Methodological approaches to support process improvement in emergency departments: a systematic review

The most commonly used techniques for addressing each Emergency Department (ED) problem (overcrowding, prolonged waiting time, extended length of stay, excessive patient flow time, and high left-without-being-seen (LWBS) rates) were specified to provide healthcare managers and researchers with a useful framework for effectively solving these operational deficiencies. Finally, we identified the existing research tendencies and highlighted opportunities for future work. We implemented the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) methodology to undertake a review including scholarly articles published between April 1993 and October 2019. The selected papers were categorized considering the leading ED problems and publication year. Two hundred and three (203) papers distributed in 120 journals were found to meet the inclusion criteria. Furthermore, computer simulation and lean manufacturing were concluded to be the most prominent approaches for addressing the leading operational problems in EDs. In future interventions, ED administrators and researchers are widely advised to combine Operations Research (OR) methods, quality-based techniques, and data-driven approaches for upgrading the performance of EDs. On a different tack, more interventions are required for tackling overcrowding and high left-without-being-seen rate

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

Modeling, assessment and design of an emergency department of a public hospital through discrete-event simulation

Emergency departments in hospitals are having many difficulties in achieving the performance levels required by health regulators and society. The waiting times as well as the total throughput time are examples of performance indicators that emergency departments need to improve in order to provide a better service to the community. To achieve improvement of performance, the present paper shows a methodology to assist the design process of an emergency department using simulation techniques. In this study, the emergency department of a hospital located in the northern region of Portugal was considered to test the proposed simulation technique. The emergency department initial state was assessed, in terms of patient flow, as well as the human resources needed at every stage of the service. In order to understand in depth the process that a patient goes through during an emergency episode, a comprehensive study was performed on the hospital database. This allowed the analytical description of an emergency episode, which was further used as an input to the simulation model. After developing the simulation model with the information obtained by the hospital’s database, a validation stage was performed. Finally, in order to achieve an optimized design for the emergency department several variant scenarios were considered and evaluated. This methodology proved to be very useful in determining an optimized operation for complex, and non-linear systems.This work was partially supported by projects UIDB/00319/2020 and POCI-01-0145FEDER-030299, from Fundacao para a Ciencia e Tecnologia (FCT), Portugal

Facility Planning and Associated Problems: A Survey

In this study, we have classified and reviewed different types of problems which are related to facility planning and layout design for different types of manufacturing processes. The main problems which are related to location of  facilities which also affects the system performance  such as distribution of man, material and machine in a plant or a factory and their optimization technique while using of mathematical models, their solutions and application related to whole problems is presented. For solving this type of problems, intelligent techniques such as expert systems, fuzzy logic and neutral networks have been used. In this paper the recent analysis on facility layout is incorporated and facility layout problem is surveyed. Many intelligent techniques and conventional algorithms for solving FLP are presented. In our discussion different research direction, general remarks and tendencies have been mentioned Keywords—Facility Planning, Material handling Optimization metho

Ecomspaces: Warehouse Workflow Optimization

Ecomspaces specializes in fulfillment services for e-commerce businesses, providing as a full-service provider for storage, shipping, and rental office space solutions. RelayShopUSA focuses on parcel forwarding services to both domestic and French international customers. The two services operate under the same roof and utilize near-identical resources. For the sake of simplicity, both services will be referenced throughout this document as Ecomspaces. Ecomspaces has been experiencing difficulty in accepting and handling a greater volume of clients due to infrastructure-related problems within their warehouse. Management is seeking the development of both scalable and sustainable systems to cut costs and achieve long-term growth for their operation. This summarizes the strategies that have been proposed and implemented by the Optimized Brain E-spaces team to benefit the overall warehouse operation through (1) the implementation of layout changes to optimize workflow and to regain floor space throughout the facility, (2) the standardization of the safety, housekeeping, and maintenance of the warehouse, (3) the development of accessible and robust key performance indicators and standard operating procedures necessary for process improvement. These goals have been accomplished through the collection and statistical analysis of time and motion study data, alongside raw historical data obtained from reports generated by Ecomspaces warehouse management systems. Several tools and methodologies have been utilized in this scenario which include (1) project management tools such as project charter, work breakdown structure, Gantt chart, financial planning/budgeting, and economic analysis, (2) Six Sigma tools such as pareto charts, process flowchart, critical to quality, key process indicators, cause and effect diagram, and the DMAIC process, and (3) traditional industrial and systems engineering tools such as time and motion studies, spaghetti diagram, and system modeling/simulation. Our team’s design proposal is based on the evaluation of both current-state and possible future-states of the warehouse through computer modeling with ARENA simulation. This information was supplemented with on-site visits to conduct interviews for management and employees, completed audits for OSHA requirements pertaining to warehouse safety and maintenance, and foundational understanding of the work-processes within the operation to develop baseline productivity levels and standard times for each station. Regarding our team’s three suggested facility layout changes, we recommend the implementation of our proposed solution A, involving the consolidation of oversized/palletized inventory to be placed adjacent to the wall between the receiving and loading docks, and to add a fourth shipping in the dock 2 area (not being utilized previously). This optimal solution was identified through TOPSIS analysis

The Impact of Work Environment on Successful Implementation of Lean Six Sigma in Emergency Department

Continuous improvement (CI) is an initiative to improve the performance of processes in alignment with the customer needs and organizational strategy. Lean Six Sigma (LSS) is one of the most successful CI techniques in redesigning and improving significant processes to improve quality and eliminate waste. The healthcare sector has benefited from applying LSS due to its complicated work practices that face many challenges including increased expenditures and difficulties related to individual or community access to appropriate care. In particular, Emergency Departments (ED) have an important unit within healthcare organizations due to their essential role in providing urgent medical care services to patients. The aim of this doctoral research study is to develop a theoretical model using grounded theory to investigate the factors for successful LSS implementation in ED including how ED work environment affects the reduction of patient length of stay, which is one of the biggest issues that ED face. Therefore, the main objectives of this research are to: (1) investigate trends in the research area using systematic literature review, (2) develop an Initial Conceptual Framework including identifying the relationships between the variables of LSS implementation, (3) use an expert study where a group of experts will provide additional evidence regarding LSS implementation, and (4) test the model using survey questionnaire that examines the behavior of the variables. This research will be documented as a manuscript-style dissertation including four peer-reviewed academic journal articles each summarizing the results from a phase of this research. The results of this research will provide a conceptual model to guide the implementation of LSS in ED bringing the potential benefits of this approach to a critical department in healthcare organizations. Further, this research will inform future research by investigating the work environment effects on application of LSS

Proposition of a method for stochastic analysis of value streams

This article aims at proposing a method to stochastically analyze values streams taking into consideration the effect of critical uncertainty sources on lead time. The proposed method combines value stream mapping (VSM) and Monte Carlo simulation to identify improvement opportunities. To illustrate this approach, we carried out a case study in the special nutrition value stream of a Brazilian public hospital. Results show that the proposed method allows the identification of improvement opportunities that would not be considered in the classical deterministic VSM approach. Further, the integration of the stochastic analysis enables the determination of a more realistic lead time, which supports a more assertive planning and scheduling of the value stream. The proposed method addresses a fundamental gap in traditional VSM without adding much complexity to the analysis procedure, which is a common practical issue in previous works that integrated other stochastic methods into VSM

A methodological approach for kaizen events in assembly lines

This paper proposes a methodology for the planning and execution of a Kaizen event in a manufacturing assembly line. The method consists in 3 steps each one divided into 2 others: Planning (Project + data collection); Execution (participants training and in loco analysis) and results (benefits and future propositions). The methodology was tested in 2015 during a Kaizen event conducted on a manufacturing lighting fixtures firm located in the industrial district of Milwaukee, WI, and applied to an assembly line whose problem consisted in excessive lead times and high mismatch times between workstations. The results show a successful application of this methodology. The Kaizen event promoted a lead time improvement of 17.8% and a reduction of 91.13% mismatch time between workstations, besides improvements regarding human aspects. In this way, we provide evidence of a powerful tool that can be used to help firms to get their own human resources to solve problems and improve the work environment.

Exploring the impact of Lean manufacturing on flexibility in SMEs

Purpose: This paper describes the use of simulation and case-study research to assess flexibility gains induced by the adoption of three Lean Manufacturing practices. Design/methodology/approach: We gather useful material and information about the manufacturing process of a selected Small-Medium Enterprise by adopting a case-research approach. The Value Stream Mapping is the method used for visualizing flows of products and information along the production system. Starting from the current arrangement of the company, computer simulation is used to assess the benefits arising from Cellular Manufacturing, Just-in-Time Delivery by Suppliers, and Single Minute Exchange of Dies. Findings: To investigate the flexibility improvements coming from the introduction of Lean Manufacturing, we present a simulation model of the described company on which we performed our analysis. We quantify the flexibility of different configurations according to the new 5-step approach in order to segregate the contribution of different lean techniques. Originality/value: We extend the combined use of Case Research and Computer Simulation to the research on Manufacturing Flexibility within Small-Medium Enterprises. We enhance the knowledge on this under investigated context collecting quantitative field data. Moreover, building on the factorial Design of Experiment, we introduce a new 5-step method to appraise the cost benefit ratio of lean techniques for flexibility. The managerial implication of this research is mostly related to the provision of a supporting method for the decision making process propaedeutic to Lean Manufacturing introduction.Peer Reviewe

Analysis of Delays in Processing Times in an Ophthalmology Clinic

Efficiency is an important component of any medical practice. It facilitates quality care, reduction in wait time, patient and staff satisfaction, and decreased cost. The purpose of this study was to identify bottlenecks in the current processing system in the Eye Center at Hershey Penn State Medical Center. Data was obtained about patients arriving at the clinic for ancillary tests such as visual field testing and retinal imaging. Analysis of this data revealed a statistically significant longer average length of visit for patients who received testing in comparison to those who did not. However, due to the small sample size of this study, we were unable to conclude that patients who received testing had longer wait times between segments. Further work in this field will need to be conducted to examine processes in the clinic in greater detail to identify those in need of improvement and guide future implementation of Lean strategies