Production and Operations Management

Massachusetts General Hospital’s Pre-Admission Testing Area

PATA Case Study

November 2015, Riga

Mārtiņš Dvinskis, Mārcis Vilcāns, Jamil Guliyev

 Question 1

In order to understand how patients’ perceive their visit at PATA, lets construct easy
to grasp – process flow diagram. The starting point for the patient is shown on the left
side (Arriving at PATA), and then subsequently each next step is represented in the
graph, where the last point is patient leaving the PATA.

Vitals
Vitals Registre
Registre Anesthe
Anesthe
Arriving
Arriving Check-
Check- Waiting
Waiting Waiting
Waiting Exam
Exam Exam
Exam Waiting
Waiting Check
Check Leaving
Leaving
and
and dd Nurde
Nurde liogolist
liogolist Lab
Lab
atat PATA
PATA InIn Room
Room Room
Room Room
Room Room
Room Room
Room Out
Out PATA
PATA
EKG
EKG work
work and MD
and MD

Once the overall process flow diagram is clear, we can assess utilization and capacity
for each of the steps through which the patient is going, as well as for the overall
process of PATA visit.

 Capacity rate, for each step

As we know, then capacity analysis involves determining the throughput capacity of

workstations in a system (in our case the PATA process-flow). In our examination we
calculated the capacity per hour, as the working hours, as stated in case, were hard to
project as the staff was working over-time on many nights. Our assumption, for the
calculations as well is that the capacity per hour could remain constant, if the
management of hospital would decide to find out the capacity per each day.

 Check-In, and Check-Out

Average time for Check-In 2minutes, and for Check-Out 1minute
Capacity per hour=60/3= 20 people per hour

 Vitals and EKG

Average time for Vitals and EKG 10minutes

Capacity per hour=60/10= 6 people per hour

However, as it was mentioned, then there are two stations, so
Capacity per hour per both stations=6*2= 12 people per hour

 Registered Nurses
Concerning registered nurses their work involved, chart review time (on average 5
minutes), nursing assessment (on average 27 minutes), and filling in paperwork,
documentation (on average 11 minutes). Thus we can calculate that the average time
they spent per patient was, 5+27+11=43 minutes

Capacity per hour=60/43= 1.39 people per hour per 1 nurse

As there were five nurses, then:

Capacity per hour per all nurses=1.39*5= 6.95 people per hour

 Anesthesiologists
Regarding anesthesiologists their work involved, chart review (on average 10
minutes), exam (on average 37 minutes), and filling in paperwork (on average
17minutes). Thus we can calculate that the average time they spent per patient was
10+37+17= 64 minutes

Capacity per hour=60/64= 0.93 people per hour

However, from figure 2a we can see that in PATA, there are 8 medical doctors.
Capacity per hour per all anesthesiologists=0.93*8= 7.44 people per hour

 Lab (Blood work)

Average time for blood work was 6minutes per patient
Capacity=60/6= 10 people per hour

 Utilization rate, for each step

As we know then from theory perspective utilization is expressed as the actual output
of design capacity. Thus, in our case in order to figure out utilization rate for each of
the steps we are going to take the actual output as the work being performed, and the
design capacity as the
 Utilization of Check-In, and Check-Out
3/3= 100%
 Utilization of Vitals and EKG
10/10 = 100%
 Utilization of Registered Nurses
27/43= 62.7%
 Utilization of Anesthesiologists
37/64= 57.8%
 Utilization of Lab (Blood work)
6/6=100%

Overall, we can see that the lowest utilization level is for anesthesiologists, and
registered nurses. Another point that we need to consider, is that the waiting times for
patients are not included in the utilization calculations, as obviously that the waiting
time would affect the utilization levels.
Question 2
In order to examine whether there is a bottleneck in PATA, we created the figure of
process, and took the average time that one patient is spending in each of the stations.
By looking at the figure, it becomes clear that in PATA there indeed exists a
bottleneck. As it can be observed then anesthesiologists is the bottleneck station
within PATA. The reasoning behind bottleneck analysis is that even if we would be
able to decrease the time spent prior to anesthesiologist’s station, the flow would stop
there – as this is the bottleneck station.

Now once we have identified the bottleneck station, we can try to figure out how
much time as a result of this bottleneck patients’ need to wait.
The throughput time of PATA is:
2+10+43+64+6+1= 120minutes or 2 hours.
Although, this number is if we are assuming that the patient is not waiting in waiting
room, which definitely is not the situation in this case.

One easy way at looking, how the bottleneck affects PATA is by looking at another
stations, to determine which would classify as the bottleneck number 2, which would
be the registered nurse station.
64-43= 21 minute
Thus, we can calculate that anesthesiologists are slowing down the whole process in
PATA by 21 minute.

Now what happens if take the perspective for one full working day, and how much
time is lost due to the bottleneck?
As shown in Figure2c, then on average 56.4 (57) patients were scheduled per day.
If we are taking the calculated 21minutes being lost due to the bottleneck, then if we
multiply by number of patients:
57*21=1197 minutes or 19.95 hours are lost for their patients due to the bottleneck.
 Question 3

As it has been presented within the case, then 3 causes concerning long patient wait
times has been proposed:
 Not enough time between time appointments
 Not enough rooms
 Not enough physicians
Now, lets consider whether the presented options are valid, and find out are they the
primary contributors to long patient wait time.
Not enough time between appointments:

The time between appointments from theory perspective is the demand management,
in our case the appointment time. Even tough, it is common practice for hospitals to
manage their demand by different appointment times; lets examine the demand
management for PATA.
The information was taken from Figure 2a.
Appointment Time Number of Patients
7:00 4
7:30 3
8:00 4
8:30 4
9:00 3
9:30 3
10:00 3
10:30 4
11:00 4
11:30 4
12:00 2
12:30 1
13:00 2
13:30 2
14:00 3
14:30 3
15:00 3
Table: Appointment time, number of patients
In the Figure 2a, there was also available information concerning each patient, time
in, and time out. By having this information, we can notice that:
 Out of 55 patients, 9 patients were late for their appointment time, which is
16.3% of total patients. And the average time that they were late for their visits
were
(patient7+patient17+patient20+patient23+patient24+patient31+patient32+pati
ent37)/9=(23min+10min+4min+7min+34min+4min+19min+8min)/9=12min

Not enough rooms:

The information about exam rooms can also be found in Figure 2a. Once looking at
the occupancy of the exam rooms, interesting pattern emerges – that from all of the
exam rooms, none is used for subsequent appointment times – meaning, that it
indicates that number of rooms is sufficient. However, once considered what the
reason behind this, we can clearly notice – that each room has 2 providers. Meaning,
that first the registered nurses are using the room, and afterwards medical doctors are
using the same room.
So for example, lets take a look, at the very first patients, and once their used exam
rooms are becoming available for other patients.
Appointment Time In Time Out Exam Exam Room
Time Room scheduled after
7:00 6:59 8:40 7 7:55
7:00 6:59 9:10 9 9:00
7:00 6:59 8:40 5 8:30
7:00 7:23 10:23 12 11:00
Table 1

As we can see then the exact same exam rooms, are being scheduled for the next
appointments at a time, prior the previous patient has finished his service. So clearly,
that there is a shortage of exam rooms within PATA.

Not enough physicians:

As we already observed in the very first question, then there are medical doctors
within PATA, and they clearly were the bottleneck station in PATA. The reason for
this was that, their assessment was most complex of all of the involved parties within
the process.
Appointment Time Out MD Next MD
Time appointment
7:00 8:40 4 8:00
7:00 9:10 5 9:00
7:00 8:40 2 7:00
7:00 10:23 6 7:30
Table 2

As we can notice from the table, then clearly there is a shortage of physicians, as they
cannot manage to be on time.
 Question 4

As it was mentioned in the case, there are many factors, which

contribute to the variability in PATA process flow. We will discuss the main
factors, which contribute to the variability. In our groups opinion the first
factor which contributes to the variability is the when the charge nurse is
sending the providers to lunch break. As it was mentioned I in the case the
charge nurse would send providers to lunch when the clinic seemed quite,
therefore less staff was available at lunchtime, which could increase the
probability that patients queue would build up in the waiting room while
providers where having lunch.

Another factor, which contributed to variability, was if a nurse or a

provider was assigned to a particular patient, but they had not realized that
they have been assigned. Therefore, resulting a patient waiting for extra
minutes. Additional problem occurred when providers would leave to get to
other work or take a break when there were no patients waiting to be seen, but
when a patient did become available to be seen, the charge nurse had to leave
their station to find an available provider. This sort of process wastes a lot of
time, which increases the patients waiting time as well as charge nurse can
miss important patient flow processes while being away from the station.
In order to eliminate such factors and take full control over them, the clinic
should implement more advanced technological system, which would allow to
manage the PATA process flow more efficiently, but this will be discussed
later in the case.
 Question 5

In order to procced with changes recommendations, it is crucial to outline the

main challenge for the PATA, which happens to be a lack of comprehensive data
transfer and communication system. In addition, the bottleneck, which in our case is
the anesthesiologist, can be related to the mentioned above issue, as if looked closer it
can be seen that most of the time jam occurs prior to the paperwork.

In addition, PATA could implement a broader intern participation program,

which will be beneficial due to its none or very low cost adaptation. Mentioned
program will essentially reduce the nurse assessment and will also compliment on the
overall data turnover process, which will help to abolish the bottleneck in coalition
with a sufficient data system.

Our team would strongly suggest an adoption of Microsoft Amalga Unified

Intelligence System, which is broadly used for storing and transferring patient data.
Whereas mentioned system has been implemented by a wide specter of hospitals all
around the world and has proven to increase the data turnover efficiency by more than
47%. In addition, the cost of adapting Amalga stands much lower than other possible
solutions such as extra staff recruitment or addition of examination rooms.