Optimizing Capital Investments in Health Facilities through Prototype Development & Simulation...
-
Upload
cannondesign -
Category
Technology
-
view
1.420 -
download
2
description
Transcript of Optimizing Capital Investments in Health Facilities through Prototype Development & Simulation...
Optimizing Capital Investments in Health Facilities through Prototype Development &
Simulation Evaluations Prior to Implementation
March 15, 2010
Speakers
Dale E. Beatty, MSN, RNExecutive Vice President Patient Services & Chief Nursing Officer Northwest Community Hospital
Deborah Sheehan, ACHE,EDAC, LEED AP
PrincipalCannon Design
Jocelyn Stroupe, AAHID, IIDA, ASID, EDACPrincipalCannon Design
Charlie Stevenson, AIA, CPE
DirectorNorthwest Community Hospital
Building Healthcare facilities without re-engineering the operational model can be risky and often is unsuccessful
Prototyping tools can enhance the ability to meet current healthcare needs quickly and effectively through the use of proven techniques that test theories related to positive outcomes
Healthcare facilities are challenged to continually deliver care with fewer resources. The simulation and prototype process assists in prioritizing value based decisions and can enable the care model to be developed in a low-risk environment
Key Issues
Agenda: Prototype Development
What can be the impact of Prototype application?
Outcomes of Prototype Development
Prototype as Process Standard;
Clinical Protocols, Workflow Patterns, Technology Applications
Prototype as Physical Standard;
Department Organization, Key Rooms, Product Specifications
Impact of Prototype Application
Research Applied To Prototype Development
Metrics Benchmarking
Clinical Measures
Environment Impact
Measures
Satisfaction Measures
Financial Measures
Impact of Prototype Applications
Metrics Benchmarking
Clinical Measures
Environment Impact
Measures
Satisfaction Measures
Financial Measures
Prototype Development
Process Protocols/Standards
Safety and Outcome Improvements
Medication Errors, Falls, Time to Treatment
Willingness to Recommend Score >85%
NPV Results
Operating Costs, Program Size, Time to Market
Outcomes of Prototype Development
Clinical Measures Benchmarking Clinical Pathway and Workflow Design
Supplies16%
Insurance3% Capital
10%
Staffing Resources71%
Clinical Measures Benchmarking Clinical Pathway and Workflow Design
AmbulatoryPatient
AmbulancePatient
Greeting/Triage
Diagnostics
Non-Urgent
NursingUnitCashier AdmitDischargeHome
Decontam
Non-Contam
Visual Barrier
ClinicalDecision
Unit
OtherFacility/NursingHome
Transfer
Observe
Admit
Transfer
HomeDischarge
Admit
Major ED Rooms/
Trauma
Radiography
In Room• Admit• Lab• RT• EKG
Exam/Treatment
Room
In Room• Admit• Lab• RT• EKG
Emergency
Published Studies on Evidence-Based Design1200
600
84
1998 2004 2008
Environment Impact Measures Application of Evidenced Based Design
Financial Measures Impact to First and Lifecycle Cost
118.2 KBtu/SF at $.08/kWh
= $ 901,244 Annual energy cost
Financial Measures Impact to First and Lifecycle Cost
48 kBtu/sf at $.08/kWh
= $ 360,500 Annual energy cost
Yield Savings of $ 540,000 per year
@ 4% margin= $10M Revenue
Financial Measures Impact to First and Lifecycle Cost
PHAMA: Establishing the Business Case
Patient and Staff Satisfaction MeasuresTarget Top Quartile in All Areas
Inpatient Likelihood to Recommend 99th%tile
Outpatient Likelihood to Recommend 50th %tile
Emergency Department Likelihood to Recommend 92 %tile
1st fy Q 10 2nd fy Q 10 3rd fy Q 10 4th fy Q10 1st fy Q110
10
20
30
40
50
60
70
80
90
Patient Satisfaction per Quarter / Year
Series1
Quarter / Year
Per
cen
tile
Ran
k
Prototype as Process Standard;
Clinical Protocols, Workflow Patterns, Technology Applications
Prototype Development: An Illustrative Model
Northwest Community Healthcare (NCH)
Evidence-based decision process–Rigorous Benchmarking–Ongoing ROI Analysis– Research to validate Key Assumptions
– Medication Distribution– Family Care Model– Established Performance Metrics
clinical, consumer, operations, financial
–Product life cycle analysis–Energy Consumption modeling
NCH Strategic Goals
1 Move from semi-private patient rooms to private rooms to meet consumer demand
2 Position hospital to adapt to a variety of acuity levels of patients easily with minimum construction disruption
3 Speed to market: competitive environment
Staff / Consumers / Technology
4 Achieve regulatory and clinical advancements
Need to convert patient population a staff neutral cost model
Apply standardization of patient units design for ease of adaptation / conversion in future
Universal size of planning module allow for prefabrication & testing of repetitive units off site
Innovate and standardize clinical protocols for medication distribution at bedside
Prototype Opportunity
Applied a model for assessing health care quality based on structure, processes and outcomes developed by Dr. Avedis Donabedian
First Step in Creating PrototypesAssess Model of Care
Structures Processes
CONSEQUENCE of the
healthcare provided
METHOD by which
healthcare provided
ENVIRONMENT in which
healthcare provided
Outcomes
StructuresPrototype Model of Care
Structure
Shared Governance leverage years of professional experience
Organizational Structures enable decision accountability
360 degree feedback/testingPatients, Families, Care Providers, Community Members, Allied Industries , Volunteers
ProcessesPrototype Model of Care
“Goal: Services should be patient centered and should be pushed to the point of service.” 2008 Transforming Care at the Bedside Initiative (TCAB)
Caregiver workflow redesign to increase patient care time Standardize materials & supplies stock and distribution to elimate
hunting and gathering time Bedside medication administration to increase patient safety
outcomes Linen exchange and distribution to ease supply managment Clinical documentation at appropriate site of care
Processes
ProcessesCaregiver Workflow Assessment
International Nursing Unit Workflow Study
conducted by Dr. Monique Lambert, PI, Intel Digital Health Group
9 Hospitals in US, UK, Singapore
18 different acute units
600 hours of direct observation in total
Documented patterns of clinical work in field notes
Captured clinical work processes using photos and video
Observed clinicians interacting with technology and paper-based systems
Processes
Processes Caregiver Workflow AssessmentMulti-Cognitive vs. Multi-Task Nurse Work Flow : 1 RN, 1Shift
SHIFT CHANGEASSESS PT
PATIENT CRASHASSESS PATIENT
CONSULT WITH MDCHECK /RECORD VITALS
START MED PASSCHART ENTRY
IV WORK CHART ENTRY
COORDINATE UAVITALSCHART
RECEIVE REPORTCONSULT W/ SOCIAL WRK
COORD DISCHARGEORDER FOOD TRAY
COORDINATE UAREMOVE INFUSION PUMP
RECONCILE ORDER TO D/C CATHETERREMOVE CATHETER
CHARTPATIENT COMFORT ADJUST
COORD ORDER FOR NAUSEA MEDSCHECK CATHETER
CHARTADL S
CHART CATHETERNEW LAB ORDERS
ADMIN MEDSGIVE REPORT
LUNCHSPK W PT FAMILY
MEDS, HOME HLTH EDUCIV FLUSH
RECEIVE REPORTIV FLUSH
NEW LABSDISCHARGE PAPERWORK
PAIN MEDS ADMINISTRCHART
RE ASSESS PTDISCHARGE EDUC
DRESSING CHANGECONSULT W SITTER, CRASHING PT
MSG TO IV NURSECHART
LOOK FOR SENSOR OXIMETERSPK W SOCIAL WORKER
CHECK I/O SCHK CHART, NEW ORDER
PICK UP MEDSIV PREP
CHART I S AND O SREVIEW ORDERS
RETRIEVE WIPES FOR PTRETRIEVE COMMODE
PASS MEDSORDER FOOD TRAY
ADL SBREAK
COORD PTPASS MEDS
CHARTREC REPORT
PREP SHIFT REPORTPAGE MD
CALL PT FAMILYCHART
REV PROGRESS NOTESGIVE REPORT
EPISODE
(73)
Nursing workflow is consumed with both cognitive and physical multitask orientation
Multiple tasks with short durations.
Medication administration being one of the largest
Multiple task with multiple interruptions present for potential patient safety issues
Facilities and information system redesign must support nursing workflow in order to improve clinical, service and financial quality
Opportunities exist to re-model care delivery to promote care coordination and critical thinking versus task orientation
Processes Prototype DevelopmentCaregiver Workflow Assessment – Summary of Findings
Processes
10/07/2008Copyright © 2007 McKesson Provider Technologies
Privileged, Proprietary and Confidential. All r ights reserved. 24
9N: Nurse 2
Industry Benchmark : Medications located at bedside can save up to 2 hours of nurse’s time walking back and forth to Med. Room.
Processes Prototype DevelopmentCaregiver Workflow Assessment – Focus on Medication Distribution
Medication Delivery: 1st Shift (8:30 – 9:30am), 1RN
Outcomes What Should be Standardized? Defining the Expectation
Idea Exchange – Cross Industry Discussion of PrototypesPurpose:- Leverage the organization and healthcare community to discuss issues & expectations- Increase awareness of best practice thoughts & ideas in an outside healthcare industry- Validation of findings from research and peer benchmarking
Anticipated Outcome: Performance measures that define success that can establish standard prototypes
Industry Perspectives;
Outcomes
ISSUES OPPORTUNITIES PROGRAM OBJECTIVES
Enh
ance
pat
ient
ex
peri
ence
Red
uce
erro
rs
Impr
ove
Pro
cess
Red
uce
Cos
ts
Gai
n co
mpe
titi
ve
Edg
eIn
corp
orat
e E
vide
nce
Bas
ed
Des
ign
Impr
ove
Safe
ty
Cre
ate
Arc
hety
pe
for
Des
ign
Current State/ Baseline
Future State/ Process Improvement Metric/Target
CLINICAL
Use of Semi-Private Rooms -80% Semi-private beds -20% privates
Increase Private Rooms -80% Semi-private beds -20% privates
X X X X X X X X Improve Pt Satisfaction Scores by 10%; Lower Infection Rates by 5%; Lower ALOS; Reduce Pain Meds, Reduce Pt Falls by 5%; Reduce Medical Errors, Reduce Wrong Pt Errors, Increase Occupancy Rates
OutcomesQuantifying Metrics to Measure Impact
Outcomes
Outcomes Define the Goal, Do Not Adjust to the Consequences
What are the current processes in place?
Which steps are not value added?
Which steps can be combined or automated?
What are the future trends in the OR we will use?
How will this impact the process and staff roles?
Based on the above, how can technologies be leveraged?
How will the facility be designed to support the new realities?
Outcome: Reduce OR case start delays by 50% in the new facility
Outcomes
Outcomes Define the Goal, Do Not Adjust to the Consequences
Outcome: Reduced OR case start delays by 50% yields Virtual Capacity, Financial Savings
Why Does This Matter?
Cost
Annual OR Total Expense $20,000,000
Annual OR Case Volume 9,500
Average Cost/Case $2,105
Average Case Time (incl. room turns) 135 minutes
Average Cost per Minute of OR Time $15
Total Annual Delays 3,100
Average Delay Time (minutes) 16
Annual Cost Impact of Delays $744,000
Cost Savings with 50% Reduction $372,000
In major metro market, $372,000 in savings funds FOUR nursing FTEs annually.
Outcomes
Prototype as Physical Standard;
Department Organization, Key Rooms, Product Specifications
Organizational DiagramsMap Function Programand Relationships
Building Support
• Janitor Closet• Mech/Elec
Building Support
• Janitor Closet• Mech/Elec
Admin Support - Offices
Family / Public SupportWaiting
Dining / VendingConsult
Staff SupportLockerLoungeOn-Call
TeamWork
Consult
Support• Clean• Soiled• Nourish• Med Prep• Equip Store
Multi- purpose
TeamWork
Priv
Priv
Priv
Priv
Priv
Priv
Priv
Priv
Priv
Priv
Private Rooms
TeamWork
Consult
Multi- purpose
TeamWork
Support• Clean• Soiled• Nourish• Med Prep• Equip
Store
Priv
Priv
Priv
Priv
Priv
Priv
Priv
Priv
Priv
Priv
TeamWork
Consult
Multi- purpose
TeamWork
Support• Clean• Soiled• Nourish• Med Prep• Equip
Store
Priv
Priv
Priv
Priv
Priv
Priv
Priv
Priv
Priv
Priv
Support• Clean• Soiled• Nourish• Med Prep• Equip Store
Private Rooms Private Rooms
Process SimulatorTest Functional / Behavior Assumptions; Work flow, size and transport time
Four step process:1. Diagram the process2. Add behavioral information3. Run the simulation4. Analyze the results5. Make adjustments
Interactive Gameboarding: Apply Organizational Grid, Test Dependants and Adjacencies
Caption for image
Facility Simulation Modeling Validate Organizational Assumptions
Key Rooms; Private Patient Room Computer Modeling Validate Travel Distance, Site Lines, Clearances, FFE
36Confidential and Proprietary © June 2009 OWP/P
Key Rooms; Private Patient Room Computer Modeling Validate Travel Distance, Site Lines, Clearances, FFE
37Confidential and Proprietary © June 2009 OWP/P
Key Rooms; Private Patient Room Computer Modeling Validate Travel Distance, Site Lines, Clearances, FFE
Physical Testing Creating a Mock Up Center
Physical Testing Creating a Mock Up Center
COSTS: Initial construction cost – carpet: $500,000 less than vinyl sheet 20-year life cost – vinyl flooring: approximately $2 Million less than carpeting
NOISE: Multi-year study Press Ganey patient satisfaction scores on noise: carpet scored same as vinyl APPEARANCE: Vinyl flooring keeps a more consistent, higher level of appearance over life cycle
SUMMARY Cleaning / Labor Costs AFTER 20-yrs/1,000 SF Annual Cleaning / Labor Costs for 110,000 sf Labor Supply
Sheet Vinyl $33,552.74 $184,540.05 $ 77,396.10 $ 107,143.95
Linoleum $28,689.82 $157,793.99 $ 73,391.76 $ 84,402.23
Carpet Tile $40,357.10 $221,964.06 $205,967.11 $15,996.95
Physical Testing Life Cycle Cost AnalysisLIFE CYCLE FLOORING COMPARISON
Product Type Comments Usable Product
Life
Installed Cost Sq.
Ft.
AverageInstalled Cost (per
1,000 sf)
Times Replaced in 20
yrs
Material cost after 20 yrs
Cleaning/Labor Costs after 20 yrs
(per 1,000sf)
Total Costs in 20 Yrs
Wax/Seal Required
PSI
Sheet Vinyl heat welded
Requires some finish
20 years
$5.25 $5,250. 0 $5,250. $33,552.74 $38,802.74 Yes 750m
Sheet VinylWood look heat welded
Requires some finish
20 years
$7.00 $7,000. 0 $7,000 $33,552.74 $40,552.74 Yes 700m
Linoleumwelded
Requires some finish (depending
on installation)
20 years
$5.25 $5,250. 0 $5.250 $28,689.82 $33,939.82 Some 400m
Carpet Tile Ease of replacemen
t
5 years $5.00 $5,000. 3 $15,000. $40,357.10 $55,357.10 n/a n/a
Physical Testing Creating a Mock Up Center
Physical Testing Creating a Mock Up Center
Mock Up Testing Results Survey Clinician, Patients, Families, Community• Patient Unit Prototype Comments • Private room ~ staff connections • Response to family needs• Continuous handrails to toilet room• Concern for privacy with charting
windows• Concern about acoustics/noise
control• Flooring analysis: ergonomics,
acoustics, rolling resistance, maintenance
• Furniture analysis: chair, recliner, overnight accommodations
• Hand wash sink access• Medication drawer locations
Prototype Results1. Strategic Impact
Increased from the 35th to the 81st percentile in “Likelihood to Recommend” from
Quarter 1 2010 to Quarter 1 2011. (December 2011 patient satisfaction was at the 99th percentile).
Growth in OB / GYN, Physician recruitment increased by 45%.
200% Growth in neonatal care program and achieved Level III Nursery status.
Growth in PSA and SSA market in competitive region offering elevated inpatient environments. 5.5% increase in discharges from FY 2010 to FY 2011.
Created market differentiation with outdoor therapeutic service on Units.
Pilot Horticultural Therapy Program – Proprietary Services offering in the region.
Exterior balcony utilization: Averaging 270 visitors / month per unit.
Nursing “Job Enjoyment” as measured by NDNQI is above the national mean (Oct. 2010).
Prototype Results2. Operational Impact
Elimination of thru room Nurse Servers.
First cost savings of $460,000 (millwork).
Mitigate historic 11-18% loss of inventory .
Decentralize medication distribution to the bedside (TCAB)
Mitigate infection control risk. (Savings +/-$11,000/blood infection).
Patient safety standardization. (Mitigate falls, decreased by 17%).
Greater adoption of clinical documentation at the bedside which promotes improvements in care coordination and communication. (Patient Satisfaction due to
increase increased patient-nurse face time).
Inventory cost control for non-chargeable due to consolidated organizational model.
Private Accommodations = 50% increase in square foot area with no FTE increase.
(All nursing staffing is within the 75% performance quartile as measured by Deloitte).
3. First Cost/Facility Impact Elimination of double door access to patient room
Net savings of $400,000.00 Flooring product testing and selection yielded 15-year lower life-cycle cost Private patient rooms resulted in higher patient utilization rates from 64% to
86% in first 6 months Energy savings forecast in first year operations of $380,000 Speed to market fabrication of prototype room components advanced
project completion 3.5 months ahead of schedule ~ patient revenue of $6.4M contribution
Prototype Results
40% reduction in baseline required FTEs per Adjusted Patient Discharge as modified for Case Mix Index
50% decrease from baseline aggregated clinical procedure cycle times
30% decrease from baseline area per Adjusted Patient Discharge as modified for Case Mix Index
50% decrease from baseline for time to build
25% decrease in natural resource use per APD
Ongoing Prototype Research
Bibliography• June A. Schmele, RN, Ph.D.; Quality Management in Nursing and Health Care. 1996. Quality in Practice.
Albany. Delmar Publishers.
• Patricia S. Schroeder, MSN, RN; Regina M. Maibusch, SSSF, MS, RN; A Unit-Based Approach. 1984. Nursing Quality Assurance: Rockville, Maryland. An Aspen Publication.
• Avedis Donebedian, MD; Measuring and Developing Hospital and Medical Care. (1976) Bulletin New York Academy of Medicine; 52(1), 51- 59.
• Avedis Donebedian, MD, MPH; The Quality of Care; How Can It Be Assessed?. JAMA September 23/30. 1988:260(12); 1743-1748.
• Monique Lambert, PhD, PI, Intel Corporation, Third Annual Nursing Leadership Congress “Designing Frameworks for Patient Safety” Conference Proceedings, Journal of Patient Safety 4(2):54-60, June 2008.
• “How Shadowing Shaped the Design of the Mobile Clinical Assistant” Intel Software Insight, Issue 12:16-17, 2007.
• “PHAMA Patient Handling and Movement Assessments: A White Paper” 2010 Health Guidelines Revision Committee Specialty Subcommittee on Patient Movement, The Facility Guidelines Institute 2010
Thank You.FOR MORE INFORMATION PLEASE CONTACT:
Jocelyn StroupeCannon [email protected]
Dale BeattyNorthwest Community [email protected]
Deborah SheehanCannon [email protected]
Charlie StevensonNorthwest Community [email protected]