bams 580b
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BAMS 580BBAMS 580B
Class 1
October 27, 2010
www.chcm.ubc.ca1
Canada Health Act - PrinciplesCanada Health Act - Principles
• Public Administration – Health care insurance plans are to be administered and operated on a non-profit basis
by a public authority.• Comprehensiveness
– The health insurance plans of the provinces and territories must insure all hospital, physician and surgical-dental health services.
• Universality – One hundred percent of the insured residents of a province or territory must be entitled
to the insured health services on uniform terms and conditions. • Portability
– Residents moving from one province or territory to another must continue to be covered for insured health care services for up to three months.
• Accessibility– Insured persons have reasonable access to hospital, medical and surgical dental
services unimpeded by charges or discrimination on the basis of age, health status or financial circumstances.
Canadian Health Care BackgroundCanadian Health Care BackgroundCIHI – Health Care in Canada 2006CIHI – Health Care in Canada 2006
• In 2005, Canada spent $142 billion on health care or $4,411 per person– This represents approximately 10% of Canada’s GDP– 30% is spent on hospitals; 17% on retail drugs
• 1.5 million people work in health care– 1 out of 10 Canadians work in health care– Nurses and Physicians are the largest groups– The workforce is rapidly aging
International ComparisonsInternational ComparisonsOECD - 2005 dataOECD - 2005 data
Country Per capita expenditure
(PP adjusted)
Government share of spending
MRIs
(per million
pop’n)
Male life expectancy
(years)
Infant mortality rate (per 1000
births)
US $6,347 45% 26.6 (2004) 75.2 6.9
Canada $3,460 70% 5.7 78.0 5.4
France $3,306 80% 4.7 76.7 3.8
UK $2,580 87% 5.4 77.1 5.1
Source: Stats.oecd.org
Health System ChallengesHealth System Challenges
• Reducing wait times • Meeting the increased health care demands of an aging
population• Replacing an aging and diminishing workforce• Using costly new technologies and therapies
appropriately• Delivering high quality and safe care
Five questionsFive questions
• How do we know whether patients are flowing well?
• Why does it matter? • How can we improve flow? • How do we know that what we did improved
flow?• How do we maintain our improvements?
www.chcm.ubc.ca6
Why is health care OM different than usual OM?
“If you’re not keeping score, you’re just practicing”
Vince Lombardi
MetricsMetrics
• Queue lengths• Waiting times• Percent who meet target• Patient Satisfaction scores• Staff Satisfaction scores
www.chcm.ubc.ca9
Marty’s LeversMarty’s Levers
• Manage Demand• Manage Resources• (Manage Efficiency) Use Resources Better
www.chcm.ubc.ca10
Derek’s EquationDerek’s Equation
• Variability + Fixed Capacity + High Utilization = Trouble
www.chcm.ubc.ca11
Scheduling Unplanned Arrivals:Scheduling Unplanned Arrivals:Appointment SchedulingAppointment Scheduling
TopicsTopics
• The Appointment Scheduling Game• Measuring Wait Times• The “Capacity equals Demand” Fallacy• Levers for Managing Capacity
– Operations Research and Surge Capacity– Intelligent Scheduling
• What We Are Doing Now• Concluding Comments
Appointment Scheduling GameAppointment Scheduling Game
++
The Appointment Scheduling GameThe Appointment Scheduling Game
• Provide a timeline and process diagram for the scheduling clerk’s task.
• What is realistic and what is unrealistic about this game?
• What scheduling rule are you using?• How is it performing?
Metrics
• Demand by color• Lateness
– Percent served in time by color– Days late
• Capacity Utilization• Wait time by color
Scheduling Rules
• First Come First Served• Reservation Policy
Appointment Scheduling Game – More QuestionsAppointment Scheduling Game – More Questions
• What will be tomorrow’s demand? Next week’s?• How should you set capacity?• What levers do you have to regulate this process?• In what situations is this type of scheduling relevant?• What information are you keeping track of?• What does this assume about appointment lengths and start
times?• What if the system is unavailable on a given day?• What if an extremely urgent case has to be slotted in ASAP?
Return to game – measure performanceReturn to game – measure performance
++
Appointment Scheduling Game Issues Appointment Scheduling Game Issues
• Quantifying performance• Forecasting demand• Urgency classes and criteria• Scheduling rules• Surge capacity• Scheduling within a day• Breakdowns/Cancellation by Provider• No Shows by patients• Simulation
Performance MetricsPerformance Metrics
• Patient Wait Times– How to measure?
• Averages• Min, Max; Percentiles• Service levels
• Capacity Utilization• Overtime• ?
Challenges in measuring wait timesChallenges in measuring wait times
• Patients are not homogeneous– Different priority classes of patients face different wait times.
• Wait times, as currently measured, do not tell the whole story. – Wait Time equals the length of time between when request for service
and service delivery.– Ignores upstream process steps and delays.
Challenges in measuring wait timesChallenges in measuring wait times
• Averages do not tell the whole story – Wait times vary between patients, over time and between sites.– Performance measures must account for variability – Wait time distributions are skewed.
• Recommended Metrics– “Proportion of patients of a specific priority class who receive the service within
a specific clinically desirable time” – These provide meaningful guarantees to decision makers and system users.
• Reliable and complete wait time data is often not available– Variability and performance cannot be determined
Scheduling GameSimulation Results
Simulation Output is VariableSimulation Output is Variable
0
5
10
15
20
25
30
35
40
1 5 9 13 17 21 25 29 33 37 41 45 49 53 57 61 65 69 73 77 81 85 89 93 97
aver
age
wai
t ti
me
[day
s]
run
Average wait time across simulation runs
PT1
Policy ComparisonPolicy Comparison
0
5
10
15
20
25
30
35
401 5 9 13 17 21 25 29 33 37 41 45 49 53 57 61 65 69 73 77 81 85 89 93 97
aver
age
wai
t ti
me
[day
s]
run
First Available Slot vs. Protection Level
FAS
PL
Simulation SummariesSimulation Summaries
Capacity Policy usage PT1 PT2 PT3 PT1 PT2 PT3FAS 3.00 0% 0% 0% 77.94 78.41 78.67PL 3.00 0% 0% 0% 64.48 85.16 85.58BT 3.00 0% 0% 0% 78.66 79.13 79.39
FAS 3.47 94% 100% 100% 0.33 0.53 0.81PL 3.47 96% 100% 100% 0.27 0.54 0.86BT 3.47 95% 99% 100% 0.26 1.12 3.07
FAS 2.97 12% 23% 36% 9.39 9.67 10.02PL 2.97 26% 18% 25% 6.09 11.68 12.40BT 2.97 12% 17% 28% 10.27 10.69 11.39
FAS 19.93 32% 60% 77% 3.16 3.39 3.79PL -- -- -- -- -- -- --BT 19.93 41% 50% 65% 3.43 4.09 5.63
Poisson 20
3
4
on target average wait time
Poisson 3
VGH CT Scanning Study VGH CT Scanning Study
www.chcm.ubc.ca28
www.chcm.ubc.ca29
VGH CT Scanner QuestionsVGH CT Scanner Questions
• Determine whether an additional scanner was needed and if so, where should it be located?
• Define and measure current waiting times for CT scans at VGH
• Identify system bottlenecks and inefficiencies• Identify strategies for eliminating current backlogs and
compare the short term and long term costs and benefits of each
• Propose ways to expand analyses to other sites and explore improvements in booking and centralized planning
Step1: The appointment systemStep1: The appointment system
• Process– Requisition arrives
• Info – scan type and urgency
– Clerk assigns date– Clerk contacts patient– Clerk records date
• We will investigate management of appointment systems like this in depth this afternoon!
www.chcm.ubc.ca30
Data ChallengesData Challenges
• How do we determine if the system is performing well?– Performance Metrics– Urgency Levels
• What data is required?– Time stamps
• Requisition received• Scan completed
– Upstream measures• Where do we get it?
– Databases– Appointment systems– ?
www.chcm.ubc.ca31
More on DataMore on Data
• Perspective vs. Retrospective data– Perspective – from now going forward
• Based on appointment data
– Retrospective – from now going back• Based on scan date
– Historical• Complete records
• What are the strengths and weakness of each type of data?
• What we did - Obtain booked requisitions at the end of each day – Copy them
• What are the shortcomings of the approach we used?
www.chcm.ubc.ca32
33
Sample Wait Time DataSample Wait Time Data
Nov-0
3
Nov-0
3
Jan-
04
Jan-
04
Mar
-04
Mar
-04
May
-04
May
-04
Jul-0
4
Jul-0
4
Sep-0
4
Sep-0
4
Nov-0
4
Nov-0
4
Jan-
05
Jan-
05
Mar
-05
Mar
-05
May
-05
May
-05
Jul-0
5
Jul-0
5
Sep-0
5
Sep-0
5
Nov-0
5
Nov-0
5
Jan-
06
Jan-
06
Mar
-06
Mar
-06
May
-06
May
-06
Jul-0
6
Jul-0
6
Sep-0
6
Sep-0
6
Nov-0
6
Nov-0
6
Jan-
07
Jan-
07
Mar
-07
Mar
-07
Calendar TimeCalendar Time
Clie
nts
Clie
nts
www.chcm.ubc.ca34
Data Summary - Outpatient Waiting TimeData Summary - Outpatient Waiting TimeOutpatient Categories OP1 OP2 OP3
Recommended WT (RWT) < 1 wk < 2 wks < 4 wks
Actual WT
Average (wks) 1.6 3.6 6.3
Max 6.6 10.4 13.9
Min 0.0 0.0 0.1
Sample Size 42 86 103 % scanned after
RWT 50.0% 68.6% 74.8%
CT Wait Times for Outpatients at VGH (Priority OP1: < 1 week)
0
5
10
15
20
0 1 2 3 4 5 6 7
Weeks
Fre
qu
en
cy Scheduled after 1 week: 50.0%
CT Wait Times for Outpatients at VGH (Priority OP2: < 2 weeks)
0
5
10
15
20
0 1 2 3 4 5 6 7 8 9 10 11Weeks
Fre
qu
en
cy
Scheduled after 2 weeks: 68.6%
CT Wait Times for Outpatients at VGH
(Priority OP3: < 4 weeks)
0
5
10
15
20
0 1 2 3 4 5 6 7 8 9 10 11 12 13 14Weeks
Fre
qu
en
cy Scheduled after 4 weeks: 74.8%
Step 2: the scanning processStep 2: the scanning process
• Key steps– Check in– Get ready– Enter room– Scan– Check scan– Out of room
• How do we assess its performance?• What data do we need?• How do we get data?
www.chcm.ubc.ca35
www.chcm.ubc.ca36
On Site Observations - VGHOn Site Observations - VGH
Scanners are not being used efficiently; capacity is wasted
Date Scanner % time spent scanning % time room empty09-Jan-04 1 43% 17%16-Jan-04 1 24% 49%23-Jan-04 1 31% 21%25-Jan-04 1 18% 37%09-Jan-04 2 13% 58%21-Jan-04 2 24% 41%23-Jan-04 2 25% 38%25-Jan-04 2 12% 66%16-Jan-04 4 12% 52%23-Jan-04 4 24% 61%
Total* 1 33% 28%2 21% 44%4 19% 57%
all 25% 41%*Totals do not include Sunday
www.chcm.ubc.ca37
Possible impediments to flowPossible impediments to flow
• System starved• No patient available • Why?
• Porter delays• No exams scheduled during tech lunch breaks• Excessive time scheduled for an exam• Outpatients arrive late • Outpatients do not arrive (no shows)l
• System congested• Exam times too short• Patients not picked up
• Reformatting of images • Maintenance • Difficult IVs
www.chcm.ubc.ca38
Outcomes of study
• Added dedicated porter to CT area• Management accepted idea of overbooking• Hired lunch time technologist• Commissioned in-depth study of porter services at VGH• VCHA hired several grads• Generated further research
– Allocation of capacity between outpatients and inpatients– Jonathan Patrick’s PhD Dissertation on scheduling
Scheduling RulesScheduling Rules
Scheduling RulesScheduling Rules
• Earliest available slot– a.k.a. first come first served
• Reserve capacity– For most urgent cases– For each class
• Patrick - Puterman rule– Fill tomorrow– Then book as late as possible without exceeding target– If exceed target, use overtime or surge capacity– Based on complex stochastic optimization model
• Markov decision processes
““Current Practice” – Simulation resultsCurrent Practice” – Simulation results
0
5000
10000
15000
20000
25000
30000
1 3 5 7 9 11
13
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27
29
Day
Nu
mb
er o
f O
P
OP1 OP2 OP3
53% of OP1,
36% of OP2,
25% of OP3
booked late!
Reservation Policy – Simulation Results Reservation Policy – Simulation Results
0
10000
20000
30000
40000
50000
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700001 3 5 7 9 11
13
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Days
Nu
m o
f O
P
OP1 OP2 OP3
Cost: 21% of OP3 demand overtime, 50% of booked OP3 late.
0
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7000
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9000
10000
1 3 5 7 9 11 13 15 17 19 21 23 25 27 29
Days
Nu
m o
f O
P
OP1 OP2 OP3
Patrick Puterman Rule – Simulation ResultsPatrick Puterman Rule – Simulation Results
Cost: 1.5% of OP1 demand removed from the queue but only at
special times
Comparative ResultsComparative Results
% of Patients with late scans % of Patients served through OT
OP1 OP2 OP3 Total OP1 OP2 OP3 Total
PP Rule 0 0 0 0 1.44 0 0 0.72
Reservation Policy
0 0.02 49.52 9.94 0 0 21 4.13
Current Practice
53.17 35.77 24.85 42.29 0.08 0.43 0 0.17
Policy InsightsPolicy Insights
• In a system where demand is close to capacity, the judicious use of a small amount of overtime coupled with intelligent patient scheduling can meet wait time targets– Overtime gives the resource manager the ability to deal with spikes
in demand– Without this ability, once the system is behind, it can’t catch up– This reduces the need for excess base capacity
• Booking demand later and later merely compounds the problem– Best to address the problem directly through the judicious use of
overtime
Forecasting DemandForecasting Demand
Forecasting DemandForecasting Demand
• What is the arrival rate per day?• How variable is it?• Two ways to find this
– Theory (at least for dice)– Empirical or data driven
• Means or medians• Standard Deviations and Quantiles
• What data to use
Forecasting Forecasting
• Forecasts are necessary for effective decision making– Forecasting, planning and control are interrelated
• Forecasts are usually (almost always) wrong– Quantifying forecast variability is as important as
determining the forecast; it is the basis for decision making.– Rare events happen and can have significant impact on
forecasts
• Scientific methods improve forecasting• “Don’t predict the future, invent it!”
– Alan Kay
Quantitative Forecasting methodsQuantitative Forecasting methods
• Naïve: Last Period or Same Period Last Year• Regression
– Extrapolation
– Causal
• Exponential Smoothing– Simple
– Trend / Damped Trend
– Holt-Winters
• ARIMA models• Simulations• These require software and analyst expertise
Data PatternsData Patterns
Diagram 1.2: Seasonal - more or less regular movements
w ithin a year
0
20
40
60
80
100
120
Year 5 10
15
20
25
30
35
40
45
Diagram 1.1: Trend - long-term growth or decline occuring
w ithin a series
0
20
40
60
80
100
Year 3 6 9 12
15
18
21
24
27
30
Diagram 1.3: Cycle - alternating upswings of varied length
and intensity
0
2
4
6
8
10
Year 5 10
15
20
25
30
35
40
45
Diagram 1.4: Irregular - random movements and those which
reflect unusual events
0
50
100
150
200
250
300
350
1 10
19
28
37
46
55
64
73
82
VariabilityVariability
• Two types– Systematic – occurs at calendar intervals
• Time of day• Day of week• Week (or month) of year• We can forecast this
– Random• Unexplained variation
– Might be understandable in retrospect– Not predictable
• This is described through standard deviations and helps us determine service levels
Sample dataSample data
Number of Inpatient CT scans performed at VGH (Daily volume, Jan-Sept 2003)
0
10
20
30
40
50
60
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80
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100
01/01/03 31/01/03 02/03/03 01/04/03 01/05/03 31/05/03 30/06/03 30/07/03 29/08/03 28/09/03
Date
Nu
mb
er
of
Sc
an
s
Weekdays
Weekends
Do we want to forecast this?
Scan data by monthScan data by month
Average number of CT scans performed at VGH (Daily average by month, Jan-Sept 2003)
0.0
10.0
20.0
30.0
40.0
50.0
60.0
70.0
Jan Feb March April May June July Aug Sept
Nu
mb
er o
f sca
ns
IP-Weekday
OP-Weekday
IP-Weekend
Sample DataSample Data
15
20
25
30
0 50 100 150 200 250 300 350 400
Mid
nig
ht
ce
ns
us
Day
Ward Occupancy
How can we forecast ward occupancy?Should we forecast ward occupancy?What impacts ward occupancy?
Another way to look at dataAnother way to look at data
200000.0
450000.0
700000.0
950000.0
200000.0
0.9 55.4 109.9 164.4 218.9
Monthly Ferry Traffic Vancouver Victoria - 1980- 1998
Month
Tra
ffic
200000.0
533333.3
866666.7
200000.0
1 2 3 4 5 6 7 8 9 10 11 12
Monthly Ferry Traffic - Box Plots
Month
Tra
ffic
What is the advantage of each type of data display?Why would we want to forecast this?
Ferry Traffic Forecast Ferry Traffic Forecast
200000.0
450000.0
700000.0
950000.0
200000.0
1979.9 1984.9 1989.9 1994.9 1999.9
Traffic Forecast Plot
Time
Tr
af
fic
Holt-Winters model – Multiplicative seasonal factors
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