4 Insights to Build a Better Command Center

As more command centers launch around the nation, Johns Hopkins Medicine shares tips to achieve greater operational efficiency and ROI.

This article appears in the July/August 2018 edition of HealthLeaders magazine.

Johns Hopkins Medicine has cracked a complex puzzle: How could they increase hospital capacity without adding beds?

The solution came from the health system's command center, launched in October 2016. Operational efficiency has improved so greatly, "we've essentially created 16 additional beds of capacity, without actually opening 16 beds," says Jim Scheulen, MBA, PA, chief administrative officer for emergency medicine and capacity management at Johns Hopkins Medicine.

The massive 5,200-square-foot hub, developed with GE Healthcare Partners, resembles the NASA nerve center. More than 20 gigantic digital screens line the walls, filled with dashboards that deliver real-time information to staff members situated at 38 work stations.

It employs predictive analytics and artificial intelligence, aggregates data from 15 IT systems, and has significantly improved the patient experience at The Johns Hopkins Hospital by enhancing access and reducing wait times.

Since the implementation of the command center, OR holds are down by 80%, emergency department boarding has been reduced by 20%, and there has been a 60% increase in patient transfers from other hospitals.

No additional people were hired, and the facility is on track to deliver a complete return on investment three years from now.

With nearly two years of command center operations under its belt, Johns Hopkins' facility offers a look into its processes and resources that helped the organization become functional and operate effectively. Here are the four insights it shares.

1.  Act Like a Clinician; Think Like an Engineer

Command centers enable healthcare to take advantage of systems engineering principles used by other complex industries such as airlines, aerospace, and air traffic control, says Scheulen.

"For me," says Scheulen, "systems engineering means an organized approach to improving your flow. It means using advanced technology, like simulation and optimization modeling—heavy statistical analysis of data—and colocating all of the resources that have to do with managing your operations on a day-to-day basis."

He describes the command center as a tool, capacity management as a function, and systems engineering as the approach to managing Johns Hopkins' operations.

A recent visit to Air Canada's control center in Toronto, Ontario, crystalized the similarities between the airline and healthcare industries in Scheulen's mind.

"It was incredible how many parallels we drew from seeing how they operated," he says.

He watched as the airline received information from all over the world in real time, just as Johns Hopkins does in its hospitals; monitored performance of its flights, which he likens to "our patients;" and observed performance of airports, akin to hospital beds.

"It gave us a great sense of security that we were on the right track," he says.

Headquartered in Baltimore, Maryland, each year Johns Hopkins Medicine handles more than 115,000 inpatient admissions and 360,000 emergency visits at its six academic and community hospitals, which include 2,671 beds.

The command center is responsible for each patient who enters the system through the Hopkins Access Line (HAL), where referring physicians call to transfer a patient, as well as Johns Hopkins Lifeline, which dispatches critical-care transport teams.

About three years before the command center opened, "we realized that we were managing an incredibly, incredibly complex operation, trying to manage the flow of thousands of patients through our system safely with high-quality outcomes," says Scheulen.

"When there is a mismatch between supply and demand, you see wait times where you don't want to see them. It played out in our inability to bring in as many patients as we thought our [tertiary referral center] should handle," he says.

2.  Simulation Modeling: The Wizard Behind the Curtain

The chief administrative officer knew that change could only begin with a sophisticated computer simulation model of the entire hospital. He had previously used this approach when managing the system's emergency departments, and he said he found it indispensable.

"We knew if we didn't change some of the ways we were doing business, we would just have a pretty command center that didn't do anything differently," says Scheulen.

"When I had a question, or I wanted to try something, I didn't have to run a pilot," he says.

GE built a model to handle all the complexities. Input included data related to arrivals, numbers of patients, length of stay, pathways through the institution, procedures, and more.

Once it was operational, the team made queries about the impact of reducing length of stay and bed distribution, for example, on emergency room boarding, OR holds, and the ability to accommodate new patients.

The simulation model helped the command center team select the projects and processes that would deliver the greatest results. In addition, it demonstrated the domino effect each change would have throughout the health system.

For example, the team tested changing a process related to the management of patients on a certain medical service and discovered the proposed adjustment would negatively impact surgical data. Each entity would end up competing for the same lab services, which didn't have the bandwidth to accommodate both.

"It pointed out that everything in this institution at some point is dependent on everything else," says Scheulen. "It's the true definition of a system from an engineering perspective because no one single thing can make the entire system work; everything has to work together to get the best outcomes."

The attention to detail is paying off.

"Opening the command center and having access to all of this incredible data was like shining a light on the institution," says Scheulen. "We were able to learn a lot more about how we operate and where we can continue to improve."

3.  Clinicians on Board and Culture Change

While utilizing technology to develop the facility was essential, so was the human factor. Command center management instituted a two-pronged approach to ensure success. They brought clinical leadership on board early in the process, while also forming a cross-functional team with representatives from the four departments who would work in the new facility.

"Having clinical department leadership working with you [is] the right thing to do, and it's more likely to lead to success," says Scheulen.

The simulation model demonstrated a commitment to addressing operational issues in an objective, scientific manner—a strategy that appealed to clinicians. Before the team moved ahead with process improvement and system redesign, each project was reviewed by a clinical advisory panel before proceeding to executive leadership for approval.

One key input was that the educational process of physicians, including rounds and teaching conferences, should not be disrupted.

"We needed to think about how we were going to make things work operationally, while maintaining the educational mission of Johns Hopkins," says Scheulen.

Another essential decision was to give command center bed management coordinators final authority for patient placement.

"At every hospital, no matter what anyone says, there are arguments from time to time about what level of care the patient should go to, what level of bed the patient should go to, the service the patient should go to," says Scheulen.

While the coordinators listen to opinions and engage in discussions, the command center has "final, absolute authority for patient placement. Once the decision is made, the decision is made," he says.  

In addition to corralling clinical leadership, Scheulen's command center partner, Mary Margaret Jacobs, MS, RN, director of capacity management, The Johns Hopkins Hospital, led a cross- functional team to tackle process improvement projects and address cultural issues.

Four departments operate out of the facility, including the physician referral service and critical care transport, which Scheulen manages, plus admissions and bed management, which Jacobs oversees. Before the command center was built, a wall divided many of the workers.

"Every time they needed to talk to each other – which was about every single patient – they had to call or fax each other, explains Scheulen. "They needed to be together, but they were two very different groups of people. They didn't know each other, and they actually didn't like each other very much."

Discord resulted because those dealing with incoming patients placed constant demands on the staff members responsible for placing them, and it was often difficult to find an available bed or operating room.

"Part of the miracle here, quite frankly, is that these four groups are now a team," says Scheulen. All the credit for that work goes to Mary Margaret. She absolutely had the vision to go through a change management process and bring together representatives of all the groups and work diligently for months."

Representatives from each department worked together to create the new combined workspace. They determined what appeared on the digital screens, what systems would be used and designed how they sat, where they sat, and even helped select the desks. The effort, says Scheulen, forged an enduring bond.

On the first day of operation, the payoff was apparent. A HAL expeditor took the first call, Scheulen recalls, "turns in their chair and signals to a nurse a couple of desks away, saying, 'I need you to hear this.' " In that moment, witnessed by Scheulen and Jacobs, they realized the literal and metaphorical walls that had separated the groups literally came tumbling down.

"That was a real accomplishment to bring four groups of people together," says Scheulen. "They have never missed a beat. They have come together and worked as a team since day one, and it's just remarkable."

4.  One Size Does Not Fit All

For health systems focused on efficiency and better matching supply with demand, a command center with real-time information provides advantages.

"Do you need the same level of complexity of a model that we built?" asks Scheulen. "Probably not in most situations. Organizational strategy will drive what you do."

Health systems measure ROI by reducing excess days and cost per patient day, or by adding virtual capacity through increased efficiency, as Johns Hopkins did. The technology is scalable for smaller organizations, but something on this scale would not be an effective solution for hospitals with fewer than 200 beds.

As more health systems deploy command centers and the technology behind them evolves, their functionality will expand. The GE system installed at Johns Hopkins feature a real-time cross-system data model that integrates information from all relevant software and machines to create a more accurate picture than a single software solution or device can deliver. 

It also includes artificial intelligence. The version at Johns Hopkins features machine learning to predict census, available beds and occupancy, as well as natural language processing.

"Computer vision is next," says Jeff Terry, MBA, FACHE, who is CEO of healthcare command centers for GE Healthcare Partners. "Six years ago, IBM taught a computer to play chess," he says. "We're teaching it to spot patients who may be in danger or to find the best way to preserve capacity for patients who will need it tomorrow. Over time, command centers will take on a bigger role supporting patients and caregivers. It's exciting to see each new opportunity be identified."