Category: Thought Leadership

Thought Leadership

Patient flows: Where engineering meets medicine

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Engineering in medicine is not just about linear accelerators or medical technology scattered across wards, operating rooms (ORs) and other health spaces – Jim Wilkerson, System Director at Memorial Health System in Illinois, USA, and Terry Young of Datchet Consulting, write for ACJ.

As with icebergs, these are just the visible tip of an enormous engineering presence in healthcare today, especially in designing how people flow through the system to make better use of its resources. Jim Wilkerson, System Director at Memorial Health System in Illinois, USA, and Terry Young of Datchet Consulting write for ACJ.

An example of visible engineering is the CT scanner, a sophisticated product that costs around $2,000,000 and must operate in a lead-lined room (an engineering exercise in itself). Nearby, staff capture, manipulate and store 3D, high-resolution images from patients with anything from brain injury to arthritis. As a powerful, versatile, diagnostic, it is widely in demand.

Because it is so useful, expensive and immovable, invisible engineering must plan for as many patients as possible to use it. The engineering team at Memorial Health System exists to design the flows between wards, clinics, ORs, and facilities such as catheterisation laboratories (cath labs) or radiology departments.

This industrialised approach involves concepts still at the periphery of medical experience. The terminology may be familiar, but routine application is not. Memorial Health System promotes a Lean Six Sigma approach, a combination of Japanese and US manufacturing innovation, using point of care technology to speed diagnosis and move people through the system. There are strong reasons to do so in any care system, but access to a CT scanner makes such a focus particularly easy to justify.

Under this framework, computer models create prototype designs in search of greater service resilience or to eliminate waiting and other forms of waste. This highly numerate approach relies on a variety of data sources from internal information services to voice of the customer (VoC) systems in order to refine a model until it mirrors the existing system accurately. It is then used to trial new scenarios. In this case, one scenario was found to agree with the measured post-implementation situation to within 58 seconds in reducing delays by half an hour.

In 2014, a CT scanner at Memorial Health was becoming overloaded, but before purchasing a second machine, the design team explored the situation. It became clear that one source of delay concerned patients who arrived for a scan but had not been fully prepared – in some cases, they had to receive further medication first. To address this, a scenario was modelled in which an extra member of staff would check patients earlier and ensure that those arriving were ready to be scanned. It showed that creating this extra position for 8½ hours a day during peak demand would reduce the peak delay from requesting a scan to starting it by around a third. It was trialled for a limited time and then implemented permanently.

The in-house modeller used a package known as SIMUL8 to build and run the scenarios in less than a week, which at an internal charge-out rate of <$50/hour, came to <$1,500. Getting a decision through the board was estimated at <$20,000, while the extra staff member cost just over $50,000/year. Whatever the exact costs, the benefits were huge: $2,000,000 saved in not buying a new scanner and an estimated benefit of $700,000/year based on shortening patients’ lengths of stay through better flow and thus reducing costs.

This spectacular example is by no means unusual where models are routinely applied in designing services but it does not fully describe the value of the improvement, either. The full benefit of smoother, faster patient flows through CT will vary from patient to patient. If someone has just had a stroke, saving half an hour could have a big impact upon their survival and the quality of recovery. It will usually have less of an impact for patients needing a routine scan. To include the full health premium in a business case would involve collecting much more data (starting with the case mix of patients using the scanner).

At a time when health services are stressed and stretched, and there is a steady cry for more resources, this type of engineering is more important than ever. Evidence is starting to emerge that design plays a valuable role in services and we anticipate that it will not be long before this evidence is overwhelming. Until then, a failure to design systematically within an engineering framework is looking ever more negligent.

About the authors

Jim Wilkerson serves as the System Director for Operations Improvement for Memorial Health System of Springfield, Illinois. In this position, Jim oversees the training, development, and deployment of the system’s Lean Six Sigma resources and performance improvement work. Jim has been involved in designing Memorial’s quality and safety program that has been recognized as a state, national and international leader in healthcare. He holds two Bachelors of Science degrees in Finance and Business Economics and a Master’s in Rehabilitation Counselling. He is a Certified Lean Six Sigma Master Black Belt and a Licensed Clinical Professional Counsellor.

Terry Young is Professor Emeritus at Brunel University London. Following a PhD in laser spectroscopy, he worked for 16½ years in industrial R&D with GEC and technology strategy with Marconi. His research focus shifted during this time to healthcare services and his academic research, since 2001, when he moved to Brunel University London, has focused on the organisation and delivery of health services with emphasis on the value and role of technology. He is now an emeritus professor and Director of Datchet Consulting.

This case study was published in Health Systems under the title, The costs and value of modelling-based design in healthcare delivery: five case studies from the US (https://doi.org/10.1080/20476965.2018.1548255).

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Thought Leadership

NHS: Using technology to wage war on waste

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Professor Terry Young analyses why the NHS has failed to reduce waste where other sectors have succeeded. Could technology enable an answer to be found at last?

While waiting for a flight in the departure lounge of an airport recently, I asked the pilot when we were expecting to leave. He dug out his tablet, swished about with his finger and said the inbound flight was the other side of Glasgow and would be on stand in 20 minutes. I asked about refuelling and the stacking over Heathrow and his trusty tablet told him everything.

As he left to do his pre-flight checks, I reflected that I could not have had such a conversation with any NHS manager, nurse or doctor. But then, pilots did not talk that way, either, when the NHS was born, 70 years ago.

It is tempting to look at the pilot’s world of timely figures and tracking information and to prescribe the same for the NHS. But what is it about flying or any of a dozen other sectors that has transformed them ahead of the NHS?

The answer involves two deceptively simple ideas – knowledge and process. Leaders in these other sectors were not specifically seeking knowledge or process but invested in them relentlessly because they were chasing something else – something that is critical to the NHS today.

Surprisingly, it was a deep-seated aversion to waste that drove this change. By the 1960s, for instance, supermarkets could see that delay in getting produce to the shop was a waste, not just because food goes off, but because the supermarket must spend money on a product right up to the moment a sale is made. Walmart’s investment in computer systems, barcode scanners, smart tags, and networks in the 1970s is testament to a frighteningly expensive war on waiting.

In the 1990s, a decade before the NHS attempted its national IT network, Walmart spent a similar amount on its own network, persuading its suppliers to invest considerably more, and made it work. The reason the NHS failed while Walmart succeeded was that the NHS had no clear idea of what waste the network was meant to eliminate, while Walmart knew exactly how the network would help make better decisions faster and how much decisions were worth.

Today, health researchers all over the world are working hard to identify waste in all its forms; from the obvious waste of prescriptions and treatments that are not needed to the less visible business of variation in practice. Lord Carter, for instance, has shown that similar NHS services can cost wildly different amounts to run, depending on where they are. So, what is holding the NHS back from a decisive victory over waste?

Firstly, many in healthcare find it at least as distasteful to express waste in financial terms as they find the waste itself. This is understandable to some extent since many NHS staff encounter several examples a month where money, or the paperwork that goes with it, comes before the patient. However, without a more reasonable relationship between the NHS’s mandate and the resources that make it run, there will always be significant, invisible waste.

Secondly, one cannot reduce waste without metrics, and the NHS struggles with measures of effectiveness. Too often these are associated with punishment, not often enough with polishing the process. Winning the war on waste will need better metrics applied in better ways.

Finally, if other sectors are anything to go by, waste often hides in the most unlikely places. The fact that a ward is full, or that the list at a surgery is overflowing, does not tell us whether either is efficiently run. It usually requires information from a long way back as well as knowledge of the wider service, to judge what is going on.

Given robust definitions of waste, however, the ingenuity of the NHS could be unleashed to track and eliminate it. The NHS employs some of the brightest people in the world – robust design and technology empowered delivery is not beyond them, nor is affordable, high quality, care at scale. What the NHS needs now is a clear target and the will to pursue it relentlessly.

Professor Terry Young worked in industrial R&D before becoming an academic and is now Director of Datchet Consulting. With over 30 years’ experience in technology development and strategy, health systems, and methods to ensure value for money, his current focus lies in designing services using computer models and he set up the Cumberland Initiative to support healthcare organisations wishing to develop their services more systematically. Three of his downloadable papers are:

Using industrial processes to improve patient care (2004, with Brailsford et al., British Medical Journal)

Performing or not performing: what’s in a target? (2017, with Eatock & Cooke, Future Hospital Journal)

Systems, design and value-for-money in the NHS: mission impossible? (2018, with Morton and Soorapanth, Future Hospital Journal)

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Thought Leadership

Health systems: What should they deliver and why is this so difficult?

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What do we want from a health system? Professor Terry Young looks at the advantages of modelling to understand what solutions will be most effective and the difficulties of implementing change in the UK.

What do we want from a health system? Surprisingly, there is a consensus. Our STPs (Sustainability and Transformation Partnerships) are seeking:

  • Hospitals with unified points of entry and ways to track all patients’ needs all the time
  • Streamlined services elsewhere that are responsive, connect to one another and avoid duplication.
  • Smart information to make this new world of care affordable and manageable.

Many also want preventative measures, measures promoting healthier lifestyles, and mental health measures which, if anything, present an even trickier challenge. There are a number of tensions that contribute to our inability to make the health and care service we want.

The first reason health and care services in the UK struggle to deliver change is that we have been inordinately successful in delivering good care in the past.

This creates a sense that the skill-set needed to shape the future is already within our grasp.

The systems that we currently have in place have been shaped by those earlier successes. When there were fewer of us and we didn’t live so long or suffer from more than one condition at a time, systems could be simpler to meet more manageable needs. Even our ideas for measuring performance were shaped by, or are a reaction to, that context.

From the healthcare estate, we have inherited across the country to the way we think about care, the specialised clinical disciplines and the delegation of responsibility and accountability between services are all a result of heritage within the sector. However, things have changed somewhat. People are living longer, developing more long-term lifestyle diseases and multi-morbidity.

Moving care into the community

One cannot simply make like-for-like substitutions when transferring care from the hospital to the community since community services operate completely differently. In 2016, the Whole Systems Partnership built a model to explore a community-based cardio-respiratory service to accept 10 per cent of urgent cases and 50 per cent of GP referrals, replace 15 per cent of inpatient admissions, and manage 80 per cent of follow-up appointments. The model redefined the workforce into four skill levels to deliver a leaner skill-mix, a smaller overall workforce with a clear idea of the structures needed in both hospital and community.

Finding a new language

Our second challenge is to live with our legacy while finding a new language to articulate a wholly different future.

Even without a legacy, healthcare systems would still be almost impossible to design because they are so complicated and different pieces of the puzzle take wildly different amounts of time to develop. People take time to train – more than a decade in many cases – while drugs and technology develop at vastly different rates. At the other end of the spectrum, buildings go up quickly, but approvals and funding slow the process down. How then, do you introduce a new idea and ensure that it can be delivered?

The key to any design is knowing what to keep and what to change. Taking a cancer centre, for example: should it be designed for those heavy linear accelerators? Will the treatments in 25 years be mainly energy beams, chemistry, genomics or nanotechnology? And will oncologists, gerontologists, GPs or nurse practitioners run the service?

This is a fiendishly difficult problem because it involves great uncertainty about the future and requires great confidence that the final system will deliver what we want, without unpleasant, unintended consequences.

Simulation: try before you buy

In other sectors, people simulate or even game to explore such extremes. In the ‘60s, for instance, when nobody knew how to land people on the moon, huge effort went into simulation and simulators. Part of this was cultural; teams that created unfamiliar launch or recovery scenarios competing against teams that would run the missions, adding new pieces of doctrine every time a simulated mission crashed. On the other hand, there were mock-ups of each capsule and piece of equipment and the astronauts learned to work with, or within, it.

Today, one would not plan a new route for an airline or launch a new smartphone without extensive simulation of each operation and the impact of changing demand and other external forces. Even our cars have simple simulators that estimate whether we will reach our destination or run out of fuel.

It doesn’t matter where you start simulating: In a clinic, consulting room, ward, theatre, or at home. Simulations are part of our industrial heritage, so we understand well how to build, test and use models. Good models eventually enmesh the whole system to show where delays will build up, how much an extra nurse on the ward will cost or what benefit a new scanner will bring to all the people who will use it.

The Memorial Health System in Illinois models all patient journeys in detail from the emergency department to CT scanners and on to wards. Its engineering design methods routinely identify savings that can be applied. In one case, an extra elevator implemented to cut delays as patients moved from wards to the operating theatre paid for itself in a few days. In another study to streamline CT scanning, the addition of an extra individual to check the preparation of the patients saved half an hour per patient, which fell within a minute of modelled predictions.

We know an enormous amount about health and have leveraged that knowledge miraculously over the past half-century. What we must now learn is how to design systems to leverage that knowledge more cheaply and consistently than anything anyone has yet achieved. For the real challenge is more difficult still: To design the new while keeping the old system going until it is replaced.

Professor Terry Young worked in industrial R&D before becoming an academic. He has over 30 years’ experience in technology development and strategy, health systems, and value for money. His recent sabbatical was spent gathering evidence of where simulation has been used in healthcare and how much it is worth to design new processes. Three of his downloadable papers are:

Using industrial processes to improve patient care (2004, with Brailsford et al., British Medical Journal)

Performing or not performing: what’s in a target? (2017, with Eatock & Cooke, Future Hospital Journal)

Systems, design and value-for-money in the NHS: mission impossible? (2018, with Morton and Soorapanth, Future Hospital Journal)

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