Allen J. Giannakopoulos, PhD describes how simulation shows the most promise in improving our business as we move into the next zone of reality.

In much of the present day model of health care our role as management has us looking to new ideas and processes in order to move us to the next zone of reality for health care.  I’m not coining zone of reality to create a new buzz-phrase. But rather to impress to everyone in health care that the health care environment that we’ve been accustomed to is rapidly shifting: complex changes that we are now seeing in health care, agreeable or not, are moving forward and are creating a zone of reality that this industry has never experienced. While a few still believe that this will all settle down and we will get back to the ways things were, the vast majority recognize undeniable shifts in the manner that business will be conducted.  Simply put, the past is the past, and a new landscape emerges.  To this end, two things are certain:

Primarily, reimbursements are going to decrease. Every component of the health care user continuum is pushing for costs to come down (including ourselves as patients and purchasers of health insurance) and for quality of care to increase.  Several major initiatives by the government already match reimbursement amounts to quality of care and patient satisfaction.  Dealing with cuts in the past is going to be dramatically different than how we will deal with it in the future. In the past we could change vendors to trim the costs for supplies. But how many times can we do that? There are certain elements of the business that we cannot trim further than has already been done.

Second – since reimbursements are decreasing, health systems need to address maintaining their revenue stream else face the same fate as many other industries. Since prices cannot go up, then a knee-jerk reaction typically insists that costs go down. Whereas this strategy does not address the issue of falling revenue, it is not the correct solution.  The solution lies in what manufacturing has had to do for decades: increase productivity by improving processes so that more work is performed with the same amount of manpower in a shorter period of time.

Transporting a Patient. Image Credit: Baptist Health South Florida
Transporting a Patient. Image Credit: Baptist Health South Florida

How do health systems differ as a business from other industries?  Aside from the expected ranks of physicians, nurses, and scores of other allied health professional trades, our health systems function nearly as stand-alone cities with food services, security forces, landscaping, trash collection, all the skilled trades including electricians, plumbing, and HVAC crews; and naturally all the corporate departments that represent the areas required to run a business. When we measure all of the support groups for a health system, it’s easier to list the skilled staff that we don’t have versus those that we do have.  All of these different trades represent processes that occur between many areas and as any process engineer has experienced, it is there that we have gross inefficiencies and extra costs. When no one looks at how processes are performed over different areas, inefficient elements flourish.

Computer Simulation

Simulation, as we have become accustomed to it, - concerns training health care givers on mannequins in either a training environment or a controlled environment. What has been the reality in performing this type of simulation activity shows that this is both time intensive and staffing intensive – two characteristics that do not coincide with our new zone of reality. Unless a simulation budget exists that will not be scrutinized and reduced then these activities will also have to adjust according to the new zone of reality.

There are more faces to healthcare simulation than the one just described. In the past five years a growing number of firms have presented better tools to provide us with the ability to use computer simulation of discrete and specific processes. Using these tools shows that the path to improvement does not lie in providing expensive immersive simulation training to everyone; it simply cannot be sustained.  So the area of simulation is affected as the rest of the health system is – it must adjust to the new zone of reality. Computer simulation aids from that perspective. Simulation is not new, having been used by industry and the government, such as NASA, for decades. It’s only recently that  simulation is being embraced by health care as a cost-effective tool to realize true process improvements that allows processes to perform more value-added activities while maintaining staffing numbers and improving efficiency of operations. Our teams have used this to redesign processes in clinical and administrative areas of the health system.

It Takes a Village

Coordination of many efforts results in the successful completion of healthcare processes; the same is true for any business. In the grocery industry computer modeling is performed to improve the logistics of the supply chain and inventory arrival, and modeling is used to determine what position within the store specific merchandise should be placed. The reasoning is clear: there are multiple factors affecting the flow of product and consumer through the store. In the past managers would simply move things around in the store and then measure the results to see what would improve, or in some cases, what would be negatively impacted. While effective to a degree, this is both time intensive and staff intensive – both factors that the grocery industry has to deal with in their environment of narrow profits. Using computer modeling shortened the amount of time to see results and allowed instant changes to the floor-plan without having to perform the actual physical moving of store merchandise. Now the model is changed and improved, and then these elements are put into place on the grocery floor.

A health system is more than a hospital; it is an entity with multiple hospitals, support service locations, transport services, and corporate campuses. These elements have people and processes that flow between them, with the important factor being that not all of these are direct patient care; most are supportive of patient care. In the new zone of reality looking at how these elements interact is a key in improving the efficiency and thus adjusting to the constraints that many other industries have become accustomed to – doing more with the same amount of time and staff.

Nurse station. Image Credit: Baptist Health South Florida
Nurse station. Image Credit: Baptist Health South Florida

Thus the concept of  “It Takes a Village” takes root to impress that the change in the industry can occur when the realization surfaces that indeed a village is what it takes to make the improvements – not one area alone can accomplish that.

Entire emergency department. Image Credit: Baptist Health South Florida
Entire emergency department. Image Credit: Baptist Health South Florida

The cost factors here for staffing and for time are tremendous when looking at an entire process. If we can take some non-value-added time out of any process and plan that no other unnecessary steps fill the void created by their removal, then the time remaining theoretically becomes available to perform more value-added functions that will produce chargeable activities – adding revenue without adding staff.

Modeling using 3-D rotational tools allows us to look at processes from the perspective of the person that is going through that process, be it the patient, an allied health professional, support personnel – whoever is actually a part of the process. In an Emergency Department simulation we created a model that actually takes us through the day to day functions of all these personnel – and then run them simultaneously to mimic real time. Once that is done, we began modifying various elements of the model to start measuring improvements.

Think this was done by just two or three people? You guessed correctly – it took a village of people to provide the information to build the model of the area itself, then to gather the data on all of the requirements to accurately construct a model that included everything that occurs in an ED.  These were just some of the components that had to be modeled:

  • The building and all entries;
  • The walls, furniture, and non-movable structures;
  • Electrical, plumbing, and HVAC systems;
  • Computer and IT equipment;
  • Nursing supplies cabinets;
  • Medical supplies cabinets;
  • Ambulance point of entry;
  • Patient waiting and exam rooms;
  • Pharmacy, Laboratory, and Radiology sites;
  • Daily support services and cleaning / sterilization;
  • Staffing of all personnel; and
  • Patient flows and acuity levels.
ED, ED EXAM ROOM PICS

Each of these was discussed, flowed, and then entered into the simulation. Teams for each of these areas gathered data which was entered into the simulation. The current data sets then flow into the model; the model is actually run several hundred times to simulate several hundred days of actual operation.  This allows the staff in the ED to review the information that is generated and judge if the model is simulating reality as closely as possible. Once done, the model is certified and the benchmark data used in the model is saved.

The modeling changes that occur afterwards are then compared against the initial benchmark.  The changes occur one or two at a time as the downstream effects of multiple changes tends to create a  “domino” effect and skew end results.

The impacts in the computer model are apparent from the beginning of the data entry and show up as gaps, bottlenecks, and metrics that cannot possibly be true, given time constraints. Distance to walk for supplies, elapsed time for labs and radiological events, and staffing issues all percolate to the surface giving the team starting points from where the model can be changed.

Evolutionary Change

Minor improvements – even minutes a day in just one process – accumulate and create both upstream and downstream savings in time and efficiency of operation.  This succeeds in accomplishing the goal of maintaining staffing while increasing throughput. We have called this evolutionary change, and there is no doubt that this is a strong component of the next zone of reality.  Other industries have been down this pathway, and it is now healthcare’s turn.

Has health care made large gains in the past, which we could even call revolutionary change?  Certainly and almost always within the confines of the clinical setting. Investments are made in most clinical areas to provide the most current technology along with the capital for expansion and remodeling.  Health care has as an industry lagged behind most other industries in automation, administrative and financial technology.  Operationally health care lags behind in most of the support services in terms of automation and current technology. While most businesses have been using some sort of anti-theft devices, for example, on merchandise and proprietary devices, most health care institutions have yet to embrace the change to that technology, much less entertain the use of RFID (radio frequency identification) technology to safeguard assets at all points of entry. Some areas within the hospitals have embraced that technology for some time now, and nearly all of those areas reside in the clinical setting.

The next zone of reality for healthcare is changing the manner in which we will look at the supporting processes of the administrative, financial, and operational services.  Until now each was on their own to provide improvements and maintain their costs.  This will no longer suffice. The drive to reduce costs can only be attained through greater efficiencies in the interrelated processes between these areas and the clinical setting.   Computer Simulation shows the most promise in improving our business as we move into the next zone of reality.

About the Author

Allen J. Giannakopoulos, PhD is the Corporate Director for Reengineering and Redesign at Baptist Health South Florida in Miami. His duties include process reengineering and computer simulation of processes in clinical and business departments; knowledge reports development; auditing for ePHI and HIPAA; and the management of processes for Role Based Security.  Dr. Giannakopoulos earned his academic credentials from the State University of New York in Brockport, BS in Business; University of Rochester, MBA in Business and Marketing; and his PhD in Health Administration from Kennedy–Western University.

Dr. Giannakopoulos been published in over 50 health care journals and publications and has been a featured speaker and presenter over the past 25 years in health care, quality improvement and process simulation.