Energy modelling of patient pathways

Posted on: March 21st, 2014 by matthew_bacon

The Conclude Consultancy has recently completed a fascinating study into the energy modelling of patient pathways. We believe that this work will make a significant contribution to understanding how energy is consumed in complex facilities such as acute hospitals. We believe that this will be the case because we have succeeded in directly correlating the energy impacts of use to each patient episode within any part of the hospital.

Why is this important?

It is important for a number of reasons. Firstly because current norms of energy consumption are usually based on building area and volume. So typical norms are: kWh/m² or GJ/100m³ . Many of the standards used in health care facility energy performance use these norms. Yet they can be both very misleading as well as potentially irrelevant to the needs of a clinician who might just be interested in how they personally or how their department could improve energy consumption. Such norms are misleading because they do not reflect intensity of use. For example for the energy conscious clinician when they see that despite the results of their efforts consumption actually goes up, would that not be a little deflating for them? Perhaps the reason for the increase in consumption is because the number of patients processed through the department has risen, and perhaps it is that increase which has caused the increase in consumption?  This is what we mean by intensity of use: more patients per hour, per day, per month for example.  Perhaps it is the difference of intensity of use between UK hospitals and those in Europe that explains why UK hospitals do not appear to perform as well from an energy consumption perspective?

Figure 1. Intensity of use. [Source: http://www.hope.be]

In Figure 1 we can see (if you click on the image it will enlarge) that France and Finland for example have similar intensity of use, but the evidence is that their acute hospitals appear to perform  better than the UK from an energy performance perspective. In contrast Swedish hospitals appear to perform much better than the UK hospitals, but then they have much lower intensity of use. So if intensity of use might partially explain the difference in performance (all supposing we are comparing like for like) then what are the other factors that drive energy consumption and how might these be controlled?

This leads is to the second point as to why area or volume based norms are misleading. It is because of this – that unless the clinicians can be presented with concrete evidence to explain how their working practices impact energy consumption, then they are unlikely to appreciate the need for change. Consequently area or volume based norms mean little to them, because they are intangible measures unrelated to their work.  However, by correlating their working practices directly to patient centric energy consumption, then compelling evidence to support the need for change can be provided.  We mean by patient centric energy consumption that energy consumption is directly correlated to each patient episode for each patient type. It follows that the energy needs of different patient types will vary according to the demand for clinical services of that patient type.  Clearly a patient requiring a video fluoroscopy will consume more energy in their episode than an orthopaedic patient having a plaster cast removed. Furthermore, studies in the United States have demonstrated how different x-ray equipment can impact the working practices of the clinician and yet have very different energy consumption profiles. Both the studies that we have been involved in and the research that we have undertaken have demonstrated much potential for control of energy consumption through analysis of working practices and operational policies. This is the evidence that clinicians require to start to see the need for change.

How did we carry out our analysis?

We have developed two forms of analytics: OCCUPANCY ANALYTICS ™ and Whole Facility Energy Modelling. (Please refer to the Conclude Process at the bottom of our web page). By taking a whole systems perspective of organisational processes and energy modelling focused on patient demand, we have been able to understand the impact of working practices and the energy impacts of those practices from different perspectives within the organisation. For example we can study consumption from a whole hospital perspective, but we can also study it from a departmental, or specialist function perspective. Yet we can also study it from a patient perspective.  We have been able to achieve this because we understand the statistical probability of where each patient type will be in the hospital at any hour of the day. We also understand the energy consumption within each part of the hospital at each hour of the day, and thus by modelling these two datasets we can forecast the statistical probability of energy consumption for each patient type for each patient episode at any period of the day.

Figure 2. – Energy consumption probability profile for a Nuclear Medicine outpatient appointment

How does this help the clinician to understand how they could influence energy consumption?

Because we use the documented working practices and operational processes as the basis of our simulation (quantitative analysis) and so provide the evidence to explains the impact on energy consumption. We then work with the clinicians to consider ‘what-if’ scenarios where we consider the energy impacts of different working practices and operational policies.  We discuss the issues and the challenges and in doing so establish a clear context for improvement (qualitative) analysis.  It is through this process that clinicians are empowered through learning – learning about how to they can impact energy consumption – consumption focused on each patient pathway through the organisation.

It is through this learning that clinicians can also start to understand how the control of patient flow impacts energy consumption, because flow impacts the demand on the environmental systems that provide occupant comfort. As flow becomes interrupted it places larger demands on those systems – a demand which drives energy consumption.  In Conclude, we argue that if we can improve patient flow – we can also improve energy consumption. In fact we can also impact the sizing of the engineering systems, which drives down the capital cost of them. Effective management of patient flow impacts not just the patient experience (reduced waiting times for example) but improved energy performance.

It is for all of these reasons that modelling of patient pathways offers many benefits, and not just providing visibility to the factors that drive energy consumption. It also becomes a valuable means to bridge the divide between the coupling of hospital engineering design with In-use working practices, and that must be a good thing.

 

 

Decentralisation of clinical services

Posted on: March 20th, 2014 by matthew_bacon

Whilst the concept of the decentralisation of health care services (and by this we mean the relocation of centralised clinical services into the community) is not new, there appears to be a dirth of data to support an informed debate as to the merits of it.  A report in 2011 titled: ‘Getting out of Hospital‘, published by the Health Foundation(1), summarised their analysis of decentralisation in these terms:

“The conclusions are appropriately cautious, however. The majority of the published evidence fails to contain robust cost information on infrastructure, planning and start-up costs. Furthermore, much of the evidence is based on small, highly [patient] selective pilots making it difficult to make system-wide generalisations for a broader range of patients.”

The authors make the following recommendations:

“Developing a consistent framework for research and analysis, identifying key factors that can be monitored and evaluated across interventions and settings, would help to inform commissioning decisions. A consistent analytical framework for summarising information would support the collection of comparable information that could show how to successfully implement systemic and strategic changes to service provision. “

Establishing a framework for research and analysis is where The Conclude Consultancy has focused its efforts in the mid-term evaluation for a Community Eye Centres (CEC) contract in Leeds. Conclude were appointed to analyse the Approved Quality Provider (AQP) contract from the perspective of the ‘Triple Bottom Line’ (2) – a means for evaluating not just the economic impacts, but the social and environmental impacts too. To establish the foundation for an evaluation framework, The Conclude Consultancy developed a CEC Measurement Protocol that would ensure consistent processing of data and standardised norms for reporting the results.  As the primary objective for Conclude’s appointment was to study the environmental impacts of decentralisation, the measurement protocol was developed to analyse the energy and carbon impact of the CEC’s. However the work was also extended to study the impact of space and equipment utilisation, which would inform the economic impacts too.

This latter perspective highlights the need for a framework as advocated by the Health Foundation. It was clear from the analysis that the cost of decentralisation must include the less tangible costs of space and equipment utilisation, as well as other costs such as the carbon tax. This points to the need to establish the evaluation criteria in the planning of decentralisation projects, and to determine what data needs to be managed to enable a proper evaluation (using a measurement protocol) to be conducted. Conclude’s experience mirrors that of the the Health Foundation: the difficulties of obtaining robust data constrained the analysis. Yet despite this, the CEC team now understands what data it needs to manage for the remainder of the contract and how it should analyse the performance of the AQP contract from the perspective of the ‘Triple Bottom Line’.

 A Case Study for the project can be accessed here: Decentralisation of Health care services

1 See: http://www.health.org.uk/publications/getting-out-of-hospital

2 See: http://www.economist.com/node/14301663

  

OCCUPANCY ANALYTICS ™: a new basis for low-energy–low-carbon hospital design and operation in the UK

Posted on: November 12th, 2013 by matthew_bacon

Our latest referreed scientific journal paper has just been published by Taylor and Francis in a special edition of the Architectural Engineering and Design Management Journal: The Impact of the Building Occupant on Energy Consumption.

It can be downloaded for free here: http://www.tandfonline.com/eprint/RTGSmimUqH3cgMI9TaTs/full

The paper explains the science behind OCCUPANCY ANALYTICS ™.  It also explains the impact of this work on the low energy – low carbon performance of a major new hospital in the UK.

We are currently writing another scientific paper that explains how this work has been developed to model the energy and carbon impacts of each patient pathway through an acute hospital facility. We believe that this work will also make a significant contribution to low energy – low carbon hospital design and operation. This is because, (for the what we believe will be the first time) it will be possible to transparently model the impacts of clinical working practices on energy consumption and carbon emissions for each patient type on each pathway. We believe that this could provide the basis for new norms for the measurement of energy and carbon performance, founded in OCCUPANCY ANALYTICS ™.

Should you wish to receive more information about our research in these areas please do use the contact form here: http://www.conclude.org.uk/contact/

 

Clean Med Europe 2013

Posted on: September 25th, 2013 by matthew_bacon

Professor Bacon has just returned from CleanMed Europe where he presented our latest work on the energy and carbon analysis of patient pathways in acute hospitals.  For those readers who are unfamiliar with this concept, it is a means for analysis of the patient journey both to and through a hospital, as well as the return journey to their home. Our current focus concerns the journey through a hospital as it relates to each different type of Outpatient visit.

You will find a poster about our work here.

What is the value of such an analysis?  

The simple answer is that it provides the clincians in the hospital with a whole new understanding of how their working practices impact energy consumption and carbon emissions.

But what prevents clinicians from gaining this understanding today?

(more…)

Leveraging OCCUPANCY ANALYTICS ™: Lift passenger demand modelling in hospitals

Posted on: June 8th, 2013 by matthew_bacon

The Conclude Consultancy Limited has recently completed a lift passenger demand modelling study for a Lift Traffic Analysis in a major acute hospital in the UK. The work clearly demonstrates the value of OCCUPANCY ANALYTICS ™.

The challenges for Lift Traffic Analysis in hospital design

Conventional practice in lift traffic analysis for hospitals relies on lift engineers being obliged to utilise less than perfect analysis models to forecast demand at each lift lobby in the hospital as well as the destination floors for each occupant. The difficulties of forecasting passenger demand in complex buildings, such as hospitals, has challenged lift engineers for decades.  Experts have developed imperfect models of analysis, but our research has shown that such models are inappropriate to hopsitals, because they have usually been conceived for use in the planning of lift provision in office buildings.  For example, the simulation software that one major lift manufacturer attempted to use in the hospital was to approximate demand by using a combination of shopping centre and office data models. Inevitably the lift traffic analysis has to incorporate many assumptions, because of these imperfect models.

The risk for the engineer is both one of over-sizing as well as under-sizing the lift provision.  Indeed a recent comparative study in Germany found that using conventional UK design guides and an alternative method, resulted in a difference of  two lift banks.  Over-sizing of lift provision can directly impact energy consumption and the associated carbon emissions. It could also lead to much greater capital costs, but the operating costs could be significantly greater too….that is until now.  Conclude’s OCCUPANCY ANALYTICS ™ work provides the science that lift traffic analysis has long sought: the ability to reliably forecast passenger demand and thus ‘right-size’ the lift provision.

Occupancy analytics

In achieving the forgoing, occupancy analytics provides a rich dataset for lift traffic engineers, because it provides a total forecast demand profile for every occupant type in the hospital that would conceiveably need to use a lift. The occupancy data that is produced provides a detailed insight into forecast occupancy flux throughout the whole hospital, resulting in the following reporting:

  • Numbers of occupants at each floor level at any minute of the day.
  • Occupant pathways and amount of traffic on each for each lift lobby.
  • Occupant demand profile for each floor of the  hospital at whatever frequency is required.
  • Occupant type profile: Porters, Cleaners, Engineering staff, Administrative staff, Medical staff, Patients and Visitors.

Figure 1 – Example of passenger demand modelling in a hospital

 How has Conclude been able to achieve this breakthrough when it has preoccupied specialists for some decades?  Put simply OCCUPANCY ANALYTICS ™ was conceived to enable a whole hospital understanding of occupancy to use this new knowledge in the analysis of space utilsation, and the energy and carbon impacts of us.  The same data that predicts occupancy at any time of the day anywhere in the hospital can be used to predict occupancy in each lift lobby.  It is because the occupancy profile also enables Conclude to model the physical route of each journey for every occupant type in the hospital that we are also able to provide the detailed data required for Lift Traffic Analysis.  Conveniently, the output has been conceived so that it can be processed directly into a simulation model for Lift Traffice Analysis.

If you would like to learn more about this work, please do get in contact by using the contact form on this web site.

OCCUPANCY ANALYTICS ™: Optimising Endoscopy

Posted on: May 13th, 2013 by matthew_bacon

The Conclude Consultancy has recently completed (April 2013) a detailed study of an Endoscopy Unit. The results provide a whole new insight into the factors that impact the variability of the patient experience in the endoscopy service.  The analsyis carried out by Conclude exposes key factors that cause poor performance in patient experience  when measured against the Global Rating Scale (http://www.globalratingscale.com/Default.aspx).  The work identifies the strategies that could be adopted by Endoscopy Units in order to improve this aspect of performance, which would directly impact patient waiting times and improve patient flow through the process.

Deatils of the Case Study can be found here: Endoscopy Unit Case Study

The OCCUPANCY ANALYTICS ™simulation model is a unique approach to service analysis where demand and capacity need to be understood, such that both can be optimised.

NHS Scotland – Annual Conference

Posted on: January 6th, 2013 by matthew_bacon

The Conclude Consultancy Limited has been in a dialogue with Health Facilities Scotland over the course of 2012, culiminating in an invitation for Professor Bacon to address their annual conference in November.  A copy of the presentation can be found here:

http://www.hfs.scot.nhs.uk/conference-/conference-2012/programme/parallel-sessions-c/

HFS are very interested in the new building science developed by Conclude called OCCUPANCY ANALYTICS ™. Scotland has an aggressive low carbon agenda and the Sottish government is determined to reduce the carbon impact of the health estate. A report by Davies Langdon last year concluded that the pay-back period for improving the energy and carbon performance of existing buildings was going to run into decades.  Clearly we need to make fundamental changes in the way that we design and operate our hospitals.

Here at Conclude, we believe that the solution to this challenge is by society learning to use it’s built assets quite differently, because it is only through a change in how we use our built assets, and specifically how we change the way that we use our hospitals, can we hope to achieve a the major  reduction in carbon emissions required by the Carbon Reduction Commitment.  It is the results of our work over the last two years that provides us with the confidence to substantiate this belief.  Nevertheless  it remains a significant challenge for Trusts and Hospital Boards in Scotland, England and Wales.  The scale of the problem can be appreciated by reading the Sustainability Development Unit’s 2012 Carbon Footprint report:

http://www.sdu.nhs.uk/documents/resources/Carbon_Footprint_Published_2012.pdf

Note from this report how building efficiency is forecast to get worse.  Indeed in most Strategic Health Authorities in Engand, carbon emission’s have risen over the reporting period.  This should not be a surprise, because the Royal Academy of Engineering commented in 2011 that buildings today perform little better than they did in the 1980’s.  They too lamented the demise of building science. Yet there is an alternative that some have commented is all too obvious: change the way that we operate our hospitals!  Conclude’s work in this area has clearly demonstrated the dramatic effects of changes in both how hospitals are operated as well as how they need to be designed.

Our work has been warmly received by clincians, and when asked why they feel so positive about it, the common answer has been: “for the first time we have real, tangible evidence of the impacts of our working practices”. Our work truly bridges the ‘Great Divide’ between designer and users, and provides the basis for a new dialogue between them. Our work speaks to the clinicians because it is evidence-based, and directly corelates their working practices to energy and carbon outcomes, as well as health outcomes.

Please do contact us to find out more.

 

OCCUPANCY ANALYTICS ™: A new approach to space optimisation

Posted on: November 21st, 2012 by matthew_bacon

The Need

This NHS Trust had been considering the opportunities to rationalise its estate, and had identified two facilities that were both very old, and which required substantial back-log maintenance.  Prior to the identification of this need, The Conclude Consultancy had carried out an analysis of the candidate facility using  their uniqueOCCUPANCY ANALYTICS ™ methodology.   The purpose of the analysis was to forecast potential space under-utilisation within the candidate facility.  Our work had demonstrated the probability of available capacity at each hour of the day based on a statistical analysis of the data from our model.

Methodology

The analysis of the candidate facility was based on PAS data and forecasts of growth in patient demand. Conclude, also used operational policies to study the efficiency of the clincial processes.  Working with the clinical leadership teams we studied the impacts of alternative operational policies on patient flux and from this dialogue we were able to identify the optimised process  changes that would be required within each department. From this work we produced a schedule of departments with the available capacity at each hourly period of the day.

The analysis of the existing buildings which the Trust wished to consider for redevelopment followed a similar method, but in this case we were forecasting patient demand for each service.  The challenge was to establish the best fit between the functions being provided in the candidate facility and the services to be relocated.

Our OCCUPANCY ANALYTICS ™ specialists provided the core data and this enabled a basic match to be made between the candidate facility and the services to be relocated. However, simply because there is available space within the candidate facility it obviously does not mean that it is desirable to merge the relocated service(s) into it.  Consequently, the planning specialists then assesed the functional, clinical and operational affinities between the them.  It was out of this process that we were able to obtain the best fit between available capacity and the best affinity between the functions.

Results

The table below provides an illustration of the utilsation in terms of room availability relative to each function within the candidate facility. The hours of the day (this is an extract only) are shown across the head of the table.

OCCUPANCY ANALYTICS ™ provides a mean occupancy, as well as a forecast of probability of under-utilsaed spaces. For example: a 90 % probability that in nine days in every ten there would be at least ‘x’ unused rooms over specified hours of the day,  or alternatively a 10% probability that for one day in every ten there would be up to ‘y’ rooms available over specified hours of the day. The study investigated the potential to merge existing facilities into the candidate facility, and through the affinity analysis considered the best fit.  The study is now beeing used to inform the business case for the merging of the functions in the candidate facility.

The Conclude Consultancy has recently been appointed (November 2012) to conduct an analysis for another NHS Trust, to answer a question no doubt being asked by many Trust’s at present: What operational policy changes do we need to make in order to expand capacity of an existing service, WITHOUT having to enlarge the facility?  If we do need to enlarge the facility, how much bigger do we need to make it?  The study will recommend optimised operational policies informed by our OCCUPANCY ANALYTICS ™ studies. May 2013 update: Please refer to this Case Stydy here: occupancy-analytics-optimising-endoscopy )

Please use the contact form should you require information about our services.

Brighton2Brugge

Posted on: September 6th, 2012 by matthew_bacon

The Conclude Consultancy is sponsoring a group of intrepid young people to cycle to Brugge from Brighton and back again. They are raising money for Macmillan Cancer Care a national charity, and  St Peter and St James Hospice in Wivelsfield, Sussex, in the UK.

These two charities have helped Ollie (team member) and his family since Ollie’s mum, Val, was diagnosed with a terminal brain tumour in June 2008.
Val took the news amazingly well, always determined to remain as happy and healthy as she could. Her regular visits to Brighton hospital for chemo and radiotherapy must have been distressing and painful, but she never once lost her smile or positive outlook.

Conclude’s work at Brighton & Sussex University Hospitals NHS Trust and specifically with the Oncology team there is just one of life’s little coincidences – helped by the fact that our esteemed leader’s son Laurie, is one of the team members too!  If any reader feels inspired to sponsor the team, their web page can be found at: http://uk.virginmoneygiving.com/fundraiser-web/fundraiser/showFundraiserPage.action?userUrl=Brighton2Brugge&faId=225061&isTeam=true

 

Laurie Bacon displaying the ‘official’ team shirt!

 

Guardian Sustainable Business Awards 2012

Posted on: June 2nd, 2012 by matthew_bacon

The Conclude Consultancy was long-listed for the Guardian Sustainability Awards 2012, which have only just been published.  Please see: http://www.guardian.co.uk/sustainable-business/best-practice-exchange/the-conclude-consultancy-science-energy.

Our work in OCCUPANCY ANALYTICS ™ has delivered compelling new data to inform hospital design.  Our work has identified that traditional approaches to hospital planning lead to significant over-estimation of occupancy.  The impacts of over-estimating occupancy lead to unnecessary capital and operating expenditure in the following areas:

  • Significant over-sizing of the systems that service hospitals.
  • Over provision of space.
  • Over provision of Imaging equipment.

We have recently completed a validation process with clinical specialists and service managers on one project concerning OCCUPANCY ANALYTICS ™ studies for Oncology, Radiotherapy and Imaging.  The work is of significant importance because it has also clearly demonstrates its potential to inform the Department of Health, transformation programme called QIPP. Please see: http://www.dh.gov.uk/en/Healthcare/Qualityandproductivity/QIPP/index.htm.

Conclude are now working on projects that both drive efficiency into integrated care pathways AND which drive for low carbon performance.  This is achieved through a strategy developed by Conclude called ‘Peak Load Smoothing’.

Operational Policies tend to result in peak occupancy in a hospital during the middle part of the working day.  Peak occupancy drives peak energy loads.  Peak energy loads incur peak load energy tariffs. At Conclude we argue that if Operational Policies can be planned across the hospital such that peak occupancy of each clinical specialism can be managed relative to other specialisms then peak energy loads can be reduced by at least 23%.  The benefit of reducing peak loads is that engineering plant can be smaller, and work more efficiently, resulting in reduced carbon emissions.

Operational Policy tends to focus on discreet clinical specialisms, whereas ‘joined up’ policies ensure better co-ordination of working practices, better flow of patients, resulting in better patient experience, and as we have already mentioned, much improved carbon performance.  In bringing together the issues of space efficiency, process efficiency and carbon efficiency all resulting in low capital and operational costs, we consider this to be real innovation.

Dr David Pencheon OBE at the NHS Sustainability Development Unit describes our work in these terms:

It’s an impressive way of thinking through an important dimension of sustainable, flexible, cost effective management of estate and probably an important step on the way to a more coherent approach to assessing health care premises.”

If you would like to learn more about our work please fill out the contact form on this site.