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An Introduction to Industrial & Systems Engineering in Healthcare

Submitted by: Stephen Watt

Submitted to: Professor Khasawneh

Binghamton University: Spring 2017

02/08/2017
Question 1

The knowledge hierarchy is a foundation of knowledge-based management, comprising five


categories of learning: data, information, knowledge, understanding, and wisdom (pp 20., Reid, 2005).
These fundamental pillars are what drive the widespread shift
in decision making from intuition to data science techniques.
The example in the textbook that helps to describe the
knowledge hierarchy displays the contextual thought process
of using data to calculate ones BMI all the way until they
realize they need to take action (and exercise) to reduce it.

Figure 1 - Knowledge Hierarchy (pp20., Reid, Data is raw numbers, information is organized raw data that
2005)
has meaning, knowledge is information that enables decision
making, understanding allows one to extrapolate new conclusions and knowns from what is known already,
wisdom adds moral and ethical perspectives to which there is no clear right answer (pp 20., Reid, 2005).

A healthcare based example could pertain to the high level data analysis regarding hospital
readmission rates. Lets say, from a data driven standpoint we know that Lourdes hospital has had 15
people readmitted for percutaneous transluminal coronary angioplasty (PTCA) this month. This is evident
from the IT systems data. After further analysis we find out that 15 out of 100 patients were readmitted this
past month for the PTCA procedure. Not wanting readmission at all, we can research who, what, where,
and when these procedures occurred. After a hospital technician analyst performs readmission rates
research, he finds out the national average for readmission for this procedure is 8-10%. This is knowledge
because it enables decision making in the future. Understanding is truly represented when he organizes a
hospital and team meeting with the operating room staff, surgeons, and senior leadership to present that
the hospital is in danger of an out of control readmission process (and it is unacceptable). Wisdom is in
effect, when that same technician in collaboration with co-workers design an experiment or implement a
program to reduce the readmission rates from this procedure/find out why they are occurring. There is a
natural progression from a known number, to the use of that number to find a metric, the metric in the
context of averages and statistical data, the understanding of what comes of that relative comparison, and
then the moral, ethical, and unclear problem solving that occurs after it.
References

[1] Reid, P.R, and W.D Grossman. "Building a Better Delivery System: A New Engineering/Health Care
Partnership." Institute of Medicine and National Academy of Engineering. The National Academy Press,
2005. Web. 03 Feb. 2017
Question 2

Upon general inspection and introspection of the definition of turnaround time it is evident that the
term is an operational definition for a gray area of application. It has been used to describe the
effectiveness and efficiency throughout many industries. It is important because turnaround time is a direct
indicator of patient satisfaction, and prevents organizations from losing time and money from employees
and potential services to other people in need. The effective planning and modeling is of critical importance
in the healthcare industry. In the healthcare industry PTAT (patient turnaround time) is used for these very
reasons. From the evidence described in a recent literature review, PTAT is a highly variable definition
given the setting and activity that is being evaluated. One PTAT can be defined as the time a patient
completes filling out their medical records to proceed with treatment until that patient is discharged. Another
definition can be the time from the physicians request until the time the physician views the result (Breil,
2011). The paper examined over 1000 articles and defined turnaround time in various laboratory and
healthcare contexts. The applicable scenarios explored are radiology and whole clinics (emergency
department, medication, and other processes in a whole clinic). The radiology department found the two
most common reports were the time from the x-ray completion until the availability of the radiology report in
the HIS and the time from radiology request to x-ray completion (Breil, 2011). In a clinic or hospital domain
there were 21 different domains identified in this same paper. From a high level this is a general trend
throughout healthcare in various terms and scenarios. This is the relatively constant definition.

According to literature patient length of stay (PLOS) describes the number of days a patient spends
inpatient care (total number of days/number of patients). In order for a patient to be considered inpatient,
they must be under hospital care for more than one day. Turnaround time and patient length of stay are
similar in that they measure a general metric of quality and efficiency based on a given condition and how
patients respond to their treatment cycles. However, they are different because patient turnaround time can
be applied to a variety of scoped clinical settings and scenarios. Medicare directly uses length of stay as a
quality metric for reimbursing hospitals in order to reduce healthcare costs and increase quality. Other
studies have been higher proponents of the median instead of the average used in both metrics. An
example of the measurement of turnaround time with this broad definition is exemplified in a study by
Stefan Kropp with the emergency department of the Hanover Medical School in Germany. They monitored
the time including registration all the way until discharge of the emergency department (Kropp, 2005). This
study was solely confined to emergency situations relating to psychiatric care.
There are some critical national statistics that were published in 2014 regarding PLOS and PTAT. It
showed that the northeast had an almost entire extra day in length of stay compared to the rest of the
country (more so the west coast). Additionally, the northeasts aggregate costs were lower than others.
Also, Medicare recipients are receiving a longer length of stay care (Weiss, 2014). A study done in 2001,
worked with physicians and patients to indicate satisfaction and emergency department turnaround time.
Generally, 40 minutes or lower was considered to be in the 90 th percentile of quality (Hawkins, 2007).

References

[1] Breil, Bernhard et al. Mapping Turnaround Times (TAT) to a Generic Timeline: A Systematic Review of
TAT Definitions in Clinical Domains. BMC Medical Informatics and Decision Making 11 (2011): 34. PMC.
Web. 9 Feb. 2017.

[2] Kropp, Stefan et al. Psychiatric Patients Turnaround Times in the Emergency Department. Clinical
Practice and Epidemiology in Mental Health: CP & EMH 1 (2005): 27. PMC. Web. 9 Feb. 2017.

[3] Weiss, Audrey, and Anne Elixhauser. "Overview of Hospital Stays in the United States,
2012."Healthcare Cost and Utilization Project 94.1 (2014): n. pag. Statistical Brief #180. Agency for
Healthcare Research and Quality. Web.

[4] Hawkins, Robert C. Laboratory Turnaround Time. The Clinical Biochemist Reviews 28.4 (2007): 179
194. Print.
Question 3

The ten steps to close the quality chasm gaps are essential to the progression of the United States
healthcare system. The easiest (number 1) is safety as a system property. Patients should not be getting
incorrect operations and developing chronic injuries due to systematic and procedural standards. Much like
any other industry, it needs automation of processes and checks in place every step of the way. All of the
while not incorporating more complexity into the system. The second one is cooperation among clinicians.
The third one is shared knowledge and the free flow of information. I coupled these two together because
they go hand in hand. The digitization of medical records and streamline of information based
communication is not a difficult task. What makes it difficult is the lack of cooperation from stakeholders
across the board. Moreover, patients own their medical records and for their safety and transparency they
should have a very easy ability to access this critical information in times of emergency. This is why a
standardized and secure central system is needed for information exchange and transfer. The 4 th chasm
that is on the easier spectrum of implementation is care based on continuing relationships. A responsive
healthcare system 24/7 is very much lacking in a capitalistic society. We are moving more towards a tele
medicine industry access but cooperation of physicians and early residents could provide high level insight
into minor problems. This is an effective way to reduce hospital clutter/operations while maintaining
revenue. It aligns the interests of all parties and should be deployed. 5 th the system should be customizable
based on patient needs and values. It should be a shrink wrapped industry to meet the simplest and high
level complications and capability to respond in a personalized manner to treat patients. I believe this ties
heavily into telemedicine. The 6th chasm is the need for transparency. This becomes difficult because
keeping patients completely informed of complex procedures and what is happening becomes difficult due
to their lack of expertise. They should have all of the information but should refrain from coming to
conclusions and demanding procedures themselves. Checks need to be in place for physicians to deny
certain surgeries if they feel it is not their expertise. Additionally, the hospital should make public its
statistics regarding admission, readmission, specialties, performance, safety, etc. This would increase the
competitive landscape and force them to apply systems engineering to reduce quality and performance
issues. 7 is that the system should not waste the patients time or resources in general. This is difficult due
to the lack of standardization of systems and automation of procedures. Diagnostically, there is a lot of
measurements to perform and analyze before an effective and truthful diagnosis can happen. Additionally,
this lack of waste depends on the disease being explored or discussed. It is highly variable and difficult to
develop this system. Number 8 is the patient as a source of control. It is related to the need for
transparency and becomes difficult because patients are not subject matter experts and do not have an
idea of the competitive landscape around certain specialty fields. There can be complications in devices,
medications, conditions, diseases, etc. This is difficult to give patient control for decisions regarding
treatment. However, regarding insurance and forms of payment it should be much easier. Number 9 is
evidence based decision making. This will require an extensive review of current medicine, devices,
pharmaceuticals, and all of their interactions in various specialties and indications. Plus, this information will
need to be centralized and digitized. There are only a handful of physicians and surgeons that can
effectively understand specialized spaces to make informed decisions. The best course of treatment is
difficult to know. But the standardized course of treatment should be known throughout many hospitals for
specific complications. Lastly, anticipation of needs is the hardest due to the random distribution of
cancellations, availability (in terms of scheduling), and complexity/lack of knowledge about specific
diseases. Yes, we should use biomarkers, vital signs, etc. as a form of preliminary indication, but they
cannot be used at a high level to anticipate events in the future and react in truth.

References

[1] Reid, P.R, and W.D Grossman. "Building a Better Delivery System: A New Engineering/Health Care
Partnership." Institute of Medicine and National Academy of Engineering. The National Academy Press,
2005. Web. 03 Feb. 2017
Question 4

Dr.Donald Berwick opens his keynote speech with a story about the beginnings of something called
an escape fire (It eventually ties into being the solution for the problems of the healthcare industry). An
escape fire is an intentionally ignited barrier of flames in order to protect a desired entity from an oncoming
blaze. More accurately analyzed as an effective and unique solution to a crisis that simply cannot be
solved using traditional approaches. Branching from this he depicts the ideologies of organizations. How
they begin, what they do, and how they make a difference. An organization creates sense, and sense
creates an organization. They are generally started because something is broken and leadership and a
team are needed to make goals and plans for fixing them. After, he discusses the potential crisis point that
healthcare is at. We have racial gaps, high costs, low quality, millions of Americans uninsured, and
dangerously low morale throughout personnel. All of these chasms were first hand proven evident while he
was caring for his ailing wife. The family simply did not get what they needed and his story depicts
amazing errors and follies that should not have happened. This is why we are towards a crisis. He goes on
to say there were documentation errors, wrong medications and conflicting medications were advised to
be administered, doctors had conflicting advice, it took 60 hours for his wife to get a drug that she was told
was vital to her survival, multiple testing of invasive procedures occurred because of improper extraction,
and there were risky and expensive decisions based off of inaccurate and bad data. Every step of the way
there was advice and communication errors throughout all staff. Some of these decisions were small but
some were also critical to his wifes life. The worst part about all of it is that 4/32 clinicians or nurses found
out their true prognosis. This means 24/32 do not know if their diagnosis was correct and dont know what
to look for in the future. We need a data driven diagnosis with procedures to continuously inform doctors of
their abilities. The organization is of critical need in order to make sense of the chaos that surrounds them
and make healthcare better. Sense making is the ability to invent when old formulas fail. The loss of sense-
making, virtual role systems, trust, honesty, and self-respect were all evident in their instance of healthcare
and emulates the system on a macroscopic level. Some institutions are better than others, but overall
there are critical to quality characteristics that need to be streamlines, fixed, or adjusted.

The healthcare escape fire indicates we need to change at the precondition (making sense-making
possible) and design (new schemes) levels. First and foremost, we need to admit we have a huge
problem. Challenge the status quo and name the problems clearly and boldly without demoralizing and
putting people and industries down. We also need leadership for come up with solutions to the problems
and disavow perfection. Through this we will build an effective team to combat the fire. The escape fire
they are looking to implement will have complete access, Clinicians and healthcare will be available 24/7-
365. Science will be continuously implemented and improved where knowledge matches the care a patient
receives. Lastly, the relationships will improve. People need to start to understand that the relationship is
the care. This will immensely enhance quality. Patients must be considered an opportunity and not a
burden. The focus on relationship, changed mindset of all the parties involved to see opportunities, safety,
open information, individualized quality, and complete transparency will increase quality and lower costs. In
order to be successful we need everyone on board.

Dr.Don Berwicks speech was a chance to hear what everyone was thinking. We all know what we
need and are in the process of defining it. The difference is that he is a leader of the movement and is
putting together strives and programs to implement the quality chasms present in modern healthcare. He
accurately and effectively depicts the idea of fighting fire with fire and altering the complete mindset that
we have about healthcare. This is an accurate and needed thing to do however people are not that easily
bought in to. Leaders across organizations need to build programs that enable their employees to see
advantages of increasing quality of care. The alignment of interests of all across the board are incredibly
important to the success of implementing his idea of the healthcare escape fire. This includes the
government, local and major hospitals, insurers, and more. How can we get everyone to buy into this
program without decreasing revenue significantly for the involved bodies? Some of the most difficult things
that will come of this are the transparency and open information from all of these organizations. History
has shown that large entities only listen when the people scream loud enough and the government steps
in. I believe that we are capable of making these changes but they will take some loss and some time in
order to get to our global tipping point of frustration.

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