What is the cost of a minute of intra-unit patient transport time….from LinkedIn conversation

What is the cost of a minute of intra-unit patient transport time?

The cost of a minute of time in patient transport is a questions we get asked quite often by acute care leaders. Is anyone aware of a study or analysis of costs of patient time by minutes?

The context of the question is an attempt to quantify the hidden cost of searching for full O2 tanks to transport patients.

I am grateful for any thoughts or ideas on this item.

8 days ago

You, Peter Van de Kerkhove, MHACatelyn S. and 1 other like this

24 comments • Jump to most recent comments

Brian Gregory, MD, MBA

Brian Gregory, MD, MBA • Depends on who’s waiting for it. Add up the opportunity costs for ALL those who that extra bit of time effects. Also, time cost is not continuous, it has quantum (stair-step) increases; sometimes an hours doesn’t matter, but sometimes a few seconds does–with an extra 5 seconds you can miss a train or a plane. Ask the patient who needs the oxygen…an extra 15 seconds could mean life or death.

If you frequently have to wait, rearrange dependent events (buffers, alternate pathways, sequencing, parallel activities, slow/quiet times, break the event into smaller sections, etc) so that the waiting time has little effect on other things.

8 days ago1
Brian Gregory, MD, MBA

Brian Gregory, MD, MBA • You might also consider giving the ‘job’ of moving the patient to the department (floor nurses, transport department, whomever…) who can better schedule and integrate the act of moving with their other chores.

8 days ago1

Brendan McSheffrey • Thank you for the comments Dr. Gregory. I think your comments are spot on. The time durring a critical life safety event is incalculably high. Like the time cost in response to a growing fire, time is invaluable.

That said, there is a labor and billing cost to patient transport. It happens often where emergency department or transport team members will be ready to move a patient (either in an emergency or non-threatening situation) and will have to stall the process to find a full supplemental tank to use in the transport process. This process can be quick (2-5 minutes) or take as much as an hour to find a tank if storage locations are not at full par value.

The question that has been poised to us is, what is the actual cost of having the patient wait and the staff “hunt and gather” O2? One way it has been asked is “what is the cost of a patient minute?”

8 days ago• Like
Brian Gregory, MD, MBA

Brian Gregory, MD, MBA • Cost questions rarely have single answers. It’s possible to give answers on how to improve the situation with recognition of externalities and holistic effects. A single dollar per minute answer might be comforting, and create a fiction for billing purposes, but it won’t help you improve things.

8 days ago1

Brendan McSheffrey • Again, Dr. Gregory, I agree whole heartedly. There is rarely (if ever) a single root cause answer in any complex system. Agreed, patient transport is a very complex system with lots of root causes in considering costs.

We as a manufacturing company embraced lean thinking a very long time ago to address the complex questions of quality, a core tenet is to seek all root causes in complete system. In lean there is a term called Takt time ( or cycle time ) used to measure the time a part spends in the process. In using Takt time approach we can estimate the time cost of inventory. While not a perfect analogy, perhaps someone knows of a parallel in patient time.

Outside of the clinical, do you think it is fair to think of patient transport time having base-line? i.e. labor costs of the transporter? Inventory consumed durring transport?

Thank you for the thoughtful responses

7 days ago• Like
Brian Gregory, MD, MBA

Brian Gregory, MD, MBA • The baseline transport time (defined either in context or under ideal conditions) is useful. You can even benchmark it and use it with other information to decide whether you need to transport a patient for a process, or move the process to a grouping of patients based on their diagnoses.

So, yes, a ‘baseline’ transport time is useful if you’re defining ‘cost’ in units of time: “the cost of a minute of intra-unit patient transport time” vs ‘the cost in minutes of intra-unit transport time’.

Maybe I’m not understanding you. Elaborate more with an example so that I have a better sense of where you’re coming from. I tend to learn a lot from these discussions once I get the framework.

Also, first names please, Brendan.
Thanks, Brian

7 days ago

Brendan McSheffrey • A bit more detail. Our firm produces systems for remote monitoring of safety equipment, fire extinguishers, crash carts, AEDs and medical O2 tanks. The purpose of our technologies is to make people safer by keeping safety assets ready when you need them.

In the case of medical O2 monitoring we help respiratory (or central supply) have digital transparency into O2 tank inventories by providing pressure and location status over RTLS systems. Whether the in storage locations (ED storage, transport storage, Cath lab etc.) or on gurneys, crash carts and other equipment. This allows tank managers to quickly identify low pressure tanks, where full tanks are needed and reduce tank inventories on the floor.

As we have deployed O2 tracking, the most passionate response we get is not due to the reduction in tank leases but rather the improvement in patient flow. Simply having full O2 tanks at the ready in the emergency department and the empty tanks removed from gurneys has proven to have a very strong benefit. We know that the simple fact of having tanks at the ready reduces waste in transport time, one ED we work with estimates more than 5 minutes per patient. Our customers are asking us to help quantify this positive result.

Thus the question, what does a minute of patient transport cost?

Ultimately our technology is about improving patient outcomes, but costs drive adoption and we have been surprised at the lack of readily available cost analysis in this area.

Thank you again for taking the thoughtful responses. It is greatly appreciated.

7 days ago• Like
Brian Gregory, MD, MBA

Brian Gregory, MD, MBA • Ahhh…
Yes, I’ve been the recipient of many an empty O2 tank on a gurney before transporting a patient. In fact, protocol dictates that you check the tank pressure and delivery mechanism before taking off down the hall with the patient. There’s also the problem of empty backup O2 tanks on anesthesia machines and anywhere else sedation is given.

I like your RTLS ability, and wasn’t aware that you had the means of monitoring the pressure within the tanks. But, I’d still do a manual check before using one on a patient 🙂

In the case of an empty tank in the OR, you have the cost an OR crew for the next case being delayed however long it takes to find a full tank. That’s quite expensive.

7 days ago
Brian Gregory, MD, MBA

Brian Gregory, MD, MBA • Plus you have the opportunity cost for the anesthesiologist and surgeon who could make a significant amount of money if they can do another case before the 4pm cut-off time for having the next patient in the room.

Similar opportunity costs could apply to radiologist seeing another patient for the day, the overtime costs of the staff for the delay…etc.

Only if no one other process is waiting for the patient could you come up with a base cost for the time delay.

7 days ago
Brian Gregory, MD, MBA

Brian Gregory, MD, MBA • “Only if no one other process is waiting on the patient could you come up with a base cost for the time delay.”

In an odd way, that means the base cost is zero unless you’re paying the person hunting for the O2 tank by the minute (no guaranteed 8 hour day…piecemeal work).

::grin:: My wife and close friends are PhDs who teach finance. This is typical fun dinner conversation.

7 days ago

Peter Van de Kerkhove, MHA • The issue of “fictionalized value” is not only spot-on as being problematic for defining the cost of delays in patient flows, but it may in fact be the root cause for the lack of an industry standard model for controlling hospital inpatient Transport logistics!
In my experience, the “cost” of waste due to delays with inpatient logistics is best approached from 2 directions: A) identifying the opportunity cost as it can be related to clinical billing and B) as a labor differential cost, when clinical staff have to perform non-clinical transports. I have a SixSigma study as proof that a systematic reduction in Patient Transport delays will correspond directly to an increase in billable procedures (i.e. CT procedures). However, that will only be true when the demand for a clinical procedure is greater than the supply, and the efficiency can tap that pent up demand. That addresses option A. To address the B option, I would like to refer back to Dr. Gregory’s comment: “You might also consider giving the ‘job’ of moving the patient to the department (floor nurses, transport department, whomever…) who can better schedule and integrate the act of moving with their other chores.”. There are 2 great elements to this suggestion.
First, there is still a cost to transferring Patient Transport work, so at what point does that transfer, from lower paid transporters, to high paid clinical staff like Floor Nurses, become an issue? Second, as a promoter of consolidating Patient Transports under a central Transport Department, as Dr. Gregory pointed out, they “can better schedule and integrate the act of moving with their other chores”. I would now like to add one more dimension that will address Brendan’s original interest in putting a value on delays in patient flow. There is an opportunity that exists in a Central Transporter model, to define an ROI for solving delays due to equipment availability, like O2. The approach is to utilize Central Transporter’s time in the form of a “down-time” task. When Transporters can fill and stock O2 tanks as a deferrable or “down-time task”, which will create value on 2 levels. First, it will justify your ability to maintain the Transporter resources needed to respond to peak times for on-demand Patient Transport services, and second, “idle time” can be used productively to reduce workflow delays due to a lack of par level equipment. Not only for filled Oxygen tanks, but for also having an ample supply of wheelchairs and ED stretchers as well.
Managing this “pooled Transporter resource” requires appropriate technology to be effective. Technology can allow the use of standardized intelligent dispatching logic (automated decision support), that will not only help optimize performance, but also increase the transparency and accountability over the process. The technology should provide the data needed to labor optimize the staffing levels, to maximize utilization and productivity. Naturally, there is also an underlying assumption that the appropriate management competencies exist to manage the staff and the technology in order to achieve those goals.

7 days ago• Unlike2

Peter Van de Kerkhove, MHA • Brendan, in the context of quantifying the hidden cost of searching for full O2 tanks to transport patients, it’s not the cost of the patient’s time that is driving accountable care as much as the cost of the clinical care providers, whose time is wasted in the process of delivering high quality care. Lean processes improvements tend to focus on the clinical time lost to delays, like finding a full O2 tank.
From the Pareto perspective, the bulk of the delays to clinical workflows seem to be caused by the “patient’s availability”, which can tie more directly to either a lack of a patient care schedule or the non-clinical support staff needed to move patients or stock equipment. That’s not to say that equipment delays are mostly negligible. In certain departments or situations, they can be serious factor, particularly as they relate to a patient’s safety. Unfortunately, the value of safety is best quantified by the risk from not having equipment, like portable oxygen, and the liability associated with that risk.

7 days ago• Unlike2

Peter Van de Kerkhove, MHA • From a metrics calculation approach, knowing the cost per 1 minute of patient transport might make sense, but to use it effectively, you would need to multiply that by the # of transports that are effected by an Oxygen delay. I’ve worked with literally hundreds of hospitals on central Patient Transport service delay issues, including big names like Johns Hopkins, Cleveland Clinic, Henry Ford and Mass General, and I have personally reviewed detailed trip delay data on over 40% of them. Trip delays due to empty O2 tanks has been reported less than 2%, housewide, even when we include delays due to O2 not mentioned in the trip requirements and a Transporter has to go retrieve a tank.
Hospital administration doesn’t typically buy into “soft savings” for a minute of time is saved, unless you can prove there is a direct Labor Cost reduction that will result, and someone is willing to guarantee that reduction in their budget.
Given your background in Safety, a more likely candidate for defining value is to provide a “guarantee” your technology can offer, that you are willing to backup.
Here is one that you might be able to take to the bank: Can you guarantee that your technology will never allow a tank to go below 40% full (or whatever # they want), without notifying at least 3 different types or levels of alerts/alarms? This would provide your clients with a fail-safe that their patients would ever be on an Oxygen Tank that ran out of air, without a reasonable opportunity to be notified to prevent it. If your system prevents even just One Million $ lawsuit, it should pay for over 2 decades of your technology’s cost. Take out a Lloyd’s Policy and back up your contract with a Million Dollar money back guarantee. Now that’s what I’m talking about.

7 days ago• Unlike2
Brian Gregory, MD, MBA

Brian Gregory, MD, MBA • Nicely put, Peter.

Also, you said:
“Can you guarantee that your technology will never allow a tank to go below 40% full (or whatever # they want), without notifying at least 3 different types or levels of alerts/alarms?”

I’d recommend the ability to monitor the rate of flow (decrease in volume) from a central station. A few reasons:

1) Some tank valves leak due to the fault of the tank, and some from improper connections. Either way, the flow will be noticed, cause determined, and repaired.

2)Back up check for rates of flow for patients in various locations.

3)In the case of a rare system wide oxygen failure (I’ve seen this three times while construction was carried out in a hospital) priority and be given to those emergency tanks that are running out the quickest. This jibes with number 4…

4) Some older anesthesia machines (and possibly ICU ventilators) use the reserve O2 tank pressure as a means of powering the patient’s ventilator when the wall O2 is cut off. This cuts time capacity of the tank from 2+ hours down to 15 or 20 minutes.

7 days ago1
Brian Gregory, MD, MBA

Brian Gregory, MD, MBA • Peter, you said:

“Trip delays due to empty O2 tanks has been reported less than 2%, housewide, even when we include delays due to O2 not mentioned in the trip requirements and a Transporter has to go retrieve a tank.”

This could be due to diligent nursing/clinical personnel who spend significant time making sure that everything works well. The reason there wasn’t a delay is that the nurse already checked and discarded the first tank or two that wasn’t full and made sure a good one was ready. As usual, the less experienced the clinical personnel, the more chance of something going wrong due to not correcting the problem before it ever occurs; this includes not beginning to move the patient until all is ready.

There still is the time saved (if there’s a shortage of time due to shortage of nurses, etc) by quickly being able to find and verify a ‘good’ O2 tank that can be positioned on the gurney ahead of time.

7 days ago1
Brian Gregory, MD, MBA

Brian Gregory, MD, MBA • Peter, you commented:
“Second, as a promoter of consolidating Patient Transports under a central Transport Department, as Dr. Gregory pointed out, they “can better schedule and integrate the act of moving with their other chores”. I would now like to add one more dimension that will address Brendan’s original interest in putting a value on delays in patient flow. There is an opportunity that exists in a Central Transporter model, to define an ROI for solving delays due to equipment availability, like O2.”

A corollary comment:
This jibes with the idea of using accounting TDABC as a means of ‘benchmarking’ (time data plus more) processes and subprocesses across department silos so that comparisons can be made into the methods, efficiencies, cost, and risk of accomplishing the same task (subprocess or process). The better technique can then be adapted everywhere if applicable, or the task can be outsourced to the more efficient department. TDABC, however, needs to be combined with Throughput Accounting (more applicable to silos and hierarchical departments) so as to not lose site of the local department constraints and goals.

7 days ago1

Peter Van de Kerkhove, MHA • Brian, now you are talking my language. I was doing TD-ABC before I knew about the term. My first deep dive into ABC was to allocate Nursing time by DRG by developing a a TD-ABC based model for Nurse Staffing, utilizing a Patient Acuity assessment model, and developing task based standards for all direct and indirect nursing activities. Talk about heavy lifting. By 1984 we could accurately allocate nursing labor resources by DRG, just as that Public Law was being written.
However, to stay on point with this discussion, I have developed both a software system and a manual data collection process that captures the Transport activities, process and sub-processes. Relative to the use of Oxygen, the “system” basically isolated “equipment delays” by type and aggregated them into “sets” that were then applied as a “standard delay” based on the unique combination of equipment requirements of every patient transport.
The “manual survey process” I developed was a technique for hospitals to conduct their own house-wide 24 hour Transport Activity Survey (TAS)that followed the six steps for TD-ABC, providing fact based data across all silos, for Patient Transport activities. That process is usually performed for one of 2 reasons: 1) hospitals want fact based decisions and not depend on anecdotal information; or 2) they want to baseline the activities for the current de-centralized model, and use the data to determine the appropriate scope and standards for a centralized model. Everyone is aware that the sample size was not statistically significant, but this survey method capitalizes on the Pareto rule by validating both the benchmark estimate, as well as the “common sense” intelligence, therefore no one has ever forced us to continue the the manual data collection process in order to meet sample requirements, knowing technology will soon be deployed, and will save the 80% effort needed for the last 20% of confidence.
I’ve also utilized the TD-ABC method to provide benchmark staffing levels of centralized transport services, whether they were centralized already, or not. The 24 hr TAS is just used to validate the benchmark estimate.

6 days ago• Like
Brian Gregory, MD, MBA

Brian Gregory, MD, MBA • Yes! I thought this might be a good thread!

6 days ago

Brendan McSheffrey • Thank you both very much for the feedback, I think this discussion is bigger and more important than just the original O2 tank question we are trying to answer. In talking with Brian, it is clear there are many challenges to improving patient transport and technology is just one part of the solution.

One hospital we are working with has used the tools of a Centrak RTLS system and LEAN process engineering to reduce the average patient transport time from 70+ minutes down to less than 30, perhaps I can get them to share their experience here.

6 days ago• Like
Brian Gregory, MD, MBA

Brian Gregory, MD, MBA • Dissecting their lean process implementation and method of using RTLS would be informative. As you implied, improving transport time involves technology, theory, and experience that can also be used elsewhere. I’d like to hear about their implementation experience and any insights they gained from it.

6 days ago1

John D’Alesandro • With all due respect the cost of the transfer is zero. Read the Goal by Eli Goldratt

5 days ago• Like
Brian Gregory, MD, MBA

Brian Gregory, MD, MBA • John, you said:
“With all due respect the cost of the transfer is zero. Read the Goal by Eli Goldratt”

That is in agreement with what was already said:

“In an odd way, that means the base cost is zero unless you’re paying the person hunting for the O2 tank by the minute (no guaranteed 8 hour day…piecemeal work).”

but without the caveats. The Goal is a nice intro book…read it 23 years ago during my MBA.

5 days ago
Brian Gregory, MD, MBA

Brian Gregory, MD, MBA • Even then, the Goal presupposes one agent. The direct cost to the hospital might be zero, but the costs to other agents (anesthesiologists, surgeon, radiologist,…) could be significant.

That’s one of the problems with hospitals. The least cost (even zero) design (their constraint) for them can be a very expensive for others. That’s one reason hospitals target specific specialties (frequently surgeons) who can be considered their effective customers (often to the detriment of anesthesiologists) and eat direct costs because of the indirect revenue generation (marketing for surgeon as customer) by catering to them. This sometimes causes local anesthesia shortages (groups leave) or less optimal care (less experienced groups come in) due to that preferential treatment.

That’s why hospitals occasionally try to buy practices so that their direct costs from ‘marketing’ to various medical specialties goes down. [ok…that may not be entirely correct, but it’d take a small book to explain well].

That’s also why so many (pretty much all) OR case scheduling systems fail…they don’t know how to handle the multiple agency problem. The same would probably apply to ERs.

4 days ago
Brian Gregory, MD, MBA

Brian Gregory, MD, MBA • That’s also why…many facilities don’t realize their projected net income boost once they buy physician practices. To optimize their net income they need to alter their ‘goal’ and hence the constraints—which means altering the practice time schedules (time of day, duration, and possible case mix) of physicians. The facilities are either not aware of this necessity or the physicians were not aware of this eventuality, and implementation fails.

This really needs a thread of its own…so I’m going to stop here.

4 days ago

About Brian D Gregory

Board Certified Anesthesiologist for 20 years. MBA from U of Georgia '90: Finance, Data Management, Risk Management. Practiced in multiple US states and Saudi Arabia at KFSH&RC and KFMC Taught residents in two locations. Worked with CRNAs for 20 years.
This entry was posted in Accounting, healthcare reform, scheduling, Uncategorized and tagged , , , , , , , , , , , . Bookmark the permalink.

Leave a Reply

Fill in your details below or click an icon to log in:

WordPress.com Logo

You are commenting using your WordPress.com account. Log Out /  Change )

Google photo

You are commenting using your Google account. Log Out /  Change )

Twitter picture

You are commenting using your Twitter account. Log Out /  Change )

Facebook photo

You are commenting using your Facebook account. Log Out /  Change )

Connecting to %s