1. Pathways to the future Improving Health System Performance The role of Stochastic simulation in predicting the utility of investments

2. Pathways to the future Amid the entangled complexities of health services all aspects of performance are inter-dependent

3. Pathways to the future Mike Ardagh, National Clinical Director of Emergency Department Services Stuart Powell and Emmanuel Jo, Service Analysis, National Health Board Business Unit, Ministry of Health email; emmanuel_jo@moh.govt.nzemmanuel_jo@moh.govt.nz Joy Farley and Warwick Gilchrist, Taranaki District Health Board

4. Pathways to the future Shorter stays in the Emergency Department 95% will be admitted, discharged or transferred within 6 hours

5. Improving health system performance Shorter stays in the ED About the whole of system Overlaps with; Elective aspirations Primary care considerations Cost containment endeavors Quality concerns

6. Improving health system performance 1 2 3

7. Patients 1.43 year old man with pneumonia, waiting for the medical registrar to assess. 2.60 year old lady with a compound ankle fracture awaiting surgery. 3.A 73 year old woman with chest pain, waiting for a free ED cubicle

8. Improving health system performance Patients 1.43 year old man with pneumonia, waiting for the medical registrar to assess. What if we had a separate medical assessment unit? Or a second medical registrar? Or IV antibiotics in primary care?

9. Improving health system performance Patients 2.60 year old lady with a compound ankle fracture awaiting surgery. What if we had a dedicated acute theatre? Or another orthopaedic registrar? Or if elective orthopaedic activity was at another site?

10. Improving health system performance Patients 3.A 73 year old woman with chest pain, waiting for a free ED cubicle. Should we have more monitored cubicles? Or a bigger Coronary Care Unit? Or a low risk chest pain pathway run through the ED observation unit?

11. Improving health system performance

13. Seeking answers Value stream mapping and other lean thinking techniques Breach analysis and other measures of variance Street wisdom Turning data until it catches the light Modelling of present state compared to present state plus an intervention

14. Improving health system performance Advantages of using simulation Real life experiments without implementing in the real world Identify how changes to variables within the system can impact other parts of the system Easy identification of bottle necks

15. Improving health system performance Disadvantages of using simulation If the data doesn’t reflect reality, the results won’t be real There may be unknown/unpredicted confounders the data has not taken into account

16. Improving health system performance The Simulation Tool Witness Simulation Software Used with success in a variety of industries 3 examples of use in Health Care and Hospitals on website (2 UK, 1 USA) www.lanner.com Trialled with ADHB data*, and TDHB underway.

17. Improving health system performance Patient flow simulation for Taranaki DHB Aim: To investigate the influence on patient flow, of a short stay unit next to ED.

18. Improving health system performance Model structure

19. Improving health system performance Timeline for a process optimisation using simulation for a DHB StepTaskTime Required 1Plan and identify what to optimise1 day 2Draw up a model structure and flow diagrams1 week 3Check the structure by the MOH team1 day 4Data gathering for the model2-3 weeks 5Building the model using special simulation software 2-4 weeks 6Validate and calibrate the model for Business as Usual Scenario 1 week 7Test different policy options in the complex virtual life environment to identify better outcome 1 week Approximately 10 weeks !!!!

20. Improving health system performance Summary Achieving the Shorter Stays in the Emergency Department Target requires whole of system reforms Health systems are complex and interactive Interventions will influence many parts of the system Simulation has the potential to predict the influence of interventions The Shorter Stays Target is not competing with other priorities.