CLIENT:
Inspira Health Network CASE STUDY
Vineland, NJ
Averages are not enough to answer complex questions that involve interacting variables. Traditionally, architects rely on average utilization benchmarks to determine appropriate department sizes when planning a new facility. While these averages might adequately predict space for the design of an office building or parking lot, they sometimes fall short of accurately determining the space needed for healthcare facilities.
CHALLENGE
EXECUTIVE SUMMARY
Growth in the emergency department
Inspira Health Network experienced significant emergency department (ED) holds
caused the hospital to use inpatient,
due to a lack of inpatient capacity. Analysis of patient arrival and unit assignment data
transitional care beds for observation
led the team to believe that treating observation patients in inpatient units is causing
patients, leading to a reduction in available
the capacity problem. A discrete event simulation (DES) model helped determine the
inpatient capacity and high utilization of
appropriate size of an observation unit needed to reduce ED holds and relieve current
other inpatient units.
inpatient pressures.
SOLUTION Throughput Analysis Array developed a simulation model to quantify the impact of making the transitional care beds available for inpatient use again and adding an observation unit. The model helped the staff see how adding different quantities of observation beds would alter the utilization of different bed types.
PROJECT HIGHLIGHTS
24
Inpatient Beds Available
70%
Target Observation Utilization
30
Observation Beds Increase Capacity
CLIENT PROFILE Inspira Health Network Vineland, NJ
Current Conditions The hospital currently experiences a high volume of holds in the ED. They believe that inadequate capacity in the inpatient units is causing these holds. An addition to the facility included 25 observation beds and a 24-inpatient bed Transitional Care Unit
Inspira Health Network, a charitable
(TCU). Today, due to growth in ED visits, the facility uses the observation beds as
nonprofit organization, is the leading
additional ED beds, and designated the TCU as the observation and inpatient holding
network of healthcare providers in
area. Each inpatient bed unit, including Cardiac, Medical and Surgical, has 14 step-
southern New Jersey.
down and 36 acute-care beds. These units are experiencing high utilization rates
Delivering the full continuum of primary, acute and advanced care services across many locations, Inspira is an integral part of the community. The network comprises
throughout the year, likely because the TCU beds are not available for their intended use as transition beds for inpatients moving from the ED to an acute care unit.
Future State
three hospitals, a comprehensive cancer
Hospital administrators believe that reclaiming the 24-bed TCU will alleviate the
center and several multi-specialty health
capacity strain currently felt in the inpatient units. To use these beds as originally
centers.
intended, a dedicated observation unit will be necessary to accommodate the
www.inspirahealthnetwork.org
observation population. Traditionally, designers use the average daily census (ADC) of observation patients to generate a unit size. Unfortunately, since this number is an average, the unit will only be large enough approximately 50% of the time. After spending time and money on an expansion, and living through construction, the facility would still feel the stress of inadequate observation capacity for nearly half the year if they used the ADC to determine unit size. In this case, the observation average daily census is 35 patients. The client is interested in determining how many additional observation beds are necessary to adequately accommodate the observation population, and whether reclaiming the TCU will alleviate inpatient capacity strain.
TOOL
Throughput Analysis The processing rates of each step combine to create total throughput time. Steps with longer durations that occur later in the process create bottlenecks, and non-
Figure 1: Patient flow seen in additional scenarios.
value-added waiting time will increase the time it takes to get through the system. Array’s experienced team works with you to determine the optimal process-steps configuration that maximizes the value quotient in your system.
Simulation Model While these may seem like high-level questions easily answered using spreadsheet analysis, the movement of patients through these units is surprisingly complex and best analyzed using discrete event simulation (DES). In this case, the model includes a simple patient flow in which patients arrive to a unit specified in the data, stay for a length of time based on a distribution derived from actual patient data and leave the unit. After designing a simulation to model where patients are sent today, and ensuring that it accurately represents the current system, the modeler made changes to the assigned units for observation patients and inpatients treated in an existing TCU bed. In the first scenario, all observation patients are sent to an infinitely-sized observation unit to help
Page 2 | Case Study
the modeler determine a feasible range for the proposed bed count. Patients
TRANSFORMATION
treated in the TCU are still sent to that unit, because it is no longer being used to hold observation patients. This first scenario resulted in very low utilization
Our core mission is the same as that of
of the TCU by inpatients, which led the project team to assume that observation
our clients: improve the quality of our
patients could use a TCU bed if no capacity was available in the observation unit.
work, increase our efficiency, and motivate
Array developed additional scenarios with constrained observation bed capacities that work with an expected nursing ratio of 5:1. If a bed is available in the limited unit, the observation patient is assigned that bed. If a bed is not available, the observation patient “checks” a series of units starting with the TCU, to see if there is additional capacity in another suitable location. If there
our staff to reach for success. At Array, we are establishing a culture of continuous improvement at all levels of our organization. We seek to empower team members to be agents for good change.
are still no available beds, the patient will simply wait for an observation bed to
We begin all endeavors by considering
become available. Similarly, the inpatients treated in the TCU will first “check”
process before exploring solutions. Our
the TCU for available beds, then “check” the Medical, Cardiac and Surgical units
team can guide your organization through
for available beds (see Figure 1).
pre-design, ensuring clear goal-setting;
The model’s results were somewhat unexpected but, upon further analysis, were determined to be accurate. One surprising result was the size of the observation unit. While the infinite-capacity results suggested that 49 observation beds would be necessary to have a bed available 100% of the time, incorporating the TCU as an option for observation patients led to a smaller observation unit and higher utilization rate in the TCU, which resulted in better staffing of the system as a whole.
target outcomes; process analysis and design; and decision support. Our Lean-led approach to project definition provides a clear path to the right project before you begin to design.
How can we improve flow? There are many tools available to see
Results & Recommendations
how work flows through a system. Value stream mapping is a strategic exercise that can look at the flow of work from customer request to fulfillment. Process mapping focuses on detailed work flow elements and can identify non-valueadding steps that reduce efficiency and add to lead time.
Figure 2: Utilization of observation beds and TCU inpatient beds for four different observation bed capacities. Overall, the Health System needs to balance the utilization of their observation
Tools used: Simulation Modeling, Capacity & Utilization Assessment, Data Analysis, Data Visualization, Operations Analysis
unit and additional inpatient beds gained by reclaiming the 24-bed TCU. Figure 2 shows how utilization of these units changes as the number of observation beds changes. Due to the bed-selection assumptions defined above, the TCU utilization will increase as the number of observation beds decreases. From the perspective of staffing, it is important to keep a unit utilized about 75% of the time. In an observation unit, where patient length of stay is shorter, but more variable, this utilization might be closer to 70%. These constraints led the client to consider 30- or 35-bed observation units, which generate utilization rates for both the TCU and observation unit that lead to better staffing solutions. The world of healthcare is complex, and questions without a single solution often arise. Providing a range of options allows the client to experience how different observation bed counts impact utilization of the TCU and the observation beds, assisting with making an informed decision based on what is feasible for their system. Cast Study | Page 3
DISCOVERING YOUR HEALTHCARE SOLUTIONS TOGETHER We are innovators who specialize in the areas your system seeks out to leverage its valuable operational and facility resources. Array Advisors has the expertise and skills to reach beyond your milestones and provide you the decision support you need.
OUR SOLUTIONS
OUR SERVICES
We are dedicated to improvement.
How can we assist you?
Problem-solving and forward-thinking
We are Array Advisors, your trusted partners in Strategy Development, Organizational
individuals lead our efforts, which focus on your unique place in the healthcare delivery spectrum. Our knowledgeable staff can help you solve strategic business problems and develop a method to improve efficiency and utilization.
Transformation, and Facility Informatics. The challenges you face are not unique, but your solutions should be. Through a partnership of Strategy and Transformation we help you achieve and sustain. Our process begins by understanding your current operations and clearly defining your system’s goals before generating options. We employ a variety of integrated methods tailored to your strategic challenges, such as process mapping; operational planning; and healthcare real estate portfolio optimization, to help position your organization for future success.
MEET YOUR ADVISORS
Informatics Building Information Model management (BIM) is an enabler of most other technology trends in the Architecture, Engineering, Construction, Operations (AECO) industry, including but not limited to: sustainable design, offsite fabrication, LEAN construction, and energy efficient operations. Carefully considering how best to leverage virtual/digital representations of physical buildings can provide significant returns on innovation throughout the entire lifecycle of your facilities.
Strategy The need for healthcare real estate portfolio optimization has never been greater. With the acceleration in mergers and acquisitions, as well as the evolution of clinical models, healthcare organizations must continuously evaluate their physical assets and maximize the value they derive from them.
Transformation Transformation and lean methods are very useful when focusing on operational process improvement. By bringing all constituents together and giving them the tools to experiment and test new ideas, current state barriers can be identified and transcended.
ARRAY-ADVISORS.COM
Published: OCTOBER 2016