Peck J.S.,New England Veterans Engineering Resource Center |
Peck J.S.,Massachusetts Institute of Technology |
Gaehde S.A.,Boston Veterans Health Administration |
Nightingale D.J.,Massachusetts Institute of Technology |
And 6 more authors.
Academic Emergency Medicine | Year: 2013
Objectives: The objective was to test the generalizability, across a range of hospital sizes and demographics, of a previously developed method for predicting and aggregating, in real time, the probabilities that emergency department (ED) patients will be admitted to a hospital inpatient unit. Methods: Logistic regression models were developed that estimate inpatient admission probabilities of each patient upon entering an ED. The models were based on retrospective development (n = 4,000 to 5,000 ED visits) and validation (n = 1,000 to 2,000 ED visits) data sets from four heterogeneous hospitals. Model performance was evaluated using retrospective test data sets (n = 1,000 to 2,000 ED visits). For one hospital the developed model also was applied prospectively to a test data set (n = 910 ED visits) coded by triage nurses in real time, to compare results to those from the retrospective single investigator-coded test data set. Results: The prediction models for each hospital performed reasonably well and typically involved just a few simple-to-collect variables, which differed for each hospital. Areas under receiver operating characteristic curves (AUC) ranged from 0.80 to 0.89, R2 correlation coefficients between predicted and actual daily admissions ranged from 0.58 to 0.90, and Hosmer-Lemeshow goodness-of-fit statistics of model accuracy had p > 0.01 with one exception. Data coded prospectively by triage nurses produced comparable results. Conclusions: The accuracy of regression models to predict ED patient admission likelihood was shown to be generalizable across hospitals of different sizes, populations, and administrative structures. Each hospital used a unique combination of predictive factors that may reflect these differences. This approach performed equally well when hospital staff coded patient data in real time versus the research team retrospectively. © 2013 by the Society for Academic Emergency Medicine.
Kim B.,New England Veterans Engineering Resource Center |
Elstein Y.,New England Veterans Engineering Resource Center |
Shiner B.,New England Veterans Engineering Resource Center |
Shiner B.,White River Junction Medical Center |
And 5 more authors.
General Hospital Psychiatry | Year: 2013
Objective: To improve clinic design, trial-and-error is commonly used to discover strategies that lead to improvement. Our goal was to predict the effects of various changes before undertaking them. Method: Systems engineers collaborated with staff at an integrated primary care-mental health care clinic to create a computer simulation that mirrored how the clinic currently operates. We then simulated hypothetical changes to the staffing to understand their effects on percentage of patients seen outside scheduled clinic hours and service completion time. Results: We found that, out of the change options being considered by the clinic, extending daily clinic hours by two and including an additional psychiatrist are likely to result in the greatest incremental decreases in patients seen outside clinic hours and in service time. Conclusion: Simulation in partnership with engineers can be an attractive tool for improving mental health clinics, particularly when changes are costly and thus trial-and-error is not desirable. © 2013.
PubMed | Office of Nursing Services, Chief Business Office, University of Utah, Specialty Care Services 10P4E and 2 more.
Type: | Journal: Journal of multidisciplinary healthcare | Year: 2015
Care coordination between the specialty care provider (SCP) and the primary care provider (PCP) is a critical component of safe, efficient, and patient-centered care. Veterans Health Administration conducted a series of focus groups of providers, from specialty care and primary care clinics at VA Medical Centers nationally, to assess 1) what SCPs and PCPs perceive to be current practices that enable or hinder effective care coordination with one another and 2) how these perceptions differ between the two groups of providers. A qualitative thematic analysis of the gathered data validates previous studies that identify communication as being an important enabler of coordination, and uncovers relationship building between specialty care and primary care (particularly through both formal and informal relationship-building opportunities such as collaborative seminars and shared lunch space, respectively) to be the most notable facilitator of effective communication between the two sides. Results from this study suggest concrete next steps that medical facilities can take to improve care coordination, using as their basis the mutual understanding and respect developed between SCPs and PCPs through relationship-building efforts.
Peck J.S.,New England Veterans Engineering Resource Center |
Peck J.S.,Massachusetts Institute of Technology |
Benneyan J.C.,New England Veterans Engineering Resource Center |
Benneyan J.C.,Northeastern University |
And 2 more authors.
Academic Emergency Medicine | Year: 2012
Objectives: The objectives were to evaluate three models that use information gathered during triage to predict, in real time, the number of emergency department (ED) patients who subsequently will be admitted to a hospital inpatient unit (IU) and to introduce a new methodology for implementing these predictions in the hospital setting. Methods: Three simple methods were compared for predicting hospital admission at ED triage: expert opinion, naïve Bayes conditional probability, and a generalized linear regression model with a logit link function (logit-linear). Two months of data were gathered from the Boston VA Healthcare System's 13-bed ED, which receives approximately 1,100 patients per month. Triage nurses were asked to estimate the likelihood that each of 767 triaged patients from that 2-month period would be admitted after their ED treatment, by placing them into one of six categories ranging from low to high likelihood. Logit-linear regression and naïve Bayes models also were developed using retrospective data and used to estimate admission probabilities for each patient who entered the ED within a 2-month time frame, during triage hours (1,160 patients). Predictors considered included patient age, primary complaint, provider, designation (ED or fast track), arrival mode, and urgency level (emergency severity index assigned at triage). Results: Of the three methods considered, logit-linear regression performed the best in predicting total bed need, with a receiver operating characteristic (ROC) area under the curve (AUC) of 0.887, an R2 of 0.58, an average estimation error of 0.19 beds per day, and on average roughly 3.5 hours before peak demand occurred. Significant predictors were patient age, primary complaint, bed type designation, and arrival mode (p < 0.0001 for all factors). The naïve Bayesian model had similar positive predictive value, with an AUC of 0.841 and an R2 of 0.58, but with average difference in total bed need of approximately 2.08 per day. Triage nurse expert opinion also had some predictive capability, with an R2 of 0.52 and an average difference in total bed need of 1.87 per day. Conclusions: Simple probability models can reasonably predict ED-to-IU patient volumes based on basic data gathered at triage. This predictive information could be used for improved real-time bed management, patient flow, and discharge processes. Both statistical models were reasonably accurate, using only a minimal number of readily available independent variables. © 2012 by the Society for Academic Emergency Medicine.
Konrad R.,Worcester Polytechnic Institute |
DeSotto K.,New England Veterans Engineering Resource Center |
Grocela A.,Worcester Polytechnic Institute |
McAuley P.,Worcester Polytechnic Institute |
And 3 more authors.
Operations Research for Health Care | Year: 2013
We report on the use of discrete-event simulation modeling to support process improvements in a hospital emergency department (ED), namely the implementation of a split-flow process. Our partner hospital was effective in treating patients, but wait time and congestion in the ED created patient dissatisfaction, unsafe conditions and staff morale issues. The split-flow concept is an emerging approach to manage ED processes by splitting patient flow according to patient acuity and enabling parallel processing. We contrast the split-flow operational model to other types of ED triage. While early implementations of the split-flow concept have demonstrated significant improvements in patient wait times, a systematic evaluation of operational configurations is lacking.We created a discrete-event simulation model and established its face validity for Saint Vincent Hospital in Worcester, USA, a community-teaching, Level II Trauma Center. Seventeen scenarios were tested to estimate the likely impact of a split-flow process redesign, including staffing level changes and patient volume changes. The scenarios were compared in terms of Door-to-Doctor time and length-of-stay for different patient acuity levels.Findings from the study supported implementation of the split-flow improvements. Statistical analysis of data taken before and after the implementation indicate that waiting time measures were significantly improved and overall patient length-of-stay was reduced. To gauge the success of the current split-flow process at Saint Vincent we compare performance metrics from three different sources: benchmark metrics, hospital data prior to split-flow implementation, and performance metrics post implementation. © 2013 Elsevier Ltd.
Heyworth L.,Veterans Affairs Boston Healthcare System |
Heyworth L.,Center for Healthcare Organization and Implementation Research |
Heyworth L.,Brigham and Women's Hospital |
Clark J.,Veterans Affairs Boston Healthcare System |
And 9 more authors.
Journal of Medical Internet Research | Year: 2013
Background: Virtual (non-face-to-face) medication reconciliation strategies may reduce adverse drug events (ADEs) among vulnerable ambulatory patients. Understanding provider perspectives on the use of technology for medication reconciliation can inform the design of patient-centered solutions to improve ambulatory medication safety. Objective: The aim of the study was to describe primary care providers' experiences of ambulatory medication reconciliation and secure messaging (secure email between patients and providers), and to elicit perceptions of a virtual medication reconciliation system using secure messaging (SM). Methods: This was a qualitative study using semi-structured interviews. From January 2012 to May 2012, we conducted structured observations of primary care clinical activities and interviewed 15 primary care providers within a Veterans Affairs Healthcare System in Boston, Massachusetts (USA). We carried out content analysis informed by the grounded theory. Results: Of the 15 participating providers, 12 were female and 11 saw 10 or fewer patients in a typical workday. Experiences and perceptions elicited from providers during in-depth interviews were organized into 12 overarching themes: 4 themes for experiences with medication reconciliation, 3 themes for perceptions on how to improve ambulatory medication reconciliation, and 5 themes for experiences with SM. Providers generally recognized medication reconciliation as a valuable component of primary care delivery and all agreed that medication reconciliation following hospital discharge is a key priority. Most providers favored delegating the responsibility for medication reconciliation to another member of the staff, such as a nurse or a pharmacist. The 4 themes related to ambulatory medication reconciliation were (1) the approach to complex patients, (2) the effectiveness of medication reconciliation in preventing ADEs, (3) challenges to completing medication reconciliation, and (4) medication reconciliation during transitions of care. Specifically, providers emphasized the importance of medication reconciliation at the post-hospital visit. Providers indicated that assistance from a caregiver (eg, a family member) for medication reconciliation was helpful for complex or elderly patients and that patients' social or cognitive factors often made medication reconciliation challenging. Regarding providers' use of SM, about half reported using SM frequently, but all felt that it improved their clinical workflow and nearly all providers were enthusiastic about a virtual medication reconciliation system, such as one using SM. All providers thought that such a system could reduce ADEs. Conclusions: Although providers recognize the importance and value of ambulatory medication reconciliation, various factors make it difficult to execute this task effectively, particularly among complex or elderly patients and patients with complicated.
PubMed | Northeastern University, New England Veterans Engineering Resource Center, VA Office of Academic Affairs and Veterans Engineering Resource Centers National Program Office
Type: Journal Article | Journal: American journal of medical quality : the official journal of the American College of Medical Quality | Year: 2015
Industrial engineering and related disciplines have been used widely in improvement efforts in many industries. These approaches have been less commonly attempted in health care. One factor limiting application is the limited workforce resulting from a lack of specific education and professional development in health systems engineering (HSE). The authors describe the development of an HSE fellowship within the United States Department of Veterans Affairs, Veterans Health Administration (VA). This fellowship includes a novel curriculum based on specifically established competencies for HSE. A 1-year HSE curriculum was developed and delivered to fellows at several VA engineering resource centers over several years. On graduation, a majority of the fellows accepted positions in the health care field. Challenges faced in developing the fellowship are discussed. Advanced educational opportunities in applied HSE have the potential to develop the workforce capacity needed to improve the quality of health care.
PubMed | New England Veterans Engineering Resource Center and Massachusetts Institute of Technology
Type: Journal Article | Journal: Military medicine | Year: 2015
The Veterans Health Administration (VHA) provides care to over 8 million Veterans and operates over 1,700 sites of care across 21 regional networks in the United States. Health care providers within VHA report large seasonal variation in the demand for services, especially in the southern United States because of arrival of snowbirds during the winter. Because resource allocation activities are primarily carried out through an annual budgeting process, the seasonal load imposed by traveling Veterans-Veterans that seek care at VHA sites outside of their home network-make providing high-quality services more challenging. This work constitutes the first major effort within VHA to understand the impact of traveling Veterans. We discovered strong seasonal fluctuations in demand at a clinic located in the southeastern United States and developed a seasonal autoregressive integrated moving average model to help the clinic forecast demand for its services with significantly less error than historical averaging. Monte Carlo simulation of the clinic revealed that physicians are overutilized, suggesting the need to re-evaluate how the clinic is currently staffed. More broadly, this study demonstrates how operations management methods can assist operational decision making at other clinics and medical centers both within and outside VHA.
PubMed | Boston University, New England College, New England Veterans Engineering Resource Center and Harvard University
Type: Journal Article | Journal: American journal of health-system pharmacy : AJHP : official journal of the American Society of Health-System Pharmacists | Year: 2016
Results of a two-part study to determine the proportion of anticoagulation clinic (AC) work that could potentially be shifted from a pharmacist to a clinical pharmacy technician (CPT) are presented.In part 1 of the study, a group of eight clinical pharmacists and four CPTs from Veterans Affairs (VA) ACs used a modified Delphi process to categorize AC tasks as appropriate or inappropriate for a fully trained, licensed CPT. In part 2, a three-day time study was conducted at an AC staffed by one clinical pharmacist to determine the amounts of pharmacist time spent performing the tasks delineated through the Delphi process. Based on the time study data and task appropriateness categorizations, the proportion of AC work that might be appropriate for a CPT was estimated.Two levels of CPT-appropriate tasks were identified: those appropriate for any CPT and those appropriate only for an advanced-practice CPT; the latter category of tasks included conducting follow-up phone interviews with patients found to have in-range International Normalized Ratio values. The results of the time study indicated that 21% of the AC workload could be handled by a CPT and 41% could be handled by an advanced-practice CPT.Investigation of AC roles within the VA system suggested that well-trained pharmacy technicians can perform a substantial proportion of work in an AC, including some tasks performed by pharmacists.
PubMed | New Jersey Healthcare System Center for Healthcare Knowledge Management, Clinical Pharmacy Services and Healthcare Services Research, New England Veterans Engineering Resource Center, Harvard University and 3 more.
Type: | Journal: Journal of general internal medicine | Year: 2016
There has been concern about the growing off-label use of testosterone. Understanding the context within which testosterone is prescribed may contribute to interventions to improve prescribing.To evaluate patient characteristics associated with receipt of testosterone.Cross-sectional.A national cohort of male patients, who had received at least one outpatient prescription within the Veterans Affairs (VA) system during Fiscal Year 2008- Fiscal Year 2012.The study sample consisted of 682,915 non-HIV male patients, of whom 132,764 had received testosterone and a random 10% sample, 550,151, had not.Conditions and medications associated with testosterone prescription.Only 6.3% of men who received testosterone from the VA during the study period had a disorder of the testis, pituitary or hypothalamus associated with male hypogonadism. Among patients without a diagnosed disorder of hypogonadism, the use of opioids and obesity were the strongest predictors of testosterone prescription. Patients receiving >100mg/equivalents of oral morphine daily (adjusted odds ratio=5.75, p<0.001) and those with body mass index (BMI) >40kg/mIn the VA, 93.7% of men receiving testosterone did not have a diagnosed condition of the testes, pituitary, or hypothalamus. The strongest predictors of testosterone receipt (e.g., obesity, receipt of opioids), which though are associated with unapproved, off-label use, may be valid reasons for therapy. Interventions should aim to increase the proportion of testosterone recipients who have a valid indication.