SIMULATION: RADIOLOGY’S NEW PARTNER

Michael M. Zimmer, PhD Sr. Business Consultant Systems & Procedures VIDANT HEALTH

VIDANT’S SCOPE • Serve 1.4 million people • 29 Counties • 8 Hospital System • 80+ Physician Practices

VIDANT MEDICAL CENTER • 1000 + licensed beds • Academic Medical Facility w/ ECU Brody School of Medicine • Level 1 Trauma

2 SIMIO SAVE US!!

MAGNETIC RESONANCE IMAGING VASCULAR INTERVENTIONAL RADIOLOGY

• Validate MRI utilization and performance to maximize MRI • Assess current state operating utilization capabilities with current resources and capacity

• Test new scheduling options and • Use results and analytics to determine configurations to develop improvement recommendations capital equipment need and IR expansion • Results and analytics produced will allow leaders to make informed decisions to address MRI backlog, prepare for increasing need of MRI services, ensure MRI availability for all inpatient, outpatient, and emergency department patient population.

3 MRI Simulation Model Design VIR Simulation Model Design MRI PROCESS

MRI PROCESS BREAKDOWN

No delays from Patient entrance to MRI processing MRI Service Time Total Time In Suite Arrival Rates and Pre-processing Post-processing Interarrival Times 15 min Delay accounting for 5 min Delay hospital operations delays

Enter Patients MRI Processing Patient Leaves

MRI 2 Inpatient Radiology Inpatient

MRI 1 Obspatient Patient Leaves Outpatient

MRI 3 Outpatient Outpatient DATA & ANALYSIS SUMMARY

Patient Volumes 10/2015 – 9/2016 Observed Service Times • Inpatient: 4895 • Range: 24 minutes to 160 minutes • Outpatient: 2922 • Average: 58 minutes • Obs. Patient: 724 • Standard Deviation: 11.72 • Canceled: 807 • Daily Backlog: 4.44 inpts. (1600/yr)

• Radiology supports 3 MRIs: MRI 1, MRI 2, MRI3 • MRI 1 & 3 is designated for Outpatients in the Brody School of Medicine • MRI 2 is designated for Inpatients located within VMC • Conditions: • Obs-patients may use any of the 3 MRIs when available • Inpatients may use MRI 1 & 3 when available • Under special conditions, outpatients may be required to use MRI 2 • Considerations accounted for in the model • Staffing schedules • Operating hours • MRI staffing requirements • Delays: Transportation, Sedations, Ventilator pts., Late patient arrivals, Equipment setup 6 MRI SIMIO BUILD

7 MRI RESULTS

MRI SIMULATION MODEL RESULTS 8500 100 90 8000 90

7950 75 80 7500 70 7000 74 7008 6989 60 6500 50 6000 52 40 5500

30 % MRI % UTILIZATION MRI 5388 5000 INPATIENT VOLUME / / YEAR VOLUME INPATIENT 20

4500 10

4000 0 Current State Max Schedule New Schedule 1 New Schedule 2

MRI OPERATING SCHEDULES Inpatient Volume Processed Average MRI Utilization

Mon-Fri: Operationalize 2 MRIs 24 hours and 1 MRI standard hours Sat-Sun: Operationalize 1 MRI 24 hours

Cost Avoidance of $4 million dollars for new MRI and construction + ROI on 1500 patients VIR PROCESS

VIR WORKFLOW PROCESS MAP Transport and Room setup Depending on the happen congruently. Need procedure time is variable. Patient can wait in Holding an average transport time 15 – 20 min process This will include patient Area from 1min to 2 hours RN taken away from IR. that takes away a Tech from clean-up. As long as patient depending on Need average transport IR. Need average room in the room is considered circumstances with time to units. ARU transport setup time Procedure Process Physician, room, etc short. 10-15 min process Consent, NPO recheck, Tech and RN do Physician meet-greet. Time Patient prep-work 30-40 min ------IR Tech transports Emergency only G patient to IR RN transports Patient brought into room is setup Procedure Department patient to unit Room is cleaned IR IR room Process (inpatient or ARU) Patient scheduled Holding Area INPATIENT for procedure Process Anesthesia prep- work done Tech and RN setup IR room for procedure IR or CT EMERGENCY Does this create Procedure more time longer END than 15-20 min?

Anesthesia Anesthesia needed assessment | IR or can create time OR variance ?? Tech and RN do Patient prep-work RN transports Procedure Patient brought into patient to unit Room is cleaned CT Process CT room (inpatient or ARU)

Anesthesia prep- Patients arrives to Assessment & ARU Holding work done OUTPATIENT ARU Lab Process Process RN taken away from IR. Patient can wait in Holding 10-15 min process Area from 1min to 2 hours 30-45 min process, with Need average transport depending on patient cleanup another 10- time to units. ARU transport circumstances with 15 min. Total 40-60 min short. Physician, room, 15 – 20 min process Will use ARU data to Anesthesia, etc. calculate time range of patients waiting to begin procedure. VIR MODEL – DATA & DESIGN

Epic Procedure Actual Procedure Epic Procedure Pt. Leaves Start Time Pt. Enters Room Start Time End Time Room Room Ready

Patient Cleanup Patient Prep Time Procedure Time Length EVS Clean Time Time

WORKSTREAM: RESOURCES: HOLDING AREA VIR MD MD GREET

RESOURCES: RESOURCES: VIR PA VIR RN VIR MD VIR TECH x2

WORKSTREAM: SINGLEPLANE BIPLANE CT

10 VIR SIMIO MODEL

11 VIR SOURCE

151 Procedures ~2500 Procedures over 10 months

12 VIR SERVERS

13 VIR RESULTS

UTILIZATION UTILIZATION CURRENT STATE CURRENT STATE NEURO MD 20.36 SINGLEPLANE A 30.67 VIR MD 1 (7A-3P) 69.96 VIR MD 2 (8A-5P) 65.38 SINGLEPLANE B 29.53 VIR MD 3 (12P – 7P) 59.33 SINGLEPLANE C 29.32 VIR PA 47.95 BIPLANE 21.46 VIR RN 1 32.76 VIR RN 2 30.74 VIR EQUIPMENT CT 17.48 VIR RN 3 32.22 VIR RN 4 32.74 VIR RN 5 31.31 VIR TECH 1 (7A-330P) 64.22 VIR TECH 2 (7A-330P) 65.23 UTILIZATION ∆ VIR WORKERS VIR VIR TECH 3 (8A-430P) 62.27 VIR TECH 4 (8A-430P) 60.59 Worker Productivity ≠ VIR TECH 5 (9A-530P) 60.06 Equipment Productivity VIR TECH 6 (7A-530P) 63.81 VIR TECH 7 (1030A-7P) 55.38 VIR TECH 8 (1030A-7P) 55.25 VIR POST DELIVERABLES WORK

QUESTIONS OR COMMENTS DURING PRESENTATION: • IR feels closed down between 11A – 2P. • From observations and looking at the data information nothing indicates that this actually occurs. The Epic data report shows a number of procedures occurring between this timeframe where gaps should be visible if true. • Outpatients are healthier versus Inpatients that affect procedure work • Nothing in our work will dispute that. The information gathered from the logged data for every procedure was accounted for in the simulation. Therefore the time spent on more complex inpatient cases was also used in the simulation. The model did not bias against out or inpatients but ran the operations as it actually occurred in real life. • Emergency and Anesthesia cases • The Epic report has every procedure that was done in IR, this data report would account for emergency and anesthesia cases. The intricacies that happen during emergency and anesthesia cases were not modeled. Reasons being is the frequency in which emergency cases happen were very very low that it would not have impacted results. Emergency cases would only lower the utilization due to the resources pulled to handle them. Anesthesia cases impact the holding area time. Patients do not remain in an IR room waiting for anesthesia, they are either in the holding area or in their ARU room. Utilization is calculated based on wheels in (patient entering the room) to when the room is finished being cleaned by EVS. • The Epic begin Time – when does that start • It was verified that the Epic Begin Exam Time is when IR assumes responsibility of the patient to reserve an IR room. Patient may be still in their inpatient bed on the floor or in ARU when this occurs. It is not the true start of when the procedure begins with the MD doing time out and performing the work. • CT is more in the afternoon – may affect usage • Regardless of when CT procedures are done, it will not alter utilization time since it is purely calculated when the patient enters the room and when the rooms is cleaned. • Surprised that Biplane usage is higher than expected • Since the model is ran based on real data of when biplane procedures occurred, this is the result of its utilization. • Procedure loads are seasonal • This is difficult to corroborate. Looking at the Data Compilation excel file, there is nothing to suggest there are lower or higher peaks in procedures during certain seasons. The only thing that is cyclical is the swing in weekdays. Mondays being the lowest load and a spike of procedures being done on Fridays. Perhaps on Fridays more is done to offset the weekends so that Mondays are not loaded, hence lower caseloads for Mondays.

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