Preface
Regardlessofcurrentbackground,position,ordemographiccharacteristics,atime willcomewhenyouwillbedeeplyconcernedaboutthefunctionofsystemsthat providehealthcareservices.Thepersonmostdirectlyinvolvedmaybeyou,butit maybeaparent,achild,afriend,orsomeotherlovedone.Nolifewillescapethe needforafunctioningsystemtodeliverhealthrelatedcare.Thus,millionsofhours havebeenspentdeveloping,managing,andworkingtoimprovethefunctioningof suchsystems.
Earlyeffortstodevelophealthcaresystemssurelybeganbeforerecordedhistory. Thedesiretoavoidormanagepainisinstinctivetoallsentientbeings.Theearliestwritingthatiscommonlylabeledasamedicaltextstemsfromsixpapyrifrom ancientEgyptanddatetobetween2000and1500BCE(Stiefeletal(1996),Castiglioni(2019)).Theseearliestrecordedeffortsincludetheuseofherbsandpractices thoughttobehelpfulbasedonseriesofrecordedobservations.Theeffectivenessof sucheffortswasamixedbag,butovertimehumansmademorediscoveriesabout howdifferentpractices,andingestionofvariouselementseasedpain,orprolonged life.
Muchlater,theenlightenmentandthedevelopmentofthescientifcmethod yieldedmoreformalwaystoexperiment,testmethods,andmeasureresultsineffortstoidentifybetterapproaches.(Bernard(1957))Theneedtoco-locatevaried resourcesandnewlydiscoveredelementsofcareeventuallyledtotheconsolidation ofsucheffortsandthecollectionofresourcesinlargerspacesthatbecameformal hospitalsandclinics.
Beginninginthe19thcenturyavariousareasofengineeringandappliedmath weredirectedtotheproblemofbuildingandmanagingthehospitalanditshoused
processes.TheneedtoimprovethesesystemswasaprimarydriverofthefrstAmericanuniversitiesthatfocusedonresearchinadditiontoteaching.OneoftheearliestleadersinthisregardswasasmallschoolinBaltimore,Marylandfoundedby JohnsHopkins(French(1946)).Thisearlymedicalschoolandassociatedcollectionofsmallerschoolswasaleaderinthecreationofmanypracticesstillused todayincludinggrandrounds,asystemofinternsandresidents,andtheformation ofspecialtiesthatfocusonasubsetofdiseasesorpatientssuchasneurosurgeryand pediatrics(Long(1991)).
Effortstomakethehospitalrunbetterandserveagrowingpopulationquickly includedexpertisefromfacultywithskillsinengineeringandmathematics.Consequently,JohnsHopkinsdevelopedthefrstdepartmentinanAmericanuniversityfocusedonwhateventuallybecomeknownasOperationsResearchin1952 (Flagle(2002)).ThetoolsdevelopedinOperationsResearchdepartmentsincluded suchesoterictopicsasQueueingtheory,DiscreteEventSimulation,andotherforms ofmathematicalmodelinginwhichanabstractrepresentationofanactualsystem couldbeconstructedandanalyzedaspartofthesearchforbetterwaystogetthings done(GassandAssad(2005)).Thus,thelinkbetweenhospitaloperationsandOperationsResearchwasinstitutionalizedintheUS.(SimilareffortstookplacesimultaneouslyintheUK.)
Theeconomicrealityofthecountryevolvedatthesametime.Intheearly1800’s barteringforserviceswascommonbecausethetypicalworkerhadverylimitedabilitytopayforhealthcaredelivery.Atthesametime,theskillsandeducationneeded todelivermedicalcaregrewrapidlyasscientifcapproachestocareproducedthousandsofnewideas,drugs,devices,andprocedures.Itquicklybecameverydiffcult andtimeconsumingforonetolearnallthatneededtobeunderstoodforthegeneral practiceofmedicine.Theneedformoredevices,equipment,space,andtraininginevitablyledtoincreasesinboththequalityofcareandthecosttodeliverit.
Socialresponsestoincreasingexpensesincludedtheriseofmanybenevolentsocieties,religiouscharities,insurancecompanies,andevengovernmentprogramsto helpindividualsmanagethecostoftheseessentialservices.Overtimethisindustry grewtobecomethelargestsinglesectorintheworld’slargesteconomyandthat growthshowsnosignofstoppingintheforeseeablefuture.(CMS(2020),Lorenzonietal(2014))Suchgrowthhasconsequencesnotimaginedinthe19thcentury.
Governmenteffortstodealwithhealthcarecostsincludeeverexpandingbodies ofregulationsandamyriadofwaystorestrictpaymentsthatarepresentedasefforts to“manage”costs.Theneedformeanstoimproveeffciencyandmanagecostsare readilyapparentfromconsiderationofafewsimplefacts.Forfullservicehospitals intheUnitedStates,themedianproftperpatientdischargeisnegative(-$82)(Bai andAnderson(2016)).Inotherwords,mosthospitalslosemoneyonthetypicaladmittedpatient.Administratorsstrugglenotjusttomaximizepatientsatisfaction,but tosimplykeepthedoorsopen.Mostruralareashaveashortageofcareproviders,
andalmosteveryhospitaladministratororclinicmanagerwillreportthattheshortagesofnurses(Lasateretal(2020))andgeneralpractitioners(Majeed(2017))show nosignofrelenting.
Thehighcostofinpatientcareleadstoincreaseddemandforoutpatientservices.Theshortageandgrowingcostsofprovidersforoutpatientservicesdrivesthe searchforincreasedthroughputfromfxedlevelsofresources.Consequently,the roleofengineersandmathematiciansthatwasfrstseenintheearlyconstruction ofmedicalfacilitiesemergesonceagaininaverydifferentcontext.Theengineers neededtodesignthebuildingsandspacesmustnowbesupplementedwiththose neededtoimprovetheprocessesthattakeplacewithinthosespaces.
Thismonographismeanttobeasmallcontributiontothebodyofknowledge directedtowardthisendeavor.Overthepastdecadetheauthorshaveworkedon dozensofqualityimprovementprojects,supervisedmanyeffortstogatherdataon systemperformanceandquality,taughtthousandsofstudentsfrombusinessand medicaldisciplines,andconstructedmanymodels,cases,researchpublications,and readingsonthiscriticaltopic.Allofthisworkhasbeencarriedoutwithintheenvironmentoftheworld’smostfamoushospital.
Wemakenoclaimstohavealloftheanswersoreventofullyunderstandallof themanynuancesoftheproblems.However,itdoesseemfairtosaythatthereader maybeaidedbyexposuretowhatwehavewitnessed,tested,andappliedinthis setting.
OrganizationofContent
Ifwethinkaboutimprovingtheoperationsfunctionofasmalltomediumsized serviceunitwecaneasilyfndrecipesforthetaskasaseriesofsimplesteps.First, defnetheprocessesinplacetodelivertheserviceandanalyzethemintermsof resourceusage,capacity,quality,andoutput.Assumingthatpricingisexogenous totheunitmanager,(asisalmostalwaysthecaseinhealthcaredelivery)onethen focusesontheconnectionsbetweenthevaluedelivered,andthecostincurredtodeliverthatvalue.Oncethisunderstandingisinhandwecancomparetheperformance ofoneunittothatofanotheraspartofthemissiontoseekwaystoimproveoneor bothpartsofthisperformancemetric.
Unfortunately,whenweapplymanycommontoolsofthisapproachtotheprocessesofhealthcaredelivery,theyoftenbreakdown.Thisisnottosaythatthe inherentlogicofprocessanalysis,costreduction,andperformancemeasurement donotapplyinhealthcare.Rather,werepeatedlyfndthatspecialcareandadjustmentsareneededintheirapplication.Forexample,introductoryapproachesto processanalysistendtofocusontheidentifcationofabottleneckresource,and aparallelsearchforsourcesofvariabilitythatcanbeeliminated.Thisapproach facilitatesamatchingofcapacitytodemand,andincreasestheeffciencyandpre-
dictabilityofprocessperformance.However,severaldistinctivecharacteristicsof healthcareservicescomplicatethisapproach.Thesecharacteristicsincludepatient participation,simultaneity,perishability,intangibility,andheterogeneity(FitzsimmonsandFitzsimmons(2006)).
Tothislist,weaddtwoadditionalelementsthatwehavefoundtobequitecommon.First,manyresourcesaresharedamonganeverchangingcollectionofjobs. Resourcesfoatfromroomtoroom,orpatienttopatientwithfrequentinterruptions, repeatingsometasksandsplittingothersintosmallerpartsthatmustbeperformed bymultiplespecializedresources.Thehighdivisionoflaborinhospitalsandthe hierarchicalstructuresthatresultinterferewitheffortstodefne,measure,andcompareperformance.Therefore,improvingtheseprocessesrequiresadditionaltools andmodifedapproachesareneeded.
Second,thepsychologyandcultureofhealthcareprovidersissuchthatthinking ofcostreductionasafrstpriorityisanathematotheirnature.Fewprovidersholda clearideaofwhataprocesscostsbecausetheirmindswillnotallowthisconsiderationtobetheirprimaryconcern.Someproviderssimplyrefusetospeakinterms ofcosts,becausetodosofeelslikeitisimplicitlypricinghumansuffering.Onthe otherhand,administratorscannotescapetherealitythatmosthospitalslosemoney andthatifnoactionistaken,theywillceasetofunction.Costingisnotwidelyunderstoodinhealthcarebutthesystemwillcollapseifitisnotaddressed.
Thiscomplexityalsoaffectsthenotionsofqualityofserviceandvalueofoutcomes.Healthoutcomesforthemanymustbebalancedagainstattentiontothe relativefewwhoareonsiterightnowinwaysthateffecthealthoutcomes,costs, waitingtimes,andmanyotherelementsofpatientandproviderexperience.Thefact thatoutcomeslayalongsomanydimensionssimultaneouslymakessimplemetrics suchasproftandlosswoefullyinadequate.Again,thisisnottoimplythatsuch measurementsareimmaterial,butthattheirtreatmentmustbemanagedinastyle thatrespectsthecontextandcultureoftheindustry.
Afterwedodevelopanunderstandingofprocessperformance,quality,andcosts wecaneasilyidentifyasetofissuestobeaddressed.Withtheseissuesinmind, wewilladdressnewquestionsinthesecondphaseofthistext.Howarewegoing tomakethissystembetter?Canweidentifyanapproachthatcanbereplicatedand appliedacrosssystemswithsuchcomplexissuesandvaryingsettings?Itisclear thatmanagersneedtoolsthatarerobustenoughtobeusedinmanysettings,andyet powerfulenoughtohelpgetthisjobdone.
Thisshortbookisacompendiumofreadings,examples,exercises,andcasestudiesintendedtohelpidentifybothareasinneedofimprovement,andsomemeans tobringthatimprovementabout.InChapter1webeginwithaprimeronbasicelementsofProcessAnalysiswithaspecialefforttoplacetheterms,andapproaches withinthecontextofHealthCareManagement.Thereaderwillquicklyrealizethat
manycomplicatingfactorscommoninhealthcaresettingswarrantadditionaltools andadjustmentstothesegenericapproaches.Chapters2and3dealwithtoolsto helpinthisregard,andpresentexamplestoshowwhytheyareneeded.Morespecifically,Chapter2discussessimpletoolsincludingGanttChartsandtheCriticalPath Methodasaidstopresentingandunderstandingcomplexsystems.Chapter3considersissuesrelatedtosharedresourcesandschedulesthatcanberepeatedascycles throughoutasession,orshift.Chapter4introducesQueueingtheoryasawayto formalizetheconsiderationofvariabilityrelatedtointer-arrivalandactivitytimes. Chapter5wrestleswiththequestion“howmuchwillanepisodeofcarecost?” These5chaptersconstitutethefrstmajorsectionofthetext.
Withanunderstandingofthisfoundationalmaterialinhand,weturntothequestionofhowtomovefromanalysistoimprovement.InChapter6welayoutaframeworkthathasoftenhelpedusinthisregard.Asixstepprocessisdepictedtomove fromprocessmappingtoeventualprocessimprovement.Technicallyspeakingthe centerpieceofthismethodologyistheuseofDiscreteEventSimulationasamanagementtool.Consequently,Chapter7exploreswhythistoolisneeded,andwhat typesofinsightsitislikelytoproduce.Examplesofimplementationsandissuesuncoveredareinterspersedinthesechapterstohighlightapplicationsoftheapproach. WeconcludewithacollectionofcasestudiesasChapters8through11thatrelate tomajorportionsoftheprecedingchaptersandhelpcontextualizetheirapplication.
Readersareencouragedtoworkfromstarttofnish.However,eachchapteris writtenwiththeideathatmostpeoplewillpickandchoosewhatismostrelevantto thematanypointintime.Consequently,wehavemadeanefforttoalloweachchaptertoserveasastandalonereadingontherelevanttopic.Thisdesignresultsina bitofredundancy,buthopefullyreinforceskeymessageswithoutbecomingtedious.
BackgroundandIntendedAudience
OverthepastdecadewehavetaughtcoursesonServicesManagement,Health CareServices,FundamentalsofHealthCareProcesses,IntroductionstoProcess Analysis,BusinessAnalytics,andahostofImmersioncoursesfocusedonvarious processesinthesettingsofclinics,hospitals,andinsurers.Inaddition,wehave publishedacollectionofworksinvariousmedicalandbusinessjournals,andhave beeninvolvedinahostofqualityimprovementprojects,businessplanningefforts, andoperationalstudies.Overthecourseofthisworkaguidingframeworkemerged thatcanbetaughtandrepeatedlyappliedinprocessimprovementefforts(Dadaand Chambers(2019)).Thisframeworkanditsassociatedreadings,cases,assignments, lectures,videos,andprojectsthatwedevelopedorledbecamethesourcecontent forthistext.
Theprimaryaudienceforthistextisstudentsincoursessimilartooursthatmay betaughtinschoolsofBusiness,Nursing,Medicine,andPublicHealthwithafocus onhealthcaredeliveryprocesses.Thefrsteightchapterseasilymapontoan8week
courseonthetopic.Wetypicallyuseoneormoreoftheincludedcasestudiesasan endofcourseprojectoraspartofafnalexam.Thesecasesftmostdirectlyinto MBA,orMSprogramsonthetopic.However,westrivetopresentthecontentina waythatmakesitaccessibletoundergraduatestudentsinadvancedelectivesaswell. Asecondaudienceincludesadministratorssuchasclinicmanagers,anddepartment headsworkinginthisspace.
Thesequencingofthechaptersisdesignedtoftwithinacoursestructure,but eachchapterstandsonitsownasareferenceforanyoneinneedofoneofthetools discussed.Whiletheworkpresentsavarietyoftoolswenotethatthebookisnot asubstituteformoredetailedtrainingmaterialonthemosttechnicaltopics.The primaryexampleistheuseofDiscreteEventSimulation.Manyothertextsfllthis void.Ourobjectiveistopresentthelogicoftheideasandtoexplaintheiruse.
Wesubmitthatanyreaderwhohaseverponderedquestionslike,“whyisthis placesoslow,”or“whyisthischargesohigh”willbeneftfromexposuretothis material.Westronglysuspectthatthisgroupincludesanyonewhohaseverinteractedwiththissystematastressfultime,whichisvirtuallyeveryone.Again,itsnot aquestionofifyouwilleverbeinthatgroup-onlyoneofwhen.
Finally,wewishtothankthehundredsofhealthcareprofessionalsinvolvedin ourpriorstudies,projects,andpublicationsthathaveledtothispoint.Thisincludes thetechnicians,nurses,doctors,administrators,andpatientswhoallowedustoview theiractivitiesandcare.Thanksalsogoestothedozensofreaders,reviewers,and presentationaudiencememberswhohaveaddedcontent,clarity,andfocus.
Mostimportantlywethankourfamilieswhohavesufferedlonghoursasreaders,supporters,andsoundingboardsalongtheway.ChesterChambersparticularly thanksS,L,andC:theQueenofAll,TheLightoftheWorld,andtheJoyousContinuationrespectively.
MaqboolDadaparticularlythankshiswifeShamimandourchildrenNatasha andMyrafortheirloveandsupportovermanydecadeswhiletoleratinginnumerablelong-windeddiscoursesonallthingsacademic.
KayodeWilliamsdedicatesthisworktohiswifeOyinkansolawithoutwhose loveandsupporthiscareerachievementswouldnotbepossible,theirsonsand daughter-in-law,OlatunjiandhiswifeVictoria,Oluwatomi,andtheirgranddaughter,Rosie,allofwhoseenquiringmindshavespurredhisquesttoacquireknowledge.
Baltimore,MD,USA
ChesterChambers July2022
MaqboolDada KayodeWilliams
Prologue
Asweseektobuildintuitionregardingthemanagementofhealthcareprocesses, wemustwrestlewiththevastnessofthesystemunderstudy.Forexample,ifone looksintothebreadthofthesystemsconnectedwithJohnsHopkinsmedicineone fndsavastarrayofoutpatientclinicsandsurgicalcentersintheUSthathandle almostamillionpatientvisitsperyear,andhospitalsthathandleover4millionvisitsperyearincludingmorethan350,000emergencydepartmentvisits(Chambers andWilliams(2017b)).ThesystemalsoincludeshospitalmanagementandfacilitiesinChina,Singapore,India,Japan,UnitedArabEmirates,SaudiArabia,Turkey, Lebanon,Pakistan,Chile,Peru,Mexico,Brazil,Panama,Columbia,andCanada.In addition,thesystemaddsinsurancecompanies,andschoolsofmedicine,nursing, andpublichealth.
Intheconsiderationofsuchalargeandcomplexnetwork,itisimperativethatwe focusonlessonsandtoolsthatareapplicableacrossaplethoraofsettings.Withthis inmindwewillfocusonsmallerproblemsinproto-typicalsettingstohelpdevelop insightsthatcanbegeneralizedandadjustedtoftwhateversystemyouwishtoimprove.Itisinstructivetofocusonbitesizedchunksofacaredeliverysystemsuch asasingleclinic,emergencydepartment(ED),operatingroom(OR)suite,hospital ward,orhospital.Narrowingthefocusfacilitatescalculationsandallowsfortheexplorationofsmallexamplesthatcanbecreatedtoconveykeypoints.
Unfortunately,thisapproachfiesinthefaceofthefactthathealthcareisthe largestsingleindustryintheworld’slargesteconomy(forEconomicCo-operation andDevelopment(2020)).Asaresult,itinvolvesavastnetworkoffacilities,staff, physicians,andresourcesspreadacrossalmosteverycommunity.Thisvastlandscapecreatesamultitudeofhand-offsbetweenunits,andcoordinationamongfarfungagents.Anyanalysisofthesepartssuffersifconnectionstotherestofthe systemareignored.Thesimultaneousneedtobreaklargeproblemsintomanageableportionsandtounderstandthenatureofconnectionsamongsystempartsmakes thestudyofhealthcareprocessesuniquelydiffcultandcomplex.Withthisinmind, itishelpfultoenvisionavirtualsystemthatcanserveasamicrocosmofthelarger
reality.Wewillfrequentlyrefertothismentalmodelthroughoutthechaptersthat follow.
Envisionalargehospitallocatedinamoderatesizedcityontheeastcoastof theUnitedStates.LetusrefertothisunitasEasternUniversityHospital.Weuse thisconstructasaliterarydevice.Whilethebulkofourresearchandexperience hastakenplacewithintheJohnsHopkinssystem,Easternisnotintendedtobea replicationofanyparticularclinic,ward,unit,orhospital.Asaresult,theproblems presentedherearefullyinformedbyourstudyofactualsettings,butnotmeantto beduplicationsofanysingularunit.Thedatapresentedareacompositeofsources thatwehavegatheredoverthepast10years.
Easternhappenstobeateachinghospital,meaningthatmanyprocesseswillinvolveresidentsinadditiontothenurses,clinicalassistants,attendingphysicians, andahostoftechniciansandotherstaff.WewillconsiderpatientsenteringEastern throughatleast3routes.SomepatientswillarriveattheED.Wewillassumethat thesepatientsarriveoneatatimewithrandomtimesbetweenarrivals.Wewillalso assumethattheEDhassomefxednumberofexaminationrooms,butwewilltreat thewaitingareaasthoughithasinfnitecapacity.Mostpatientswhoenterviathe EDwilllaterbedischargedandsenthome.However,someportionofthesepatients willneedtomovetoanORsuite.TheORsuitewillhaveafxednumberofrooms. Mostsurgeriesinthissuitewillbescheduledinadvance(electivesurgeries)whereas thosethatstemfromEDvisitswillnot(emergencysurgeries).Afterpatientsleave theED,theymaytraveltoawardsuchasmedical,orthopedic,orneurologyward. Otherpatientswillbeincriticalconditionandwillbesenttoanintensivecareunit (ICU).TheICUwillhavefnitecapacityaswell.
MostpatientswhointeractwithEasternwilldosothroughtheEasternHospital OutpatientClinic(E-HOC).Thisclinicdealswithpatientsbyappointment,andhas scheduledopeningandclosingtimeseachworkingday.Thevastmajorityofpatients thatenterE-HOCwillgohomeaftertheirvisit.However,itispossiblethatthey willneedtomovetoanOR,ward,orveryrarelytheICU.ManagersatE-HOC andotherclinicsroutinelydealwiththeproblemofdeveloping,andfne-tuningan appointmentschedule.Thisscheduleisdesignedtostrikeabalancebetweenwaiting timesandovertimeoperationsfortheclinic.Anypatientsstillintheclinicatthe proposedclosingtimewillbeseen,meaningthattheclinicdoesnotreallyclose untilallofthepatientsontheschedulehavebeentreated.
0.1APatient’sJourneyThroughtheEasternUniversityHospital System
FrankCaldwellresidesinthesamecityasEasternHospitalandisingenerally goodhealth.Frankdoesn’tthinkmuchaboutthehealthcaresystem,eventhough
0.1APatient’sJourneyThroughtheEasternUniversityHospitalSystemxvii
herecognizesitasthelargestsectoroftheeconomy,andthelargestemployerin histown.Frankhashealthinsurancethroughhisemployerbuthasn’tpaidmuch attentiontoitscostbecauseheisyoung,hedoesn’tusethesystemmuch,andhis co-paysareprettylow.OneafternoonFranksuffersaninjurytohisrighthandduring apickupbasketballgameafterworkanddecidestodrivehimselftotheED.Thisis hisentrypointtotheEasternHospitalSystem.
0.1.1EntryThroughtheED
Frankhassufferedaninjurytohisrighthandduringthepickupbasketballgame, buthasalsohadsomepaininthishandbefore.Heisprettysurethatthisparticular injuryisjustasprain,buttheEDwasclosebyandhewantedtobesure.Either way,thisiscertainlynotalife-threateningcondition.1 AsheenterstheEDhesees alineof7patientswaitinginfrontofwhatlookslikeaNurses’station.Frankis prettysurethattherearemorethanoneofthesestationsbuttheothersarearound thecornersohedoesnotseeexactlyhowmanyareinplace.Whileheiswaiting henoticesthatpatientsarewalkingintotheEDataratethatheestimatestobe about1perminute.(actually55patientsperhour.)Duringashorttriagestepthat takesroughly4minutesheistoldthat,typically10%ofthepatientswhoenterthe EDareadmittedtothehospital.Therestarereleasedandgohome;usuallywitha prescriptionandsomeinstructionsabouthowtodealwiththemalady.Frankistold thatsincehisconditionisnotcriticalhewillhaveashortwaitbeforeseeingthe doctor.Heisalsotoldthatforpatientswhoareadmittedthetimewiththedoctor averagesabout30minutes,butforsimplercaseslikehisitislikelytobearound10 minutes.Frankwalksovertoawaitingareaandtakesaseat.Whenhelooksaround hecounts34patientsintheroomwithhim.Frankisconcernedthatthewaitwill beratherlong,butistoldthatmorethanonedoctorisintheEDthatday;andthat thestaffcanprocesspatientsquicklyenoughtomaintainafairlystablenumberof patientsinthewaitingroom.
FrankalsohappenstobeafairlynewstudentinaneveningMBAprogramin town,andrecallssomereadingsaboutprocessmanagement.Hewondersifhecan fgureoutafewthingsabouthowthissystemisworking.Likemostpatientshe isprimarilyworriedabouthishealth,butsincehehasafewminutestothink,he wondersifhecandeterminehowlongtheaveragepatientspendsintheED,how manydoctorsareworkingintheEDthatday,andhowmanypatientsareintheED intotal.
1 ThisvignetteparallelsaproblempresentedinAnupindietal(1999)andwillalsoberevisitedin thereviewmaterialafterChapter1.
0.1.2SpecialtyOutpatientClinic
ItturnsoutthatFrankhasnotbrokenanybones.However,thedoctorrecommends thatFrankvisitDr.Twofer,whoisaspecialistinsportsmedicine.Thisparticular specialistisrenownforhisuseofarthroscopicprocedurestoremovefoatingbodies inwristandhandjointsandtheEDphysiciansuspectsthatthisissueiscontributing toFrank’sproblems.However,beforetheprocedurecanbescheduledFrankwill haveavisittoaclinicthatthissurgeonshareswithseveralotherphysiciansinthe Orthopedicsdepartmenttodeterminewhetherthesurgeryisreallynecessary.Upon arrivalattheclinic,Frankchecksinandisinformedthat,sincethisclinicisaffliatedwithateachinghospitalhewillbeseenbyaresidentfrst,beforeseeingDr. Twofer.FrankseesDr.Twoferchattingonthephoneinthehallwayandwonders whyhehastowait.Heistoldthatthedoctorisonthephonegettinginformationon anothercase,andthatFrankshouldnothavetowaitlongbecausetheresidentand theattendingphysicianwillworkinparallel,atfrst,andthencomebacktogether tocompleteFrank’svisit.
WhenFrankmadethisappointmentseveralslotswereavailable.Frankselected thefrstappointmentforthedayhopingthatthiswouldminimizehiswaitingtime. Hewassurprisedtofndthatanotherpatienthadthesameappointmenttimethathe did,buttheclinicalassistant(CA)atthedeskinformedFrankthatthiswasanormal practiceforthisclinic.WhilestandingatthedeskFranknoticesatemplatenextto thescreenthattheCAwasviewinglabeled“AppointmentScheduleforDr.Twofer”. Itlookedsomethinglikethis,
T
ABLE 1:APPOINTMENT SCHEDULEFOR ORTHO
AsFranklooksovertheschedulingtemplatehethinkstohimself,thesepeople makeeverythingsocomplicatedtheycan’tsimplyaddtwonumberstogether.Why can’ttheyjusthavepatientscomeineveryhalfhour?Theyhave9patientsonthe schedulesotheycaneasilyfnishatnoon.It’sobvioustoFrankthatthiswouldbea
muchsimplerscheduleanditwouldhavetoworkbetterthantheoddlookingmess postedhere. 2
0.1.3ProcedureCapacityandParallelProcessing
Attheendofthevisit,Dr.Twoferschedulesasimplearthroscopicprocedureto cleanoutsomefoatingdebriswithinFrank’swrist.DrTwoferiswellknownfor theseproceduresandhasworkedoverthepast20yearstostreamlinehisoperating process.Inhisconsultationwiththesurgeon,Franklearnsthatthesurgeonuses2 roomsinaproceduresuiteatthesametime.Apatientisprepped,andpositioned inRoom1.Thisprocess,whichtakes35minutesinvolvesoneORandthestaffassignedtothatcase.Dr.TwoferthenentersRoom1andcompleteshisportionofthe processoverthenext25minutes.Aftereachcase,ittakes15minutestocleanthe room,butonly5minutesforthesurgeontoscrubandchangegownsbeforemoving toRoom2toworkonthenextpatient,whoisalreadypreppedandreadybythis time.Thiscyclethenrepeatssothatthesurgeoncancomplete3surgeriesinone session. 3
Frankiscuriousaboutthisoddprocess.Itseemslikeawastetoassign2OR’s toonesurgeonwhocanonlybeinoneplaceatatime.HeoncereadthattheOR isamongthemostexpensiveresourcesinthehospitalandthinkstohimself,“no wonderhealthcarecostsaresohigh”.
0.1.4PatientFlowsandTransfersBetweenUnits
Frank’stimeintheORgoesaccordingtoplan,buttheeffectsoftheanesthesia lingermuchlongerthanistypical,andthesurgeonbelievesthatFrankshouldbe heldovernightforobservation.Dr.TwoferexplainstoFrankthatthishappensin 1to2%ofhispatientsandisnothingtobealarmedabout.Frankwillwaitinthe post-anesthesiacareunit(PACU)untilheismovedtoabedononeofthehospital foors.Frankisstillgroggybutalertenoughtoaskhowlongitwillbebeforeheis movedtoaroom.Dr.Twoferexplainsthatitcantakeanywherefromafewminutes toafewhours,andthatthenursingstaffwilltakecareofhimfromhere.Thedoctor thenmovesontothenextcase.
AsFrankliesinwaitinthePACUhegetsabitirritatedthinkingaboutthewait. “Thishospitalhasover800bedsandIhavetowaittofndjustone?”Frankvaguely
2 ThisscheduleparallelsthatusedintheclinicdiscussedindetailinChapter10,andisalso discussedinthereviewmaterialafterChapter3.
3 ThisvignetteisinspiredbythatdepictedinBohmeretal(2007)andwillberevisitedinthe reviewmaterialafterChapter2.
remembersthatEasternusuallyhasanoccupancyrateofaround70%(AHA(2017)) andwonders,“if30%of800bedsareempty,itdoesn’tmakeanysenseformetobe waitingthislong.Theredoesn’tseemtobeanywaytomakesenseofthismess.”
0.1.5BillingandtheCostofCare
Frankismovedtoabedinthemedicalwardafterahalfhourorsoandspendsthe night.Heisalittleuncomfortableatfrst,buthismedicalsymptomsdissipateover thenext8hours.Bymorningheisreadytogohomeandanurseinformshimthat hewillbeleavingsoon.Hissurgeoncomesbyabout8AMandtellsFrankthathe isclearedtogo.Therearejustafewadministrativeissuestoworkthroughanda fewformstosign,butitshouldn’ttaketoolong.ForsomereasonthatFrankdoesn’t understandhisdischargeisnotcompleteduntilthemiddleoftheafternoon.
AboutaweeklaterFrankgetsastatementfromthehospitalthatshowscosts of$18,000.Stampedacrossthetopofthestatementisanotethatreads,“THISIS NOTABILL”butitsurelookslikeabilltoFrank.InthecomingdaysFrankgets asimilarstatementfromthesurgeon’soffceandanotherfromsomeanesthesiology partnership.Frankisalittleupsetbythesestatements.Whenallofthesechargesare totaledtheyarecloseto$30,000.Frankwondersifsomeofthese“costs”occurred becausethehospitalwassoslowinmovinghimfromthePACUtothebed,andthen notallowinghimtogohomeassoonashewasready.Eventually,Frankgetsabill fromhisinsuranceprovider.Thebillshowsthetotalchargesofcloseto$30,000, butitseemstoindicatethattheinsurerpaysroughly$12,000andthatFrankowes about$600ofthatamount.Frankdoesn’treallyunderstandwhatisgoingonhere, butheissorelievedthatthis$30,000inchargestranslatestoa$600checkfromhim thathedecidesnottoaskanyquestions.However,hedoeswonderhowthehospital cansurviveifthegapbetweenitscostsandrevenuesisthathigh.
0.2HealthCareProcessAnalytics
Aswefollowapatient’sjourneythroughanepisodeofcarewearestruckbythe numberofintersectionpointsbetweenthepatientandthemedicalsystem.AsingleeventeasilyleadstointeractionswithanED,aspecialtyclinic,aPACU,an ORsuite,amedicalward,andabillingsystem.Thislistomitstheinteractionswith pharmacies,counselingservices,socialworkers,andgovernmentagenciesthatare commonwhenconsideringolderpatientswhomakeupthebulkofthepatientpopulation.
Inthecomingpagesweintroduceacollectionoftools,andobservationsused toshedlightonthemyriadofquestionsthatnaturallyarisethroughthepatient’s
experiencewiththislarge,complexsystem.WewillfrequentlyrefertoFrank’sstory toprovidecontexttothediscussionofanumberoftheanalyticaltechniquesthatwe use.However,thelargerissueisthatthesesettingsandproblemsarereallyminilaboratoriesinwhichwedeveloptoolsthatcanbeappliedgenerallytosettingsof thereader’sinterest.
0.1APatient’sJourneyThroughtheEasternUniversityHospitalSystemxvi 0.1.1EntryThroughtheED................................xvii
0.1.2SpecialtyOutpatientClinic............................xviii
0.1.3ProcedureCapacityandParallelProcessing..............xix
0.1.4PatientFlowsandTransfersBetweenUnits..............xix
0.1.5BillingandtheCostofCare...........................xx
0.2HealthCareProcessAnalytics................................xx
1APrimeronProcessAnalysisforHealthCareDelivery
1.2.2GoalsofProcessManagement.........................11
1.3KeyProcessMeasures:Throughput,WorkinProcess,andCycle Time.....................................................12
1.3.1Little’sLaw.........................................13
1.4PuttingthePiecesTogether:InstrumentationPreparation.........18 1.5KeyTake-Aways...........................................24
1.6ReviewMaterialandPriorWorks.............................25
1.6.1ProcessAnalysisforED..............................25
1.6.2ProcessAnalysisforHerniaClinic......................25
2SpecialIssuesinProcessAnalysisforHealthCare:Visualization,& ProjectManagement
2.3GanttCharts:AValuableTooltoUnderstandHealthCare DeliveryProcesses.........................................31
2.3.1CreatingGanttCharts................................33
2.4ExamplesofClinicVisits....................................34
2.5CollectedCommentsonGanttCharts..........................41
2.6MakespanandtheCriticalPathMethod........................43
2.6.1EarliestStart,EarliestFinishandtheForwardPass........44
2.6.2LatestFinish,LatestStart,andtheBackwardPass.........46
2.7PuttingthePiecesTogether:AppointmentSchedulingatEastern HospitalOutpatientClinic...................................46 2.8KeyTake-Aways...........................................50 2.9ReviewMaterialandPriorWorks.............................50
2.9.1SurgeonUsingTwoRooms:NormalCases...............51
2.9.2SurgeonUsingTwoRoomsDoubleCases...............51
3SpecialIssuesinProcessAnalysisforHealthCare:Shared ResourcesandCycles
3.7ACyclicApproachtoAppointmentScheduling.................62
3.7.1ProblemSettingandIdentifcation......................64
3.7.2FindinganOptimalSchedule..........................67
3.7.3CompositeJobs......................................69
3.7.4ApplicationintheAMC..............................69
3.7.5HeuristicsforAppointmentScheduling..................71
3.7.6GanttChartofSimpleHeuristic........................73
3.8KeyTake-Aways...........................................75
3.9ReviewMaterial...........................................76
3.9.1CyclicSchedulingTemplatewithNEWandRETURN Patients............................................76
3.9.2CyclicSchedulingTemplatewithonlyRETURNPatients..77
4.3.1ResourceUtilization..................................85
4.4TheoreticalFoundationsfortheStudyofQueues................87
4.4.1AnatomyofaQueueingSystem........................87
4.4.2ExponentialTimeDistributions........................88
4.4.3ContributionsofMarkov..............................91
4.4.4Little’sLaw&Queues................................93
4.4.5M|M|1Queues......................................94
4.4.6M|M|sQueues......................................96
4.5ExaminationofVaccineDeliveryProcess......................98
4.5.1SystemCapacity.....................................98
4.5.2AverageCycleTimeandCensus.......................98
4.5.3AverageWaitingTime................................99
4.5.4ProcessB:TwoServerswitha50/50Split...............99
4.5.5ProcessC:TwoLessExperiencedServerswithReduced Speed..............................................100
4.6KeyTake-Aways...........................................101
4.7ReviewMaterial...........................................103
4.7.1LargeScaleVaccinationSite:ProcessA.................103
4.7.2LargeScaleVaccinationSite:ProcessB.................104
5CostEstimationandProcessImprovement ........................107
5.1Introduction...............................................107
5.1.1CostareJustaPercentageofCharges-Right?............109
5.2CostMeasurementataPrototypicalOutpatientClinic:Process1...111
5.3Time-Driven,Activity-BasedCosting..........................115
5.3.1CostMeasurementatEasternHospitalOutpatientCenter: Process2...........................................117
5.3.2ProcessMetricsUsingProcess1.......................120
5.3.3ProcessMetricsUsingProcess2.......................121
5.4KeyTakeAways...........................................123
5.5ReviewMaterial&PriorWorks..............................124
5.5.1CostforBloodTestwithAttendingFollow-Up...........124
5.5.2CostforBloodTestwithNurseFollow-Up...............124
6.1Introduction...............................................127
6.2ARepresentativeClinic:PartI................................129
6.3HowtoFixHealthCareProcesses............................131
6.4TheProcessImprovementProcess............................133
6.4.1Step1:ProcessDescription............................133
6.4.2Step2:DataCollection...............................134
6.4.3Step3:CreateaDESoftheSystem.....................136
6.4.4Step4:MetricsofInterest.............................138
6.4.5Step5:ProposeProcessChanges.......................140
6.4.6Step6:PredictImpactofProcessChanges...............140
6.5Experiments,Simulations,andResults.........................141
6.5.1ArrivalProcess......................................142
6.5.2PhysicianProcessingTimes...........................143
6.5.3PrivatePracticeversustheAMC.......................145
6.5.4Pre-processing......................................146
6.5.5CyclicScheduling...................................147
6.6KeyTake-Aways...........................................148
6.7ReviewMaterial...........................................150
6.7.1SearchingforaBetterAppointmentSchedule............150
6.7.2SearchingforaBetterAppointmentSchedule............150
7DiscreteEventSimulations:Concepts,Metrics,andCanonicalModels153
7.1Introduction...............................................153
7.2OutpatientClinics..........................................156
7.2.1VariabilityandSystemPerformance....................161
7.2.2PoolingResources...................................162
7.2.3MixingPatientTypes.................................165
7.2.4StateDependentFaceTime............................166
7.3EmergencyDepartments.....................................169
7.3.1DownstreamResourcesandBlocking...................171
7.3.2LengthofStayfromEDtoDischarge...................172
7.4KeyTake-Aways...........................................174
7.5ReviewMaterial&PriorWorks..............................175
7.5.1PatientUnpunctuality.................................176
7.5.2AnAcademicModelwithDistributionsofTeachingTime..177
7.5.3StateDependentActivityTimes........................178
8CaseStudy:MillerPainTreatmentCenter ........................179
8.1Introduction...............................................179
8.4EffciencyofClinicOperations...............................182
8.5PatientTardinessandWaitingTimes...........................184
8.6MergingClinics............................................186
8.7MillerPainTreatmentClinic.................................187
8.8IssuesintheAMC..........................................190
8.9ReviewMaterial...........................................193
9CaseStudy:CollectingActivityTimesUsingaRealTimeLocation System ........................................................195
9.1CollectingActivityTimeDatainEasternHospital...............195
9.1.1Kick-OffMeeting....................................196
9.1.2AdditionalIssues....................................198
9.2TheGITeam..............................................199
9.2.1ProcessingAMSandRTLSData.......................200
9.3ReviewMaterialandPriorWorks.............................205
10CaseStudy:TheRadOncClinicExpansion .......................207
10.1AnalyzingFlowData.......................................207
10.2VisualizingKeyData.......................................208
10.3ReviewMaterial...........................................212
11.2ProcessA:TheEarlierProcess(FollowedbyPatientsUntil December2018............................................220
11.3ProcessB:TheCurrentProcess(BeingFollowedbyPatients SinceJanuary2019)........................................223
11.4ANewPotentialAddition:GeneticCounsellingandPhysical TherapySession...........................................224
11.5ProcessRedesign:SeparateUpfrontExaminationsbytheDoctor...226 11.6DiscussionQuestions.......................................226
