Improving Safety In the ICU

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Application of Simulation Technology to Optimize
Quality of Surgical Patient Care A
Sub-Initiative of the Henderson Site Patient Flow
Innovation and Learning Initiative
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Acknowledgements

• Daphne Sniekers, PhD Candidate, Mechanical
  Industrial Engineering, University of
• Toronto, Leslie Gauthier, Director, Perioperative
  Services, HHS, Kelly Campbell,
• Assistant Vice President, Clinical Planning, HHS,
  Ivan Yuen, Quality Specialist,
• Quality, Patient Safety, and Clinical Resource
  Management, Steve Metham, Manager,
• Quality, Patient Safety, and Clinical Resource
  Management, HHS, Dr. Bill Evans,
• President, Juravinski Cancer Center, HHS, Dr.
  Michael Carter, Centre for Research
• in Healthcare Engineering, Mechanical
  Industrial Engineering, University of Toronto,
• Gail Johnson, Director, Orthopedic Medicine
  Program, HHS, Carol Potvin, Director,
• Surgical Radiation, Oncology Programs
  Henderson/Juravinski Cancer Center Site
• Administrator, HHS, Susan Taylor, Senior
  Consultant, Quality, Patient Safety, and
• Clinical Resource Management, HHS, Teresa Smith,
  Assistant Vice President, Quality,
• Patient Safety, and Clinical Resource Management,
  HHS, Carolyn Busby, PhD
• Candidate, Mechanical Industrial Engineering,
  University of Toronto, Dr. Justin
• DeBeer, Orthopedic Surgeon, HHS, Wendy Boles,
  Clinical Manager, Perioperative
• Services, HHS, HHS, Nancy Henderson, Quality
  Specialist, Quality, Patient Safety, and
• Clinical Resource Management, HHS, Anne Kempen,
  Information Systems Specialist,
• Perioperative Services, HHS, Sharon Pierson,
  Director, Quality, Patient Safety, and
• Clinical Resource Management, HHS, Enoch Ho,
  Evaluation Specialist, Quality, Patient
• Safety, and Clinical Resource Management, HHS.

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How do we know that a problem or opportunity
exists?
System bottlenecks opportunities to smooth
flow of elective procedures and admissions Change
to types and volumes of specific surgical
procedures
HHS Change and Quality Improvement Model
What are we trying to accomplish?
To achieve the targeted volume of orthopedic
surgery knee/hip total joint replacements within
the allocated perioperative and inpatient
resources
Define
How will we know a change is an improvement?
of cases completed per year, Cancellation
rates (Lack of bed, Out of scheduled time), OR
utilization (OT, Underutilization)
Plan
Act
What changes will result in an improvement?
Study
Do
Implement OR block and case mix schedule and
rules, align inpatient beds to optimize volumes,
patient flow, and clinical resource utilization
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PDSA Cycle 1 Developing a Simulation Model
Plan
Gather stakeholder input to develop conceptual
model Develop computer simulation model to
capture high level of complexity Model surgical
process as queue systems Analyze historical
patient flow data and identify sampling
distributions
Do
Run computer model populated with historical case
data to replicate historical patient flow through
existing process
Study
Compare results - simulation model output versus
known historical measures Identify bottlenecks
and variability in the process
Act
Proceed with testing changes within validated
computer simulation model
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PDSA Cycle 2 Testing Changes within the
Simulation Model
Plan
Identify changes to process and resources to be
tested (simulated) based upon analysis of
bottlenecks, variability, and stakeholder input
Do
Run computer model with identified changes to
process and resources tested individually and/or
in combinations Multiple trials of each scenario
run and results outputted
Study
Review scenario results and compare with targets
Act
Select scenario for live implementation and
move to PDSA Cycle 3 Implementing the Changes
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Changes to Process Variables
Length of wait list Wait list arrival
rate Number of SDS, PACU, ICU, Step-down, and
ward beds Off service rates, ALC beds, Isolation
beds, ICU holdovers OR days and hours, number of
rooms Allowable OR overtime, allowable OR
under-utilization Surgical case mixes by day of
week Scheduled closures Procedure times Equipment
room availability Transport times etc
Plan
Act
Study
Do
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Simulated Scenario Output
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Benefits of Simulation Incorporates HHS-specific
historical data in generating solutions specific
to HHS patient and provider needs Allows
innovative stakeholder input and strategies to be
tested sequentially or simultaneously while
minimizing risk to patients and
resources Dazzling visuals Limitations of
Simulation Time consuming to develop Decision
making set as yes or no Does not support
day-to-day (operational) decisions
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Next Steps
Continue implementation of identified optimal
changes into orthopedic surgery
process Coordinate with other Henderson Site
Patient Flow Innovation Learning Initiative
activities Proceed with development of site-wide
all-services simulation model in collaboration
with University of Toronto, Visual8 Corporation,
and peer hospital participants
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Contact

• Steve Metham
• Manager, Quality
• Quality, Patient Safety and Clinical Resource
  Management Hamilton Health Sciences
• [phone] Ext.46425
• methams_at_hhsc.ca