Simulation Project: Improving the X-Ray Process

at County Hospital


County Hospital wishes to improve the service level of its regular X-
ray operation, which runs from 8 A.M. to 5 P.M. Patients have
identified the total required time as their main concern with this
process. Management, on the other hand, is concerned with
utilization of available resources. Management has created a
process-improvement team to study this problem. The process
might be redesigned as a result of the teams recommendations.

The team has defined the entry point to the X-ray process to be the
instant a patient leaves the physicians office en route to the X-ray
lab. The exit point has been defined as the instant at which the
patient exits the X-ray facility and the completed X-ray is delivered
to the physicians office.

Patients are registered as they enter by a desk assistant, and a sample
of the arrival time data is provided in Table-1. Until now, no
attempt has been made to further analyze this data, so there is no
insight into what the arrival process looks like.

The team has identified 9 activities in the current X-ray process (see
Table-2), which is the same irrespective of the patient. The activity
times and their distributions are specified in Table-3.

The resource data for the X-ray process is specified in Table-3. There
are one desk clerk, three X-ray technicians, one dark room
technician, two X-ray labs, one dark room and one X-ray inspection
room. The two X-ray labs and the inspection room are staffed by X-
ray technicians while the dark room is staffed by a dark room
technician.


PART I: ANALYZING THE CURRENT PROCESS DESIGN

1. Step #1--Draw a flowchart of the current X-ray process.
2. Step #2--Develop a simulation model of this process.

The model requires analysis of input data regarding
the arrival process of patients. Look at the lecture
PowerPoint materials on analyzing input data as a
guide for your modeling. A combination of descriptive
statistics and a histogram can help you eyeball the
data to help determine the most appropriate
probability distribution function to help model
interarrival times.
Modeling Hint: Build the model incrementally based
on your flowchart. Do not try to put everything
together at once and then test whether it works. The
key is to use individual, small steps.
Be sure to specify your priorities and resources
correctly with SimQuick. Remember, a higher priority
has a lower number workstation. For instance, if you
have two workstations that compete for a resource, the
workstation with the higher priority is always entered
into the model first.
Table-1 presents patient arrival times. You need to
come up with some estimate of interarrival times,
meaning the time between arrivals, to come up with a
pattern for how patients enter into the X-ray facility. I
highly encourage you to create a histogram, run the
descriptive statistics from the analysis toolpack in Excel
and estimate an appropriate, average interarrival time.
You may need to include more buffers than noted in
Table-2. Assume that theres plenty of space available
for patients to wait while theyre in the service system.

3. Step #3First cut analysis based on one simulation run: As a
first-cut analysis, run one simulation, using the correct
activity time distributions. Look at the average cycle time, the
throughput rate, the queue lengths, and the descriptive
statistics, such as the mean and standard deviations. What
are the problems in this process?

4. Step #4Multiple simulation runs: Run 100 simulations and
compute the cycle time and daily throughput (average and
standard deviation). Also compute the queue and resource
utilization statistics with 95 percent confidence intervals.
Assume that any patients remaining in the system at the end
of the day will be taken care of by the night shift. Every
morning, the system is assumed to be empty. Are there any
surprises when you compare these results with the ones in
question 3?

5. Step #5Analysis based on multiple simulation runs: Assess
the performance of the process using the values calculated in
question 4. Where is the bottleneck? What is the problem
area in terms of reducing the cycle time and increasing the
throughput rate?



PART II: SUGGEST AND EVALUATE NEW PROCESS
DESIGNS

6. Step #6Creative process design based on acquired process
understanding: Based on your insight about the current
operations, identify and model at least two plausible ways of
reducing the average cycle time by redesigning the process.
For example, what if more personnel are hired? What type of
personnel would be most useful? What, if any, improvement
would adding a dark room and/or an X-ray lab have on cycle
time and throughput? What if the X-ray technicians receive
training designed to reduce the probability of rejecting X-rays
from 25% to 10%? Test at least two alternative, future-state
models against your baseline model.

7. Step #7Compare the as-is process with two alternative state
processes and two alternative state processes against each
other: Investigate the performance of the redesigned process
in terms of the cycle time, daily throughput and resource
utilization of key resources, such as the x-ray rooms and the
dark room(s). Also look at the resource and activity
utilization statistics and queue statistics with 95 percent
confidence intervals as before. What are your conclusions? Is
the new design significantly better than the old process with
regards to the cycle time and throughput? Are any
drawbacks obvious?

Helpful Hint: Although regression models or ANOVA
models would be most appropriate, the SimQuick book
(pages 98-106) walks you through statistical modeling with
descriptive statistics and the T-test for unequal variances.
Develop the appropriate T-test comparisons and report.
Remember, to fully assess the likely effectiveness of
alternative, future-state models vis--vis a baseline model or
two or more alternative models, we need to compare the
results using statistical inference methods to provide us
assessments of process averages as well as likely variation in
our processes. You need to report on both process averages
and process variation.

PART III: REPORT TO MANAGEMENT

You are the leader of the process improvement team, and you were
chosen to write-up the results from the process simulation and
report your findings and recommendations to the management team
of the hospital. In particular, the CEO, the CFO and the CMO are
members of the executive team and have their concerns you must
address. The CFO is concerned with resource utilization and
throughput rate and is skeptical about the need to hire additional
staff while the CMO is more concerned with patient satisfaction with
the X-ray process. You need to address both types of concerns as
well as support your findings with analyses drawn from your
process simulations.

Your grade is assessed based on your report to management and
whether you followed the steps in the simulation process.
Remember, the CEO, CFO, and CMO do not want the technical
details about how you ran the analyses; theyre not the technicians
and really dont have any interest in the technical aspects of process
simulation models. They primarily want to know about the current
process and whether your recommendations save time, save money,
save resources or create potential new revenue. Dont bore them
with the details. Save the details for a technical appendix, footnotes,
or end notes.













Table-1 Sample Arrival Times of Patients
1



Patient #
Time of Arrival
(in min. from time 0)

Patient #
Time of Arrival
(in min. from time 0)

1 6.30 31 197.89
2 10.13 32 205.50
3 17.07 33 215.42
4 17.09 34 219.95
5 23.94 35 223.50
6 26.06 36 233.33
7 27.65 37 234.89
8 29.21 38 239.20
9 41.65 39 244.29
10 44.69 40 247.29
11 60.07 41 249.90
12 70.34 42 250.25
13 70.73 43 256.34
14 74.32 44 257.90
15 84.59 45 268.97
16 91.77 46 276.82
17 95.78 47 280.43
18 98.20 48 281.94
19 117.24 49 293.23
20 122.85 50 299.79
21 130.58 51 303.75
22 137.46 52 306.58
23 139.76 53 308.13
24 142.52 54 314.06
25 150.70 55 322.82
26 151.95 56 326.51
27 154.74 57 338.21
28 157.48 58 339.91
29 193.25 59 353.65
30 195.46 60 359.79




1
Note: These are arrival times, not interarrival times. Interarrival means the time between
arrivals, so you need to subtract the time between subsequent arrivals. For instance, patient
number 29 arrived 193.25 minutes after the clinic opened while patient number 30 arrived
195.46 minutes after the clinic opened. The interarrival time between patient number 29
and patient number 30 is =195.46 193.25 or 2.21 minutes. From the interarrival times,
you should run the descriptive statistics for interarrival times in MS Excel and note the
mean and standard deviation from the statistics. You should also create a histogram in MS
Excel to try to determine which statistical distribution best fits the data. At a very
minimum, the mean or average interarrival time and the appropriate statistical distribution
are needed to estimate the interarrival time when patients enter into the clinic.




Table 2 Activities in the Current X-Ray Process
2


Activity Description Type
1 Patient leaves physicians office with instructions and enter
the X-ray center at an unspecified interarrival rate.

Start of X-ray
process

2 Patient takes a number and waits for the front desk assistant
to call.

Lobby
(Waiting Line)
3 The front desk assistant fills out a standard form based on
information supplied by the physician and the patient. The
patient then leaves the front desk, and queues up in front of
the X-ray labs.

Work Station
(Value-Added)
4 The patient enters the X-ray lab, undresses, and an X-ray
technician takes the required X-rays (all done in the X-ray
labs).

Work Station
(Value-Added)
5 A darkroom technician develops the X-rays. (Assume that
the patient accompanies his/her X-rays).

Work Station
(Value-Added)

6 An X-ray technician checks the X-rays for clarity. (Assume
that the patient accompanies his/her X-rays.)

Work Station
(Inspection)
7 If X-rays are not clear, the patient returns to the waiting room
in anticipation of repeating steps 4, 5 and 6. Historically, the
probability of rejecting X-rays has been 25%. If the X-rays are
acceptable, the patient proceeds to activity 8 and the X-rays
are put in the outbox, where eventually a messenger service
will pick them up.

Decision Point
8 Patient waits for the front-desk assistant to out-process.

Buffer
(Waiting Line)

9 The patient out-processes with the front-desk assistant and
goes home.

Work Station
(Out-Process)

10 Completed X-rays are taken to requesting physicians offices. Finish Process


2
You may need more elements than listed here for the SimQuick model to work properly.
You need to assume that the patient follows the x-ray, meaning that the patient waits as the
x-ray waits to be processed. In short, you will need more buffers than indicated by table-2.




Table 3 Resource Data for X-Ray Process
3


Resources Activities # of Units Available
X-ray technician 4 and 6 3
X-ray lab 4 2
Darkroom technician 5 1
Darkroom 5 1
Front-desk assistant 3 and 9 1



Table 4 Standard Times for X-Ray
Process


Activity
Activity Time
Distribution
Parameter Values
(in minutes)

1 See Table-1 See Table-1
2 Non Applicable Non Applicable
3 Uniform Max=5, Min=2
4 Normal Mean=15, SD=5
5 Normal Mean=10, SD=5
6 Normal Mean=3, SD=1.5
7 Not Applicable Not Applicable
8 Not Applicable Not Applicable
9 Uniform Max=5, Min=2
10 Batch Process Daily



3
Heres a word of advice: keep the resource modeling as simple as possible. Having a
resource listed in the table doesnt necessarily mean that you have to use the resource
modeling capabilities in SimQuick to model resources. For instance, if you have two of a
certain resource available and two workstations that need the resource, its generally
reasonable to assume that each workstation would have a dedicated resource. Resources
dont necessarily need to be shared. If, however, you either want to or if the situation
requires that two or more workstations share a common resource, such as using cross-
trained workers in exercise #10 in the SimQuick book, you need to use the resources
table(s) in SimQuick to model shared resources.