1. USA BUFFER IN THE HEALTHCARE IS STUDIED BY VARIOUS AUTHORS (PRACTIONEERS AND ACADEMICS) FROM DIFFERENT COUNTRIES. THE GOAL IS TO REDUCE LONG TIME DELAY (REDUCE QUEING) IN THE HEALTHCARE INDUSTRY (THUS REDUCING DEATH RATIO DUE TO HOSPITAL DIVERSTION STATUS ). RELEVANT LESSONS LEARNED WOULD SERVED AS A MODEL WORLDWIDE MYSELF, I AM INTERESTING WITH THIS STUDIES AS FINDING FOR AN APPROPRIATE MODEL TO RAPIDE RESPONSE AS A MEAN OF OVERALL FLOOD RISK REDUCTION AND THE COUPLING/GAP BETWEEN FORCASTED COSTS OF ADAPTION STRATEGIES AND MITIGATIONS WITH WEATHER AND HYDROLOGY FORECASTS. IN THE PROJECT WAER I DEVELOPPED POSTERIOR TO THE MBA PROJECT WAER (POST WAER PROJECT). THE SEASIDE FRONT - ALSO, I CALLED IT SEAFRONT, WHICH IS AT THE JUNCTION BETWEEN 2 MEDIA -MEDIUM 1: SEA WATER AND MEDIUM 2: THE LAND- IT IS SIMILAR TO A BUFFER. THEREFORE MY BUFFER MODEL FOR COST ASSESSMENT IN ANTICIPATORY MANAGEMENT OF WATER HAZARDS WITH FORECASTED WEATHER IS TECHNICALLY ABOUT LEAD-TIME REDUCTIONS. THE KNOWLEDGE OF THE BUFFER CHARACTERISTICS CAN IMPACT THE FUTURE OF THE REGION RESCUE ORGANIZATION WITH LESS RESSOURCE ALLOCATIONS. I HAVE BUILD MY PROCESS ON A REAL EVENT WITH THE MEDIA ATTENTION BASED ON THE XYNTHIA FLOOD IN VENDEE. GS RADJOU 5/07/2010

2. So, I have developed a model looking like the US Healthcare buffer or it just a business buffer model applied to flood zones where Hi (with i= 0, 1 and 2)are water elevation chareteristics of the buffer. For example: H1, lower volume of water with sea tide is the lower limit of the tide H2= average water volume, which is an indicator for surge water height, and all buildings and infrastructures are build to the best of our knowledge to this surge water elevations. It is a prerequisite of flood defence systems in landlocked countries and the policy goal for helping the post recovery operations. -when H2 moves to H3, which is the critical value for inundating dangerously the flood prone regions-. These heights are monitored permanently of twice a day on a daily basis. Hi (H1, H2 and H3) are made by WMO through satellite detections or gauging stations and help to measure the cost of intervention in case of flood by anticipation with the coupling of weather forecast estimates. This buffer is a basic process with no unknown (policy 1).The model is a metaphore of an hospital model of the study where numbers of patients are replaced by Water heights of tides. Also, the community souls are known from council townhall registration office) If we know Hi (heights), which is predictable because of the forecasts and monitors -recorded twice per day-, we can assess the best policy in nearly real time for cost management of inundated regions and diagnostic a solution either in anticipatory management through the predictions or in emergency planning from observing data.

3. BUFFER IS A BUZZWORD ITCAN BE FOUND IN ALL INDUSTRIES A TOOL FOR HOLDING PRODCUTION OF GOODS AND AVOID DISRUPTION OF THE SUPPLY CHAIN. CUSTOMER NEEDS ARE DELIVERED ON TIME EITHER THROUGH THE JUST IN TIME PRODUCTION THEY BUY ON ORDER AND THE FIRM SUPPLIES ON ORDER AND/OR THROUGH FORCASTED DEMAND. BUFFERS ARE HOLDINGS IN « C » language: reduce the number of system calls at the (small) expense of having a section of memory to store larger dat for read or write. Find also, in chemistry when a acidic solution is neutelize by a basic solution PH cannot varies in the Buffer zone Also, in economics, after the World War 2 germany calls foreign labors to buffer the lack of national labors. So, the buffer concept as seen as a stock keeper concept is regulate by a condition which is the variation of the stock value around a mean value and within value limits that are dfined by the resplenishment policy. Etc. In the case, I try to find (re-discover form the authors cited in the slide show the model (or seveval models), which could help to model interface between medium between water (during a flood) and the land. If I manage to find this appropriate model, I could link it to flood forecast). This would be my flood buffer. So at could organize the ressources and assess the costs for emergency, preparadness in flood treatment and post recovery operation. Knowing the quantity of water is the pond is like a black box GS RADJOU

4. Cause: Holding Patients in Emergency Room Impact on triage to bed time Buffer: 5 patients/room Triage rduction : 24% -> 22% Prototyping a model ------> implementing worldwide? Test: discret event simulation for patient safety Diversion status Hospital Full New diversion status due to intial diversion status Higher Mortality rate for the diverted Source: Cowan and Trzeciak 2005; McCaig and Burt 2004, Andrulis et Al. 1991 Systemic Pb, Schneider et al. 2001 Ressource stress and waiting time GS RADJOU ambulance

5. Perceived situation : More patients than staffed treatment beds and waiting time exceed reasonable periods Types of patients: - patients waiting for ED -patients under monitors in non treatment area -patient waiting for transfer to inpatient unit (IU) Issue: criteria for diversion status (very nebulous -Derlet, Richards and Kravitz 2001; Jones et al.2006; Hoot et al 2007) Crowding conditions (conditional indicators have been selected by Kolb, Lee and Peck 2007), if: 1- 100% if beds in ER fully occupied 2-queuing length >50% of ER Beds ( Note : By the way, I remember I read in Vocable magazine comparing 2 health systems in North America. The Canadian Social security is free for all but there are long delays when queuing for a therapy at the hospital. When somebody need a treatment it is faster to cross the US/Canadian border for the health services , but of course, it is a paying service) GS RADJOU

6. Influencing factors for patient flows: PATIENT FLOWS INFLUX THROUGHOUPUT OUTFLUX Sources Products Old Patients increased in numbers More emergency medical needs Emergency Department Source: Mcaig and Burt 2004; Cowan and Trezeciak 2005

7. Time to enter : influx time (Ti) Time spend in the emergency department: throughput time (Ts) Time to go out: outflux time (To) T i T o Ts' Ts'' Ts' is the real time spent for the cure Ts' = Ts'' - (Ti+To) Uncertainties on throughput times ISSUE ABOUT ACCESS TO HEALTH IS TIME. (TIME UNCERTAINTY) (Ts'' – Ts')

8. PROJECT CONCEPTS FLOOD CONCEPT BUFFER CONCEPT RIPARIAN CONCEPT HYDROGRAPH

9. UNCERTAINTY ON THROUGHPUT TIMES INFLUENCE SOURCES T s Infrastructure layout (issue with walking distance) Communication Promotion TRIAGE REGISTRATION Note : In Project, I have suspected that promotion is th main factor of water poisoning. In fact what the service should make is to study the 4Ps marketing rule. I have illustrated with the example of the Canadian Health that price has nothing to make for buying a health service. There is also, a second dimension in Health service which is the time to supply these service and people are willing to pay for time. Also, communication promotion is a driver of speed of changes. Bertoty 2007 Subash 2004 (under research) Miro et al 2003

10. TESTS FOR LOW ACUITY CASES WITH FAST TRACK ELECTONIC SYSTEMS (Garcia 1995; Peck et al . 2008) PATIENT OUTFLOWS Note: the use of electronic Speed-up the patient out flow for low acuity cases. The hospital are like supermarkets With fast tills or with selfpaying automated machined where the customer process himself the provisions Traditional medical treatment versus electonical treatment of patient are competing and reduce the throughtput time for low acuity cases

11. OVERCROWDING CONDITIONS (Qualitative and quantitative) Emergency Department (ED) Sources: Schull et al 2003 Foster et al 2003 Rathlev et al 2007 US GAO 2003

12. ED IU INFLOW OUTFLOW 1RST BACKLOG INVESTIGATION RESULTS Source: Kolb, Lee and Peck (2007) Normally, the backlog should serve the investigation in determined in which step of the process between ED and IU, the Patient congestion (time delays and queueing is important° AND IF backlog is F (IU) -> it is the bottleneck Back log = F (IU) ED : Emergency Department ER : Emergency Room IU : Inpatient Unit

13. Problem of time delay of Patient Is located between ER and IU The slowest service gives the speed for all the department Which is unfair for patient waiting to be treated -> goal would be to find a solution at this level if the hospital want to avoid diversion status and reduce deaths My qualitative Solution: « Pseudo Bison futé »: -No diversion cause of deads -Forecast IU frequentation -improve IU -buy new machines -trained staff -motivation -health policy -treatment can be diverted in the ED itself by rorganizing the service either people or influences

14. CROWDING MEASURES AND UNCERTAINTIES ON MEASURES SPEED UP PATIENT IU-INFLOW HOW? WHEN? WHO? IU-INFLOW = ED-OUTFLOW Yancer et al 2007 Solutions Uncertainty Author names Principles UTILIZATION OF IU AS WAITNG ROOM INSTEAD OF ED. FALSE DECONGESTION VERSUS REAL DECONGESTION Greene 2007 How to improve is unclear (who, what, why, when, where, how, characteristics, frequency, etc. GOOD TO REDUCE CROWDING Richardson, Dick, Schneider 2007

15. CONCEPTUAL MODEL OF US HEALTHCARE (KOLB 2008) ACQUISITION OF KNOWLEDGE: 1° OBSERVING THE ENVIRONMENT (US HOSPITAL SUBURBAN AREA, ONE MILE FROM THE HIGHWAY) 2° DATA GATHERING ABOUT: Beds => 24 adult ER beds => 8 pediatric ER beds, and => 4 fast-track beds Rooms: => 2 X ray rooms, => 3 triage rooms, and => 2 registration rooms. (Unvisible details) => interview staffs + mangers helps to understand ED process in theory and practice and, which aspect is needed for the simulation (modelling)

16. Branching points BASIC MODEL (ED-IU SYSTEM)

17. DETAILED MODEL Influx channels Front start Front end Fast track Adult ER IU Diagnostic Pediatric ER Greeter Waiting area Triage room

18. DETAILED MODEL OF THE AUTHORS

19. COMPUTERIZED MODEL

20. APLLIED SCENARIO TO XANTHIA FLOOD RISK REDUCTION BASIC MODEL

21. H° Average sea tide H ¹ Surge tide Surge water Inundated land H ² Disaster tide GS RADJOU SCENARIO BUFFER XANTHIA

22. PROJECT GLOBAL ARCHITECTURE (Requirement and specifications)

23. LEVEL ONE FLOATING SCREEN (like a wrap in standy) WASTE SCREEN WATER INFILTRATIONS WATER ELIMINATION DRAINAGE CONTROL DEBORDEMENT 2ND PROTECTION WITH PLANTED TREES ELEVATED TOWER MODEL ONE (for the new urbanism) -the dock and the elevated building- The dock side WALL (Optional) Or stands to support the floating screen when in deployment CANAL OR TUNNEL Water stock zone Impervious surfaces ( or saturated soil create the flood zone) Protection levels from flood (flood wall) Buildings, shelters, dry feets GS RADJOU Global architecture

24. MODEL TWO: LEAVE WATER TO ITS OWN EXPANSION = NO WALL, NO SCREEN BUT... RIVER FLOWS INUNDATION Monitoring stations Flood zone Pool for Evacuation drainage FLOOD ZONE RIVER LAND DEMARCATION LINE

25. CONFIGURATION CHANGES

26. 22 m 60 m 32 m PROJECT SKETCH VARIATION SIMILAR BARCELONA SEA FRONT (LE PASSEIG COLOM ET LE MOLL DE LA FUSTA) [1] SEA TREE ZONE TREE ZONE ELEVATION HOUSE CANAL TUNNEL [1] Exact detailed of the seafront drawning in L »urbanisme végétal, Institut pour le dévelopment forestier, Caroline Stefulesco, Collection Mission du Paysage GS RADJOU Adaptation strategy No screen, no wall,only planting trees and elevation house in flood prone region b

27. SEA FRONT CONFIGURATION VARIATION [2] For details of the Front sea Archachon Le Parc Pereire, see page 194 of the book L'urbanisme végétale, Caroline stefulesco SEA LAND (TREE ZONE)