meljun cortes telfer emergencyroom

7/30/2019 MELJUN CORTES Telfer EmergencyRoom

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Case Study: THE EMERGENCY ROOM


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IntroductionThis case introduces the notion of the emergency room as a production site

The notion of demand/supply matching is a concept borrowed from supply-chain management that is being applied to hospital management in anumber of lean hospital projects

Before analyzing the data, students should discuss the following:

1. What constraints impinge on hospital management, especially as itrelates to the ER? (Note that this is another way of analyzing theexternal environment.) Close this discussion by showing how theiranalysis fits with a five-forces type of approach.

2. Generate a strategy map for the ER. In addition, what is the ultimateoutcome and what can one do to influence these outcomes?


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OverviewThe Emergency Room

Dr. Brownlee manages the emergency room (ER) at the BigTown Hospital (BTH),

Ontario.

On a recent vacation, he took time to speak number of doctors and administratorsin a newly created ER

hospital was privately run

it enjoyed a higher degree of operational flexibility

higher compensation for meeting certain treatment time targets

higher compensation for following treatment protocols

Same management practices adopted at BTH in early 2004 that were in line with

what he saw in the privately operated hospital in Italy


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Background Recent studies, both in the United States and in Canada, have suggested

that ER usage can be expected to increase.

U.S. study noted a rise of 18% in ER usage between 1993 and 2004

similar study in Ontario found a trend towards decreased visits closure of 20 ERs during the period under study

remaining ERs experienced an actual increase in traffic of approximately 10%

main challenges: escalation in demand

pressure to reduce the number of beds

Pressure to reduce wait times for specific surgeries

compete for staff in the face of a shrinking labour pool of physicians andnurses

Dr. Brownlee felt that the time was right to examine more carefully thebusiness model of an ER.


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The ER Business Model Main characteristic noted about ER operations - the careful approach

taken to developing and implementing a business model Focus needed on examining administrative aspects from a strategic

perspective

Italian administrators modeled the ER as a form of production system

Key elements included: Physical layout to allow for the efficient flow of patients, and The height of counters in the reception areas

Ensure that patients could maintain good eye contact with thereception staff

Reception staff could clearly view the body language of patientsentering the ER

Better communication meant more effective triage whichcontributed to reduced wait times

Health care in Canada is a public-sector service, therefore, there is not asmuch administrative freedom

There is scope for taking a systemic view that could help improve overall

efficiency and effectiveness


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Late 2003

Dr. Brownlee and his administrative team debated on the notion of abrokerage system

Key discussions

role of the administrative team role - matching demand and supply bylinking patients with certain types of symptoms to doctors with certaintypes of skills

Argument - the symptom-skill matching process did not matter for alarge majority of ER cases as ER is staffed mainly by general practitioners(any doctor would suffice)

some situations required specialists to be called in, so the matchingprocess was important in these instances (but not for all)

Result

the brokerage model would provide a good start for their evaluation andimprovement of ER management

The ER Business Model (contd)


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Core aspects of the system:

Outcome of the system patients whose issues have beenresolved (resolution could mean treated or referred)

Key outputs the number of patients treated in a certainperiod of time, and the cost of this throughput

Critical inputs material (medical and surgical supplies) andlabour

The ER Business Model (contd)


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Deep Dive - System Outcomes and Outputs

all patients were either treated or referred

Argument

the number of patients who returned with the same ailment andthose who gave up waiting and either went home or to anotherclinic should also be important metrics for the ER

Majority vote patients leaving without being seen occurred so rarely that this

aspect did not merit inclusion in the model for the time being

Not to be forgotten:

a strictly clinical approach to measuring system outcomes wouldbe inadequate

something about patient satisfaction should also be addressed Dr. Naismith (2nd in command) vocal about the need to consider patient

satisfaction

the number of patients who returned with the same ailment and thenumber of patients who left before being treated should be importantcomponents of the business model.


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Compromise:

throughput the interval of time from when a patient firstenters the ER to when he or she leaves was adopted as thekey output metric

separated into treatment time and wait time.

Rationale:

patient satisfaction mainly determined by wait time

treatment or how long it took was not often in question wait time would be used as a proxy for patient satisfaction

Deep Dive - System Outcomes and Outputs (contd)


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Budget

administrative team responsible for meeting the cost budget set by thehospital

doctors worked on a fee-for-service basis (billed to public healthinsurance) - this cost was not reflected in the hospitals budget.

cost of throughput included labour costs for nurses and administrativestaff and material costs which varied with each procedure

Overhead costs were more or less fixed

Other Considerations:

influence of ancillary services such as radiology

time spent in ancillary services influenced overall treatment time

impact of ancillary services on throughput would be more or lessconstant

given the low level of control on these services, it would be better toleave this aspect out of the model for now

Deep Dive - System Outcomes and Outputs (contd)


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Trading Floor

ER provided a trading floor where buyers (patients) could be linked to sellers(doctors and nurses)

The physical facilities represented the constraint on the system

The behaviours of the buyers and sellers within this constraint contributed toexpected outputs

Brokerage System effectiveness

Staff had to be recruited and trained

Materials (medical and surgical supplies) need to be coordinated so that thesewould be available when required

Key Factors Well-developed supply management system (very rarely stocked out)

Steady supply of health-care professionals

Administrative procedures for using this talent effectively

Deep Dive - System Inputs


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Base Year

It was decided to gather information on the

functioning of the ER using 2004 the year in

which the business model was first developed

Other information

severity of cases being handled and specific

procedures performed would be needed

a selection of measures

Deep Dive - System Inputs (contd)


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Severity

rating scale to define the severity of a patients condition was collapsed into thefollowing three categories:

Category 1 Urgent cases (life-threatening and close to life-threatening)

Category 2 Semi-urgent cases (serious but not life-threatening)

Category 3 Non-urgent cases

Procedures

The specific treatment codes used in the hospital were collapsed into the followingsix broad categories:

1. Trauma patients with injuries caused by external forces (accidents, fights,etc.)

2. Upper respiratory patients with problems related primarily to breathing3. Skin and gastrointestinal patients with skin or intestinal disorders

4. Signs and symptoms patients with unspecified signs and symptoms of adisorder

5. Cardiac: patients with heart problems

6. Psychological, endocrine and poison this category includes patients with

psychological problems, endocrine disorders or poison-related issues

Deep Dive - System Inputs (contd)


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1. Would a different physician staffing formula make a difference for waittimes, treatment times and costs? The current model is a contractormodel: independent doctors provide services to the hospital in addition torunning their own practices. Some ERs had made use of Alternate FundingArrangements to create a salaried group of doctors dedicated to the ER.*

2. The planned labour and material cost targets assumed that a specifictreatment protocol would be followed. Does it make sense to enforceprotocols or is it better to allow doctors to follow practices learned in theirown training and in their individual practices?

3. Does it make sense to exclude ancillary services from their businessmodel? Even if members of the administrative team do not have directcontrol over these services, they could, as a team within BTH, influencewhat goes on there.

4. What is the boundary of an ER? Is it really constrained by the physicallayout of the hospital? Are paramedics, for example, part of the ERteam?

Outstanding Questions


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Discussion PointsTime: 20 minutes each

Discussion 1:Patient satisfaction appears to be improving slightly (students can explorethe data here to verify).

What does patient satisfaction mean? Are Brownlee and his team measuring the right things? (Students can

explore the web to find definitions of patient satisfaction.)

Summary:

A wide variety of stakeholders with different needs influence ER

management (In Ontario, these are the Ministry of Health and LongTerm Care, the LHINs and, of course, doctors and patients)

Is it possible to satisfy all expectations?

Which should take priority?


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Discussion Points (contd)

Time: 20 minutes each

Discussion 2:

In 2004 and 2005, Brownlee tried to make a number of changes.

What changes are evident?

Students should explore to find out the changes that are relevant. Theidea of creating teams of doctor and leveling out the number ofprocedures each doctor performs is one of the main changesintroduced.

Summary:

In the hospital environment, what degrees of freedom exist in improvingefficiencies?

What are the constraints? Key questions:

Can one force treatment protocols on doctors?

Can one provide incentives for cost control?

Does the administrative team influence patient satisfaction?


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Conclusions The purpose of this case was to explore the notion of applying

different business models as a performance-managementframework in the health-care environment. There are severalkey things to consider:

First, to what extent can one apply production-type

business models to such an environment? Second, what are the key outcomes?

Third, who are the most important stakeholders?

The most likely responses for Brownlee are: to consider the constraints,

to continue to team the MDs

to review the treatment protocols

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