Table of Contents

Title Page

Acknowledgments

Chapter 1: The Healthcare Delivery System

Overview
1.1 Healthcare Delivery Components
1.2 Major Stakeholders
1.3 Global Issues in Health
1.4 Drivers for Healthcare Systems
References

Chapter 2: Complexity and Systems in Healthcare

Overview
2.1 Taking a Systems Approach to Healthcare
2.2 Complex Adaptive Systems
2.3 Systems Thinking and System Dynamics
References

Chapter 3: Patient Flow

Overview
3.1 Healthcare Settings and Clinical Workflows
3.2 Patient Flow through a Hospital
3.3 Care Transitions
3.4 Process Mapping
3.5 Queuing
References

Chapter 4: Healthcare Financing

Overview
4.1 Financing Models for Health Services
4.2 Compensation Models for Providers
4.3 Cost Allocation and Charges
4.4 Capital Budgeting
References

Chapter 5: Health Data and Informatics

Overview
5.1 Healthcare Data
5.2 Electronic Health Records
5.3 Health Information Exchange
5.4 Publicly Reported Healthcare Data
References

Chapter 6: Lean

Overview
6.1 Lean Philosophy and Methods
6.2 Drivers for Lean Healthcare Systems
6.3 A Toolset for Eliminating Wastes
6.4 Value Stream Mapping
6.5 A3
6.6 5S
6.7 Kanban
6.8 Lean Implementations
6.9 Lean Thinking
References

Chapter 7: Six Sigma

Overview
7.1 Six Sigma Philosophy
7.2 Six Sigma Quality
References

Chapter 8: Reliability and Patient Safety

Overview
8.1 Human Reliability
8.2 Errors in Healthcare
8.3 Medication Errors
8.4 Patient Falls
8.5 Human Factors and Ergonomics for Patient Safety
References

Chapter 9: Health Analytics

Overview
9.1 Data Mining
9.2 Data Visualization
Social Network Analysis
9.4 Data Envelopment Analysis
9.5 Multicriteria Decision Making
References

Chapter 10: Capacity Management

Overview
10.1 Capacity Management Challenges
10.2 Managing Nursing Units
10.3 Managing Operating Rooms
10.4 Managing Diagnostic Units
10.5 Nurse Staffing and Scheduling
References

Chapter 11: Healthcare Logistics

Overview
11.1 Facility Location
11.2 Home Healthcare Routing and Scheduling
References

Chapter 12: Health Supply Chains

Overview
12.1 Forecasting Demand
12.2 Inventory Control
12.3 Healthcare Distribution
12.4 Coordinating Activities in the Supply Chain
References

Chapter 13: Infection Control

Overview
13.1 Historical Perspective
13.2 Infection Control Classification
13.3 Checklists for Infection Control
13.4 The Case of Sepsis
13.5 Mathematical Modeling of Hospital Infection Control
References

Index

End User License Agreement

List of Illustrations

Chapter 1: The Healthcare Delivery System

Figure 1.1 Comparison of Healthcare Spending for OECD Countries, 1980–2011
Figure 1.2 OECD County Health Rankings
Figure 1.3 Health Outcomes Rank versus Spending Rank by Country

Chapter 2: Complexity and Systems in Healthcare

Figure 2.1 Six Levels of the Healthcare System
Figure 2.2 Sense-Making Framework
Figure 2.3 Summary of the Complexity of Five Markets in the Healthcare Delivery Network
Figure 2.4 People Who Were Aware of Their Disease by eGFR 1999–2012
Figure 2.5 A Framework for Disease Detection in a Complex Adaptive System
Figure 2.6 High-Level Flowchart of CKD Care for the Primary Care Physician
Figure 2.7 Three Views on the Definition and Role of Systems Thinking
Figure 2.8 Dimensions of Systems Thinking
Figure 2.9 Linear View Example
Figure 2.10 Feedback View Example
Figure 2.11 Reinforcing Loop on Eating and Weight
Figure 2.12 Balancing Loop to Use a Self-Control Intervention
Figure 2.13 Causal Loop Diagram for the Long-Run Impact of Educating PCPs about the KDOQI Guideline
Figure 2.14 Causal Loop Diagram for the Impact of the Limited PCP Hours
Figure 2.15 Basic Structure of a Stock Flow Model
Figure 2.16 Stock Flow Diagram for Patients with CKD
Figure 2.17 Chart Showing How the Four Interventions Affected the Number of Patients with Stage 3 (S3) CKD Who Are Not Engaged in Care Management (NCM) and Who Are Engaged in Care Management (CM)

Chapter 3: Patient Flow

Figure 3.1 Surgical Safety Checklist (2008)
Figure 3.2 Process Map Symbols
Figure 3.3 Process Map for a Physician Visit Appointment
Figure 3.4 (a) Regular arrivals and departures spaced so there's no queue. (b) Irregular arrivals and departures spaced so there's no queue. (c) Regular arrivals with service length variation cause queuing delays. (d) Irregular arrivals queues with queuing delays
Figure 3.5 A Process Map of Patient Flow from the ED to Inpatient Ward

Chapter 4: Healthcare Financing

Figure 4.1 Utility versus Income for Health Insurance Example
Figure 4.2 Aggregate U.S. Hospital Payment-to-Cost Ratios for Private Payers, Medicare, and Medicaid, 1993–2013

Chapter 5: Health Data and Informatics

Figure 5.1 Schematic of the Discipline of Health Informatics
Figure 5.2 Information Hierarchy Used in Health Informatics
Figure 5.3 IHI Triple Aim
Figure 5.4 Relationships between Decisions and Data
Figure 5.5 Increasingly Sophisticated and Standardized Data
Figure 5.6 History of the Electronic Health Record
Figure 5.7 Overview of the National Health Information Network
Figure 5.8 Relation between NHIN Direct and HISP

Chapter 6: Lean

Figure 6.1 Value Stream Map Symbols
Figure 6.2 A Value Stream Map (VSM) for an Emergency Treatment Encounter
Figure 6.3 A3 Worksheet
Figure 6.4 A3 Worksheets Record the Progress in Moving from a Current State VSM to a New Current State VSM
Figure 6.5a A3 for Orthopedic Discharge Rounding
Figure 6.5b A3 for Orthopedic Discharge Rounding
Figure 6.6 An Anesthesia Board before the Use of Visual Factory Concepts
Figure 6.7 An Anesthesia Board after the Use of Visual Factory Concepts
Figure 6.8 A Typical Kanban CardA Typical Kanban Card
Figure 6.9 Circulation of Kanban Cards and Containers
Figure 6.10 A reorganized hospital supply room after the application of kanbans.

Chapter 7: Six Sigma

Figure 7.1 Frequency Distribution
Figure 7.2 CTQ Flowdown for Emergency Department
Figure 7.3 SIPOC Diagram for Patient Discharge
Figure 7.4 Fishbone Diagram of Medication Errors
Figure 7.5 Pareto Chart of Missing Information on Patient Records
Figure 7.6 Dotplot and Boxplot of 30-Day Readmission Rates
Figure 7.7 Two-Sample t-Test and Related Statistics
Figure 7.8 Control Charts for ED Wait Times
Figure 7.9 A Hand Hygiene Communication Poster
Figure 7.10 The Process of Leading and Managing for Quality
Figure 7.11 Aligning Improvement with Strategy and Health Outcomes
Figure 7.12 Expanded Quality Improvement Toolkit
Figure 7.13 Markers’ Relative Importance
Figure 7.14 Technical Requirements’ Relative Importance for Each Translational Phase
Figure 7.15 Intra-Institutional Obesity Collaboration Network
Figure 7.16 Cross-Institutional Obesity Collaboration Network

Chapter 8: Reliability and Patient Safety

Figure 8.1 Swiss Cheese Model of Error Causation
Figure 8.2 Left: Colored Identification Bracelet (http://www.pdchealthcare.com) Right: Fall Prevention Alarm (http://www.rehabmart.com/product/fall-prevention-monitor-260.html)
Figure 8.3 Three Categories of Healthcare System Components That Affect Patient Safety
Figure 8.4 Conceptual Model of Situation Awareness
Figure 8.5 Framework for Device Design Based on Intended Use and Safety

Chapter 9: Health Analytics

Figure 9.1 The Knowledge Discovery in Databases (KDD) Methodology
Figure 9.2 Skeletal Image of a Person with 20 Nodes and Example Data Table for the Shoulder Center Node
Figure 9.3 Dynamic PD Prediction
Figure 9.4 Visualization Pipeline
Figure 9.5 DV Process
Figure 9.6 Comparison of Images with and without DV
Figure 9.7 Visualization of Risk
Figure 9.8 Visualization of Scale
Figure 9.9 Visualization of Scale
Figure 9.10 Timeline in EMR
Figure 9.11 Visualization of Frequency
Figure 9.12 Visualization of Workflow
Figure 9.13 Visualization of Period
Figure 9.14 Visualization of Time
Figure 9.15 Glyph
Figure 9.16 Visualization of Overlap
Figure 9.17 Example of a Custom Glyph for Obesity Counseling
Figure 9.18 Map of Koningsberg
Figure 9.19 Example Social Network
Figure 9.20 Directed and Undirected Graphs
Figure 9.21 Communities in a Network
Figure 9.22 Network Graph for Task Categories
Figure 9.23 Network Graph of Detailed TasksSource: Muñoz et al. (2014)
Figure 9.24 Network Graph of Coordinated Tasks Source: Muñoz et al. (2014)
Figure 9.25 Example of Input-Oriented Efficiency Models
Figure 9.26 Weighted GP Model Solution with MEDEVAC Helicopter Emplacements

Chapter 10: Capacity Management

Figure 10.1 Units and Flow in Bed Management
Figure 10.2 ICU Queueing System
Figure 10.3 Impact of Number of Beds on Average Time in the ICU System
Figure 10.4 Number of Patients Boarded as a Function of Arrival Rate for Various Squared Coefficients of Variation
Figure 10.5 Birth-Death Diagram for Two-Bed Example

Chapter 11: Healthcare Logistics

Figure 11.1 FQHC Optimal Locations Comparing (a) Access and (b) Coverage Status
Figure 11.2 Solution of a 4-Nurse 20-Patient Example

Chapter 12: Health Supply Chains

Figure 12.1 Healthcare Supply Chain
Figure 12.2 Healthcare Distribution Network Example
Figure 12.3 Illustration of the Bullwhip Effect

Chapter 13: Infection Control

Figure 13.1 Coxcomb Diagram Showing Causes of Death Over Time during the Crimean War
Figure 13.2 Severe Sepsis/Septic Shock Top 10 Checklist
Figure 13.3 Flow Diagram of Compartment Model
Figure 13.4 Sequential Box Model for the Two-Segmentation Case
Figure 13.5 Sequential Box Model for the Four-Segmentation Case
Figure 13.6 Number of Infection Cases and Cost of Different Intervention Options
Figure 13.7 Annual Infections as a Function of Equivalent Air Exchange

List of Tables

Chapter 1: The Healthcare Delivery System

Table 1.1 Delivery of Healthcare Services
Table 1.2 Stakeholder Groups

Chapter 2: Complexity and Systems in Healthcare

Table 2.1 Comparison of Organizational Behaviors

Chapter 3: Patient Flow

Table 3.1 Clinical Workflows in Healthcare Settings
Table 3.2 Classification of Admission Process Policies (APPs)

Chapter 5: Health Data and Informatics

Table 5.1 ICD-9 to 10 Comparison of Complexity and Specificity
Table 5.2 Stages of Meaningful Use for EHR Implementation
Table 5.3 Medicare and Medicaid EHR Incentive Programs
Table 5.4 Common Types of Health-Related Data Exchanged

Chapter 6: Lean

Table 6.1 Wastes in Healthcare
Table 6.2 Lean Tools and Methods
Table 6.3 The Four Rules of the TPS

Chapter 7: Six Sigma

Table 7.1 Quality Levels and Corresponding Number of Defects
Table 7.2 Examples of Healthcare Quality Problems Viewed as Defects per Million and Compared with Airline Examples
Table 7.3 Estimating the Costs of a Six Sigma Initiative
Table 7.4 Examples of Six Sigma DMAIC Concepts and Tools
Table 7.5 FMEA worksheet for ED Triage
Table 7.6 Types of Control Charts
Table 7.7 Six Sigma Implementations in Healthcare Using DMAIC Methodology
Table 7.8 Patient Discharge Times
Table 7.9 Considerations for Gaining Physician Support for Six Sigma

Chapter 8: Reliability and Patient Safety

Table 8.1 Risk Factors for Falls
Table 8.2 Factors Associated with Communication Barriers

Chapter 9: Health Analytics

Table 9.1 Word-Frequency Analysis of News Articles
Table 9.2 Performance of the Data-Mining Classification Algorithms
Table 9.3 Data from Real-World Example of Military Hospital Network

Chapter 10: Capacity Management

Table 10.1 Numerical Parameters When GCU Has Finite Capacity
Table 10.2 Block Schedule Example

Chapter 11: Healthcare Logistics

Table 11.1 Population Groups by Access and Coverage
Table 11.2 Adjusted Weights for the Four Service Types

Chapter 13: Infection Control

Table 13.1 Checklist for Reducing Catheter-Related Bloodstream Infection Rates
Table 13.2 Events and Rates
Table 13.3 Summary of Variables in the Infection Risk Model
Table 13.4 Summary Variables for the Example Clinical Waiting Room
Table 13.5 Different Intervention Options and Results

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Acknowledgments

This book evolved after a series of annual workshops by the Penn State Center for Integrated Healthcare Delivery Systems, projects funded by the National Science Foundation Center for Health Organization Transformation (ICURC 1067885), and course development for IE 568 Healthcare Systems Engineering. These outlets allowed us to explore and develop several aspects of this emerging domain.

We would like to acknowledge and thank all of the colleagues, faculty, staff, and students who have been a part of these endeavors, especially Michael Beck, Diane Brannon, Beth Colledge, Yining Chen, Cheng Chi, William Curry, Nasr Ghahramani, Xuemei Huang, Marija Jankovic, Mehmet Kilinc, Min-Jung Kim, Lisa Korman, Jennifer Kraschnewski, Hyunji Lee, Deirdre McCaughey, Colleen Rafferty, Madhu Reddy, Jaideep Sood, Conrad Tucker, Monifa Vaughn-Cooke, Steven Wagman, Beatrice Winkler, Renfei (Iris) Yan, and Sai Zhang.

We are deeply grateful to Liz Welker for her help in editing this book and developing some of the artwork.

The encouragement and funding support provided by Charles Schneider through the Service Enterprise Engineering 360 initiative is very much appreciated, as is the support of Virginia and Joseph Mello.

The people at Wiley made this endeavor a reality. We want to acknowledge and thank our editor, Amanda Shettleton, and also Margaret Cummins, Nanda Gopal, and Michael New.