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Massachusetts General Hospital's Pre-Admission Testing Area (PATA)
Jireh Philip B. Acabal Bachelor of Science in Accountancy - III Daverah M. Banagodos Bachelor of Science in Accountancy – II Carla Marie F. Primicias Bachelor of Science in Accountancy - III Gyle Angela V. Sabacahan Bachelor of Science in Accountancy - II Vnzichro V. Sarno Bachelor of Science in Accountancy - III Aileen E. Suminguit Bachelor of Science in Accountancy - III
Mr. Earl Z. Calingacion Management 31 - C April 26, 2017
I. Brief Description The Massachusetts General Hospital was founded in 1811 and has been committed to delivering standard-setting medical care. The hospital has 907 beds in a 4.6 million square foot campus as one of the largest hospitals in America. Also, it consistently ranked as one of the top five hospitals in the country. It is considered the cradle of anesthesia since it was there in the Ether Dome where the ether was first supplied during a surgical procedure in the year 1846. The Department of Anesthesia, Critical Care and Pain Management (DACCPM) was accredited in 1938 and since then has maintained a leading position in the field of innovation and research of anesthesiology. They have 278 physicians and 198 nurses in the hospital. The department is able to support patients before, during and after their surgery. With that, the hospital has a Pre Admission Testing Area (PATA), where they are responsible for outpatients having 43% of that had undergone surgery. They are ones who evaluate safety anesthesia before surgery, who inform the patients, and who obtains the legal acknowledgment and consent from the patients. The purpose of PATA was to thoroughly evaluate each patient To determine if they could withstand anesthesia during the operation and perform all laboratory tests prior to surgery. PATA was an outpatient clinic with 12 exam rooms, a lab, and a waiting room. Patients typically spent about 80-90 minutes of face time with providers in PATA, but even in the bestcase scenario, appointments lasted at least two hours. The average appointment was two-and-ahalf hours and many patients spent over four hours in PATA. Long waiting times were particularly troubling due to the goal of high quality patient- and family-focused care that MGH espoused. The system they have used until today has proven to be ineffective which creates a rather tense situation for patients and employees and has repercussions in turn In the surgery department. The group exerted their efforts to settle this case until a letter forwarded from the president’s office emphasizing that the problem is not getting any better. Patients spend long hours waiting to be evaluated and staff needs to work long hours to be able to serve the large number of patients. PATA had been struggling with inefficiencies and long patient wait times for over two years.
II. Central Problem The Pre-Admission Testing Area (PATA) of the Massachusetts General Hospital has been struggling with their inefficiencies. Patients would be waiting for a long time, and this has been happening for the past two years. They would be in the clinic for four hours, but in that span the patients only have one hour and a half of face time. With that, patients are frustrated and providers would have to overtime to cater the patients’ needs. This long wait was due to the clinic’s goal of having high quality patient and family focused care that the Massachusetts General Hospital aim.
III. Minor Problem Due to the long wait problem of PATA, it caused a domino effect where other areas are affected. One of these minor problems is when registered nurses and medical doctors have to work overtime. Instead of finishing their work by 5:00 pm, they have to stay and finish their jobs as late as 7:00 pm or 8:00 pm. Surgeons are also affected in the PATA’s dilemma of long wait, another minor problem for the clinic. They are tasked to book the patient’s appointments in the PATA. Since the clinic’s capacity is limited, they had to make priority for complex cases, but their lack of guidelines often resulted to sick patients not being sent to the PATA. Another minor problem is the presence of many unhappy patients that would walk out with no screening, and would show up on the day of surgery, resulting to delays and backlog on the surgeon’s schedule. Lastly, a minor problem caused by the long time wait is that the clinic isn’t able to bring in any revenue that made it even harder to justify additional resources. The operating room director would cancel surgeries, resulting to upsetting patients. And fewer surgeries result to less revenues.
IV. Key Analysis SWOT ANALYSIS
STRENGTH • The quality of care and concern for the patients' safety was very high. • The staff remained committed to thorough pre-admission work-ups to ensure a safe and uneventful surgery
OPPORTUNITY • Considered as one of the top five hospitals • Known as the birthplace of anesthesia
WEAKNESS • Long wait time • Insufficient number of rooms, physicians and nurses
THREATS • Due to long waits, other potential patients would rather go to other clinic.
PROCESS FLOW DIAGRAM AND CAPACITY Arrival rate = 8 pts/hr
7 am-12 and 2-3pm
Arrival rate = 4 pts/hr
12-2pm (Lunch)
Calculating PATA Process Capacities 1. Check-in:
2. Vitals + EKG in Lab:
3. RN Visit: Service time =43 min/pt
Service time = 2 min/pt
Service time =10 min/pt
Service rate = 30 pt/h
Service rate =6 pt/h
o Chart review = 5 min/pt
m = 1 attendant
m = 2 technicians
o Visit with patient = 27
Capacity = 30 pts/hr
Capacity = 12 pt/hr (lunch: 6 pt/hr)
min/pt o Chart write-up = 11 min/pt Service rate = 1.4 pt/h m = 5 nurses Capacity = 7 pt/hr (lunch: 2.8 pt/hr)
6. Check-out:
5. Blood Work in Lab:
4. MD Visit:
Service time = 6 min/pt
Service time = 1 min/pt
o Chart review = 10 min/pt
Service rate = 10 pt/h
Service rate = 60 pt/h
o Visit with patient = 37
m = 3 technicians
m=1 attendant
Capacity = 30 pt/hr
Capacity = 60 pt/hr
Service time = 64 min/pt
min/pt o Chart write-up = 17 min/pt
(lunch: 20 pt/hr)
Service rate = 0.94 pt/h m = 8 MDs Capacity = 7.5 pt/hr (lunch: 3.75 pt/hr)
PROCESS CAPACITIES Non-Lunch Step
Service Time (min/pt)
Check-in
2
30
1
Vitals + EKG in Lab
10
6
RN Visit
43
MD Visit
Lunch
Service # of Capacity Rate (pts/hr) Employees (pts/hr)
# of Employees
Capacity (pts/hr)
30
1
30
2
12
1
6
1.40
5
7
2
2.8
64
0.94
8
7.5
4
3.75
Blood Work in Lab
6
10
3
30
2
20
Check-out
1
60
1
60
1
60
The Registered nurses are the bottleneck.
PROCESS FLOW DIAGRAM AND CAPACITY (BOTTLENECK)
Bottleneck
Before the registered nurse step, the patients can flow through at the arrival rate until the waiting room is full. The capacity of the waiting room was not mentioned; therefore it was assumed that it is large that it never fills up. Then the flow rate at steps before the registered nurse is eight patients per hour in non-lunch times and four patients per hour during lunch. During the registered nurse step and afterwards, the RN capacity limits flow, thus the flow rate would be seven patients per hour in non-lunch times and 2.8 patients per hour during lunch.
UTILIZATION ANALYSIS
Non-Lunch
Lunch
Step
Flow Rate (pts/hr)
Check-in
8
1
30
0.27
4
1
30
0.13
Vitals+EKG in Lab
8
2
12
0.67
4
1
6
0.67
RN Visit
7
5
7
1.00
2.8
2
2.8
1.00
MD Visit
7
8
7.5
0.93
2.8
4
3.75
0.74
Blood Work in Lab
7
3
30
0.23
2.8
2
20
0.14
Check-out
7
1
60
0.12
2.8
1
60
0.05
# of Capacity Employees (pts/hr)
Util.
Flow # of Capacity Rate Util. Employees (pts/hr) (pts/hr)
In this process, the registered nurses are overloaded. They build up a backlog of work and would only work after the patients would stop arriving. With the use of the inventory build-up diagrams, it can be easily analyzed the backlog of the registered nurses.
Analyzing Inventory Buildup at the Registered Nurse Station Capacity
Thus, the backlog accumulates at
7 am – 12 pm: 7 patients per hour
7 am –12 pm: 1 patients per hour
12 pm – 2 pm: 2.8 patients per hour
12 pm –2 pm: 1.2 patients per hour
2 pm – end of day: 7 patients per hour
2 pm – 3pm: 1 patients per hour 3 pm+: -7 patients per hour
Arrivals 7 am – 12 pm: 8 patients per hour 12 pm – 2 pm: 4 patients per hour 2 pm – 3 pm: 8 patients per hour After 3 pm: 0 patients per hour
INVENTORY BUILD UP DIAGRAM
Average Inventory at RN Station Time
Length (hours)
Start Inventory
End Inventory
Avg Inventory
7 am - 12 pm
5
0
5
2.5
12 pm - 2 pm
2
5
7.4
6.2
2 pm - 3 pm
1
7.4
8.4
7.9
1.2
8.4
0
4.2
3 pm - 4:12 pm Grand Average
4.11
Thus the average patients that are waiting is 4.11. Average Patient Waiting Time Average flow rate (out of RN queue) 7 patients/hour from 7 am to 12 pm (5 hours) 2.8 patients/hour from 12 pm to 2 pm (2 hours) 7 patients/hour from 2 pm to 4:12 pm (2.2
Average patient waiting time Little’s Law: Inventory = Flow Rate x Flow Time Flow Time = Inventory/Flow Rate Waiting Time = (4.11 pts) / (6.1 pts/hr) = 0.67 hrs = 40 min
hours) Weighted average = 6.1 patients/hour
The average patient waits for 40 minutes at registered nurse station.
Other stations have utilizations less than 1. Waiting times in front of other stations will be driven by randomness in arrivals/processing. This can be analyzed using queueing tools.
Waiting at Vitals + EKG (Queue 1, 9 am to 12 pm only) Arrivals Arrival rate = 1/a = 8 patients/hr Average Interarrival time = a = 60/8 = 7.5 minutes Std Dev of Interarrival Times from 9 am to 12 pm (Fig 2a) = 8.9 min CVa = Std Dev/Mean = 8.9/7.5 = 1.2 Service Average Processing Time = 10 min (case p. 10) Std Dev of Processing Time = 3.5 min (case p. 10 footnote 9) CVp = Std Dev/Mean = 3.5/10 = 0.35 Number of Technicians/Stations = m = 2
u = p/ma = 10/(2x7.5) = 0.667 Tq= 6.4 minutes
Waiting Time Analysis at MD & Blood Work Vitals + EKG
MD
Blood Work
a [min]
7.5
8.6
8.6
Std Dev a [min]
8.9
1.7
3.4
CVa
1.2
0.2
0.4
p [min]
10
64
6
Std Dev p [min]
3.5
29
2
CVp
0.35
0.45
0.33
m
2
8
3
u
0.67
0.93
0.23
Tq [min]
6.38
11.77
0.02
Queue 1
Queue 3
Queue 4
The arrival rate (1/a) after registered nurse equals the capacity at RN is 7/60 which is equal to 1/8.6. Thus, the total waiting time from queueing effects is about 18 minutes.
PROCESS FLOW DIAGRAM AND TOTAL FLOW TIMES
This diagram shows that the total wait time is 58 minutes, 98 minutes for total service time, and an average flow time of 156 minutes.
V. Alternative Course of Action 1. Extend hours to 6:30 pm and increase the time between appointments to 45 minutes. The current system’s schedule of appointments during non-lunch times is 4 arrivals for every 30 minutes, which is equivalent to 8 patients per hour. While during lunch, there is an estimate of 2 arrivals for every 30 minutes deriving to 4 patients per hour. The new proposed schedule of appointments during non-lunch times will have 5.3 patients per hour as a result of 4 arrivals for every 45 minutes, and 2 arrivals for every 30 minutes resulting to 2.67 patients per hour during lunch time. Thus, with the new proposed schedule of appointments, there is a need to extend scheduled arrivals from 3 pm to 6:30 pm to maintain the same number of total arrivals (56) in 1 day.
Advantage: The new proposal eliminates build-up at the registered Disadvantage: Eliminates build-up at RN
only queueing times remain
waiting time at RN is not zero! Reduces queueing waiting times at other steps (lower arrival rate) Total average waiting time is down from about 1 hour to less than 15 minutes 2. Patent Advantage: Disadvantage:
3. Add an Anesthesiologist (MD). The current medical doctor utilization is 93% causing queuing delays due to randomness. The present average wait time is 12 minutes per patient. If the hospital will add 1 medical doctor, it should focus more on non-lunch times (9 am- 12 pm) which will result to a decrease in utilization rate of 83%. Hiring anesthesiologists are expensive but this will help lessen the waiting time of each patient. Waiting time will drop to 2.68 minutes.
Advantage: Disadvantage:
4. Letting Advantage: Disadvantage:
VI. Implementation Strategy The hospital should hire additional registered nurses to avoid nurse fatigue. The present utilization rate of nurses in MGH is 100%. They have been working past their normal shifts risking their own health leading to inefficiency in their workplace. Hiring additional nurses will lead to the elimination of inventory buildup (bottleneck) in the registered nurse visit. Due to increase in capacity of patients per hour in the registered nurse visit, the bottleneck in the operations is now passed on to the medical doctor visit. To eliminate this patient build up, they should hire medical doctors to increase their capacity of patients per hour. Currently, the medical doctors have a utilization rate of 93%, and adding medical doctors will reduce waiting time to 2.68 minutes per patient. Timeline:
Hire registered nurses
VII. Conclusion
Eliminate inventory buildup in the registered nurse visit
The medical doctor visit is now the bottleneck
Hire medical doctors (Anesthesiaologist)
VIII. Recommendations
Financial Analysis
Alternative Course of Action Immediate changes • Establish shared responsibility for operations among the staff. Reduce burden on Charge Nurse • Situate Lab Technicians close to front-desk to expedite EKG and Vitals • Recommend having MDs and RNs use the same operating room Long term changes
• Add 3 additional RNs to match the number of MDs • Proactively display current wait times to patients in the waiting room
Implementation Strategy
Conclusion
Recommendation
Key analysis (Fishbone diagram, SWOT matrix, STEEPLE, Porter’s Five Forces, Environmental scanning, or any other business tools, technique, or theories to help you in your analysis; a brief analysis should be included)
Alternative Course of Action (the ideas should come from the different key analysis, it may not be the possible but can be of consideration)
Implementation strategy (should be based on the ACA and a timeline should be given which would include the operational and marketing strategy)