Integr al process optimization of the plaster cast room at AMC Siebe-Thijs Hoogwout January, 2010 Integral process optimization of the plaster cast room at AMC MSc. Graduation Thesis S.T. Hoogwout Dr. Ir. E.W. Hans Associate professor University of Twente School of Management and Governance Dep. of Operational Methods for Production and Logistics N. Kortbeek, Msc. PhD Candidate University of Twente School of Electrical Engineering, Mathematics, and Computer Science Dep. of Applied Mathematics Academic Medical Center (AMC), Amsterdam Dep. of Quality Assurance and Process Innovation P.E. Joustra, Msc. Academic Medical Center (AMC), Amsterdam Dep. of Quality Assurance and Process Innovation JANUARY 2010 2 MANAGEMENT SUMMARY INTRODUCTION This report describes the research of the plaster cast room in the outpatient clinic Orthopedics, Traumatology, and Plastic Surgery at Academic Medical Center, Amsterdam. The cast room annually treats 6,300 patients, which include both inpatients and outpatients. This research focuses on the improvement of the cast room process regarding the interaction between patient flow and capacity. PROBLEM DESCRIPTION The cast room has an unbalance in patient waiting time, quality of labor, and quality of care. Hereby, the workload during the week as well as during shifts is not balanced. In addition, the cast room capacity in terms of personnel is not constant as Orthopedic Cast Technicians (OCTS) encounter unscheduled unavailability during the day. The combination of peaks in workload and continuous changes in capacity result in patient waiting time. In addition, the quality of care decreases during busy periods as a result of disturbances during patient treatment. Hereby, quality of labor decreases as shifts both combine high peaks in workload and moments of idle time. The quality of labor further decreases as a result of overtime. RESEARCH OBJECTIVE The objective of the research is to design and evaluate several recommendations to improve the performance and service level of the current cast room performance as well as balance the OCT workload per shift. This research uses average patient waiting time and the average number of patients seen within 20 minutes of waiting as the service level measures. RESEARCH APPROACH First, this research provides a detailed context analysis of the current cast room process, its actors, and its performance according to the key performance indicators patient waiting time, utilization, and overtime. We connect the findings regarding the cast room performance to the literature and our practical insight of the situation. Hereby, we formulate several recommendations to improve the current situation. These recommendations vary in required commitment, dedication, and resources to improve the current situation. This research focuses on the recommendations regarding appointment planning, staff scheduling, and patient prioritization. We group our recommendations in three interventions:  Intervention 1: Less invasive improvement actions Intervention 1 combines recommendations regarding improvements in communication and behavior of both the OCTs as the DAs. The goal of intervention 1 is to decrease or remove delay in the cast room process. Hereby, we mean delay as a result of lack in communication between the OCTs and DAs, as well as timeliness of the OCTs at the start of shifts.  Intervention 2: Redesign of the agenda system and of the appointment scheduling Intervention 2 provides a redesign of the agenda system in combination with several rules of thumb regarding appointment scheduling to spread patients over a shift. Furthermore, we try to schedule patients around peak 3 moments to stimulate the balance in workload during the entire shift. Hereby, the goal of intervention 2 is to balance the workload for OCTs throughout the shift. Intervention 2 also uses intervention 1.  Intervention 3: More invasive improvement actions Intervention 3 requires additional personnel resources and commitment compared to interventions 1 and 2. Hereby, the sub-interventions of intervention 3 include further alterations in the agenda system regarding the slot duration, improvement in communication regarding the lack in appointment scheduling of walk-in patients and same-day patients, reducing the percentage of no-shows and cancellations, and adjustments in the outpatient clinic capacity to further improve the performance of our interventions in the cast room. Intervention 3 also uses intervention 1 and 2. RESULTS We use a computer simulation model to analyze the current situation and evaluate our (sub)-interventions, extensions, and capacity evaluation. We determine a base situation as representation of the current situation. The service level of the base situation is 72.3% with an average patient waiting time of 18.3 minutes. Hereby, the average OCT overtime for the morning and afternoon equals 4.3 minutes and -7.6 minutes respectively. We compare our interventions with this base situation according to 95% confidence interval to evaluate if changes are significant. Intervention 1 increases the service level to 77.7% with an average patient waiting time of 13.9 minutes. The OCT overtime remains 4.3 minutes overtime in the morning, and increases to -11.1 minutes undertime in the afternoon. Furthermore, we find that we decrease the patient waiting time at the start of shifts. Intervention 2 increases the service level to 81.3% with an average patient waiting time of 11.4 minutes. The OCT undertime increases to 13.7 minutes overtime in the morning, and decreases to -0.6 minutes undertime in the afternoon. The best case of Intervention 3 increases the service level to 95%, which is our target service level. However, this situation is hard to implement. The best case situation assumes the elimination of OCT unavailability, the extensive use of a DA to reduce or remove process delays and disturbances, and the spread of specialists’ consulting hours. Hereby, the OCT overtime decreases to -6.7 minutes overtime in the morning, and to -46.3 minutes n the afternoon. CONCLUSIONS & RECOMMENDATIONS We find that the best case situation improves the service level to 95% and the average patient waiting time to 2.9 minutes. However, the best case situation is hard to implement, certainly on a short notice. Intervention 1 shows that we can improve the current situation with low invasive improvement actions with a reduction of 21% of the average patient waiting time. Furthermore, the adjustments regarding appointment scheduling contribute to the spread of workload for OCTs. We recommend to implement intervention 1 and 2 as soon as possible, as they do not require additional (financial) resources. Intervention 3 indicates the importance of controlling cast room capacity as well as reducing disturbances and variance during treatments. Hereby, we adjust capacity to deal with these occurrences (see Section 4.5.3). Those adjustments require additional financial resources. Therefore, we also recommend that the OCTs collaborate with the outpatient clinic stakeholders to adjust the current capacity levels so that no additional financial resources are required. Furthermore, the increase in coordination of external tasks around peak moments contributes to the desired performance as well. 4 PREFACE This report describes my research of the plaster cast room of AMC hospital, Amsterdam. This research is the conclusion of my master Production and logistics management (Industrial Engineering & Management) at University of Twente, Enschede. During my research, I was part of the department Quality & Process Innovation (KPI) – Patient oriented Logistics. Overall, I am satisfied with my research projects and its results. The project included many different stages, which kept the entire process interesting for me. However, throughout the project, it seems that all rumours about a graduation thesis are true, both in positive and less positive aspects. However, that is all in the past now! This research resulted in several additional documents to this report. These include the detailed analysis report for the observation period, and the recommendations document. Hereby, I am especially satisfied to see that part of the recommendations, as described in this report, already is being implemented at the moment of writing. To conclude, I thank the following people who were indispensable to my research:  the Orthopedic Cast Technicians Anja, Bas, Francis, Frank, José, Michel, as well the outpatient clinic personnel. It is a pleasure to see how enthusiastic these people perform their work in and around the cast room every day. In addition, they are always eager to answer my questions and discuss process considerations.  the cast room project group including Anja, Betty, Dicky, and Matthias. These people are the key stakeholders in the cast room process and provided me with value input and insight of the cast room process and its relation to the outpatient clinic Orthopedics, Traumatology, and Plastic Surgery.  the KPI project group including Delphine, Nikky, and Paul. These people acted in several roles during our cast room collaboration. Their expertise and skills regarding both logistics as well as coping with the hospital culture and people is a major contribution to my research.  my KPI colleagues. The ambiance in the KPI department was very pleasant, thanks to my KPI colleagues, who always allowed for amusement and variation to the tasks at hand. Special gratitude is in place for the supervisors of this research project: Nikky Kortbeek and Erwin Hans. Nikky Kortbeek started this project in December 2008, and played a key role in my research project. We had several meetings to discuss the scope and aspects of the cast room leading to the results included in this report. Erwin Hans is my supervisor from University of Twente. His extensive experience regarding the application of operations research in hospitals is highly valuable. In addition, Erwin made sure that I continuously kept track of the end goal, a high level academic report. To conclude, I am very proud to finish my master at University of Twente with this report and its findings. But this is not an end, nor is it a beginning, as I just passed another stop on the railway towards the future. Siebe-Thijs Hoogwout January, 2010 5 TABLE OF CONTENTS Management summary ........................................................................................................................................... 3 Preface .................................................................................................................................................................... 5 Chapter 1 - Introduction ......................................................................................................................................... 8 1.1 Context description ................................................................................................................................... 8 1.2 Problem description .................................................................................................................................. 8 1.3 Research objective & approach ................................................................................................................ 9 Chapter 2 - Context analysis of the current situation ........................................................................................... 12 2.1 Actors in the cast room process .............................................................................................................. 12 2.2 Description of the cast room process ..................................................................................................... 14 2.3 Performance of the current situation ..................................................................................................... 21 Chapter 3 - Formulation of solution approach ..................................................................................................... 31 3.1 Framework for hospital planning and control ........................................................................................ 31 3.2 Formal problem description .................................................................................................................... 32 3.3 Organizational interventions ................................................................................................................... 33 3.4 Discussion for evaluation tool ................................................................................................................. 38 Chapter 4 - Simulation study................................................................................................................................. 41 4.1 Conceptual design of the model ............................................................................................................. 41 4.2 Data gathering: fitting data to probability distributions ......................................................................... 47 4.3 Technical design of the model ................................................................................................................ 55 4.4 Verification and validation of the simulation model ............................................................................... 55 4.5 Experimental interventions ..................................................................................................................... 61 Chapter 5 - Results of the simulation study .......................................................................................................... 75 5.1 Base situation ........................................................................................................................................... 75 5.2 Intervention 1: Less invasive improvement actions ................................................................................. 78 5.3 Intervention 2: Redesign of the agenda system and appointment scheduling ....................................... 83 5.4 Intervention 3: More invasive improvement actions............................................................................... 90 6 Chapter 6 - Organizational implementation ....................................................................................................... 100 6.1 intervention 1: Less invasive improvement actions ............................................................................... 100 6.2 Intervention 2: Redesign of the agenda system and appointment scheduling ..................................... 102 6.3 Intervention 3: More invasive improvement actions............................................................................. 102 Chapter 7 - Conclusions & Recommendations .................................................................................................... 105 7.1 Conclusions ........................................................................................................................................... 105 7.2 Recommendations ................................................................................................................................ 106 7.3 Further research .................................................................................................................................... 107 References .......................................................................................................................................................... 109 Appendix A: Description of the patient groups ................................................................................................... 112 Appendix B: specialist consulting hours schedule .............................................................................................. 113 Appendix C: Specification of the treatment types .............................................................................................. 114 Appendix D: Glossary for formal problem description ....................................................................................... 115 Appendix E: Shift specifications for validation .................................................................................................... 117 Appendix F: Specialist schedule optimization ..................................................................................................... 119 7 CHAPTER 1 - INTRODUCTION The orthopedic plaster cast room (cast room) of Academic Medical Center (AMC) in Amsterdam, The Netherlands, has an unbalance between supply and demand that results in increased patient waiting times and decreased quality of labor and quality of care. In this report, we describe our research in detail. This includes an in-depth overview of the current cast room performance followed by our research to identify and evaluate several organizational interventions in order to improve the current performance. This chapter provides an introduction to the research topic. We start with a short context description of AMC (Section 1.1). Next, we formulate the problem description of the cast room (Section 1.2). To conclude, we present the research objectives and approach to reach the research objectives in this report (Section 1.3). 1.1 CONTEXT DESCRIPTION AMC consists of the Academic Hospital and the Faculty of Medicine of the University of Amsterdam. The core activities of AMC are patient care, scientific education and scientific research (AMC, 2007). AMC has three cast rooms, namely the cast room at the outpatient clinic Orthopedics, Traumatology and Plastic Surgery, the cast room at the Emergency department and the cast room at the Pediatric outpatient clinic. We focus our research on the first cast room. This cast room annually performs about 6,300 treatments. The cast room treats mainly patients with bone fractures by placing a plaster cast around the broken bone. These patients visit the cast room for a check of the healing process as they already have a cast around their fracture. The first cast is given to a patient at the Emergency department or at an operating room. Furthermore, patients with weakened physical bone conditions visit the cast room. These patients receive a cast or corset as a support for their bone conditions. During treatment at the cast room, an Orthopedic Cast Technician (OCT) removes a patient’s cast, after which in some cases a specialist inspects the healing process of the fracture or the bone conditions. Subsequently, the OCT treats the patient if the fracture has not healed yet or if the patient does not have to visit another AMC-department first. We provide a detailed process description in Section 2.1. 1.2 PROBLEM DESCRIPTION The stakeholders in the cast room process experience an unbalance between cast room capacity and patient demand. The unbalance results in a decrease of both quality of care and quality of labor. Highly fluctuating workloads during both day and week lead to increasing patient waiting times and practitioner overtime. The fluctuating workload and overtime lead to a decrease in practitioner satisfaction and quality of labor, whereas fluctuating workload and waiting times both decrease the patient-centeredness and quality of care. Furthermore, high patient waiting times conflict with the maximum allowable waiting time per patient as stated in the AMC Patient Manifest. AMC has introduced the AMC Patient Manifest in 2009. That document states several duties for practitioners to fulfill in the patient care process. We quote the following statement about maximum allowable waiting time per patient: “Your maximum waiting time before treatment is 20 minutes. When the consulting hours exceed regular hours, we will inform you about the reason and the expected delay. You will not go home without being treated.” First, the current performance shows a performance gap for the maximum allowable waiting time per patient: 74 % of all cast room patients is treated within 20 minutes of waiting time (Section 2.2). 8 Walk-in patients, patients without a prescheduled appointment at the cast room, represent a large and more unpredictable part of the total amount of patients (35 % of the total amount of cast room patients in 2008 (Section 2.2)). These patients contribute to an increase in waiting time for both walk-in patients as scheduled patients. This increase results in times that exceed the maximum allowable waiting time per patient of 20 minutes. Second, the number of patients fluctuates during both week and day. In addition, capacity decreases as a result of arbitrary external treatments and meetings (Section 2.2). Together, these factors result in highly fluctuating workloads and overtime for the OCTs. Subsequently, OCT-satisfaction and patient friendliness decrease during workload peaks. Finally, the process of scheduling patients lacks clear communication between patients, doctors’ assistants (DAs), OCTs and specialists. For example, this could result in patients visiting the cast room with an appointment on their patient card while the appointment is not registered in the cast room schedule. In addition, a lack of organization in the outpatient clinic contributes to the lack in clear communication. Based on these facts, we formulate the problem statement for the cast room: “The cast room in AMC has an unbalance in supply and demand that results in increased patient waiting times and decreased quality of care and quality of labor.” 1.3 RESEARCH OBJECTIVE & APPROACH Given the problem statement, we derive the main research objective as follows: “What organizational interventions for OCT capacity and appointment scheduling can we design and evaluate in optimizing the cast room performance” In order to reach the main research objective, we answer the following research questions and investigative sub questions: 1. What is the current performance of the cast room process?  What are the actors in the cast room process? We observe the cast room process to identify the actors and we interview both patients as cast room personnel. Due to a lack in availability of both historical and detailed data, we also use the observation to register detailed information about the actors in the cast room process. In addition to the observation period, we gather actor data from the hospital information system and cast room reports from the past. We analyze the gathered data to identify characteristics in order to group actors if necessary. Section 2.1 describes the main actors of the cast room process.  What is the cast room process? We observe the cast room process in detail during a four week observation period, we interview both patients as cast room personnel, and we use data from the hospital information system and cast room reports from the past. We combine the results to describe the cast room process. Section 2.2 provides a detailed description of the cast room process. 9  What are key performance indicators of the cast room process? We identify process key performance indicators from the literature and from our collaboration with the cast room stakeholders. We use these indicators to measure the current performance of the cast room process. Section 2.3.1 describes the key performance indicators.  What is the performance of the cast room process for the key performance indicators? During our observation period, we gather detailed information about the cast room process from difference sources. We combine and analyze the data to find scores for the key performance indicators and visualize the performance through graphs and tables. Section 2.3.3 summarizes the current performance of the cast room process for the key performance indicators as well as other interesting figures. The document ‘Optimalisatie logistiek gipskamer: Analyserapport’ (2009) includes the detailed analysis of the current cast room performance. Furthermore, we use a personnel questionnaire to identify strengths and potential improvement points of the cast room process. Section 2.3.3 includes the results of the personnel questionnaire.  What are bottlenecks in the current cast room process? We evaluate the results of our observation period to identify bottlenecks in the cast room process (Section 2.3.4). In addition, we formulate recommended approaches for these bottlenecks. 2. What organizational interventions can we develop to improve the current performance?  What topics relate to the cast room process and its problems? We link subjects from the literature to our process bottlenecks, and we choose the bottlenecks and subjects for further research (Section 2.3.4).  What concepts/theories can we find in the literature when searching with the key terms and topics? We use the literature subjects to find relevant concepts and theories. In Section 3.3, we discuss and summarize the literature that is related to the cast room process and bottlenecks.  What organizational interventions can we develop from the literature and the observation results? We connect our literature findings to the process bottlenecks to design recommendations. In addition, we organize a workshop with the cast room stakeholders to further identify possible recommendations. The report ‘Verbeteracties gipskamer’ (2009) describes the recommendations. We group the recommendations in organizational interventions for evaluation (Section 4.5). 3. What is the performance of the organizational interventions?  What technique can we use to evaluate the organizational interventions? We describe the aspects of our problem to identify the most suitable tool to evaluate the organizational interventions (Section 3.4). We use the tool to build a model that represents the current situation and is able to evaluate the organizational interventions (Chapter 4). 10