Modeling the workflow of one primary care physician-nurse team.

Primary care has been identified as a vital part of the healthcare system in the U.S., and one that operates in a challenging, unique environment. Primary care sees a wide variety of patients and is undergoing a series of major transformations simultaneously. As a result, primary care would greatly benefit from a systemic approach to the analysis of its workflows. Discrete-event simulation has been identified as a good tool to evaluate complex healthcare systems. The existing primary care DES models focus on the physician. Also, those models are limited in (a) their usefulness to produce generic models that can easily and quickly be customized and (b) the analysis of the specific tasks performed to treat a patient. Hence, a research idea was developed to address these limitations, which led to a progressive multi-part study developing the necessary components to model a primary clinic. The study was constructed to allow each progressive study to build on the previous. The first part of the study developed a new approach to address those limitations: modeling a primary care clinic from the viewpoint that the physician is the entity that moves through the system. This approach was implemented based on observational data and a standardized primary care physician task list using ARENA© simulation software. The completed model is evidence-based, with the simulation producing predictions and analysis associated with a given patient visit that has not happened by mimicking reality. The benefits of this type of flexible model are that it allows for analysis of any type of “cost” that can be quantified, and it can then be utilized for predicting and potentially subsequently reducing procedural errors and variation in order to increase operational efficiency. The second part of the study was to develop a standardized primary care nurse task list, which is needed given the current transformation of primary care from a doctor-based model to a team-based model. A comprehensive, validated list of tasks occurring during clinic visits was complied from a secondary data analysis. For this, primary care clinics in Wisconsin were selected from a pre-existing study based on 100% participation of the physician-nurse teams. The final task list had 18 major tasks and 174 second-level subtasks, with 103 additional third-level tasks. This task list, combined with the primary care physician task list, provides a tool set that facilitates clinics’ analysis of the workflow associated with a complete patient encounter. Finally, the third part of the study used observational data, the standardized primary care nurse task list, and a similar modeling methodology to the first part to develop a simulation model of the primary care nurse. The model was implemented using ARENA© simulation software. This model is flexible, resulting in an easily-customizable model, and robust in that it allows the analysis of any type of “cost” that can be quantified, such as time, physical or mental resources, money, et cetera. This can potentially be used to predict, and reduce, procedural errors and variation in response to changes to the workflows or environment; hence, the operational efficiency and medical accuracy can be more accurately evaluated

Essays in Healthcare Operations

This dissertation includes three essays, which address significant issues that healthcare practitioners throughout the world face today. The fundamental research that I first address is a research agenda for reimbursement impacts upon healthcare operations management. The purpose of the first essay is to offer conceptual frameworks that portray the fundamental architecture of the U.S. healthcare system and its connections to healthcare reimbursement systems. The research method involves inductive theory development. I contend such frameworks are useful for healthcare operations management research. Using the frameworks, this essay suggests promising research opportunities that should stimulate emerging research themes in the healthcare industry and in academic healthcare operations research. These findings furnish a research agenda with timely insights for practitioners and academia. One conclusion of the essay is the lack of prior research relevant to healthcare reimbursement processes and their impacts on healthcare operations. The essay also concludes that key research opportunities relate to reimbursement boundaries, reimbursement strategy, reimbursement resources, reimbursement impacts, and reimbursement technology. In the second essay, I examine how scheduling policies can improve healthcare quality and doctor efficiency in outpatient healthcare facilities. The purpose is to develop an outpatient appointment scheduling approach under situations of patient no-shows and patient heterogeneity. Based on detailed analytical and simulation methods, the essay evaluates and compares the performance of my approach against several outpatient scheduling policies under various scenarios, and provides advice regarding optimal policies for outpatient clinics. The findings show that my proposed scheduling algorithms show efficient scheduling performance relative to prior proposed policies. In short, the findings of the second essay provide new applicable scheduling polices for outpatient scheduling. The findings also derive qualitative implications for clinic schedulers for improving the most effective way of scheduling outpatient operations. The conclusion is that the proposed scheduling approach can be potentially useful for outpatient facilities. Finally, the third essay empirically examines how managerial operational responses of hospitals vary in response to external pressures imposed upon them by government policies. The purpose is to examine whether hospitals respond to such policies by improving operating processes and quality outcomes, or by gaming their response by adjusting patient case mixes and other metrics associated with financial benefits for the hospital, instead of operational improvement. To validate whether hospitals respond suitably to an ongoing U.S. government quality improvement program, called the Value Based Purchasing (VBP) program, I explore how the program influences subsequent behaviors of U.S. hospitals. Using observational data from the Center for Medicare & Medicaid Services (CMS) and several other sources, I use regression analysis methods to provide empirical evidence of the effects of this government policy. The essay findings show that financially penalized hospitals use tactics consistent with symbolic practices, which may be an unintended outcome from the VBP project. The conclusion is that theoretically motivated contextual differences exist in the behaviors of hospitals when facing these external government pressures

Boston University Bulletin

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University of Windsor Graduate Calendar 2022 Spring

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Quality and coordination in home care: a national cross-sectional multicenter study – SPOTnat

Homecare services include a wide range of medical treatments and therapies, basic care (e.g., personal hygiene), domestic services (e.g., household support) and social services. However, it has been neglected in most countries compared to hospitals and nursing homes, especially regarding healthcare research. As a result, while many countries see high-quality, sustainable care at home as a high-value goal, there are many knowledge gaps in the homecare setting. For agencies, challenges include an increasing demand combined with a workforce shortage, constant cost pressure, and issues with both care coordination and care quality. Problematically, owing to a long shortage of research, knowledge of these elements is scant. In this sector, large-scale studies that consider macro-, meso-, and micro-level factors and incorporate multiple perspectives and measurements to capture coordination and quality of care are extremely rare. When the SPOTnat study (Spitex Koordination und Qualität - eine nationale Studie (homecare coordination and quality – a national study)) began, no published study had examined how homecare agencies perform regarding care coordination. More importantly, though, none had determined which factors are associated with care coordination in the homecare setting. Moreover, across the entire health sector, no clear, accepted concept was available either of what exactly constitutes coordination, or of what it entails. This dissertation is embedded in the SPOTnat study. Preparing it, the overall goal was to deepen our understanding of the homecare sector regarding care coordination and quality. Therefore, a preliminary goal was to clarify the concept of care coordination. Later goals included describing the various financial and regulatory mechanisms operating in the Swiss homecare setting. That information made it possible to explore how those factors relate to homecare agencies’ structures, processes, and working environments, how system and agency factors are related to care coordination, and ultimately how care coordination is related to quality of care. CHAPTER 1 presents the background, the target research gap and the rationale behind this dissertation. We look closely at the unique challenges of the homecare setting, particularly regarding coordination and care quality. In CHAPTER 2 we establish a theoretical basis for care coordination and explain how the concept of coordination can be understood and measured. Our newly-constructed COORA (care coordination) framework differentiates clearly between coordination as a process—i.e., tasks people perform to coordinate versus coordination as a state, i.e., the desired outcome of the coordination process. Applying this distinction to both measurement and interpretation of results helps avoid misleading conclusions. The COORA theoretical framework is based on the full range of influential coordination literature. Iteratively developed in consultation with healthcare professionals, patients and their relatives, it considers the complex relationships between the many factors influencing coordination (as an outcome), and is applicable not only to homecare but across healthcare settings. However, measurement of both care coordination and quality of care remains a challenge. Further research will be necessary to develop and validate a questionnaire that reliably measures care coordination as an outcome. CHAPTER 3 presents the research protocol for the SPOTnat study, a national multi-center cross-sectional survey in Swiss homecare settings. That study included 88 homecare agencies. Using public records and data from questionnaires sent to those agencies’ 3323 employees (including managers and homecare staff), 1508 clients and 1105 relatives of those clients, the SPOTnat research team gathered data on homecare financing mechanisms, agency characteristics and homecare employees' working environments and coordination activities, as well as staff- and patient-level perceptions of coordination and quality of care. CHAPTER 4 discusses our analyses of how regulatory and financial mechanisms explain differences in agency structures, processes and work environments. Based on the mechanisms acting on the participating agencies, we divided them into four groups. Our analyses showed considerable inter-group differences, especially in the range and volume of services provided, but also regarding their employment conditions and cost structures. The most prominent inter-group differences related to the conditions of their cantonal and municipal service agreements. Alongside such details, financial incentives must harmonize the care goals, i.e., achieving and maintaining accessible, high-quality homecare, with the regulatory goals, i.e., assuring the quality and financial sustainability of that care. CHAPTER 5 includes an analysis of how selected explicit and implicit agency-level coordination (process) mechanisms are linked to successful coordination (as an outcome). The results revealed that several implicit mechanisms, i.e., communication/information exchange, role clarity, mutual respect/trust, accountability/predictability/common perspectives, and knowledge of the health system, all correlate with employee-perceived coordination ratings. We also found that certain coordination mechanisms mediated the effects both of agency characteristics (i.e., staffing/ workload and overtime) and of external factors (i.e., regulations). In CHAPTER 6, the final included study gives insights regarding how both homecare employees’ and clients’ coordination-relevant perceptions relate to one another’s quality-of-care ratings. Our analyses indicate that employee-perceived care coordination ratings correlate positively with their own ratings of their quality of care, while client-perceived care coordination problems correlated inversely with client-reported quality of care. Client-perceived coordination problems also correlated positively with hospitalizations and unscheduled urgent medical visits, but not significantly with emergency department visits. No associations were found between employee-perceived coordination and either healthcare service utilization or client quality-of-care ratings. Alongside these relationships, various coordination deficiencies, for example, poor information flow, also became apparent. To conclude, CHAPTER 7 provides a synthesis of the main findings and discusses the results in relation to practical, political and research implications. While contributing further to the understanding of care coordination via the COORA framework, this dissertation also raises various methodological issues. From a practical perspective, measuring and operationalizing both coordinating processes and quality of care outcomes remain challenging issues. While our qualitative results suggest that improving coordination will lead to higher-quality care, testing and ultimately exploiting any such relationship will require not only improved financial and technical structures, but the abandonment of outmoded siloed attitudes regarding the entire homecare sector