Cost comparison of orthopaedic fracture pathways using discrete event simulation in a Glasgow hospital

Objective: Healthcare faces the continual challenge of improving outcome whilst aiming to reduce cost. The aim of this study was to determine the micro cost differences of the Glasgow non-operative trauma virtual pathway in comparison to a traditional pathway. Design:  Discrete event simulation was used to model and analyse cost and resource utilisation with an activity based costing approach. Data for a full comparison before the process change was unavailable so we utilised a modelling approach, comparing a Virtual Fracture Clinic (VFC) to a simulated Traditional Fracture Clinic (TFC). Setting:  The orthopaedic unit VFC pathway pioneered at Glasgow Royal Infirmary has attracted significant attention and interest and is the focus of this cost study. Outcome measures: Our study focused exclusively on non-operative trauma patients attending Emergency Department or the minor injuries unit and the subsequent step in the patient pathway. Retrospective studies of patient outcomes as a result of the protocol introductions for specific injuries in association with activity costs from the models.ResultsPatients are satisfied with the new pathway, the information provided and the outcome of their injuries (Evidence Level IV). There was a 65% reduction in the number of first outpatient face-to-face attendances in orthopaedics. In the VFC pathway, the resources required per day were significantly lower for all staff groups (p=<0.001). The overall cost per patient of the VFC pathway was £22.84 (95% CI: 21.74, 23.92) per patient compared with £36.81 (95% CI: 35.65, 37.97) for the TFC pathway.  Conclusions:  Our results give a clearer picture of the cost comparison of the virtual pathway over a wholly traditional face-to-face clinic system. The use of simulation-based stochastic costings in healthcare economic analysis has been limited to date, but this study provides evidence for adoption of this method as a basis for its application in other healthcare settings

Fracture clinic redesign reduces the cost of outpatient orthopaedic trauma care

Objectives: “Virtual fracture clinics” have been reported as a safe and effective alternative to the traditional fracture clinic. Robust protocols are used to identify cases that do not require further review, with the remainder triaged to the most appropriate subspecialist at the optimum time for review. The objective of this study was to perform a “top-down” analysis of the cost effectiveness of this virtual fracture clinic pathway. Methods: National Health Service financial returns relating to our institution were examined for the time period 2009 to 2014 which spanned the service redesign. Results: The total staffing costs rose by 4% over the time period (from £1 744 933 to £1 811 301) compared with a national increase of 16%. The total outpatient department rate of attendance fell by 15% compared with a national fall of 5%. Had our local costs increased in line with the national average, an excess expenditure of £212 705 would have been required for staffing costs. Conclusions: The virtual fracture clinic system was associated with less overall use of staff resources in comparison to national cost data. Adoption of this system nationally may have the potential to achieve significant cost savings

Full-time employee optimisation of emergency departments

The Emergency Departments (ED) of public hospitals is an area in continuous improvement. The Emergency Departments are places where the efficiency of the services provided can save lives and therefore it should be seen as an area of maximum interest in order to make the processes optimised. This research aims to verify if the application of redesign heuristics, from the perspective of Business Process Management, results in the improvement of the length of stay (LoS), without deteriorating the quality of the service provided. For the same process, three scenarios of the ED were considered. The methodology that underlies this research is supported by a case study carried out in the Emergency Department of a public hospital. The data obtained during the investigation was gathered from individual interviews and focus groups, as well as direct observation and analysis of documents. According to the Business Process Management perspective, its life cycle stages were taken into account. In addition, a simulation tool was used, as well as the Devil’s Quadrangle. The results of the investigation indicate that positive impacts over variable time are possible without affecting the quality of the service, resulting in value gains for the patient, in this case, the client of the process. In terms of time, the average length of stay (LoS) in the process was reduced by 22.5%, 15.9%, and 20.9% for each of the scenarios, while the maximum length of stay (LoS) was reduced by 29.2%, 36.2% % and 37.4%.As Urgências Gerais dos hospitais públicos são uma área em melhoria contínua. As Urgências Gerais são locais onde a eficiência dos serviços prestados pode salvar vidas e, portanto, devem ser vistas como uma área de máximo interesse com o objetivo de tornar os processos otimizados. Esta investigação visa verificar se a aplicação de heurísticas de redesenho, na perspetiva do Business Process Management, resulta na melhoria dos tempos (length of stay), sem que a qualidade do serviço seja deteriorada. Para o mesmo processo, três cenários da Urgência Geral foram considerados. A metodologia que serve de base à investigação é sustentada num caso de estudo levado a cabo na urgência geral de um hospital público. A informação obtida durante a investigação foi recolhida a partir de entrevistas individuais e focus groups, bem como de observação direta e análise de documentos. Segundo a perspetiva Business Process Management, foram tidas em conta as suas fases do ciclo de vida. Adicionalmente, foi utilizada uma ferramenta de simulação e o Devil’s Quadrangle. Os resultados da investigação indicam que impactos positivos no tempo são possíveis sem que a qualidade do serviço seja afetada, originando ganhos de valor para o paciente, neste caso, o cliente do processo. Em termos de tempo, o length of stay (LoS) médio no processo foi reduzido em 22.5%, 15.9%, e 20.9% para cada um dos cenários apresentado, enquanto o length of stay (LoS) máximo foi reduzido em 29.2%, 36.2% e 37.4%

Target costing in construction: a comparative study

Target costing is an approach for the development of new products in the automobile industry, aimed at reducing their life-cycle costs while ensuring quality, reliability and other client requirements, by examining all possible ideas for cost reduction at the product planning, research and development and prototyping phases. Prior studies have attempted to adapt the manufacturing target costing process to the project-based nature of the construction industry. This paper aims to provide insights for future target costing implementations in the public sector projects. A qualitative comparison of three studies is performed through the lens of a set of target costing influencing factors. Similarities and differences revealed in the comparison suggest that factors related to supplier-base strategy and to the nature of customer are potentially relevant to future target costing implementations in public sector projects

Patient flow within UK emergency departments: a systematic review of the use of computer simulation modelling methods

Background: Overcrowding in the emergency department (ED) is common in the UK as in other countries worldwide. Computer simulation is one approach used for understanding the causes of ED overcrowding and assessing the likely impact of changes to the delivery of emergency care. However, little is known about the usefulness of computer simulation for analysis of ED patient flow. We undertook a systematic review to investigate the different computer simulation methods and their contribution for analysis of patient flow within EDs in the UK. Methods: We searched eight bibliographic databases (MEDLINE; EMBASE; COCHRANE; WEB OF SCIENCE; CINAHL; INSPEC; MATHSCINET; and ACM DIGITAL LIBRARY) from date of inception until 31 March 2016. Studies were included if they used a computer simulation method to capture patient progression within the ED of an established UK NHS hospital. Studies were summarised in terms of simulation method, key assumptions, input and output data, conclusions drawn, and implementation of results. Results: Twenty one studies met the inclusion criteria. Of these, 19 used discrete event simulation and 2 used system dynamics models. The purpose of many of these studies (n=16; 76%) centred on service redesign. Seven studies (33%) provided no details about the ED being investigated. Most studies (n=18; 86%) used specific hospital models of ED patient flow. Overall, the reporting of underlying modelling assumptions was poor. Nineteen studies (90%) considered patient waiting or throughput times as the key outcome measure. Twelve studies (57%) reported some involvement of stakeholders in the simulation study. However, only 3 studies (14%) reported on the implementation of changes supported by the simulation. Conclusions: We found that computer simulation can provide a means to pre-test changes to ED care delivery before implementation in a safe and efficient manner. However, there are some methodological, data, stakeholder, implementation, and reporting issues, which must be addressed by future studies

Analytical models to determine room requirements in outpatient clinics

Outpatient clinics traditionally organize processes such that the doctor remains in a consultation room while patients visit for consultation, we call this the Patient-to-Doctor policy (PtD-policy). A different approach is the Doctor-to-Patient policy (DtP-policy), whereby the doctor travels between multiple consultation rooms, in which patients prepare for their consultation. In the latter approach, the doctor saves time by consulting fully prepared patients. We use a queueing theoretic and a discrete-event simulation approach to provide generic models that enable performance evaluations of the two policies for different parameter settings. These models can be used by managers of outpatient clinics to compare the two policies and choose a particular policy when redesigning the patient process.We use the models to analytically show that the DtP-policy is superior to the PtD-policy under the condition that the doctor’s travel time between rooms is lower than the patient’s preparation time. In addition, to calculate the required number of consultation rooms in the DtP-policy, we provide an expression for the fraction of consultations that are in immediate succession; or, in other words, the fraction of time the next patient is prepared and ready, immediately after a doctor finishes a consultation. We apply our methods for a range of distributions and parameters and to a case study in a medium-sized general hospital that inspired this research

Presenting Business Process Improvement Changes – A Systematic Literature Review

Äriprotsessi täiustamine aitab parandada lõppkasutaja kogemust, vähendada kulutusi ja kiirendada tööd. Eksisteerib mitmeid äriprotsessi täiustamise tehnikaid. Olemasolevate protsesside juures ei ole aga demonstreeritud muutuste mõju. Et täita see lünk, pakub antud lõputöö ülevaadet viisidest, kuidas demonstreerida äriprotsesside muutuste mõju päris elu näidete põhjal. Sel eesmärgil on tehtud süstemaatiline kirjanduse ülevaade artiklitest, mis kasutavad äriprotsesside täiustamist päris elu näidetes, et näha, kuidas need muutuseid on esitletud. Leitud artikleid analüüsiti ning leiti vastused uurimuse küsimustele. Analüüsi tulemusena leiti, et nagu igas teises teadusvaldkonnas, mis käsitleb muutusi, saab neid esitleda visuaalselt, numbriliselt või mitte- struktureeritud viisil, kasutates erinevaid esitlemise strateegiaid. Teadmine, kuidas antakse edasi asjade muutumist, aitab inimestel paremini aru saada nende sisust. Võimalik on paremini aru saada äriprotsesside muutustest.Business Process Improvement (BPI) has a big potential by helping to improve end-user satisfaction, to reduce costs and throughput times. A lot of business process improvement techniques exist, but they lack the information about the presentation of the effects of business process change. In order to fill this gap, this thesis provides an overview of the ways that are used to present the effects of business process change in real-life business process scenarios. For that purpose, a systematic literature review is performed to identify papers that apply BPI on real-life cases from industry to see what means are used to capture and present those changes. The identified final papers are analysed in order to answer to Research Questions (RQ). The analysis reveals that as in any other scientific field where change is occurring the change could be presented either visually, or in a numerical way, or in a not structured (narrative) way using some presentation strategies. This knowledge that gives some hints on how changes are conveyed can be used to support people to better understand the changes which occur in a process after a BPI

SAFE-FLOW : a systematic approach for safety analysis of clinical workflows

The increasing use of technology in delivering clinical services brings substantial benefits to the healthcare industry. At the same time, it introduces potential new complications to clinical workflows that generate new risks and hazards with the potential to affect patients’ safety. These workflows are safety critical and can have a damaging impact on all the involved parties if they fail.Due to the large number of processes included in the delivery of a clinical service, it can be difficult to determine the individuals or the processes that are responsible for adverse events. Using methodological approaches and automated tools to carry out an analysis of the workflow can help in determining the origins of potential adverse events and consequently help in avoiding preventable errors. There is a scarcity of studies addressing this problem; this was a partial motivation for this thesis.The main aim of the research is to demonstrate the potential value of computer science based dependability approaches to healthcare and in particular, the appropriateness and benefits of these dependability approaches to overall clinical workflows. A particular focus is to show that model-based safety analysis techniques can be usefully applied to such areas and then to evaluate this application.This thesis develops the SAFE-FLOW approach for safety analysis of clinical workflows in order to establish the relevance of such application. SAFE-FLOW detailed steps and guidelines for its application are explained. Then, SAFE-FLOW is applied to a case study and is systematically evaluated. The proposed evaluation design provides a generic evaluation strategy that can be used to evaluate the adoption of safety analysis methods in healthcare.It is concluded that safety of clinical workflows can be significantly improved by performing safety analysis on workflow models. The evaluation results show that SAFE-FLOW is feasible and it has the potential to provide various benefits; it provides a mechanism for a systematic identification of both adverse events and safeguards, which is helpful in terms of identifying the causes of possible adverse events before they happen and can assist in the design of workflows to avoid such occurrences. The clear definition of the workflow including its processes and tasks provides a valuable opportunity for formulation of safety improvement strategies