Assessed and mitigated impact of sharing resources to optimize resource capacity cost rate and reduce unused capacity

1. CAREY BUSINESS SCHOOL
HEALTH SERVICES
IMPROVEMENT
JOHNS HOPKINS HOSPITAL
PEDIATRIC DERMATOLOGY
Puraskar Ingale
Tobias Breuer
Anvit Goyal
Healthcare Process Service and Process Improvement
Spring 2018 (I and II)
Prof. Dada, Prof. Chambers, Prof. Williams

2. TEAM
12 years diverse healthcare
experience in clinical
research and project
management.
Helped in interviews,
observations, project
management, model data
scrubbing and simulations
5 years experience in
Operations in
manufacturing sector.
Helped in
observations, project
simulation model
building, hypothesis
testing, data analysis
BA, Global MBABE, MS, Global MBA BE, Global MBA
Tobias BreuerPuraskar
Ingale
Anvit Goyal
Experience in HR
analytics while
working on global
projects.
Helped in
observations, project
review literature,
data presentation

3. AGENDA
Process Flow
Observations
ObservationsProcess Flow
Simulation
Model outputsResults
• Constraining of the resources at end of shift
• Effect of Changes in No Show %
• Effect of Interpreters
Recommendations
Q&A

4. QUICK FACTS
•10 days
• 3/6/18 – 4/5/18
•16 shifts
• AM & PM
•184 patients
• 16 Patient Types
•9,016 patient-specific
unique data points
• 49 categories per Patient
•432 shift data points
• 22 weather categories per day
• 5 categories per shift
9,448
unique data
points
analyzed
• Personal Interviews
6 Residents 2 Interpreters

5. RECOMMENDATIONSShort-term
•Optimal ratio of MD : Resident is 1:2
•Optimal double booking per shift per
doctor
•Three double bookings earlier in the day
mostly for follow-up patients
•Additional two-three double booking if
high no show rate is predicted for that
day
•Follow the new schedule to accommodate
18th patient in the schedule
•Visual changes in the patient pre-
appointment text and waiting area
Long-term
•Resource re-allocation
could help in further
increasing the patient
and medical personnel
satisfaction
•Repeat observations
based on the
recommendations for
room and resources

6. QUALITATIVE - QUOTES &
REMARKS
•Scheduling:
• Book according to anticipated
time
• Siblings scheduled separately –
arrive at once
• Inclement weather
• Restroom breaks – patients,
residents, and attending’s
•Facility:
• Children remember exit better
than parents
•Resources Based:
• Interpreter arrives late
• Requested only to see attending
• Both residents entered to teach
new resident
• Every resident enters for an
unexpected special observation
Interviewe
d
6 Residents
2 Interpreters

7. PROCESS FLOW Flow diagram
Simulation Model

8. JOHNS HOPKINS CHILDREN'S
CENTER
DERMATOLOGY 1ST FLOOR
Examination Area Pre-Examination Area
NP: Registered Nurse Practitio
MT: Medical Technician
Att: Attending Physician
Res: Resident

9. Patient Nemo
Check-in
Patient PSC
desk Check-in
MT/NP escorts
Patient to room
MT/NP takes
patient
information
NP-Res
Interaction
Res visits
patient
Res-Att
Interaction
Res-Att visit
patient
Res-Att
interact again
Res re-visits
patient
NP re-visits
patient
Patient Check-
out
PROCESS FLOW
Entry Exit
Interpreter
Vitals
Optional

10. INITIAL
MODEL
Model_
Extend
Att_
Count
Res_
Count
Pt_
Type
Count Probability
1 1 1 1_7 25 13.59%
2 1 2 2_8 66 35.87%
3 1 3 3_9 55 29.89%
4 2 3 6_12 38 20.65%
Total 184 100%
NP: Registered Nurse Practitione
MT: Medical Technician
Att: Attending Physician
Res: Resident

11. PRE-EXAMINATION
Appointment
Type
New
Patient
(NP)
Follow-
Up (FU)
Walk-In
(WI)
Booking
Date
MM/D
D/YYY
Y
Nemo Booth
Check-In
Slip
Number
C/I
Timestamp
PSC Station
Check-In
C/I
Timestamp
C/O
Timestamp
Waiting
Room
After
Nemo
After PSC
MT/Nurse
Calls
MT calls
patient
Escorts to
room
C/I: Check-in
C/O: Check-out
MT: Medical Technician
NP: Registered Nurse Practitio

12. Exam Room Pt. 1
•Interpreter (optional)
•Resident Enters
•Resident Leaves
Resident
Attending
•Resident Waits
•Resident/Attending Interaction
Exam Room Pt. 2
•Resident/Attending Enter
•Resident/Attending Leave
Departure
•Resident re-enters and
completes review
•NP signs-up patients for MyChart
•Questions
•Check Out
EXAMINATI
ON

13. OBSERVATIONS

14. QUANTITATIVE
Connection Between Weather and No
Shows
 No shows average 20% total
 No shows average 40% (worst weather)
 Increase double booking for two/three more time slots
 Inform patients who are waiting with open
appointments slots
Double-Booking Improvements
 60 minute double-booking shouldn't change
 Change 120 minute double booking to 90 minute
Correlation r
0.6687
More
historical
data from
Nancy Yang
could help to
build a more
robust model

15. SIMULATIONS

16. MODEL
1
2
3
4

17. INPUTS

18. OUTPUT
Cycle Time: Total Time beginning
to end
 Appt: Starting from Appointment Time
 Arr: Starting from Arrival Time
Throughput: Patients processed
per unit time (minute)
Average Overtime: Average Time
spent in excess of shift end time
(240 min)
Average Wait: Average wait time
for the patient from check-in at
Nemo till exit
Utilization: Processing time/Total
available time Note: All measurements are minutes

19. OUTPUT – 1 MD, 2 RES

20. OVERALL RESULTS OF ALL
FOUR MODELS

21. RESULTS: RESOURCE BASED
UTILIZATION
Model MD Res Observations
Cycle Time
Avg.
Overtime
Avg.
Wait
Throughput
(per 4hr shift)
Utilization
Appointment Arrival Room Resident Attending Nurse
1 1 1 25 49.25 65.83 26.62 37.49 9.36 35.4% 76.0% 51.0% 15.3%
2 1 2 66 26.52 42.85 4.39 13.60 10.8 23.2% 54.8% 52.8% 13.2%
3 1 3 55 23.24 39.62 0.47 10.04 11.04 22.0% 37.9% 53.3% 16.6%
4 2 4 38 25.14 41.79 1.35 7.50 10.8 22.4% 38.2% 28.3% 27.7%
Reject schedule with 1 MD and 1 resident as much as possible

22. CONSTRAINING OF THE
RESOURCES AT END OF
SHIFT
Psychologic
al Effects

23. SCHEDULING

24. RESOURCE UTILIZATION CHART
60 90 120 150 180 210 240 270 300 330 360
Time (min)
Representative Visit for 1MD, 2 Residents
16%
53%
30%
51%
Utilization
Attending
Resident2
Resident1
Nurse
8AM 9AM 10AM 11AM 12 noon 1PM
12 patients showed u

25. EFFECT OF CHANGES IN
NO SHOW %
Minimal effect
Additional patients
could be
accommodated

26. OLD SCHEDULE
0 1 60 2 60 1
0 1 60 2 60 1
0 1 75 2 75 1
0 1 90 1 90 1
0 1 105 1 105 1
0 1 120 1 120 1
0 1 120 2 120 1
0 1 135 1 135 1
0 1 150 1 150 1
0 1 165 1 165 1
0 1 180 2 180 1
0 1 195 1 195 1
0 1 210 2 210 1
0 1 210 1 210 1
0 1 225 2 225 1
0 1 240 2 240 1
0 1 255 2 255 1
INPUT

27. NEW SCHEDULE
0 1 60 1 60 1
0 1 60 1 60 1
0 1 75 1 75 1
0 1 90 2 90 1
0 1 90 2 90 1
0 1 105 1 105 1
0 1 120 2 120 1
0 1 135 2 135 1
0 1 135 2 135 1
0 1 150 1 150 1
0 1 165 2 165 1
0 1 180 1 180 1
0 1 195 1 195 1
0 1 210 1 210 1
0 1 225 2 225 1
0 1 240 2 240 1
0 1 255 2 255 1
INPUT

28. ADDITIONAL 18TH PATIENT IN NEW
SCHEDULE
0 1 60 1 60 1
0 1 60 1 60 1
0 1 75 1 75 1
0 1 90 2 90 1
0 1 90 2 90 1
0 1 105 1 105 1
0 1 120 2 120 1
0 1 135 2 135 1
0 1 135 2 135 1
0 1 150 1 150 1
0 1 165 2 165 1
0 1 180 2 180 1
0 1 180 1 180 1
0 1 195 1 195 1
0 1 210 1 210 1
0 1 225 2 225 1
0 1 240 2 240 1
0 1 255 2 255 1
INPUT

29. 1 MD, 2 RES – WITH 10% NO SHOW RATE
OLD SCHEDULE
0 1 60 2 60 1
0 1 60 2 60 1
0 1 75 2 75 1
0 1 90 1 90 1
0 1 105 1 105 1
0 1 120 1 120 1
0 1 120 2 120 1
0 1 135 1 135 1
0 1 150 1 150 1
0 1 165 1 165 1
0 1 180 2 180 1
0 1 195 1 195 1
0 1 210 2 210 1
0 1 210 1 210 1
0 1 225 2 225 1
0 1 240 2 240 1
0 1 255 2 255 1
INPUT

30. 1 MD, 2 RES – WITH 40% NO SHOW RATE
OLD SCHEDULE
0 1 60 2 60 1
0 1 60 2 60 1
0 1 75 2 75 1
0 1 90 1 90 1
0 1 105 1 105 1
0 1 120 1 120 1
0 1 120 2 120 1
0 1 135 1 135 1
0 1 150 1 150 1
0 1 165 1 165 1
0 1 180 2 180 1
0 1 195 1 195 1
0 1 210 2 210 1
0 1 210 1 210 1
0 1 225 2 225 1
0 1 240 2 240 1
0 1 255 2 255 1
INPUT

31. 1 MD, 2 RES – WITH 40% NO SHOW RATE
NEW SCHEDULE – 3 ADDITIONAL DOUBLE
BOOKING
INPUT
0 1 60 2 60 1
0 1 60 2 60 1
0 1 75 2 75 1
0 1 90 1 90 1
0 1 90 2 90 1
0 1 105 1 105 1
0 1 120 1 120 1
0 1 120 2 120 1
0 1 135 1 135 1
0 1 150 1 150 1
0 1 150 2 150 1
0 1 165 1 165 1
0 1 180 2 180 1
0 1 180 1 180 1
0 1 195 1 195 1
0 1 210 2 210 1
0 1 210 1 210 1
0 1 225 2 225 1
0 1 240 2 240 1
0 1 255 2 255 1
15% TIME
SAVED

32. EFFECT OF
INTERPRETERS
Affects both
Pre and
Post-Check-
in

33. EFFECTS OF INTERPRETERS
Category Live Interface Machines In-person Scheduled
Number Observed 3 6
Wait time for PSC 10.7 (1-26) 5.5 (1-11)
PSC Check-in 18.3 (15-25) 5.5 (3-10)
Wait time for Setup/Interpreter 14.3 (12-17) 10.5 (3-14)
Wait for Resident NA 3.3 (0-6)
Resident_v1 15.33 (7-29) 5 (2-9)
Teach_Time 2.67 (1-4) 3 (1-5)
Attending_v1 9.7 (3-20) 9.0 (4-15)
Resident_v2 14.33 (4-33) 10.00 (8-15)
Interpreter Time 41.7 (20-65) 25.2 (19-39)
Cycle Time (Arrival) 101 (101-101) 46 (35-56)
Cycle Time (Appt.) 95.5 (90-101) 31.8 (15-42)
Total_Time in Room 60 (38-84) 32.33 (25-44)
Patient's Wait for MT 29.84(16.5-42.5) 13.17(9.5-21.5)
Patient's Wait for Resident 46.34(29.01-61) 21.5(14-30.01)
Patient's Wait for Attending 73(61-95) 34.84(24.01-46)
Patient's Wait for Room_Res 16(12.01-18) 7.84(3.01-12)
Patient's Wait for Room_Att 42.67(32-52) 21.17(12-34)
2-3 times more time
spent using machines

34. RECOMMENDATIONS

35. VISUAL CHANGES
•Text message
• Floor location
• Google Maps Directions
•Nemo Slip text
• Indicate the floor to wait or go
•Signage
• Nemo Check-in station
• Nurses station
•Stickers
“Hi John,
Kindly check-in at FIRST floor
kiosk for your appointment at
Johns Hopkins Children’s
Hospital on 05/11/2018.
https://goo.gl/maps/on9dCjjk
gS22”

36. ROOM
REALLOCATION
Room Utilization is Low
 Coordinate with Pediatrics to
move all operations to one floor
if possible
 Minimum Requirements:
 1 laser Procedure room,
 1 Office,
 1 supply room,
 4 Medical procedure rooms
0%
50%
100%
0%
50%
100%
1 2 3 4 5 6
Utlilization
Resident Attending
Nurse Room
10.50
11.00
11.50
12.00
12.50
0
20
40
60
80
100
1 2 3 4 5 6
#ROOMS
Effect of Rooms utilized
Throughput (per Shift) Appointment
Arrival Avg. Overtime

37. SPECIAL THANKS TO
Katherine Püttgen, MD
Bernard Cohen, MD
Anna Grossberg, MD
Jennifer Chirico, RN
Andrea Alt, RN
Kiki, MT
All Residents, Interpreters and patients
Officer (Mama) Burns
Professor Maqbool Dada
Professor Chester
Chambers

38. Q&A

39. PATIENT TYPES
Floor
Visit_
Speciality
Visit_
Type
Att_
Count
Res_
Count
Pt_
Type
Count Probability
Model_
Extend_v
1FL Med NP 1 1 1 10 0.0508 1
1FL Med NP 1 2 2 36 0.1827 2
1FL Med NP 1 3 3 28 0.1421 3
1FL Med NP 2 1 4 0 - Omit
1FL Med NP 2 2 5 0 - Omit
1FL Med NP 2 3 6 17 0.0863 4
1FL Med FU 1 1 7 15 0.0761 1
1FL Med FU 1 2 8 30 0.1523 2
1FL Med FU 1 3 9 27 0.1371 3
1FL Med FU 2 1 10 0 - Omit
1FL Med FU 2 2 11 0 - Omit
1FL Med FU 2 3 12 21 0.1066 4
LL Laser NP 1 2 13 0 - Omit
LL Laser FU 1 2 14 4 0.0203 Omit
1FL Pschy NP 2 1 15 2 0.0102 Omit
1FL Pschy FU 2 1 16 7 0.0355 Omit
Total 197 1.0000