Patrick Conway and Stephen Muething (Cincinnati Children's Hospital Medical Center)

"Making Pediatric Patients Safer: Developing an Automated Detection Program at Cincinnati Children's"

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Abstract: Patient safety in hospitals has gained attention due to increasing awareness that a significant percentage of patients experience an adverse event during their inpatient stay. Most of these adverse events result from system failures. Cincinnati Children's has developed an expertise in process improvement over the last 7 years. Real-time awareness of process failures has become a fundamental element of our quality improvement. Reduction of adverse events posed a significant problem as we were not aware of most events except through voluntary reporting of 5-10% of adverse events. We needed to develop a system that allowed for real-time awareness of probable adverse events and collected critical failure mode information to support process improvement teams. The presence of an electronic health record provided an opportunity to use data as triggers for potential adverse events. A project manager then investigates potential adverse events real-time and gathers specific information on system failures. This information is used by improvement teams to design interventions and measure trends over time. The objective is to decrease the rates of adverse events.

Patrick Conway is an Assistant Professor at Cincinnati Children's in the Center for Health Care Quality, Division of Health Policy and Clinical Effectiveness, and Division of General Pediatrics. He completed residency at Children's Hospital Boston, received a Master's in Health Services Research while an RWJ Clinical Scholar at the University of Pennsylvania, and served as a White House Fellow for Secretary Leavitt at the Department of Health and Human Services.

Stephen E. Muething is a hospitalist at Cincinnati Children's. He is now Assistant Vice-President of Patient Safety and Patient Safety Officer and has a special interest in design for reliability and high reliability organizations. Dr. Muething became a leader in Quality Improvement and Transformation at Cincinnati Children's. He has graduated from Dr Brent James' Advanced Training Program in Salt Lake and Advanced Improvement Methodology at Cincinnati Children's.

Andrew Friedrich (University of Cincinnati)

"Improving Perioperative Efficiency and Quality at University Hospital"

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From a process standpoint, the preoperative period can be viewed as a series of tasks that must be completed in every patient prior to the onset of a surgical procedure. Although the series of required tasks is standard across hospitals and is regulated by the Joint Commission, the completion of these tasks is highly inefficient in many hospitals, resulting in substantial underutilization of operating room time. Invariably, preoperative process inefficiency is the result of two distinct causes: 1. the complexity of perioperative care, with substantial variation in service requirements depending upon the comorbidity of the patient and the invasiveness of the procedure; 2. the fragmented nature of the typical hospital's perioperative culture, which can be described as multiple systems functioning independently rather than as a single, coordinated entity.This talk will describe strategies recently initiated at University Hospital to address the two root causes of preoperative inefficiency, and discuss their effect upon the system.

Andrew D. Friedrich is the Director of Perioperative Medicine for the Department of Anesthesiology at the University of Cincinnati. He is a staff anesthesiologist and critical care physician at University Hospital and Assistant Professor of Anesthesia at the University of Cincinnati. Dr. Friedrich received his medical degree at the University of Rochester School of Medicine. He completed a residency in Anesthesiology at Brigham and Women's Hospital and fellowships at the Massachusetts General Hospital and at Brigham and Women's Hospital. He is board certified in Anesthesiology, Critical Care Medicine, and Perioperative Echocardiography. Dr. Friedrich is actively involved in education and administration. He has published articles in several peer-reviewed journals, including Critical Care Medicine and Anesthesia and Analgesia, as well as a book chapter for a major cardiac surgery textbook. He has won the Teacher of the Year Award at both Brigham and Women's Hospital and at the University of Cincinnati, and is a member of the Governing Board of the Society for Perioperative Assessment and Quality Improvement.

Diwakar Gupta (University of Minnesota)

"Operational Evaluation of Medium- and Long-Term Nurse Staffing Decisions"

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Medium to long term staffing of hospital units is complicated by the difficulties encountered in forecasting demand, meeting nurses' union rules and work agreements with each individual nurse, and satisfying the increased pressure to cut staffing costs. This talk will use a case study approach to show how nursing unit managers can use OM techniques to evaluate certain forecasting, hiring, and scheduling policies.

Diwakar Gupta is a professor in the Industrial & Systems Graduate Program at the University of Minnesota. His research interests are in the areas of health care, transportation, and supply chain operations research. Professor Gupta has collaborated with a variety of health care providers in Canada and United States. His health care work ahs been funded by grants from the NSF, AHRQ, CHSRF, and a variety of direct grants from health service providers.

Charles E. Noon (University of Tennessee)

"Achieving Lean Flow in Healthcare - What Works, What Doesn't, and Why"

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Relative to manufacturing, healthcare has characteristics that pose additional challenges to any process improvement initiative. In additional to healthcare's organizational and cultural peculiarities, its operational environment is vastly different from that of a typical repetitive manufacturing operation. For example, an emergency department does not get to "plan production" by deciding how many patients will be treated for a particular evening. The abundance of variation on the demand side, as well as the server side, creates an operational environment that can thwart traditional approaches for process improvement, especially in the context of Lean. In this talk, we frame healthcare operations as a network of queues and illustrate when and why the most common lean approaches for achieving flow will or will not work. A brief review of a simple queuing interface is used to convey the effects of waste elimination, variation reduction, and server pooling on waiting, as well as the negative consequences of improper staffing over time. Building on that foundation, the focus then broadens to "networks of queues" and we explore the concepts of pull systems, 1-piece flow, simplification, and segmentation. Throughout the talk, real hospital data, personal experience, and computer-based simulations will be used to illustrate the concepts and evaluate performance.

Charles E. Noon is a professor in the department of Statistics, Operations, and Management Science in the College of Business at the University of Tennessee. He holds a Ph.D. in Industrial & Operations Engineering from the University of Michigan. His teaching interests include operational improvement, business modeling, simulation, and decision analysis & support. His applied research concerns computer-based models and process improvement. He is a founding member of the highly-ranked Physician Executive MBA Program and continues to teach in the program. Dr. Noon also teaches in the full-time MBA program, the Management Science Ph.D. program, and various non-degree executive education programs, including a new offering entitled Lean for Healthcare. In addition to his teaching duties at UT, he serves as a faculty member for the Institute for Healthcare Improvement (IHI) Emergency Department Collaborative. To stay current, he periodically consults with hospitals on process improvement, capacity planning, and staff scheduling.

Richard Philippe (TRIAX Consulting/Logi D Inc.)

"RFID, Cutting-Edge Technology Enhancing Material Management Processes in Nursing Departments"

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It is estimated that nursing staff spend at least 10% of their time performing hospital logistics tasks. Processes related to the acquisition, gathering and utilisation of supplies account for a great proportion of this time. The state-of-the-art RFID technology is getting great attention in the industrial logistics sector as a potential breakthrough in supply chain automation. This technology could also represent a quantum leap in the evolution of material management practices in the hospital environment. Initially introduced in Canadian hospitals in 2006 to support the two bin replenishment system, new applications deployed in 2007 now allow items requiring unit traceability to be tracked. We will discuss the impact that replenishment activities have on patient care. We will then describe certain replenishment approaches, and we will conclude with a presentation of the impact of RFID technology and the results it has generated in Canadian healthcare institutions.

Richard Philippe is co-founder and principal partner of TRIAX Consulting® and the President of Logi D Inc. Logi D Inc. is a Canadian firm specializing in the development and implementation of customized turnkey hospital logistics solutions. Notably, Logi D Inc. is known for having introduced the Scan Modul System Two Bin Point of Use replenishment system for healthcare institutions in Canada. TRIAX Consulting®, the services division of Logi D Inc., offers specialized consulting services aimed at improving the supply chain and optimizing logistics processes in the healthcare sector. Richard Philippe also represents Quebec on the board of directors of the Healthcare Supply Chain Network (HSCN), a non-profit organization focusing on supply chain integration in Canada's healthcare industry.

Edieal Pinker (University of Rochester)

"Division of Labor in Medical Office Practices"

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This paper examines the staffing, division of labor, and resulting profitability of primary care physician practices. We collected data from a sample of these practices and tested two hypotheses: H1) controlling for staff size, greater delegation through the use of more staff types will decrease the throughput of visits, and H2) controlling for staff size, income per unit time generated by the practice is decreasing in the number of staff types. We find evidence supporting both hypotheses. We conclude that many physicians are gaining little financial benefit from delegating work to support staff. This suggests that small practices with little staff may be viable alternatives to traditional practice designs.

Edieal Pinker is an Associate Professor of Operations Management and Information Systems at the Simon School of Business, University of Rochester. He is also the director of the Simon School's Center for Information Intensive Services. Professor Pinker holds a Ph.D. and MS in Operations Research from the M.I.T. and a BA in Mathematics from Columbia University. His research interests span many areas in services such as business process design, electronic commerce, healthcare operations and Homeland Security. He has published research on the use of contingent workforces, cross-training and experience-based learning in service sector environments as it applies to work and workflow design, online auctions and responses to terrorist threats. He is on the editorial board of leading journals such as: Management Science, Operations Research, Decision Science and the International Journal of Operational Research.

Martin L. Puterman (University of British Columbia) and Vincent Chow (British Columbia Cancer Agency)

"Improving Surgical Patient Flow at the Royal Jubilee Hospital"

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This talk describes a study carried out at the Royal Jubilee Hospital in Victoria British Columbia by a team of researchers from the University of British Columbia. The goal of the study was to develop an approach for scheduling surgery which takes into account its impact on patient flow and down stream bed utilization. The team developed BUS, a highly portable EXCEL simulation model to assess the impact of surgery schedules on bed utilization, and SSO, a surgical schedule optimizer to generate good schedules. The talk will describe our modeling approach, analysis and results.

Martin L. Puterman is Advisory Board Professor of Operations in UBC's Sauder School of Business and Research Director of the UBC Centre for Health Care Management at UBC. He was founder and director of the Centre for Operations Excellence at UBC and the Biostatistical Consulting Service at BC Children's Hospital. His research focuses on health care operations research especially pertaining to cancer care delivery and decision making, Markov decision processes and statistical modeling of golf performance. He has consulted widely on health care operations, statistical modeling, inventory control, forecasting, operations management and management strategy. He received the prestigious INFORMS Lanchester Prize for his book Markov Decision Processes. He is an INFORMS Fellow and recipient of the Canadian Operations Research Society (CORS) Award of Merit, the CORS Practice Prize and the INFORMS case prize. He has been an editorial board member of Mathematics of Operations Research, Operations Research, Management Science and The Journal of the American Statistical Association. He has a PhD in Operations Research and an MS in Statistics from Stanford University and AB in Mathematics from Cornell.

Vincent Chow

Vincent Chow is an Operations Researcher at the British Columbia Cancer Agency (BCCA). He is a member of the CIHR Team in Operations Research for Improved Cancer Care, a major collaboration effort between the University of British Columbia (UBC) and the BCCA to apply operations research techniques to improve cancer care delivery. Vincent holds a Masters of Management in Operations Research from the UBC, and his research interests include process improvement, lean thinking, computer simulation and mathematical optimization applied to health care. Vincent was recently awarded the Canadian Operational Research Society (CORS) Practice Prize for his work in surgical scheduling and hospital bedmanagement.

Gautham Suresh (Dartmouth Hitchcock Medical Center)

"Sepsis, Lines and Videotape: Videotape Analysis of Central Vascular Catheter Insertion using Human Factors Engineering Principles"

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Central venous catheters and arterial catheters are widely used in intensive care units. Their placement occupies a significant amount of ICU clinicians' time, and can sometimes be associated with complications, such as hemorrhage, damage to internal organs, accidental displacement, and nosocomial infection. With the aim of identifying methods to improve the efficiency and safety of placement of such catheters, we videotaped clinicians during the process of catheter insertion and analyzed the tapes using principles of human factors engineering and Lean manufacturing. Videotaping was performed after obtaining consent, without capturing identifying characteristics of specific providers or patients and the audio portion was deleted immediately after the procedure. We found numerous deficiencies in the methods used to insert vascular catheters and multiple opportunities to improve the efficiency and safety of the procedures and decrease operator fatigue that are not typically described in textbooks or articles on performance of medical procedures. The specific changes we propose are related to (1) the organization of the physical environment for the procedures (2) personnel (3) cognitive aids (4) movement and physical action during the procedures and (5) the use of 'workarounds' during the procedure. Videotaping of bedside invasive procedures is feasible, accepted by clinicians, and is a rich source of information about ways to improve the design of healthcare work.

Gautham Suresh is an Associate Professor of Pediatrics and a neonatologist at Dartmouth-Hitchcock Medical Center, Lebanon, New Hampshire. He is a graduate of the Masters Program at the Center for Evaluative Clinical Sciences (now called The Dartmouth Institute) at Dartmouth College, Hanover, NH where his concentration was Continuous Quality Improvement in Healthcare. After his fellowship in neonatology at the University of Vermont, he served as a faculty member there for four years and was a postgraduate fellow at the Vermont Oxford Network. He is the author of several peer reviewed scientific publications, presentations and book chapters, including Cochrane systematic reviews. He has worked closely with the Vermont Oxford Network for several years and is currently conducting research on Patient Safety and medical errors. His interests include patient safety, healthcare quality improvement, evidence-based decision making, cost-effectiveness analysis, translation of research into practice, and organizational culture and leadership in healthcare. He was a faculty member of the Vermont Oxford Network's quality improvement collaborative, the Neonatal Intensive Care Quality (NICQ) project, and is currently an advisory board member for NICQ.

Debra Thompson (University of Pittsburgh) and Karen Bray (Grove City Medical Center)

"Learning Together to Reduce Adverse Outcomes"

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Since the seminal IOM report raised awareness regarding the cost of medical error, humanly and fiscally, there has been an increased focus by providers, payors and consumers on patient safety and the reduction of adverse events. This presentation will discuss how senior leadership has partnered with frontline staff in point of care problem solving and rapid tests of change to reduce medication errors and falls while creating a learning organization. Implementation steps and outcomes will be presented.

Debra Thompson is currently a PhD student in the School of Nursing, at the University of Pittsburgh. Her research interests are patient safety, nursing work environment, care redesign and role of leaders in healthcare delivery. Her most recent position was the Chief Nursing Officer with the Pittsburgh Regional Health Initiative. She has worked with a variety of healthcare facilities in applying the Perfecting Patient Care System SM, which is based on the Toyota Production System to redesign healthcare systems. Prior to joining the Initiative, she was Director, Corporate Nursing, Special Projects, UPMC Health System where she worked extensively with nursing work redesign using Toyota Production Systems. She serves as Adjunct Faculty in the School of Nursing, University of Pittsburgh. Debra has held a variety of administrative roles in both academic medical centers and community hospitals. She has lectured both internationally and nationally on performance improvement, A Transformational Model for the Practice of Professional Nursing and the application of the Toyota Production System to Health Care. She is a co-author of articles, focusing on organizational transformation, application of Toyota Production Systems to health care and patient safety.

Karen A. Bray is currently serving as the Vice President of Patient Care Services at Grove City Medical Center in Grove City, Pa. Prior to that she has held various management and clinical positions in the Pittsburgh area including the VP of Patient Care Services at Pittsburgh's Ohio Valley Hospital; Director of Critical Care Services and Associate Nurse Executive at The Washington Hospital; Critical Care Educator at West Penn Hospital; Critical Care Nurse Manager at Braddock General Hospital and Staff Nurse at Allegheny General Hospital. Karen graduated from the University of Pittsburgh with her BSN as well as a Master's Degree in both Nursing Administration and Nursing Education (Cardiovascular Clinical Specialty). She is also a Licensed Nursing Home Administrator. In addition to her work in the hospital setting, Karen, together with a partner, ran her own critical care and management consulting business, Nursing Resource Associates. She has published many articles as well as presented many lectures on a national level throughout her career.

Urban Wemmerlov

"The Performance of a Focused Factory in Health Care: A Case Study"

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The concept of focus has been a mainstay of the operations strategy literature ever since the article "The Focused Factory" appeared over 30 years ago (Skinner 1974). Here, we are specifically interested in how the principles for focused work can be applied to hospital operations. We present a single, holistic case study of a focused hospital unit. The case site is a large teaching hospital in the United States, and the primary unit of analysis is one of its organizational entities referred to as the Trauma Unit. The chosen framework, The Four Perspectives on Cells, suggests dimensions important to performance in focused systems, and helps us understand the reorganization from a process perspective (Hyer and Wemmerlöv 2002). We use several data bases, maintained by the hospital, to review performance. Our analysis cannot demonstrate that the reorganization into a focused trauma center has improved the efficiency of care. What appears indisputable, however, is that the creation of a focused trauma unit turned a costly branch of the hospital into a profitable health care operation. This can be attributed to several factors, including the ability to better market the focused trauma unit, to negotiate more favorable contracts with payers, and to perform more high-margin services.

Urban Wemmerlöv is the Kress Family Wisconsin Distinguished Professor at the Wisconsin School of Business, University of Wisconsin Madison. He is the founder and executive director of the Erdman Center for Operations and Technology Management and also leads its affiliated MBA program. His teaching and research interests are in the areas of cellular manufacturing, change management, planning and control systems, and health care operations. He has published over 80 articles, books, book chapters, and proceedings papers. His latest book, Reorganizing the Factory: Competing through Cellular Manufacturing (with Nancy Hyer; Productivity Press, 2002), received the 2003 Shingo Prize for Excellence in Manufacturing Research. Professor Wemmerlöv has a B.S. in Business, an M.S. in Mechanical Engineering, a doctorate in Production Management (all from Lund University, Sweden), and an M.S. in IEOR (from the University of California-Berkeley).