Location of services and the impact on healthcare quality: insights from a simulation of a musculoskeletal physiotherapy service

Many healthcare systems are being redesigned to deliver local care with more services within the community. Relocation may enhance access but other aspects of healthcare quality should also be considered, notably waiting times and equity of care. This study examined a musculoskeletal physiotherapy service using a discrete-event simulation with simple heuristics to model patient behaviour. This combination provided an effective mechanism for incorporating the individuality of the patients in the flows along the patient pathways, subject to the varying availabilities of key resources. In particular, it captured the feedback that is critical in system performance, especially where waiting times are important. The model recognised the heterogeneity of patient attitudes and demonstrated how the behaviour of a relatively small proportion can affect the experience of all patients. The study suggested that, with careful operational management, more care could be delivered locally while exploiting many of the benefits of a centralised service

The evolution of the pathway and its role in improving patient care

Redesign in healthcare has increased the focus on the needs of the patient. The redesign process typically involves a review of current practice using the patient pathway before considering possible improvements. The patient pathway can serve various roles and it may be mapped in different ways using a variety of media. This paper reviews the evolution of the patient pathway comparing the merits of different media. Simple approaches to mapping pathways can be most useful. However, experience in the redesign of Unscheduled Care in NHS Fife suggests that computer based, hierarchical pathway models using stylised icons offer many advantages. Such approaches can increase the effectiveness of pathways in the redesign process, providing both the detail and the system view in an accessible graphical form. This enhanced capability helps staff analyse current practice, and visualise and assess redesign options. In addition, the pathway can fulfil new roles as a training tool and an effective basis for organising knowledge about patient care

Continuity of care in community midwifery

Continuity of care is often critical in delivering high quality health care. However, it is difficult to achieve in community health care where shift patterns and a need to minimise travelling time can reduce the scope for allocating staff to patients. Community midwifery is one example of such a challenge in the National Health Service where postnatal care typically involves a series of home visits. Ideally mothers would receive all of their antenatal and postnatal care from the same midwife. Minimising the number of staff-handovers helps ensure a better relationship between mothers and midwives, and provides more opportunity for staff to identify emerging problems over a series of home visits. This study examines the allocation and routing of midwives in the community using a variant of a multiple travelling salesmen problem algorithm incorporating staff preferences to explore trade-offs between travel time and continuity of care. This algorithm was integrated in a simulation to assess the additional effect of staff availability due to shift patterns and part-time working. The results indicate that continuity of care can be achieved with relatively small increases in travel time. However, shift patterns are problematic: perfect continuity of care is impractical but if there is a degree of flexibility in the visit schedule, reasonable continuity is feasible

A multicriteria resource allocation model for the redesign of services following birth

Background Many healthcare services are under considerable pressure to reduce costs while improving quality. This is particularly true in the United Kingdom’s National Health Service where postnatal care is sometimes viewed as having a low priority. There is much debate about the service’s redesign and the reallocation of resources, both along care pathways and between groups of mothers and babies with different needs. The aim of this study was to develop a decision support tool that would encourage a systemic approach to service redesign and that could assess the various quality and financial implications of service change options making the consequent trade-offs explicit. The paper describes the development process and an initial implementation as a preliminary exploration of the possible merits of this approach. Methods Other studies have suggested that combining multicriteria decision analysis with programme budgeting and marginal analysis might offer a suitable basis for resource allocation decisions in healthcare systems. The Postnatal care Resource Allocation Model incorporated this approach in a decision support tool to analyse the consequences of varying design parameters, notably staff contacts and time, on the various quality domains and costs. The initial phase of the study focussed on mapping postnatal care, involving interviews and workshops with a variety of stakeholders. This was supplemented with a literature review and the resultant knowledge base was encoded in the decision support tool. The model was then tested with various stakeholders before being used in an NHS Trust in England. Results The model provides practical support, helping staff explore options and articulate their proposals for the redesign of postnatal care. The integration of cost and quality domains facilitates trade-offs, allowing staff to explore the benefits of reallocating resources between hospital and community-based care, and different patient-categories. Conclusions The main benefits of the model include its structure for assembling the key data, sharing evidence amongst multi-professional teams and encouraging constructive, systemic debate. Although the model was developed in the context of the routine maternity services for mothers and babies in the days following birth it could be adapted for use in other health care services

SWITCH Partnership (Service Working to Integrate Therapy into Community Health): Baseline Evidence & Service Redesign Planning Report

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Roles of pathway-based models and their contribution to the redesign of health-care systems

Care pathways provide a practical analytical tool that encompasses both organizational efficiency and individual patients'care. In the UK, constructing the care pathway has been a recommended starting point for the re-design of health-caresystems. This paper examines the re-design cycle for health-care systems and looks at the role of pathway-basedmodels in the design and operation phases of the cycle. In addition, the models provide further benefits for communicatingrecommended practice and audit of care and outcomes. The models span the classic care pathway with extensions tosimulation modelling. An example of the use of care pathways in the re-design of an emergency department is used forillustration. This study shows the role of pathway models as: a tool for re-design, a catalyst for enhancing communicationand as a repository for audit information. The final role of a tool for modelling contingencies was not implemented. Fromthe example it can be concluded that sophisticated models can be useful, in some applications; however, the simplerapproaches may often be the best, offering rapid, transparent recommendations based on a multidisciplinary approach

Assessing systems for offshore emergency evacuation

Emergency evacuation is a rare event in the offshore oil industry. Nonetheless, emergency procedures must be practiced routinely for the benefit of the work force and the emergency services. These practices typically take place in good weather conditions where there is little threat to those involved. However, in reality an emergency could occur in adverse weather conditions which can affect the capabilities of vessels and helicopters. This paper describes a study in which the data from various sources are synthesised in order to estimate the effectiveness of emergency evacuation and rescue systems in a stochastic environment. The study employed a discrete event simulation incorporating a model of the evacuation and rescue operations interfaced with a file of weather data. This approach provided a measure, the probability of completing the evacuation within N hours, for the comparison of alternative systems

Concentration and the variability of orthopaedic demand

Concentrating health services with centres providing selected, specialist care offers a number of potential advantages. The benefits may include the opportunity to improve the quality of care by providing more specialist services and greater expertise, more attractive working conditions with a larger pool of specialists providing the on-call rota and an enhanced opportunity for training. Concentration will produce greater volumes of patients in the selected specialties with the possibility of various economies of scale. A series of simulation experiments explored the potential for efficiencies associated with the increasing volume of non-elective patients in an orthopaedic specialty. As the annual volume of patients increases so the relative variability of the demand for operating theatre time declines: concentrating non-elective orthopaedic activity could offer considerable savings in the theatre time allocated to trauma patients. However, the impact on the wards is much less significant, with concentration having a negligible effect on the requirement for beds

Managing uncertainty in orthopaedic trauma theatres

The management of acute healthcare involves coping with a large uncertainty in demand. This uncertainty is a prevailing feature of orthopaedic care and many scarce resources are devoted to providing the contingent theatre time for orthopaedic trauma patients. However, given the variability and uncertainty in the demand much of the theatre time is not used. Simulation was used to explore the balance between maximising the utilisation of the theatre sessions, avoiding too many overruns and ensuring a reasonable quality of care in a typical hospital in the United Kingdom. The simulation was developed to examine a policy of including planned, elective patients within the trauma session: it appears that if patients are willing to accept a possibility of their treatment being cancelled, substantially greater throughputs can be achieved. A number of approximations were examined as an alternative to the full simulation: the simpler model offers reasonable accuracy and easier implementation