Abstract

There has been much research where the flow of patients was improved, but most of this study is case-specific and only a few papers offer guidelines for patient flow analysis and improvement. In this study a general framework for the analysis and improvement of patient flow is presented, based on a literature review and on experience from a case study in a hospital in Mexico dealing with identifying improvement opportunities that reduced waiting times in the obstetrics/gynecology area of the emergency department. The framework involves an initial analysis using basic tools followed by the selection of a strategy based on system complexity; financial investment required and team participation. The alternative strategies considered were use of advanced analysis tools; use of kaizen events; or direct recommendations. The aim of the framework is to serve as guideline in patient flow improvement projects by helping select the most appropriate improvement path, resulting in project success.

Keywords:

Emergency department, healthcare , hospitals , kaizen , patient flow,

References

1. Balci, D., S.E. Kesen and B.Ö. Faruk, 2007. Adaptability of Just-In-Time (JIT) philosophy to service systems: A case study. Simulation, 83(9): 631-642.
   CrossRef    
2. Brailsford, S.C., 2005. Overcoming the barriers to implementation of operations research simulation models in healthcare. Clin. Invest. Med., 28(6): 312-315.
   PMid:16450620    
3. Brailsford, S.C. and N.A. Hilton, 2001. A comparison of discrete event simulation and system dynamics for modeling healthcare systems. In: Riley, J. (Ed.), Planning for the Future: Health Service Quality and Emergency Accessibility. Operational Research Applied to Health Services (ORAHS). Glasgow Caledonian University, pp: 18-39.
   
4. Brailsford, S.C., P.R. Harper, B. Patel and M. Pitt, 2009. An analysis of the academic literature on simulation and modelling in health care. J. Simul., 3: 130-140.
   CrossRef    
5. Brenner, S., Z. Zeng, Y. Liu, J. Wang, J. Li and P.K. Howard, 2010. Modeling and analysis of the emergency department at University of Kentucky Chanler hospital using simulations. J. Emerg. Nurs., 36(4): 303-310.
   CrossRef    PMid:20624562    
6. Burton, T.T. and S.M. Boeder, 2003. Lean Extended Enterprise: Moving Beyond the Four Walls to Value Stream Excellence. J. Ross Publishing, Inc., USA.
   
7. Carter, M.W. and J.T. Blake, 2005. Using Simulation in an Acute-care Hospital: Easier Said than Done. In: Brandeau, M.L., F. Sainfort and W.P. Pierskalla (Eds.), Operations Research and Healthcare: A Handbook of Methods and Applications. International Series in Operations Research and Management Science. Kluwer Academic Publishers, Boston, pp: 191-215.
   CrossRef    
8. Chand, S., H. Moskowitz, J.B. Norris, S. Shade and D.R. Willis, 2009. Improving patient flow at an outpatient clinic: Study of sources of variability and improvement factors. Health Care Manage. Sci., 12(3): 325-340.
   CrossRef    
9. Cochran, J.K. and A. Bharti, 2006. A multi-stage stochastic methodology for whole hospital bed planning under peak loading. Int. J. Ind. Syst. Eng., 1(1): 8-32.
   CrossRef    
10. Coffey, R.J., J.S. Richards, C.S. Remmert, S.S. LeRoy, R.R. Schoville and P.J. Baldwin, 2005. An introduction to critical paths. Qual. Manag. Health Care, 14(1): 46-55.
    CrossRef    PMid:15739581    
11. Davies, R., 1994. Modeling patient flows and resource provision in health systems. Omega, 22(2): 123-131.
    CrossRef    
12. De Souza, B.L., 2009. Trends and approaches in lean healthcare. Leadership Health Serv., 22(2): 121-139.
    CrossRef    
13. Dickson, E.W., S. Singh, D.S. Cheung, C.C. Wyatt and A.S. Nugent, 2009. Application of lean manufacturing techniques in the emergency department. J. Emerg. Med., 37(2): 177-182.
    CrossRef    PMid:18722732    
14. Duguay, C. and F. Chetouane, 2007. Modeling and improving emergency department systems using discrete event simulation. Simulation, 83: 311.
    CrossRef    
15. Eitel, D.R., S.E. Rudkin, M.A. Malvehy, J.P. Killeen and J.M. Pines, 2010. Improving service quality by understanding emergency department flow: A white paper and position statement prepared for the American academy of emergency medicine. J. Emerg. Med., 38(1): 70-79.
    CrossRef    PMid:18514465    
16. Fernandes, C.M., R. Walker, A. Price, J. Mardsden and L. Haley, 1997. Root cause analysis of laboratory delays to an emergency department. J. Emerg. Med., 15(5): 735-739.
    CrossRef    
17. Fillingham, D., 2007. Can lean save lives? Leadersh. Health Serv., 20(4): 231-241.
    CrossRef    
18. Hall, R., D. Belson, P. Murali and M. Dessouky, 2006. Modeling Patient Flows through the Healthcare System. In: Hall, R.W. (Ed.), Patient Flow Reducing Delay in Health Care Delivery. Springer, Los Angeles, pp: 1-44.
    CrossRef    PMCid:PMC4166149    
19. Hanna, V. and K. Sethuraman, 2005. The diffusion of operations management concepts into the health care sector. Proceedings of the 3rd ANZAM Operations Management Symposium.
    
20. Karnon, J. and J. Brown, 1998. Selecting a decision model for economic evaluation: A case study and review. Health Care Manage. Sci., 1(2): 133-140.
    CrossRef    
21. King, D.L., D.I. Ben-Tovim and J. Bassham, 2006. Redesigning emergency department patient flows: Application of Lean Thinking to health care. J. Emerg. Med. Australas, 18(4): 391-397.
    CrossRef    PMid:16842310    
22. Koizumi, N., E. Kuno and T.E. Smith, 2005. Modeling patient flows using a queuing network with blocking. Health Care Manage. Sci., 8(1): 49-60.
    CrossRef    
23. Konrad, R., K. DeSotto, A. Grocela, P. McAuley, J. Wang, J. Lyons and M. Bruin, 2013. Modeling the impact of changing patient flow processes in an emergency department: insights from a computer simulation study. Oper. Res. Health Care, 2(4): 66-74.
    CrossRef    
24. Langabeer, J.R., J.L. DelliFraine, J. Heineke and I. Abbass, 2009. Implementation of Lean and Six Sigma quality initiatives in hospitals: A goal theoretic perspective. Oper. Manage. Res., 2: 13-27.
    CrossRef    
25. Mahachek, A.R. and T.L. Knabe, 1984. Computer simulation of patient flow in obstetrical/ gynecology clinics. Simulation, 43(2): 95-101.
    CrossRef    
26. Maull, R.S., P.A. Smart, A. Harris and A.A. Karasneh, 2006. An evaluation of 'Fast-Track' in A&E: A discrete event simulation approach. Serv. Ind. J., 29(7): 923-941.
    CrossRef    
27. Medina, S.V., A. Medina and A. González, 2010. Reducir tiempos de espera de pacientes en el departamento de emergencias de un hospital utilizando simulación. Ind. Data, 13(1): 67-76.
    CrossRef    
28. Medina, S.V., A. Medina, A. González and C. Navarro, 2011. Utilización de la teoría de colas para asignar y balancear el número de camas entre las salas de un hospital. In: Salazar Ruíz, E., (Ed.), Libro de Ponencias del 5to Congreso Internacional de Ingeniería Industrial (ARGOS), Mexico, pp: 66-76.
    
29. Medina, S.V., A. Medina-Palomera, Á. González-Ángeles and E.N. Castillo Morones, 2012. Análisis de mejora del flujo de pacientes utilizando herramientas básicas de ingeniería industrial. In: Moras R. and M. Gutiérrez (Eds.), Memorias del Congreso Internacional de Investigación Academia Journals 2012 Chiapas, Mexico, pp: 913-918.
    
30. Naseer, A., T. Eldabi and T.P. Young, 2010. RIGHT: A toolkit for selecting healthcare modelling methods. J. Simul., 4: 2-13.
    CrossRef    
31. Nelson-Peterson, D.L. and C.J. Leppa, 2007. Creating an environment for caring using lean principles of the Virginia mason production system. J. Nurs. Admin., 37(6): 287-294.
    CrossRef    PMid:17563521    
32. Ng, D., G. Vail, S. Thomas and N. Schmidt, 2010. Applying the Lean principles of the Toyota production system to reduce wait times in the emergency department. Can. J. Emerg. Med. Care, 12(1): 50-57.
    CrossRef    PMid:20078919    
33. Paul, J.A. and L. Lin, 2012. Models for improving patient throughput and waiting at hospital emergency departments. J. Emerg. Med., 43(6): 1119-1126.
    CrossRef    PMid:22902245    
34. Pérez, K., L. Cardona, S. Gómez, T. Olarte and P. Escudero, 2008. Simulation and optimization in a health center in Medellin, Colombia. Proceedings of the 2008 Winter Simulation Conference, pp: 1362-1367.
    CrossRef    
35. Rogers, P., 2002. Optimum-seeking simulation in the design and control of manufacturing systems: Experience with OptQuest for Arena. Proceedings of the 2002 Winter Simulation Conference, pp: 1142-1150.
    CrossRef    
36. Rohleder, T.R., D. Sabapathy and R. Schorn, 2005. An operating room block allocation model to improve hospital patient flow. Clin. Invest. Med., 28(6): 353-355.
    PMid:16450633    
37. Ruohonen, T., P. Neittaanmäki and J. Teittinen, 2006. Simulation model for improving the operation of the emergency department of special health care. Proceedings of the 2006 Winter Simulation Conference (WSC, 2006), pp: 453-458.
    CrossRef    
38. Sanchez, S.M., 2007. Work smarter, not harder: guidelines for designing simulation experiments. Proceedings of the 2007 Winter Simulation Conference, pp: 84-94.
    CrossRef    
39. Santibáñez, P., V.S. Chow, J. French, M.L. Puterman and S. Tyldesley, 2009. Reducing patient wait times and improving resource utilization at British Columbia Cancer Agency's ambulatory care unit through simulation. Health Care Manage. Sci., 12(4): 392-407.
    CrossRef    
40. Stafford, E.F., 1978. Simulation vs. mathematical analysis for systems modeling: A comparison of techniques. Proceedings of the 1978 Summer Computer Simulation Conference. AFIPS Press, USA, pp: 53-159.
    
41. Tapping, D., S. Kozlowski, L. Archbold and T. Speri, 2009. Value stream management for lean healthcare. MCS Media, Chelsea, USA.
    
42. Thompson, D.N., G.A. Wolf and S.J. Spear, 2003. Driving improvement in patient care: Lessons from Toyota. J. Nurs. Admin., 33(11): 585-595.
    CrossRef    PMid:14608217    
43. Tunnicliffe, W.J.C., 1981. Implementation of computer simulation projects in health care. J. Oper. Res. Soc., 32: 825-832.
    CrossRef    
44. Venkatadri, V., R.V. Arasinapalai, V. Kesavakumaran, S.S. Lam and K. Srihari, 2011. Simulation based alternatives for overall process improvement at the cardiac catheterization lab. Simul. Model. Pract. Th., 19(7): 1544-1557.
    CrossRef    
45. Vest, J.R. and L.D. Gamm, 2009. A critical review of the research literature on Six Sigma, Lean and StuderGroup's Hardwiring Excellence in the United States: The need to demonstrate and communicate the effectiveness of transformation strategies in healthcare. Implement. Sci., 4: 35.
    CrossRef    PMid:19570218 PMCid:PMC2709888    
46. Wedgwood, I.D., 2006. Lean SIGMA a Practitioner's Guide. Prentice Hall, USA.
    
47. Zeng, Z., X. Ma, Y. Hu, J. Li and D. Bryant, 2012. A simulation study to improve quality of care in the emergency department of a community hospital. J. Emerg. Nurs., 38(4): 322-328.
    CrossRef    PMid:21963136    

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