Shahed Al-Haque, Mehmet Erkan Ceyhan, PhD
Outline
1. Background
2. Approaches: Systems thinking
3. Current state analysis
4. Initial findings
5. Next steps
© 2012 MIT Sociotechnical Systems Research Center
2
Veterans Health
Administration
To provide veterans the world-class benefits and services they have
earned - and to do so by adhering to the highest standards of compassion,
commitment, excellence, professionalism, integrity, accountability, and
stewardship.
© 2012 MIT Sociotechnical Systems Research Center
3
Traveling Veterans
2007 Directive:
“Maximize continuity and consistent, appropriate, and safe care
for traveling veterans”
© 2012 MIT Sociotechnical Systems Research Center
4
Traveling Veterans
-(.#/0"'1$%12%
(3#4#+#3#)5%
600(,,%7"'($)%
.(01.8%
!"#$%
&"'($)%
*")"+",(%
• Coordinated by RCM or social worker and eligibility clerk
• Quick process for veterans who have had previous
contact with VHA
• Must gain permission to access patient medical record
• Formatting and placement of info is inconsistent across
facilities
• Providers at temporary facility do not have access to any
non-electronic medical information
6,,#4$%7"'($)%)1%
7."0''1$(.%
&"'($)%0".(%
978")(%12%7"'($)%
.(01.8%
• Patient receives care based on need
• Allocation of resources complex and
varies among facilities as no SOP
currently exists
• Updating patient record is straightforward, provided
access has been granted
:1'/0"'1$%12%
.(,;3),%)1%&<&%")%
=1>(%2"0#3#)5%
• Notification to patients PCP is largely manual
• Occurs through flag in medical record, email, or phone
• Often unsuccessful due to workload
Source: Medical Care for Traveling Veterans, LAI Integrating the Lean Enterprise, Fall 2010
© 2012 MIT Sociotechnical Systems Research Center
5
Research Overview
1. Definition and categorization of traveling
veterans
2. Load on VHA
i. Patient appointment volume and percentage
ii. Seasonality
iii. Case mix
3. Policy Analysis
© 2012 MIT Sociotechnical Systems Research Center
6
Approaches
!"#$%&#'$()*+)*,')#'-'(./)#01'-223.-1('$.'-*-/"#)#'$(-$'4.15#%#'.*'$(%'6-"'$(-$'-'
#"#$%&7#'1.*#0$5%*$'2-3$#')*$%33%/-$%'-*8'(.6'#"#$%&#'6.3+'.9%3'0&%'-*8'6)$()*'$(%'
1.*$%:$'.4'/-3,%3'#"#$%&#;'
A5,)(>,%B=#$C#$4%
!"#$%&'()%*+,
%
• &"'($),%
• &=5,#0#"$,%
• <",(%
>"$"4(.,%
!"*-."-*%,
%
• D(4#1$"3%
$()E1.C,%
• A#$43(%7"5(.%
• F$)(4.")(8%FB%
#$2.",).;0);.(%
/%+0*%),
1-".'2%+,
%
• <1$'$;#)5%12%
0".(%
• D(8;0#$4%
E",)(,%
© 2012 MIT Sociotechnical Systems Research Center
-13;>(%
@#$"$0#"3%
#>7"0)%
<",(%>#?%
6$"35,#,%
600(,,%
&(.0($)"4(%
31"8%
7
1. Background
2. Approaches: Systems thinking
3. Current state analysis
4. Data analysis
5. Next steps
© 2012 MIT Sociotechnical Systems Research Center
8
Current State
HP%
GO%
GH%
HI%
H%
J% I%
K%
GG%
GP%
HG%
GK%
HH%
O%
GN%
GL%
G%
L%
M%
GM%
N%
© 2012 MIT Sociotechnical Systems Research Center
9
Current State
34!5,,
6%+0)%7"+,89:,
;'"#(,47<'=,89:,
47<'=,>*'2,7'7?#)@#.%7",,89:,
;'"#(,
-PG%
JQILLQNPN%RONSIT%
MJQMJM%RGSMT%
LHQJLJ%RGSJT%
JQJJGQKKK%
-PH%
HQKKHQJGN%ROGSOT%
HHLQJGM%RNSHT%
JMQMKO%RGSMT%
HQMMNQNIK%
-PI%
IQKHHQHPK%ROHSHT%
HOOQJGG%RMSNT%
KNQPPN%RGSKT%
IQNHGQLGL%
-PJ%
JQMOIQKNO%ROHSJT%
IOHQJKP%RMSLT%
OPQLLG%RGSNT%
KQGNLQPIO%
-PK%
HQHIMQHGH%RNJSNT%
JPGQHKJ%RGKSHT%
JHQMMO%RGSLT%
HQLINQJLL%
-PL%
JQOMKQJPH%ROLSGT%
HPHQIPJ%RISOT%
JOQPIH%RGSPT%
KQGMMQMPL%
-PM%
LQPJHQMGK%ROLSNT%
GONQIOH%RISHT%
GIPQNKO%RHSGT%
LQHJGQGPM%
-PN%
GGQOJHQLOP%ROLSKT%
JIKQKMI%RISKT%
HLKQLGI%RHSHT%
GHQIMNQHLI%
-PO%
JQJPLQNKI%RNLSOT%
LLJQGHH%RGISGT%
JHQNPH%RPSNT%
KQPMPQOMK%
-GP%
JQPHOQNHH%ROISGT%
IPGQGHN%RMSPT%
JKQGGG%RGSPT%
JQIIPQOKP%
-GG%
JQIJOQPMH%ROGSHT%
JGNQOHL%RNSNT%
JMQHNN%RGSPT%
JQMLMQOON%
-GH%
JQPLIQIHL%RNGSJT%
OIGQINO%RGNSMT%
MKQMMM%RGSKT%
JQOOJQMGK%
-GK%
IQKHJQOGG%ROPSGT%
INNQJGP%ROSOT%
IPQING%RPSNT%
IQOGIQIHG%
-GL%
NQKHJQOIP%ROMSHT%
HJLQMGG%RHSNT%
KMQKIN%RPSMT%
NQMMGQLJG%
-GM%
KQGPHQLIL%ROISPT%
INIQLKG%RMSPT%
MPQNMI%RGSIT%
KQJNLQHNM%
-GN%
IQONPQGJI%ROLSHT%
GKNQJMK%RISNT%
OLQPLJ%RHSIT%
JQGINQLGN%
-GO%
HQLKGQJOP%ROJSLT%
GKHQNHP%RKSJKT%
HOQMGL%RGSGT%
HQNPJQIGP%
-HP%
JQPHJQNII%ROMSPT%
GHKQOML%RISPT%
MIQOLG%RGSNT%
JQGKPQNPO%
-HG%
IQNPNQKNK%RNISNT%
MIJQNKK%RGLSGT%
GJKQGGJ%RISHT%
JQKJIQJJP%
-HH%
KQIKGQGHL%ROMSPT%
GLIQGMG%RISPT%
NIQKHP%RGSKT%
KQKGJQHOM%
-HI%
KQONKQGKN%ROMSOT%
GIPQLHL%RHSGT%
LKQIPP%RGSGT%
LQGGKQMNJ%
© 2012 MIT Sociotechnical Systems Research Center
10
Current State
5-2A%*,'>,#BB'07"2%7"+,820((0'7+:,
GSH%
Flow of patient appointments for each VISN,
GSP%
PSN%
PSL%
PSJ%
PSH%
PSP%
-PG% -PH% -PI% -PJ% -PK% -PL% -PM% -PN% -PO% -GP% -GG% -GH% -GK% -GL% -GM% -GN% -GO% -HP% -HG% -HH% -HI%
34!5,
F$U1E%
V;W31E%
<*=.6>'?./5&%'.4'2-0%*$#'43.&'.$(%3'?<!@#'#%%+)*,'1-3%'
A5B/.6>'?./5&%'.4'2-0%*$#'#%%+)*,'1-3%'-$'.$(%3'?<!@#'''
© 2012 MIT Sociotechnical Systems Research Center
11
Current State
5-2A%*,'>,#BB'07"2%7"+,8"&'-+#7)+:,
IPP%
Inflow of patient appointments from non-adjacent VISNs,
HKP%
HPP%
GKP%
GPP%
KP%
P%
-PG% -PH% -PI% -PJ% -PK% -PL% -PM% -PN% -PO% -GP% -GG% -GH% -GK% -GL% -GM% -GN% -GO% -HP% -HG% -HH% -HI%
34!5,
© 2012 MIT Sociotechnical Systems Research Center
12
Current State
ISKX%
Percentage inflow of patient appointments from non-adjacent
VISNs,
C%*.%7"#D%,'>,#BB'07"2%7"+,
ISPX%
HSKX%
HSPX%
GSKX%
GSPX%
PSKX%
PSPX%
-PG% -PH% -PI% -PJ% -PK% -PL% -PM% -PN% -PO% -GP% -GG% -GH% -GK% -GL% -GM% -GN% -GO% -HP% -HG% -HH% -HI%
34!5,
© 2012 MIT Sociotechnical Systems Research Center
13
Current State
5-2A%*,'>,#BB'07"2%7"+,8"&'-+#7)+:,
OPP%
Inflow of appointments from adjacent vs. non-adjacent VISNs ,
NPP%
MPP%
LPP%
KPP%
JPP%
IPP%
HPP%
GPP%
P%
-PG% -PH% -PI% -PJ% -PK% -PL% -PM% -PN% -PO% -GP% -GG% -GH% -GK% -GL% -GM% -GN% -GO% -HP% -HG% -HH% -HI%
34!5,
@.1>%$1$Y"8Z%-FA:%
© 2012 MIT Sociotechnical Systems Research Center
@.1>%"8Z"0($)%-FA:%
14
Current State
C%*.%7"#D%,'>,#BB'07"2%7"+,
GPPX%
Inflow of patient appointments from adjacent vs. non-adjacent VISNs ,
NPX%
LPX%
JPX%
HPX%
PX%
-PG% -PH% -PI% -PJ% -PK% -PL% -PM% -PN% -PO% -GP% -GG% -GH% -GK% -GL% -GM% -GN% -GO% -HP% -HG% -HH% -HI%
34!5,
X%2.1>%"8Z"0($)%-FA:%
© 2012 MIT Sociotechnical Systems Research Center
X%2.1>%$1$Y"8Z%-FA:%
15
Scope: VISN 8 (Florida)
© 2012 MIT Sociotechnical Systems Research Center
16
1. Background
2. Approaches: Systems thinking
3. Current state analysis
4. Initial findings
5. Next steps
© 2012 MIT Sociotechnical Systems Research Center
17
Seasonality
VISN8 (Florida),
5-2A%*,'>,EBB'07"2%7"+,8"&'-+#7)+:,
IP%
HK%
HP%
GK%
GP%
K%
P%
6;4YGP%
:1[YGP%
@(+YGG%
\;$YGG%
A(7YGG%
*(0YGG%
67.YGH%
\;3YGH%
;02%,
F$U1E%2.1>%$1$Y"8Z"0($)%-FA:%
CD%]%PSHK%
2%]%PSPHL%
© 2012 MIT Sociotechnical Systems Research Center
F$U1E%2.1>%"8Z"0($)%-FA:%
CD%]%PSNL%
2%^%PSPPG%
18
Location
Percentage of appointments by station number,
C%*.%7"#D%,'>,#BB'07"2%7"+,
IPX%
HKX%
HPX%
GKX%
GPX%
KX%
PX%
KMI%
LMH%
LMI%
LMK%
KJN%
KGL%
KJL%
34!5,F,+"#G'7,7-2A%*,
© 2012 MIT Sociotechnical Systems Research Center
19
Access
Accessibility of appointments,
HX%
HIX%
• IGX%12%"771#$)>($),%100;.%E#)=#$%
G%8"5%R8.17Y#$,T%
HNX%
• JJX%12%"771#$)>($),%100;.%E#)=#$%
1$(%E((C%12%)=(%8")(%,0=(8;3(8%
R".."$4(8%$(".%)."[(3%'>(T%
JX%
IGX%
GIX%
• IGX%)1%KJX%12%"771#$)>($),%
100;.%E#)=#$%1$(%)1%,#?%>1$)=,%
R".."$4(8%2".%#$%"8["$0(%12%)."[(3T%%
A">(%*"5%
_#)=#$%G%*"5%
_#)=#$%_((C%RH%Y%M%*"5,T%
_#)=#$%!1$)=%RN%Y%IP%*"5,T%
_#)=#$%A#?%!1$)=,%RIG%Y%GNP%*"5,T%
V[(.%A#?%!1$)=,%R`]%GNG%*"5,T%
© 2012 MIT Sociotechnical Systems Research Center
20
Appointment Distribution
Distribution of VISN 8 appointments,
IJQIMK%
E%-*>'
NSL%
E%8)-*>'
J%
FG>'
H%
FH>'
GP%
25000
20000
15000
10000
5000
0
20
40
60
80
100 120 140 160 180 200 220 240 260 280 300 320 340 360 380
© 2012 MIT Sociotechnical Systems Research Center
21
Count
@>'
Appointment Distribution
Distribution
of VISN
appointments
Appointments
per8patient
vs. Time by time,
30
25
Appointments per patient
20
15
10
5
0
10-2010
01-2011
04-2011
© 2012 MIT Sociotechnical Systems Research Center
07-2011
Time
10-2011
01-2012
04-2012
22
Case Mix
Percentage of appointments by case type,
IKX%
C%*.%7"#D%,'>,.#+%+,
IPX%
HKX%
HPX%
GKX%
GPX%
KX%
PX%
H#+%,"IB%,
© 2012 MIT Sociotechnical Systems Research Center
23
Case Mix
Percentage of specialty care appointments by type,
KSPX%
C%*.%7"#D%,'>,.#+%+,
JSKX%
JSPX%
ISKX%
ISPX%
HSKX%
HSPX%
GSKX%
GSPX%
PSKX%
PSPX%
!B%.0#("I,.#+%,"IB%,
© 2012 MIT Sociotechnical Systems Research Center
24
Summary
-a6%
c GPM!%"771#$)>($),%
)1)"3%%
V;)Y12Y-FA:%
c M!%RLSLXT%1;)Y12Y-FA:%
"771#$)>($),%
c GSL!%RGSKXT%$1$Y
"8Z"0($)%"771#$)>($),%%
-FA:%N%R@bT%
c HLLC%RHSHXT%$1$Y
"8Z"0($)%"771#$)>($),%
c IJQIMK%;$#d;(%7"'($),%
&.#>".5%<".(%
c LKC%RHHXT%7.#>".5%0".(%
"771#$)>($),%%
© 2012 MIT Sociotechnical Systems Research Center
25
Next Steps
1. Impact of traveling veterans on primary care
delivery
a. Next available appointments: wait times
b. Physician utilization
2. Financial impact
3. Interventions / policy testing
© 2012 MIT Sociotechnical Systems Research Center
26