Paediatric Orthopedic Clinic at Children's Hospital

1. What is activity utilization at every step in the process? What is the direct labor utilization? In the simplest of words utilization is a measure of time spent working. It is the ratio between the time worked and time that could have been spent working. i.e. Utilization =

Actual time spent working ÷ Time available for work

We are specifically looking at two types of utilization here. First we will look into the utilization for each of the departments and then we look into direct labor utilization. The details of how the calculations were done are provided in Appendix. Activity Utilization For the purpose of calculating activity utilization, we look into the utilization of each of the four departments – Front office (registration and verification), X-ray and radiology, X-ray hand off and examination. For calculations we add all the times spent by all the staffs at each department doing their tasks and divide this sum by the sum of the total man minutes available at each department. From the calculation of the utilization we can see that the overall utilization of the clinic is 76.36%. This logically seems a good utilization rate but a bit higher utilization could be targeted for. Looking at the 4 departments individually, the examination activity looks very much utilized at a rate of 97.6%. This department looks to be under very high pressure and a little bit of variability in could cause lots of problems. And as we will see in the next section, the employees including the surgeon, cast technician and senior resident are all under immense pressure with the surgeon’s utilization exceeding 100%. The front desk that is responsible for the registration, verification, collection of X-Rays and filing/preparation of examination room is utilized at a rate of 76.02%, which is comparable to the clinic’s overall utilization and cannot be called over utilized. The X-Ray and radiology department seems to be underutilized at just about 70%. Given the very long waiting times at this department, a serious process improvement looks essential. Direct Labor Utilization The surgeon is being utilized for almost 110% i.e. he has to work more than the time he is supposed to work and hence the complaint from him about being over utilized looks fair. The senior resident also has a utilization rate of 92.23% and can be regarded fair enough although a comparison to other human resources and the overall clinic utilization might make them look

over utilized as well. The third member of the examination hall in the cast technician has a utilization rate of 90.03% and is also a good utilization rate. The nurses are being utilized at a rate of 77.05% whereas the clerks are being utilized at a rate of 74.07%. If we consider the radiology/X-Ray department as a part of the clinic then the labor utilization for the technicians and the radiologists are 83.44% and 69.79% respectively.

2. How is variability affecting capacity at the clinic? How can variability be controlled? Most of the data are variable in nature based on their occurrences. Here, we are concerning about the flow of patients in a pediatric orthopedic clinic. We cannot control the number and type of patient flow for check up in a clinic. We can only manage and schedule the resources available in a clinic in efficient manner so that the service could be delivered in optimized way. Based on collected data, it shows that clinic examines about 80 patients each half of the day, of which 60 percent returns for follow up appointment. In this case clinic can predict, in advance, the case and its nature of about 48 patients who register for follow-up every day. According to the exhibit 3, the bottleneck of all the process seems to be the radiology department where patients have to wait 58 minutes on an average and also has high standard deviation of 22 patients. The high waiting time and also a very large standard deviation shows that the variability at this department is very high. The Radiology Department is used by the Pediatric, Urology and Chest Clinic and the ER. This leads to varying demands that depend on patient arrivals for each department which causes variability in the amount of time a patient has to wait to get treated. The more patients, the more likely the wait time will increase. One way to control this variability would be to improve scheduling of the clinic with the other departments. Test can be performed to see when the machines are used the least amount of time and try to schedule appointments then. Also additional equipment purchases and staff may be considered to reduce the effect of variability. Similarly, the nature of the X-Ray needed is also affecting the variability at the clinic. Depending on the type of X-ray, the machine needs major adjustment. Here, the variable nature of incoming patients affects the time taken for X-ray due to the adjustment needed to switch between upper and lower extremities. The variable requirement of patient can, somewhat be controlled by using each machine to take either upper or lower extremities’ X-Ray. The six available machines can be dedicated to a certain type of X-Ray based on the previous data. But the flexibility in the machines should still be retained to address situations where need do not follow the trends.

The hospital might also think of buying a new X-Ray machine which would help reduce the waiting time (but we cannot say for sure) and also help control variability to some extent. However, given the cost of the new machine and more importantly given that the utilization of the X-Ray filming process is only about 80% and the X-Ray development is only about 60%, better scheduling can certainly give better results even with the existing number of machines.

3. Where is the bottleneck in the process? What are the capacity constraints at the clinic? Bottlenecks are the hindrances and obstructions to the processes that cause waits and delays. Bottlenecks interrupt the natural flow and determine the pace at which the whole process works. In this case the bottleneck in the processes is inherent in the wait times and the utilization rates at some of the departments and activities. The major bottlenecks in the case are seen in the radiology department and the examination hall. In the radiology department, the patients might have to wait up to double the time they spend at any other department. Patients are required to wait in reception area of radiology department until X-ray machine is available. Depending on the type of X-ray image, machine has to be adjusted and to adjust the machine from one extremity to other it took several minutes. After Xray, patient again has to wait to collect the X-ray image on film. The radiology department is also being used by Urology, Pediatrics and Chest clinic. Exceptions are frequently made for some patients from Emergency who required an X-ray urgently on short notice. Hence we can find high volume of patient in radiology department which has significantly increased the wait times in the radiology department. In the examination room, it was observed that the staffs are over utilized or close to being utilized. Either the surgeon or one of the senior residents performed the medical examination of the patient. The surgeon examined all the new patients and about 30% of follow up patients with greater complexity. A senior resident examined the remaining follow-up patients and has a utilization rate of more than 90%. The bottleneck has been determined to be the examination room, where the surgeon in particular has been working over capacity at over 110%. The demand of the services, especially at the examination room is more than the capacity. Although the overall utilization is 97% for the examination hall, the surgeon is over utilized representing a capacity constraint. All other departments have the capacity to handle the current demand of 80 patients at the moment, although the variability can make the capacity seem inadequate.

4. What is the economic cost of wait times? As given in the case, the average annual income of for full time workers in London is $44000 which means the average income per minute is $ 0.08 (since 44000/(365*24*60)) .The calculation given below has been made taking a confidence level of 95% i.e. 2 sigma and the data as provided below New Patients Follow up Patients Department Total Process Waiting Total Proces Time Time time Time s Time Waiting time Upper limit 38 14 24 33 9 24 Front Desk Lower limit 22 14 8 17 9 8 Upper limit 102 23 79 102 23 79 Radiology Department Lower limit 14 23 0 14 23 0 Hand-off of Upper limit 7 4 3 7 4 3 X-Ray to clinic Lower limit 0 4 0 0 4 0 Upper limit 76 24 52 71 24 47 Examinatio n Room Lower limit 0 24 0 0 24 0 Upper limit 223 65 158 213 60 153 Total Lower limit 36 65 8 31 60 8

Average Annual Income Average Income per minute

Economic Cost of Wait times for one visit

44000 0.0837

New Patients

Follow up patients

Upper limit Lower Limit Upper limit Lower Limit

13.23 0.67 12.81 0.67

Hence, the economic cost of one visit for a new patient can range from $0.67 to $13.23 and that for a follow up patient can range from $0.67 to $12.81.

5. What recommendations would you make and why?

a. Change Clinic Timings The clinic operation coincides with the usual office hours and hence many parents are complaining. This could be handled by changing the clinic operating time, probably to evening time when most of the parents would be done with their work. b. Allow both the senior residents to check patients The examination hall is seen to be a bottle neck. The surgeon is over utilized and another senior resident almost utilized whereas the second resident is limited to being a mere observer. If this is done for training purposes the clinic can place the surgeon and one senior resident in the same examination hall so that the surgeon can supervise the senior resident while also checking other patients. c. Proper scheduling with other clinics At the moment different clinics are operating at the same time and are sharing the Radiology department. The radiology department is a bottleneck and faces lots of variability. Scheduling clinic operating time will help ease the pressure and also decrease the variability faced by the department. d. Purchasing a new X-Ray machine Although we cannot say for certainty, it is estimated that a new machine could decrease the waiting time by 25%. The current waiting time of 35 minutes can be reduced to 26.25 minutes and this reduction would show up as a significant reduction in total time. But this purchase would increase the total cost and other options should be explored first. e. Dedicated machines to upper and lower extremities The adjustment time of the X-Ray machines when switching between extremities is a source of variability and is causing some delays. This could be avoided by dedicating some machines to the upper extremities while others to lower. Proper trend analysis should be done to determine how many machines should be dedicated to which part. f. Preparation and pre operations activities There are few activities that the clinic and the patients can do even before the patients arrive at the clinic. For example follow up patients who are arriving from a far location can have their X-ray done in their own locality before they come to the clinic. The nurses need to provide instructions during the previous visits. Similarly it would be more efficient to retrieve the records of the follow up patients before-hand i.e. as soon as the appointment was made for a re-visit instead of retrieving the records only after the patient arrives thus wasting time in doing so. g. Automated information flow

Most of the information flow between the departments is happening manually in the form of internal referrals and hard copy. An automated and real time information system would save a lot of time. For example, the X-ray report could be fed into the system by the radiology department for the use of the doctor rather than the patients waiting for the development, walking 25 meters, handing it to the nurse who files it and gives it to the examiner. Automating would allow the examination nurse to prepare the room and the surgeon to be informed even before the patient arrives. There are many other activities an automated information system would be useful.

Appendix: Calculation of Utilization Rate 1. Front Desk 1.1. Registration Operating time – 8:30 AM – 11:30 AM i.e. 3 hours or 180 minutes Total Staffs involved – 3 clerks Total time available = 3 × 180 = 540 minutes Time spent on registration = 80 patients × 5 minutes = 400 minutes Utilization of clerks = utilization of the registration process = 400 ÷ 540 = 74.07% 1.2. Verification Operating time – 8:30 AM – 12:45 PM i.e. 4 hours 15 minutes or 255 minutes Total Staffs involved – 3 nurses Total time available = 3 × 255 = 765 minutes Time spent on Verification = 9 min × 32 new patients + 4 min × 48 follow up = 480 min Utilization of the verification process = 480 ÷ 765 = 62.75% (Since the nurses are also involved in X-Ray collection, this is not equal to nurse direct labor utilization) Total utilization of the registration and verification activity = (400+480) ÷ (540+765) = 67.43% 1.3. X-Ray Hand off 1.3.1. Collection of X-Ray Total number of X-rays = 11 min × (all new patients + 85% of follow up) =11 × (32 + .85 ×48) = 72.8 Total time available = 3 nurses × 255 min = 765 minutes Total time required = 2 minutes × 72.8 X-rays = 146 minutes Utilization = 146 ÷ 765 = 19.04% 1.3.2. Filing and exam room preparation Total time available = 1 nurse operating for 255 minutes (8:45 – 1:00) = 255 min Time needed = 2 min × 80 patients (assuming all patients necessitate preparation of examination hall) = 160 minutes Utilization of the activity = 160 ÷ 255 = 62.75% Utilization of the X-Ray Hand off activity = (146+160) ÷ (765+255) = 30%

2. Radiology Department 2.1. X-Ray Filming Operating for 4 hours or 240 minutes from 8:30 to 12:30 with 6 technicians/machines But out of this 240 minutes only 2/3 of the total time is for the clinic i.e. 160 minutes Total time available for x-ray filming for the clinic = 160 × 6 = 960 minutes Total time required = 72.8 X-rays × 11 minutes = 801 minutes Process utilization = 801 ÷ 960 = 83.44% 2.2. X-Ray Development This is a non-labor activity and is carried out totally by the machines Time available = 960 Time needed = 72.8 x-rays × 7 min = 510 minutes Process utilization = 510 ÷ 960 = 53.13% 2.3. Diagnosis reading and analysis Operating time = 160 minutes for the clinic with 3 radiologists Total time available = 160 × 3 = 480 minutes Total time required = 5 min × 72.8 x-rays = 364 Process utilization = 364 ÷ 480 = 75.83% Overall utilization of the radiology department = (801+510+364) ÷ (960+960+480) = 69.79% 3. Examination 3.1. By the surgeon Operating time: 8:45 – 1: 00 i.e. 255 minutes, one surgeon Total time available = 255 minutes Total time required = 7 min × all new patients + 4 min × 30% of follow up = 7 × 32 + 4 × .3 × 48 = 282 minutes Utilization of the surgeon = 282 ÷ 255 = 110.6% 3.2. By the senior resident Time available = 255 minutes Time required = 7 min × 70% of all follow up patients = 7 × .7 × 48 = 235.2

Utilization rate for the senior resident = 235.2 ÷ 255 = 92.23% 3.3. Cast Technician Total time available = 255 minutes Total time required = 17 min × 25% of new patients + 13 min × 15% of followup = 17 × .25 × 32 + 13 × .15 × 48 = 229.6 Process/labor utilization = 229.6 ÷ 255 = 90.03% Overall utilization of the examination hall = (282+235.2+229.6) ÷ (255+255+255) = 97.6% 4. Labor utilization for the nurses Total time available = Time for the three nurses at verification and x-ray collection + time for the nurse at the exam prep duty = 765 + 255 = 1020 minutes Total time required = Verification + X-Ray collection + Filing and exam hall prep =480 + 146 + 160 = 786 minutes Labor utilization = 786 ÷ 1020 = 77.05 5. Overall utilization of the clinic resources Total time available Clerks Nurses X-ray technicians X-ray development Radiologists Surgeons Senior Resident Cast Technicians Total Total time required for Registration and registration X-ray processes X-ray hand off Examination Total

540 1020 960 960 480 255 255 255 4725 880 1675 306 746 3607

Overall Utilization rate of the clinic = 3607 ÷ 4725 = 76.36%