve Hagedorn, Mayo Clinic, joined the conference to discuss the development of the Medical Home [14]. Dr. Hagedorn outlined five principles for creating a team-based, medical home model:
• • • • •
Standardize the processes to support the infrastructure. Develop the multidisciplinary team. Develop the metrics to support the changes. Think patient-centered. Leverage the power of teams.
12. Conclusion For the first time in the four years of the conference, a patient and family member were invited to participate in an open panel discussion regarding the care they received during a recent health experience. Members of the patient’s care team were in attendance to describe the systems in place to support the patient’s care in the outpatient and inpatient setting. Dr. Michael Rock, Mayo Clinic, and well known healthcare OR practitioner, Distinguished Professor Emeritus William Pierskalla, Ph.D., UCLA, co-facilitated the session.
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The opportunities for SEOR skills were highlighted throughout the session. Dr. Pierskalla told participants ‘‘. . . when SEOR is done well, it is largely invisible to the patient, clinician, and hospital employee’’. Pierskalla noted the following enablers to success in applying SEOR skills in healthcare: 1. 2. 3. 4. 5. 6.
Patient Centered Culture of the system. Information Technology/Information System availabilities. Teamwork from all involved parties. Salaried versus fee for service physicians. Capable, knowledgeable SEOR staff employees. A culture of always looking for ways to improve.
The patient’s story served as a powerful reminder of the challenges faced by health care. The collaboration between clinical practitioners and SEOR practitioners is critical in the next few years as the US healthcare system faces an aging population, growing chronic illness, and dwindling monetary resources. As engineering principles and models are gradually incorporated into the fabric of health care delivery systems, a deliberate commitment must be made by health care professionals and engineers alike to build nimble yet robust evaluation systems centered on patient choices and preference for care delivery and outcomes [15]. References [1] See the 2011 Mayo Clinic Conference on Systems Engineering and Operations Research in Health Care web site. http://www.mayo.edu/cme/special-topicsin-health-care-2011r092. Accessed December 23, 2011. [2] J. Kamath, J. Osborn, V. Roger, T. Rohleder, Highlights From the Third Annual Mayo Clinic Conference on Systems Engineering and Operations Research in Health Care, Mayo Clinic Proceedings, August 2011, p. 781. [3] Crossing the Quality Chasm: A New Health System for the 21st Century, National Academies Press, 2001.
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[4] Second life. http://secondlife.com. Accessed December 15, 2011. [5] Panel size is the number of patients assigned to a clinician for ongoing care, Mark Murray, Mike Davies, Barbara Boushon, Panel Size: How Many Patients Can One Doctor Manage?, Family Practice Management, April 2007, p. 44. [6] Engineering a learning healthcare system: a look at the future—workshop summary, Released: July 8, 2011. http://www.iom.edu/Reports/2011/ Engineering-a-Learning-Healthcare-System.aspx. Accessed December 6, 2011. [7] Dartmouth Atlas of Health Care. http://www.dartmouthatlas.org. [8] Atul Gawande, The cost conundrum, what a texas town can teach us about health care, The New Yorker, June 1, 2009. [9] Clostridium difficile, often called C. difficile or C. diff, is a bacterium that can cause symptoms ranging from diarrhea to life-threatening inflammation of the colon. Illness from C. difficile most commonly affects older adults in hospitals or in long term care facilities and typically occurs after use of antibiotic medications. http://www.mayoclinic.com/health/c-difficile/ DS00736. Accessed December 23, 2011. [10] Value in health care: key information for policymakers to assess efforts to improve quality while reducing costs, US General Accountability Office, GAO11-445, July 26, 2011. http://www.gao.gov/products/GAO-11-445, Accessed December 12, 2011. [11] High value health care collaborative expands, June 1, 2011. http://www. dartmouth-hitchcock.org/news/newsdetail/59724/. Accessed 12/11/2011. [12] R.R. Cima, A. Kollengode, J. Clark, S. Pool, C. Weisbrod, G.J. Amstutz, C. Deschamps, Using a data-matrix-coded sponge counting system across a surgical practice: impact after 18 months, Jt. Comm. J. Qual. Patient. Saf. 37 (2) (2011) 51–58. [13] E.P. Hess, R.J. Brison, J.J. Perry, L.A. Calder, V. Thiruganasambandamoorthy, D. Agarwal, A.T. Sadosty, M.L. Silvilotti, A.S. Jaffe, V.M. Montori, G.A. Wells, I.G. Stiell, Development of a clinical prediction rule for 30-day cardiac events in emergency department patients with chest pain and possible acute coronary syndrome, Ann. Emerg. Med. (2011). [14] The Patient Centered Medical Home is a health care setting that facilitates partnerships between individual patients, and their personal physicians, and when appropriate, the patient’s family. Source: National Committee on Quality Assurance. http://www.ncqa.org/tabid/631/default.aspx. Accessed December 23, 2011. [15] J. Kamath, J. Osborn, V. Roger, T. Rohleder, Highlights From the Third Annual Mayo Clinic Conference on Systems Engineering and Operations Research in Health Care, Mayo Clinic Proceedings, August 2011, p. 781.