Modelling and analysis of unwarranted variation of standard operating

(diversion) from a care pathway

This section discusses the literature review in the area of service delivery system modelling illustrated as item 4 in Fig. 1.1.

Variations are identified to be major challenge in healthcare systems (Vayda, 1973; Birkmeyer, et al., 1998; Groff, et al., 2000; Smith, 1991). These variations are often linked with the medical errors in care delivery (Sanwlippo and Robinson 2002). Weingart, et al., (2000) estimated that medical error results in 44000–98000 unnecessary deaths each year in US. Therefore, reducing care variations by

standardizing care delivery processes in healthcare systems or developing & implementation of integrated care pathway (ICP) is identified to be an effective approach (Kitchiner and Bundred, 1999; Pearson, et al., 1995; Wilson, 1998; Archer,

et al., 1997; Wentworth and Atkinson, 1996; Willis, et al., 2000).

Integrated care pathway (ICP) is a structured multidisciplinary outline of anticipated care plans which details the steps in the care of patients with specific clinical condition or set of symptoms (Campbell, et al., 1998). ICP generally involves multidisciplinary communication among several speciality units in hospital to efficiently provide care to patients. Hence, several research studies have worked on creation of ICPs (Kitchiner and Bundred, 1999; Pearson, et al., 1995; Wilson, 1998; Archer, et al., 1997; Wentworth and Atkinson 1996; Willis, et al., 2000). As a result, ICPs are implemented in predominantly used in hospital to reduce and control care delivery variations in providing care to patients (Panella, et al., 2003). However, effectively implementing ICPs in hospital is often associated with problems due to large variations from care pathway. These variations from care pathway are largely unnecessary and lead to longer waiting times, delays, and lower productivity of care pathways. For example, patients diversion from care pathway to other medical units, which compromises the care delivered to patients. Therefore, variations from care pathway are crucial for improving the overall performance of care pathway in hospital. Hence, Chapter 7 develops an approach for pathway variations analysis to reduce variations from care pathway for effective and efficient use of complex care pathway in hospital.

The research on identification of variations from care pathways and pathway improvements are limited. Majority of research studies are focused around developing and implementing integrated care pathways within hospital rather than

identifying variations from pathway when care pathways are implemented in the hospital (Wilde, 2009, DoH 2006; 2010; Wentworth, et al., 1996; Campbell, et al., 1998). In following paragraphs, issues in care pathway improvements (variations on

a care pathway) are classified and approaches used in literature for addressing those issues are discussed.

Several issues in improving care pathways based on reducing variations on a care pathway have been identified in literature. These issues can be broadly classified into: (i) process redesign and communication; (ii) diagnostic accuracy; and, (iii) efficiency improvements or optimum resource utilisation (see Table 3.5).

Table 3.5: Review of the approaches used in care pathway improvements

Approaches Issues

Pathway

Modelling Clinical Tests

Hospital Operations Simulation Variations on a care pathway Process redesign and communication Crabbe, et al., 1994, Stevens, et al., 1974, Staccini, et al., 2006, Rother and Shook, 2003, Patel, 2000; Shukla, et al., 2009 - - Clinical accuracy - Harbison, et al., 2003; Mohd Nor, et al., 2005; Kasner, et al., 1999; Kobayashi, et al., 2009; Chalela, et al., 2007; Wardlaw, et al., 2004 - Efficiency improvements /optimum resource utilisation - - Duguay&Chetouane, 2007; Molema, et al., 2007; VanBerkel and Blake, 2007; Bayer, et al., 2010; Dodds, 2005; Connelly & Bair, 2004; Kotiadis& Mackenzie, 2004; Davies, et al., 2002;

Brailsford, et al., 2006

Issues related to process redesign and communications are commonly studied in healthcare literature (Crabbe, et al., 1994; Staccini, et al., 2006; Shukla, et al., 2009; Mould, et al., 2010). Process redesign generally involves review of current processes used in patient pathway before suggesting improvements. The review of existing processes are performed based on the process mapping approaches, which are finally used for process redesign, process documentation, training and communication about existing processes among staff.

Improving diagnostic accuracy for identifying and treating appropriate sub-group of patients within care pathways is identified to be major issue for pathway improvements. Several studies have been conducted by designing and assessing clinical tests to improve diagnostic accuracies (Harbison, et al., 2003; Mohd Nor, et al., 2005; Kasner, et al., 1999; Kobayashi, et al., 2009). This helps in the performance of care pathway by identifying appropriate sub-group of patients for treatment care.

One of the other issues in improving care pathways is optimum utilization of resources for efficiency improvements. This issue have been tackled in previous research studies to develop a prototype model in healthcare for resource planning, bottleneck analysis, and exploring improvement alternatives for care delivery (Bayer,

et al., 2010; Dodds, 2005; Connelly and Bair, 2004; Kotiadis and Mackenzie, 2004).

It involves simulation modelling of care delivery, which is then used as a decision making tool for different types of scenario based analysis and determining its impact on overall performance.

Several types of approaches are used in literature for solving issues related to variations on care pathway such as process redesign, diagnostic accuracies, and

optimum utilisation of resources. The approaches used to address abovementioned issues are then broadly classified into: (i) care pathway modelling; (ii) clinical tests; and, (iii) hospital operations simulation modelling. Pathway modelling refers to the approaches dealing with service delivery system modelling for process redesign. Approaches related to clinical tests deals with the development & assessment of clinical tests for accurate identification of sub-group of patients for treatment in care pathways. Hospital operations simulations approaches deals with the discrete event simulation modelling and analysis of the care delivery. However, there is no approach that deals with the analysis of variations from care pathway. In following paragraphs we discuss more about the abovementioned approaches and their limitations.

Approaches used in care pathway modelling rely on identifying detailed process steps in a care delivery process in diagrammatic form, which is then used for process redesign, documentation, and improvement purposes. Process model describes the flow of information, patients, and staff; decisions made for delivering services; and the essential inter-relationships and interdependence between the process steps. Several studies have explored models such as flowcharts (Crabbe, et al., 1994), data flow diagrams (Stevens, et al., 1974), Integrated Definition for Function Modelling (IDEF, Staccini, et al., 2006); value stream mapping (Rother and Shook, 2003); and role activity diagram (Shukla, et al., 2009) to examine service delivery system for improvements, analysis of clinical information systems, and information systems requirements (see Table 3.5). Shukla, et al., (2009) have proposed that RAD is suitable for service delivery system in healthcare. However, process modelling and redesign alone will have challenges in suggesting overall improvements for care

pathways which includes disease specific clinical decisions and hospital operational attributes.

The majority of research in improving care pathways is related to developing effective and efficient clinical tests for accurate diagnosis of patients. Some of the clinical tests involved in complex care pathway such as stroke are FAST (Face Arm Speech Test; Harbison, et al., 2003), ROSIER (Recognition of Stroke in the Emergency Room; Mohd Nor, et al., 2005), NIHSS (National Institute of Health Stroke Scale; Kasner, et al., 1999), OCSP (Oxfordshire Community Stroke Project clinical classification, Kobayashi, et al., 2009), CT/MRI scan (Chalela, et al., 2007; Wardlaw, et al., 2004). These clinical tests are developed with a view to reduce delays in accurately identifying relevant sub-group of patients for treatments using care pathway (see Table 3.5). Reducing delays and accurate diagnosis is necessary in providing access to organized care and initiation of treatment in any care pathway. These studies improves an existing or develops an individual clinical test for improving diagnostic accuracies, however, in general, multiple clinical tests and clinical decisions are involved within a pathway. Furthermore, the clinical decisions are linked with the hospital operations such as KPIs (key performance indicators), and resource utilisation. Hence, overall improvements within care pathways require an approach which considers pathway modelling, multiple clinical tests, and hospital operations.

Research studies are conducted in the literature which deals with simulation modelling of hospital operations for optimum resource utilization, reducing waiting times, LOS, improving throughput, of the care delivery processes (Duguay and Chetouane, 2007; Molema, et al., 2007; VanBerkel & Blake, 2007; Bayer, et al., 2010). Simulation modelling has been applied to various healthcare areas such as a

vascular surgery (Dodds, 2005), Accident & Emergency (Connelly and Bair, 2004), intermediate care (Kotiadis and Mackenzie, 2004) or the evaluation of screening programmes (Davies, et al., 2002; Brailsford, et al., 2006). Majority of approaches are based on discrete event simulation modelling of service delivery system to develop an understanding of the impact of service improvements scenarios on the overall performance of pathway (see Table 3.5). Once a simulation model of the existing service delivery system is developed, various “what if” questions can be investigated to predict the performance of process produced by change. Simulation models of the process are utilized to examine various scenarios with a view to identifying any bottlenecks or inefficiencies. The majority of these simulation models in hospitals were developed based on inbuilt flow diagrams available in most of the commercial DES software packages such as ARENA, FlexSim, or WITNESS. Although, these simulation models were conveniently built in commercial software packages, however, initial flow diagrams used were not suitable to represent complexity within complex care pathways. This is partly due to the fact that flow diagrams are best suited to representing sequential processes rather than representing complex integrated and interacting processes common in care pathways. Therefore, use of simulation models alone in complex care scenarios can be challenging.

Researchers in domains such as pathway modelling, clinical test development, and hospital operations simulation have utilized tools from their areas such as process modelling, operations research and clinical decision assessments for reducing variations on a care pathway (see Table 3.5). Each of them has some advantages, which can be utilized to improve pathways. However, there is lack of interdisciplinary approaches that integrates the above mentioned methods for analysis of variations from the care pathway such as patient diversions from care

pathway. Therefore, a pathway variations analysis (PVA) methodology is discussed in Chapter 7 that includes the pathway modelling, clinical decision assessment, and operations simulation to analyse pathway variations and suggest improvements (see Table 3.5).

In Chapter 7, Pathway variations analysis (PVA) methodology is proposed to identify, model and suggest improvements which reduces unnecessary patient diversions or variations from care pathway leading to performance improvement of a care pathway.

The next Chapter details the RAD based service system modelling methodology and its implementation on a case study involving MR scanning process of radiology in a large UK hospital.

CHAPTER 4: Service Delivery System Modelling based on