MGH 2015

OIT 262: Operations
Class 7: Process Improvement in Health Care

Yonatan Gur
Graduate School of Business
Stanford University
Plan for Today

Reminder: Littlefield begins Wed. 4/29, 1:00pm
- Register your teams (username, password)
- Plan on meeting before 4/29 to strategize
- Inventory Management review session on 4/29
I.
Process Flow at Mass General
II. Inventory Build-up at Bottleneck

III. Waiting Times at Non-Bottleneck Steps
IV. Recommendations
V. MGH Guest: Cecilia Zenteno
Stanford GSB
OIT 262 Prof. Gur Class 7
Goals for the MGH Case

Capstone Case in
Process Analysis Segment
How can operations help deliver
health care/services more
efficiently?
How can process and queueing
analysis help inform managerial
decisions and strategies?
Stanford GSB
Massachusetts General Hospital

Mass General Hospital
Founded 1811
950 beds, 4.6 million square feet
#2 hospital in US (2014-2015, US News)
consistently 1st or 2nd in recent years
Anesthesia Department
Birthplace of anesthesia
278 physicians, 198 nurses
Supports patients before, during, and after
surgery
Pre Admission Testing Area (PATA)
Responsible for outpatients (43% of surgeries)
Evaluate safety of anesthesia before surgery
Inform patient
Obtain legal acknowledgement and consent
Stanford GSB
PATA Problems
Dr. Peter Slavin
President, Massachusetts General Hospital
Dear Dr. Slavin,
The
very nice and
apologetic,
butinofVermont,
the almost
Last week I brought
myproviders
mother intowere
the Pre-Admission
Testing
Area. We live
almost 3
hours away, and4had
to make
specialintrip
forclinic,
this appointment,
which her oncologist, Dr. Paul
hours
we aspent
the
only 1 hours
Schneider, said was
necessary
to ensureface
a safe
and with
successful
surgery.
of that
was actually
time
anyone!
When we arrived at the clinic, the waiting room was so full, it was five minutes before my mother and I
Average patient visit length: 3h15 min
could get two seats together. We sat there for a full half-hour before they sent us back to get her blood
Face
timewaited
with back
providers:
1h20room
min for another 45 minutes before being moved
pressure reading.
We then
in the waiting
Provider
frustrated
& came
providers
to an exam room.
It was 20OT,
minutes
before a patients
nurse finally
in and she mostly just asked questions I
had already answered on a form provided by the front desk. After the nurse left, it was almost another
half-hour before the doctor finally came in and he also asked many of the same questions. The
providers were very nice and apologetic, but of the almost 4 hours we spent in the clinic, only 1 hours
of that was actually face time with anyone!
two families in the waiting room said their relatives never even
Even more aggravating,had
whiletomy
mother
was in appointment.
surgery this morning,
families
thesame
waiting room said their
have
a PATA
Onetwo
even
had inthe
relatives never even hadcondition
to have a PATA
appointment.
One
even
had
the
same
condition
as my mother so Im not sure
as my mother
why our PATA visit was even necessary.
I brought my mom from PATA
out-of-state
because
were of
toldsurgical
that Massout-patients
General provides the best care in
can only
seewe65%
all of New England, maybe even the country, but thats not at all what we experienced. I sincerely hope
or visit
delayed
surgeries
that we can expect moreCancelled
from our next
to MGH.
~ Claire Bradley
Rutland, VT
Stanford GSB
PATA Process Flow
Stanford GSB
PATA Floorplan
PATA Floor Plan
Exam Room 7
Office of the
Nursing
Director
Exam
Room
8
Exam
Room 6
Exam
Room
9
(Charge Nurse Station)

Exam
Room 5
Supply Closet
Exam
Room 4
Bathroom
Chart Room
Closet
Exam
Room 3
Exam
Room 2
Exam
Room 1
Kitchen
Bathroom
Lab
(Blood
work)
Exam
Room
11
Exam
Room
12
Lab (Vitals + EKG)
EKG Bed
Cabinets/Counter
Top
Computer Station
Front Desk
Stanford GSB
Exam
Room
10
Sign In at Front Desk

PATA Floor Plan
Exam Room 7
Office of the
Nursing
Director
Exam
Room
8
Exam
Room 6
Exam
Room
9

Exam
Room 5
Supply Closet
Exam
Room 4
Bathroom
Chart Room
Closet
Exam
Room 3
Exam
Room 2
Exam
Room 1
Kitchen
Bathroom
Lab
(Blood
work)
Exam
Room
11
Exam
Room
12
Lab (Vitals + EKG)
EKG Bed
Cabinets/Counter
Top
Computer Station
Front Desk
Stanford GSB
Exam
Room
10
Lab for Vitals and EKG

PATA Floor Plan
Exam Room 7
Office of the
Nursing
Director
Exam
Room
8
Exam
Room 6
Exam
Room
9

Exam
Room 5
Supply Closet
Exam
Room 4
Bathroom
Chart Room
Closet
Exam
Room 3
Exam
Room 2
Exam
Room 1
Kitchen
Bathroom
Lab
(Blood
work)
Exam
Room
11
Exam
Room
12
Lab (Vitals + EKG)
EKG Bed
Cabinets/Counter
Top
Computer Station
Front Desk
Stanford GSB
Exam
Room
10
Charge Nurse Station

PATA Floor Plan
Exam Room 7
Office of the
Nursing
Director
Exam
Room
8
Exam
Room 6
Exam
Room
9

Exam
Room 5
Supply Closet
Exam
Room 4
Bathroom
Chart Room
Closet
Exam
Room 3
Exam
Room 2
Exam
Room 1
Kitchen
Bathroom
Lab
(Blood
work)
Exam
Room
11
Exam
Room
12
Lab (Vitals + EKG)
EKG Bed
Cabinets/Counter
Top
Computer Station
Front Desk
Stanford GSB
Exam
Room
10
10
Exam Room
PATA Floor Plan
Exam Room 7
Office of the
Nursing
Director
Exam
Room
8
Exam
Room 6
Exam
Room
9

Exam
Room 5
Supply Closet
Exam
Room 4
Bathroom
Chart Room
Closet
Exam
Room 3
Exam
Room 2
Exam
Room 1
Kitchen
Bathroom
Lab
(Blood
work)
Exam
Room
11
Exam
Room
12
Lab (Vitals + EKG)
EKG Bed
Cabinets/Counter
Top
Computer Station
Front Desk
Stanford GSB
Exam
Room
10
11
Chart Room
PATA Floor Plan
Exam Room 7
Office of the
Nursing
Director
Exam
Room
8
Exam
Room 6
Exam
Room
9

Exam
Room 5
Supply Closet
Exam
Room 4
Bathroom
Chart Room
Closet
Exam
Room 3
Exam
Room 2
Exam
Room 1
Kitchen
Bathroom
Lab
(Blood
work)
Exam
Room
11
Exam
Room
12
Lab (Vitals + EKG)
EKG Bed
Cabinets/Counter
Top
Computer Station
Front Desk
Stanford GSB
Exam
Room
10
12
Lab (Blood Work)

PATA Floor Plan
Exam Room 7
Office of the
Nursing
Director
Exam
Room
8
Exam
Room 6
Exam
Room
9

Exam
Room 5
Supply Closet
Exam
Room 4
Bathroom
Chart Room
Closet
Exam
Room 3
Exam
Room 2
Exam
Room 1
Kitchen
Bathroom
Lab
(Blood
work)
Exam
Room
11
Exam
Room
12
Lab (Vitals + EKG)
EKG Bed
Cabinets/Counter
Top
Computer Station
Front Desk
Stanford GSB
Exam
Room
10
13
PATA Process Flow Diagram and Capacity

Arrival rate = 8 pts/hr
7am-12 and 2-3pm

12-2pm (lunch)
Queue 1
Patients
arrive
Check-in
Queue 2
Wait
Capacity = 30 pts/hr
(Waiting Room)
Vitals + EKG
in Lab
Wait
Capacity =12 pt/hr

(lunch: 6 pt/hr)
(Waiting Room
+ Exam Room)
Capacity = 7 pt/hr
(lunch: 2.8 pt/hr)
Provider path
RN Chart
Review
5 min/pt
RN Visit
Wait
RN Chart
Write-Up
(Exam Room)
10 min/pt
RN Visit
27 min/pt
Queue 3
MD Chart
Review
MP Visit
Provider path
11 min/pt
MD Visit
Capacity = 7.5 pt/hr

(lunch: 3.75 pt/hr)
37 min/pt
Queue 4
MD Chart
Write-Up
17 min/pt
Stanford GSB
Blood Work
in Lab
Wait
(Waiting Room)
Capacity = 30 pt/hr
(lunch: 20 pt/hr)
Check-out
Patients
Leave
Capacity = 60 pt/hr
14
Calculating PATA Process Capacities

Check-in
Service time = 2 min/pt
Service rate = 30 pt/h
m = 1 attendant
MD Visit
Vitals + EKG in Lab

Service time =10 min/pt
m = 2 technicians
Capacity = 12 pt/hr
(lunch: 6 pt/hr)
RN Visit
Service time =43 min/pt
Stanford GSB
Chart review = 5 min/pt

Visit with patient = 27 min/pt
Chart write-up = 11 min/pt
Service rate = 1.4 pt/h

m = 5 nurses
Capacity = 7 pt/hr
(lunch: 2.8 pt/hr)
Chart review = 10 min/pt

Visit with patient = 37 min/pt
Chart write-up = 17 min/pt
Service rate = 0.94 pt/h

m = 8 MDs
(lunch: 3.75 pt/hr)
Blood Work in Lab

m = 3 technicians
Capacity = 30 pt/hr
(lunch: 20 pt/hr)
Check-out
m=1 attendant
Capacity = 60 pt/hr
15
PATA Process Capacities
Non-Lunch
Step
Check-in
Vitals + EKG in Lab
RN Visit
MD Visit
Blood Work in Lab
Check-out
Service Time
(min/pt)
2
10
43
64
6
1
Service Rate
(pts/hr)
30
6
1.40
0.94
10
60
Lunch
# of
Capacity
# of
Capacity
Employees (pts/hr) Employees (pts/hr)
1
30
1
30
2
12
1
6
5
7
2
2.8
8
7.5
4
3.75
3
30
2
20
1
60
1
60
The RNs are the bottleneck
Stanford GSB
16

7am-12 and 2-3pm

12-2pm (lunch)
Queue 1
Patients
arrive
Check-in
Queue 2
Wait
(Waiting Room)
Vitals + EKG
in Lab
Wait
Capacity =12 pt/hr

(lunch: 6 pt/hr)
(Waiting Room
+ Exam Room)
Bottleneck
Provider path
RN Chart
Review
5 min/pt
RN Visit
Wait
RN Chart
Write-Up
(Exam Room)
10 min/pt
RN Visit
27 min/pt
Queue 3
MD Chart
Review
MP Visit
Capacity = 7 pt/hr
(lunch: 2.8 pt/hr)
Provider path
11 min/pt
MD Visit

(lunch: 3.75 pt/hr)
37 min/pt
Queue 4
MD Chart
Write-Up
17 min/pt
Stanford GSB
Blood Work
in Lab
Wait
(Waiting Room)
Capacity = 30 pt/hr
(lunch: 20 pt/hr)
Check-out
Patients
Leave
Capacity = 60 pt/hr
17
What Does Patient Flow Look Like

Before the RN step
Patients can flow through at the arrival rate until the waiting
room is full (like in Cranberry)
No info on waiting room capacity lets just assume its large
and never fills up (those who cant find a seat just stand)
Then flow rate at steps before the RN is 8 pts/hr in non-lunch
times, 4 pts/hr during lunch
At the RN step and afterwards
RN capacity limits flow
So flow rate = 7 pts/hr in non-lunch times, 2.8 pts/hr during
lunch
Stanford GSB
18
Utilization Analysis
Non-Lunch
Step
Check-in
Vitals + EKG in Lab
RN Visit
MD Visit
Blood Work in Lab
Check-out
Stanford GSB
Flow Rate
(pts/hr)
8
8
7
7
7
7
# of
Employees
1
2
5
8
3
1
Lunch
Capacity
(pts/hr)
30
12
7
7.5
30
60
Util.
0.27
0.67
1.00
0.93
0.23
0.12
Flow Rate
(pts/hr)
4
4
2.8
2.8
2.8
2.8
Capacity
# of Employees (pts/hr)
1
30
1
6
2
2.8
4
3.75
2
20
1
60
Util.
0.13
0.67
1.00
0.74
0.14
0.05
19
Time Out: Whats Going on in This Process

RNs are overloaded
Like in Cranberry, they build up a backlog of work
Will work through backlog after patients stop arriving
Can analyze using inventory build-up diagrams
Other stations have utilizations < 1
Waiting times in front of other stations will be driven by
randomness in arrivals/processing
Can analyze using queueing tools
PATA has waiting times driven both by too little capacity (at RN
station) and randomness (at other stations)
Stanford GSB
20
Analyzing Inventory Buildup at the RN Station
Capacity
7 am 12 pm: 7 pts/hr
12 pm 2 pm: 2.8 pts/hr
2 pm end of day: 7 pts/hr
Arrivals
7 am 12 pm: 8 pts/hr
12 pm 2 pm: 4 pts/hr
2 pm 3 pm: 8 pts/hr
After 3 pm: 0 pts/hr
Stanford GSB
Backlog Accumulates at
7 am 12 pm: 1 pt/hr
12 pm 2 pm: 1.2 pts/hr
2 pm 3 pm: 1 pt/hr
3 pm+: -7 pts/hr
21
Inventory Buildup at RN Station

Peak: 8.4 patients at 3 pm
4:12 pm
Stanford GSB
22
Average Inventory at RN Station

Time
Length (hours) Start Inv End Inv Avg Inv
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
3 pm - 4:12 pm
1.2
8.4
0
4.2
Grand Average
4.11
Avg Patients Waiting = 4.11

Comment: Another way is by:
Avg Patients Waiting = AUC/b
If was triangle, we would get
0.5*h*b/b = 0.5*h = 4.2
(pretty close!)
Stanford GSB
23
Average Patient Waiting Time

Average flow rate (out of RN queue)
7 patients/hr from 7 am to 12 pm (5 hours)
2.8 patients/hr from 12 pm to 2 pm (2 hours)
7 patients/hr from 2 pm to 4:12 pm (2.2 hours)
Weighted average = 6.1 patients/hr
Average patient waiting time
Littles Law: Inv = Flow Rate x Flow Time
Flow Time = Inv/Flow Rate
Waiting Time = (4.11 pts) / (6.1 pts/hr) = 0.67 hrs = 40 min
Average patient waits 40 minutes at RN station
Comment: another way is by AUC/(number of patients)
If triangle we get 0.5 x 9.2 x 8.2 / 56 = 0.664 hrs (very close!)
Stanford GSB
24
What Have We Done?

RNs are overloaded
40 minutes of waiting time at RN
station) and randomness (at other station)
Stanford GSB
25
Whats Next?
RNs are overloaded
40 minutes of waiting time at RN
station) and randomness (at other station)
Stanford GSB
26

7am-12 and 2-3pm

12-2pm (lunch)
Queue 2
Avg Wait Time = 40 min
Queue 1
Patients
arrive
Check-in
Wait
(Waiting Room)
Vitals + EKG
in Lab
Wait
Capacity =12 pt/hr

(lunch: 6 pt/hr)
(Waiting Room
+ Exam Room)
Capacity = 7 pt/hr
(lunch: 2.8 pt/hr)
Provider path
5 min/pt
RN Visit
RN Visit
27 min/pt
Wait
RN Chart
Write-Up
(Exam Room)
10 min/pt
MP Visit
RN Chart
Review
Queue 3
MD Chart
Review
Provider path
11 min/pt
MD Visit

(lunch: 3.75 pt/hr)
37 min/pt
Queue 4
MD Chart
Write-Up
17 min/pt
Stanford GSB
Blood Work
in Lab
Wait
(Waiting Room)
Capacity = 30 pt/hr
(lunch: 20 pt/hr)
Check-out
Patients
Leave
Capacity = 60 pt/hr
27
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
Stanford GSB
28
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
Std Dev p [min]
3.5
29
CVp
m
0.35
2
0.45
8
0.33
3
0.67
0.93
0.23
Tq [min]
6.38
11.77
0.02
Queue 1
Queue 3
Queue 4
Arrival rate (1/a) after RN equals the capacity at RN = 7/60 = 1/8.6

Total waiting time from queueing effects = about 18 minutes
CVa and CVp data for MD and Blood Work on page 14 of case.
Stanford GSB
29
PATA Process Flow Diagram and Total Flow Times

Queue 1
Avg Wait Time = 6.4 min
Patients
arrive
Check-in
Vitals + EKG
in Lab
Wait
Time = 2 min
Queue 3
MD Chart
Review
5 min/pt
RN Visit
RN Visit
27 min/pt
Wait
RN Chart
Write-Up
(Exam Room)
10 min/pt
11 min/pt
MD Visit
Total Time = 47 min
37 min/pt
MD Chart
Write-Up
17 min/pt
Total Wait Time = 58 minutes

Stanford GSB
(Waiting Room
+ Exam Room)
Total Time = 32 min
Provider path
RN Chart
Review
Wait
Time = 10 min
(Waiting Room)
Provider path
MP Visit
Queue 2
Queue 4
Average Wait Time = 0.02 min
Wait
Blood Work
in Lab
Check-out
(Waiting Room)
Time = 6 min
Time = 1 min
Total Service Time = 98 minutes

Patients
Leave
Avg Flow Time = 156 minutes

30
Summary of Initial Analysis

1 hour (about 1/3 of total time in system) is non-value added
waiting
Even more waiting (from patient perspective) during NP/MD writeup times (value is added during these times but the patient is not
face-to-face with a provider)
The non-value added waiting may be controllable via the design of
the system
Processing capacity/staff
Physical capacity/exam rooms
Scheduling
Now that we know whats driving the non-value added waiting
times, we can see how proposals impact that time
Stanford GSB
31
Analysis of Taskforce Recommendations

We asked you to analyze three specific recommendations:
Extend hours to 6:30 pm, increase time between appointments to

45 minutes
Add an RN
Add an MD
Lets look at each of these

Stanford GSB
32
Extend Hours to 6:30 pm, Schedule Appointments Every 45 Minutes

Current System
Non-lunch: 4 arrivals every 30
minutes 8 patients/hr
Lunch: 2 arrivals every 30 minutes
4 patients/hr
Proposal
Non-lunch: 4 arrivals every 45
minutes 5.3 patients/hr
Lunch: 2 arrivals every 45 minutes
2.67 patients/hr
To maintain same number of total arrivals
(56) in 1 day, you actually need to extend
scheduled arrivals from 3 pm to 6:30 pm
(not 6 pm as in the case)
Does this help?
Stanford GSB
33
Slow Down Arrivals: Analysis

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
Vitals + EKG
a
11.3
Std Dev a
8.9
CVa
0.8
p
10
Std Dev p
3.5
CVp
0.35
m
2
u
0.44
Tq
1.01
NP
11.3
11.3
1.0
43
21
0.49
5
0.76
11.26
MD
11.3
2.3
0.2
64
29
0.45
8
0.71
1.09
Blood Work
11.3
4.5
0.4
6
2
0.33
3
0.18
0.01
What are the main drawbacks?

Stanford GSB
34
Add a Registered Nurse (RN)

Current RN utilization is 100%, resulting
in inventory buildup, current average
wait time of 40 minutes
What happens if we add 1 RN?
Assume extra RN at both lunch and
non-lunch
RN capacity goes from 7 pts/hr to
8.4 pts/hr during non-lunch
RN capacity goes from 2.8 pts/hr to
4.2 pts/hr during lunch
Both are more than demand, so 1
extra RN eliminates inventory buildup due to insufficient capacity
Does this help?
Stanford GSB
35
Add an RN: Analysis
No more inventory build-up at RN, but now MD is bottleneck

MD capacity is 7.5 patients/hr, only slightly more than RN
Can expect inventory buildup at MD step
Even without deterministic inventory buildup at RN, will still have
queueing delays (utilization still high around 95%)
Does it worth the cost?

Stanford GSB
36
Add an Anesthesiologist (MD)

Current MD utilization is 93%, resulting
in queueing delays due to randomness,
current average wait time of almost 12
minutes
What happens if we add 1 MD?
Focus on non-lunch (9 am 12 pm)
time used in queueing analysis
above
MD staff goes from m = 8 to m = 9
Utilization at MD step goes from
93% to 83%
Does this help?
Stanford GSB
37
Add an MD: Analysis

Waiting time drops to 2.68 minutes (reduction of less than 10
minutes - at most it could be 12 minutes)
Anesthesiologists are expensive and this is a minimal decrease in
waiting time
Does it worth the cost as a standalone measure?

Stanford GSB
38
Your Recommendations: How to Fix PATA
Stanford GSB
39
MGH Wrap-up
Recall our framing thoughts:
How can operations help deliver health care
more efficiently?
How can process and queueing analysis
help inform managerial decisions and
strategies?
How process analysis helps?
Complicated system to analyze
Tools allow for solid first order
assessment of the problem and impact
of potential actions
Further analysis and simulation may be
useful to predict impact more accurately
And this is only the tip of the iceberg!
Queueing analysis has been improving
the design of health care systems in
many aspects to reduce patient waiting
times at minimal costs
Stanford GSB
40
Process Improvement in Health Care

MGH PATA Redesign
Stanford GSB
April 24, 2015
PATA Follow-Up
Immediate Actions
1. RN and MD assigned to patient at the same time.
RN Visit
Gave MD 20 25min to do chart review

Eliminated wait time between providers
Wait
2. RNs given a 5-minute patient history rule

3. No batching of intake forms at front desk
MD Visit
4. Only charge nurse allowed to modify the appointment

schedule/tracking sheet
5. Redesigned card RNs filled out in visit
Reduced patient wait time ~20min
Helped with staff morale and set up clinic for long term strategies
42
PATA Follow-Up
Long-Term Actions
Kelsey McCarty hired as Sr. Project Manager
Business plan to redesign entire process
Presented to CEO and funded at
$2.6M over 3 years
1.
See 100% of patients

Ensure positive patient experience
Generate high quality evaluations
Phone Program for low acuity, low complexity patients

RNs collect basic info over phone + 2min assessment on day of surgery
Triage grid for surgeons: phone vs clinic + lab and EKG orders
2.
Single-provider model in clinic with Nurse Practitioners (NPs)

NPs can do both RN Assessment and anesthesia evaluation
3.
Predefined schedule: Patients assigned in advance 90min visit
4.
Web-based intake form for patients to complete in advance
5.
RFID tracking of all patient and providers in PATA
2h appt = 30min for labs + 90min appt with NPs

43
MGH-MIT Collaboration: Work to date

Implemented & Results
Ready In
toImplementation
start implementation
OR block reallocation
(elective cases)
Intra-day surgical scheduling

Post-surgery Recovery Area patient flow
OR Open Blocks
(non-elective cases)
Cancer Center
Inventory management of surgical

supplies - Part I
Primary Care Redesign Rx

Management
New
In design
projects
Hospital bed capacity
management
(predictions &
decision support)
Primary Care Redesign
Provider Scheduling
Critical Care
Non-Oncology Infusion
Surgical Observation
Patient Flow
Optimization
44
OR Scheduling of Non-Elective Cases: Symptoms

T. Carnes, B. Daily, P. Dunn, R. Levi, S. Moss, D. Price, C. Zenteno
Max Prescribed Wait Time

Non Urgent
24 hours
Urgent
4 hours
Emergent
45 minutes
~30% patients waited more than

recommended wait time
Non-elective cases = wait list cases

Data source: MGH OR case data. Time frame: July 2009 vs May 2010
Surgeries performed on weekdays, excluding holidays.
45
OR Scheduling of Non-Elective Cases:

Centralized Open Blocks
Objective: Increase timely access for waitlist cases
Before project
~2.4 Reserved ORs owned
by particular services on
weekdays
Centralization
Jan Sept 2012
Two extra blocks

became available
October 2012
Simulation Model
5 Open Blocks
Block = {Operating Room, Weekday},

7am 5pm
~30% patients < 3% pts. wait more than

recommended wait time
Assumes OR is the only limiting factor
46
OR Scheduling of Non-Elective Cases: Results

Even with 9% increase in overall case volume, the average wait time decreased by 25%
for all non-elective cases.
100%
80%
% Patients had procedure within designated

wait time
87.7%
79.3%
86.2%
75.3%
70.0%
65.3%
60%
OR Type
Prime Time
Utilization
Elective
87.2%
86.2%
Non-electives
86.1%
80%
40%
20%
0%
Non-Urgent
Urgent
2011
Emergent
OR Type
Avg # Running
ORs/day
Elective
45.8
47.3
Non-electives
2.4
2.7
2012
Wait time = Booking time Into OR
Data source: MGH OR case data

Time frame: June Dec 2011 vs June Dec 2012
Surgeries performed on weekdays, excluding holidays.
47
Success Drivers and Lessons Learned

Work only on top priority burning problems
Make sure data is available to identify the problem
Understand mutual cultures, organization and community
Leadership engagement to support implementation
Analyzing impact of implementation and monitoring results
is a big challenge Very dynamic environment!
48
Q&A
azentenolangle@mgh.harvard.edu
49
OIT 262 Roadmap: 18 Sessions of Operations Greatest Hits

Class
Date
Topic
4/3
Introduction, basic concepts, Littles Law
4/6
Process Analysis
4/10
Process Improvement
4/13
Randomness and Waiting Times
4/17
Optional Review Session
4/20
Batching and the Product-Process Matrix
4/24
Process Improvement in Health Care
4/27
Supply Chain Inventory Management
5/1
Quality and Process Improvement in Health Care
10
5/4
Gurs Research Lecture
11
5/8
Toyota Production System
12
5/11
Measuring and Quantifying Quality
13
5/15
Quality Management in Luxury Services
14
5/18
Supply Chain Simulation
15
5/22
Managing Product Variety in Supply Chains
16
5/27
Forecasting Game, Contracts & Incentives
17
5/29
Leadtime Reduction and Quick Response
18
6/1
Student Presentations & Course Summary
Stanford GSB
Overview
Process Analysis
Types of processes
Dimensions of process capability
Process flow diagrams
Capacity, utilization, inventory
Uncertainty (randomness) in processes
Bottlenecks
Process Improvement and Quality Management

Process in service industries
Quality control, Total Quality Management
Just-in-time, Lean Manufacturing
Six Sigma, Statistical Process Control
Supply Chain Management
Order fulfillment and distribution
Postponement
Quick response/dual response
Information sharing, contracts, and incentives in supply chains
Fast fashion production
50
Upcoming Classes
Next Class: Tools: supply chain and inventory management
Preparation: book reading + problems (do not turn in,
will be solved in class / review session)
Wed. 4/29: Review session, Littlefield begins 1:00pm
Fri. 5/1: Quality and process in healthcare (guest speaker)
Preparation: case reading
Mon. 5/4: Gurs research lecture (Quality, lookahead and
browsing path optimization in online services);
Littlefield ends
Fri. 5/8: Quality and lean operations in TPS
Toyota case (first priority)
Textbook reading (expands on the ideas of TPS that
are discussed in the case)
NY Times article on standardization of teaching
Stanford GSB
51

MGH 2015

Enviado por

Dados do documento

Título original

Direitos autorais

Formatos disponíveis

Compartilhar este documento

Compartilhar ou incorporar documento

Opções de compartilhamento

Você considera este documento útil?

Este conteúdo é inapropriado?

Direitos autorais:

Formatos disponíveis

MGH 2015

Enviado por

Direitos autorais:

Formatos disponíveis

OIT 262: Operations

Class 7: Process Improvement in Health Care

Plan for Today

Process Flow at Mass General

II. Inventory Build-up at Bottleneck

OIT 262 Prof. Gur Class 7

Goals for the MGH Case

OIT 262 Prof. Gur Class 7

Massachusetts General Hospital

OIT 262 Prof. Gur Class 7

OIT 262 Prof. Gur Class 7

PATA Process Flow

OIT 262 Prof. Gur Class 7

(Charge Nurse Station)

Lab (Vitals + EKG)

OIT 262 Prof. Gur Class 7

Sign In at Front Desk

(Charge Nurse Station)

Lab (Vitals + EKG)

OIT 262 Prof. Gur Class 7

Lab for Vitals and EKG

(Charge Nurse Station)

Lab (Vitals + EKG)

OIT 262 Prof. Gur Class 7

Charge Nurse Station

(Charge Nurse Station)

Lab (Vitals + EKG)

OIT 262 Prof. Gur Class 7

(Charge Nurse Station)

Lab (Vitals + EKG)

OIT 262 Prof. Gur Class 7

(Charge Nurse Station)

Lab (Vitals + EKG)

OIT 262 Prof. Gur Class 7

Lab (Blood Work)

(Charge Nurse Station)

Lab (Vitals + EKG)

OIT 262 Prof. Gur Class 7

PATA Process Flow Diagram and Capacity

7am-12 and 2-3pm

Capacity =12 pt/hr

Capacity = 7.5 pt/hr

OIT 262 Prof. Gur Class 7

Calculating PATA Process Capacities

Vitals + EKG in Lab

Chart review = 5 min/pt

Service rate = 1.4 pt/h

Chart review = 10 min/pt

Service rate = 0.94 pt/h

Blood Work in Lab

OIT 262 Prof. Gur Class 7

PATA Process Capacities

The RNs are the bottleneck

OIT 262 Prof. Gur Class 7

PATA Process Flow Diagram and Capacity

7am-12 and 2-3pm

Capacity =12 pt/hr

Capacity = 7.5 pt/hr

OIT 262 Prof. Gur Class 7

What Does Patient Flow Look Like

OIT 262 Prof. Gur Class 7

OIT 262 Prof. Gur Class 7

Time Out: Whats Going on in This Process