Redesigning the Barranquilla's public emergency care network to improve the patient waiting time

Tesis por compendio[ES] La oportunidad en la atención es uno de los críticos de mayor relevancia en la satisfacción de los pacientes que acuden a los servicios de Urgencias. Por tal motivo, las instituciones prestadoras de servicio y las organizaciones gubernamentales deben propender conjuntamente por una atención cada vez más oportuna a costos operacionales razonables. En el caso de la Red Pública en Servicios de Urgencias de Barrannquilla, compuesta por 8 puntos de atención y 2 hospitales, la tendencia marca un continuo crecimiento de la oportunidad en la atención con una tasa de 3,08 minutos/semestre y una probabilidad del 93,13% de atender a los pacientes después de una espera mayor a 30 minutos. Lo anterior se constituye en un síntoma inequívoco de la incapacidad de la Red para satisfacer los estándares de oportunidad establecidos por el Ministerio de Salud, hecho que podría desencadenar el desarrollo de sintomatologías de mayor complejidad, el incremento de la probabilidad de mortalidad, el requerimiento de servicios clínicos más complejos (hospitalización y cuidados intensivos) y el aumento de los costos asociados al servicio. En consecuencia, la presente tesis doctoral presenta el rediseño de la Red Pública en Servicios de Urgencias anteriormente mencionada a fin de otorgar a la población diana un servicio eficiente y altamente oportuno donde tanto las instituciones prestadoras del servicio como los organismos gubernamentales converjan efectivamente. Para ello, fue necesaria la ejecución de 4 grandes fases a través de las cuales se consolidó una propuesta orientada al desarrollo efectivo y sostenible de las operaciones de la Red. Primero, se caracterizó la Red Pública de Servicios de Urgencias en Salud considerando su comportamiento actual en términos de demanda y oportunidad de la atención. Luego, a través de una revisión sistemática de la literatura, se identificaron los enfoques metodológicos que se han implementado para la mejora de la oportunidad y otros indicadores de rendimiento asociados al servicio de Urgencias. Posteriormente, se diseñó una metodología para la creación de redes de Urgencias eficientes y sostenibles la cual luego se validó en la Red Pública sudamericana a fin de disminuir la oportunidad de atención promedio en Urgencias y garantizar la distribución equitativa de los beneficios financieros derivados de la colaboración. Finalmente, se construyó un modelo multicriterio que permitió evaluar el rendimiento de los departamentos de Urgencia e impulsó la creación de estrategias de mejora focalizadas en incrementar su respuesta ante la demanda cambiante, los críticos de satisfacción y las condiciones de operación estipuladas en la ley. Los resultados de esta aplicación evidenciaron que los pacientes que acceden a la Red tienden a esperar en promedio 201,6 min con desviación de estándar de 81,6 min antes de ser atendidos por urgencia. Por otro lado, de acuerdo con la revisión de literatura, la combinación de técnicas de investigación de operaciones, ingeniería de la calidad y analítica de datos es ampliamente recomendada para abordar este problema. En ese sentido, una metodología basada en modelos colaterales de pago, simulación de procesos y lean seis sigma fue propuesta y validada generando un rediseño de Red cuya oportunidad de atención promedio podría disminuir entre 6,71 min y 9,08 min con beneficios financieros promedio de US$29,980/nodo. En último lugar, un modelo compuesto por 8 criterios y 35 sub-criterios fue diseñado para evaluar el rendimiento general de los departamentos de Urgencias. Los resultados del modelo evidenciaron el rol crítico de la infraestructura (Peso global = 21,5i garantir la distribució equitativa dels beneficis financers derivats de la col´laboració. Finalment, es va construir un model multicriteri que va permetre avaluar el rendiment dels departaments d'Urgència i va impulsar la creació d'estratègies de millora focalitzades en incrementar la seva resposta davant la demanda canviant, els crítics de satisfacció i les condicions d'operació estipulades en la llei. Els resultats d'aquesta aplicació van evidenciar que els pacients que accedeixen a la Xarxa tendeixen a esperar de mitjana 201,6 min amb desviació d'estàndard de 81,6 min abans de ser atesos per urgència. D'altra banda, d'acord amb la revisió de literatura, la combinació de tècniques d'investigació d'operacions, enginyeria de la qualitat i analítica de dades és àmpliament recomanada per abordar aquest problema. En aquest sentit, una metodologia basada en models col´laterals de pagament, simulació de processos i llegeixin 6 sigma va ser proposada i validada generant un redisseny de Xarxa la oportunitat d'atenció mitjana podria disminuir entre 6,71 min i 9,08 min amb beneficis financers mitjana d'US$ 29,980 / node. En darrer lloc, un model compost per 8 criteris i 35 sub-criteris va ser dissenyat per avaluar el rendiment general dels departaments d'Urgències. Els resultats de el model evidenciar el paper crític de la infraestructura (Pes global = 21,5%) en el rendiment dels departaments d'Urgència i la naturalesa interactiva de la Seguretat de l'Pacient (C + R = 12,771).[EN] Waiting time is one of the most critical measures in the satisfaction of patients admitted within emergency departments. Therefore, hospitals and governmental organizations should jointly aim to provide timely attention at reasonable costs. In the case of Barranquilla's Pubic Emergency Service Network, composed by 8 Points of care (POCs) and 2 hospitals, the trend evidences a continuous growing of the waiting time with a rate of 3,08 min/semester and a 93,13% likelihood of serving patients after waiting for more than 30 minutes. This is an unmistakable symptom of the network inability for satisfying the standards established by the Ministry of Health, which may trigger the development of more complex symptoms, increase in the death rate, requirement for more complex clinical services (hospitalization and intensive care unit) and increased service costs. This doctoral dissertation then illustrates the redesign of the aforementioned Public Emergency Service Network aiming at providing the target population with an efficient and highly timely service where both hospitals and governmental institutions effectively converge. It was then necessary to implement a 4-phase methodology consolidating a proposal oriented to the effective and sustainable development of network operations. First, the Public Emergency Service Network was characterized considering its current behavior in terms of demand and waiting time. A systematic literature review was then undertaken for identifying the methodological approaches that have been implementing for improving the waiting time and other performance indicators associated with the emergency care service. Following this, a methodology for the creation of efficient and sustainable emergency care networks was designed and later validated in the Southamerican Public network for lessening the average waiting time and ensuring the equitable distribution of profits derived from the collaboration. Ultimately, a multicriteria decision-making model was created for assessing the performance of the emergency departments and propelling the design of improvement strategies focused on bettering the response against the changing demand conditions, critical to satisfaction and operational conditions. The results evidenced that the patients accessing to the network tend to wait 201,6 min on average with a standard deviation of 81,6 min before being served by the emergency care unit. On the other hand, based on the reported literature, it is highly suggested to combine Operations Research (OR) methods, quality-based techniques, and data-driven approaches for addressing this problem. In this sense, a methodology based on collateral payment models, Discrete-event simulation, and Lean Six Sigma was proposed and validated resulting in a redesigned network whose average waiting time may diminish between 6,71 min and 9,08 min with an average profit US$29,980/node. Lately, a model comprising of 8 criteria and 35 sub-criteria was designed for evaluating the overall performance of emergency departments. The model outcomes revealed the critical role of Infrastructure (Global weight = 21,5%) in ED performance and the interactive nature of Patient Safety (C + R = 12,771).Ortíz Barrios, MÁ. (2020). Redesigning the Barranquilla's public emergency care network to improve the patient waiting time [Tesis doctoral]. Universitat Politècnica de València. https://doi.org/10.4995/Thesis/10251/156215TESISCompendi

A Hybrid Simulation Methodology To Evaluate Network Centricdecision Making Under Extreme Events

Currently the network centric operation and network centric warfare have generated a new area of research focused on determining how hierarchical organizations composed by human beings and machines make decisions over collaborative environments. One of the most stressful scenarios for these kinds of organizations is the so-called extreme events. This dissertation provides a hybrid simulation methodology based on classical simulation paradigms combined with social network analysis for evaluating and improving the organizational structures and procedures, mainly the incident command systems and plans for facing those extreme events. According to this, we provide a methodology for generating hypotheses and afterwards testing organizational procedures either in real training systems or simulation models with validated data. As long as the organization changes their dyadic relationships dynamically over time, we propose to capture the longitudinal digraph in time and analyze it by means of its adjacency matrix. Thus, by using an object oriented approach, three domains are proposed for better understanding the performance and the surrounding environment of an emergency management organization. System dynamics is used for modeling the critical infrastructure linked to the warning alerts of a given organization at federal, state and local levels. Discrete simulations based on the defined concept of community of state enables us to control the complete model. Discrete event simulation allows us to create entities that represent the data and resource flows within the organization. We propose that cognitive models might well be suited in our methodology. For instance, we show how the team performance decays in time, according to the Yerkes-Dodson curve, affecting the measures of performance of the whole organizational system. Accordingly we suggest that the hybrid model could be applied to other types of organizations, such as military peacekeeping operations and joint task forces. Along with providing insight about organizations, the methodology supports the analysis of the after action review (AAR), based on collection of data obtained from the command and control systems or the so-called training scenarios. Furthermore, a rich set of mathematical measures arises from the hybrid models such as triad census, dyad census, eigenvalues, utilization, feedback loops, etc., which provides a strong foundation for studying an emergency management organization. Future research will be necessary for analyzing real data and validating the proposed methodology

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Climate Change and Sea Level Rise Projections for Boston

While the broad outlines of how climate change would impact Boston have been known for some time, it is only recently that we have developed a more definitive understanding of what lies ahead. That understanding was advanced considerably with the publication of Climate Change and Sea Level Rise Projections for Boston by the Boston Research Advisory Group (BRAG).The BRAG report is the first major product of "Climate Ready Boston," a project led by the City of Boston in partnership with the Green Ribbon Commission and funded in part by the Barr Foundation. The BRAG team includes 20 leading experts from the region's major universities on subjects ranging from sea level rise to temperature extremes. University of Massachusetts Boston professors Ellen Douglas and Paul Kirshen headed the research.The BRAG report validates earlier studies, concluding Boston will get hotter, wetter, and saltier in the decades ahead (see figures below). But the group has produced a much more definitive set of projections than existed previously, especially for the problem of sea level rise. BRAG also concluded that some of the effects of climate change will come sooner than expected, accelerating the urgency of planning and action

Enhancing the performance of automated guided vehicles through reliability, operation and maintenance assessment

Automated guided vehicles (AGVs), a type of unmanned moving robots that move along fixed routes or are directed by laser navigation systems, are increasingly used in modern society to improve efficiency and lower the cost of production. A fleet of AGVs operate together to form a fully automatic transport system, which is known as an AGV system. To date, their added value in efficiency improvement and cost reduction has been sufficiently explored via conducting in-depth research on route optimisation, system layout configuration, and traffic control. However, their safe application has not received sufficient attention although the failure of AGVs may significantly impact the operation and efficiency of the entire system. This issue becomes more markable today particularly in the light of the fact that the size of AGV systems is becoming much larger and their operating environment is becoming more complex than ever before. This motivates the research into AGV reliability, availability and maintenance issues in this thesis, which aims to answer the following four fundamental questions: (1) How could AGVs fail? (2) How is the reliability of individual AGVs in the system assessed? (3) How does a failed AGV affect the operation of the other AGVs and the performance of the whole system? (4) How can an optimal maintenance strategy for AGV systems be achieved? In order to answer these questions, the method for identifying the critical subsystems and actions of AGVs is studied first in this thesis. Then based on the research results, mathematical models are developed in Python to simulate AGV systems and assess their performance in different scenarios. In the research of this thesis, Failure Mode, Effects and Criticality Analysis (FMECA) was adopted first to analyse the failure modes and effects of individual AGV subsystems. The interactions of these subsystems were studied via performing Fault Tree Analysis (FTA). Then, a mathematical model was developed to simulate the operation of a single AGV with the aid of Petri Nets (PNs). Since most existing AGV systems in modern industries and warehouses consist of multiple AGVs that operate synchronously to perform specific tasks, it is necessary to investigate the interactions between different AGVs in the same system. To facilitate the research of multi-AGV systems, the model of a three-AGV system with unidirectional paths was considered. In the model, an advanced concept PN, namely Coloured Petri Net (CPN), was creatively used to describe the movements of the AGVs. Attributing to the application of CPN, not only the movements of the AGVs but also the various operation and maintenance activities of the AGV systems (for example, item delivery, corrective maintenance, periodic maintenance, etc.) can be readily simulated. Such a unique technique provides us with an effective tool to investigate larger-scale AGV systems. To investigate the reliability, efficiency and maintenance of dynamic AGV systems which consist of multiple single-load and multi-load AGVs traveling along different bidirectional routes in different missions, an AGV system consisting of 9 stations was simulated using the CPN methods. Moreover, the automatic recycling of failed AGVs is studied as well in order to further reduce human participation in the operation of AGV systems. Finally, the simulation results were used to optimise the design, operation and maintenance of multi-AGV systems with the consideration of the throughputs and corresponding costs of them.The research reported in this thesis contributes to the design, reliability, operation, and maintenance of large-scale AGV systems in the modern and rapidly changing world.</div