Architecting the Healthcare System
for Stakeholder Value
Jorge Fradinho Oliveira
Massachusetts Institute of Technology
21st January 2009
US Health Care Issues
“Simply stated, the US does not have a health care system.”
William Brody, President of Johns Hopkins University, 2007
Access
15% of US population is uninsured
75% of care delivery is done by groups of five physicians or less
Quality
44,000 to 98,000 patient deaths attributed to medical error
55% of recommended care is administered to adults
Cost
16% of GDP spent on health care in 2005
30.8% of total health care expenditure is spent on hospitals
“…the strategies [hospitals] develop and implement to compete have a
significant effect on costs, quality, and access to care.”
(Devers et al. 2003)
http://lean.mit.edu
© 2009 Massachusetts Institute of Technology Jorge Oliveira 01/ 21/09 -2
Health Care is a Complex
Socio-Technical System
Regulator
Payer
Patient
Provider
Nursing
Home
Hospital
Labs
Labs
Operating
Rooms
Nurse
Specialist
Care
Ancillary
Services
Inpatient
Units
Primary
Care
Radiology
Psychologist
Physician
Supply
Technician
http://lean.mit.edu
Interest
Groups
Pharmacy
Pharmacy
Emergency
Department
Cleaning
Insurer
Primary
Care
Flu Clinic
Home
Care
Supplier
Student
resident
Admin staff
© 2009 Massachusetts Institute of Technology Jorge Oliveira 01/ 21/09 -3
Greater Boston Hospital Case
•
Leading multi specialty physician led group
practice with national and international
recognition (i.e. neuro, liver, heart & vascular, etc)
2006 Highlights
• Emergency Visits:
• Total Beds:
• Total Staff:
• Total Income:
• Total Expenses:
• Operating Income:
Problem Statement
38,631
293
4263
$679,454,000
$628,525,000
$50,929,000
• Emergency Department (ED)
struggling to keep up with demand
• Long wait times in the ED and
patient leaving without being seen
• ED staff blame inpatient staff and
vice versa
• ED staff churn levels significant
What can be done to speed patient flow in the ED?
Where should a process improvement initiative focus?
http://lean.mit.edu
© 2009 Massachusetts Institute of Technology Jorge Oliveira 01/ 21/09 -4
Emergency Department VSM
Patient
Arrives
Registration::
Patient orders (paper)
1
Not L1
L?
T System::
Patient chief complaint
MedTech Order Stack::
Patient orders (paper)
T System::
Priority assignment
(L1 :: L5)
Blood lab:
Blood vials
T System::
Patient demographic,
Insurance, etc details
Follow-up if
tests show
an issue
Patient
leaves
Radiology Lab
Patient Tired of Waiting
L1
Triage
(room 1)
Check in
ED waiting
area
1
ED waiting
area
1
L?
Not L1
Conduct
tests
(room 2)
Complete
Check in
ED waiting
area
1
ED waiting
area
Measure
vital signs
1
Patient
placed in
ED bed
ED waiting
area
Assessment/
treatment
Patient in
ED bed
waiting
diagnosis
?
First EKG, blood
draw, then external tests
Patient
leaves
Yes
No /
“Tourist”
L1
Patient
ready?
Discharge
Note (1)
Note (2)
Patient
Arrives as Transfer
or EMS pick-up
Patient
Arrives as Transfer from
‘X’-Type Facility
x
Number of operators
Information flow
Patient flow
Patient idle
Patient
healthy
Re treat
patient
Phone:
Admitting Physician
requested
Patient
healthy
Patient
In ED bed
No
Note (3)
Note: (1) if bed not available, creative
process comes into play whereby a bed is
found for the patient (i.e. hallway, other)
Note (2): Check in initiated over phone and
completed once patient arrives.
Note (3): Some hospitals have an
agreement with Lahey where patients just
roll through the ER. ‘X’ is a fill-in until we
know what to call these types of facilities.
Note (1)
Note (3)
Pre Admit Tracking System:
Bed request
Note (1)
No
Patient direct
Diagnosis?
“Kick theto floor
tires”
Patient
Observation
Diagnosis?
“Kick the
tires”
Admit
patient
Admit
patient
Initiate
Patient Admit
Process
Check
patient
Ready?
Patient
In ED bed
Waiting for admit
physician
Admit Physician arrives
and checks patient
(visual & paperwork)
Yes
Sign orders
Note (2)
Inpatient
bed
available?
No
Moving Yes
Staff
available?
Transfer
Patient
Yes
Patient
In ED bed
x
Number of operators
Information flow
Note: (1) may involve additional tests, or lab
work
Note (2): Receiving floor requests ED to
‘hold onto’ patient for a period of time to
complete shift change or catch up on work
Note (3): After 11:00 p.m. Need to call Head
Nurse shift supervisor for bed assignment.
Patient flow
Patient idle
http://lean.mit.edu
© 2009 Massachusetts Institute of Technology Jorge Oliveira 01/ 21/09 -5
Emergency Department Analysis
Description of patient time spent in ED
Description of patient arrivals and departures
Simulation Modeling
Average time for each step of the patient process
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© 2009 Massachusetts Institute of Technology Jorge Oliveira 01/ 21/09 -6
Preliminary Findings
ED average length of stay considered problematic, but non-admitted
patients took 4 hours, whereas admitted patients took over 8 hours
Main
Findings
ED interacted well with some patient wards but not with others
ED heroic employee efforts said to be common rather than sporadic
ED metrics and strategic goals misaligned with overall hospital (X-Matrix)
Questions
For
Further
Study
Why was the ED managed as a silo rather than end-to-end?
Was the varying performance of ED interactions due to the payment model?
Could it be that different observed EA configurations were directly related to
the different observed performance levels?
“The problem of redesign gets harder and the evidence weaker as one
moves from the microsystem to the organization.”
Donald Berwick, President of Institute for Healthcare Improvement, 2002
http://lean.mit.edu
© 2009 Massachusetts Institute of Technology Jorge Oliveira 01/ 21/09 -7
“As Is” Enterprise Architecture
Policy View
Organizational View
Knowledge
View
STRATEGY VIEW
Knowledge
View
Knowledge
View
Knowledge
View
SURGERY
SUPPORT
(Labs, Pharm,
Supplies)
EMERGENCY
DEPARTMENT
Knowledge
View
FLOORS/
WARDS
INTERNAL MED
Process/Service View
Process/Service View
Process/Service View
Process/Service View
IT View
T-System
Knowledge
View
HEALTH
WORKER
Bed Tracking
Medtech
http://lean.mit.edu
© 2009 Massachusetts Institute of Technology Jorge Oliveira 01/ 21/09 -8
“To Be” Enterprise Architecture
Patient In the center of the
architecture
(Service-centered architecture)
Hospital processes
oriented around the
patient
(Process-centered
architecture)
Information Technology
connects patient,
knowledge, process,
organization
(IT/knowledge centered)
http://lean.mit.edu
© 2009 Massachusetts Institute of Technology Jorge Oliveira 01/ 21/09 -9