October - Balancing Patient Satisfaction and Staff Efficiency

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1 800 547 6024 | +44 141 552 6888

Balancing Patient Satisfaction
and Staff Efficiency
LOGISTICS OF MEAL DELIVERY
October 24, 2013
Seth Hostetler
Process Engineer, Care Support Services
Geisinger Health System
Presented to:
SIMUL8: Improving Healthcare with Simulation Workshop

Heal • Teach • Discover • Serve
Copyright Geisinger Health System 2013

Not for reuse or distribution without permission
Geisinger Health System Confidential and Proprietary

Agenda
• Introduction and objectives
• Approach and the proposed system
• Phase 1 Modeling
• Experiment
• Results and insights
• Recommendations and future directions

• Phase 2 Modeling
•
•
•
•

Model adjustments
Operational strategy testing
Analysis and recommendations
Complete experimental results

|5


Introduction
• Geisinger Medical Center’s (GMC) food service
department was planning a transition to on-demand,
room service style delivery of meals to inpatients in 2013

• 18 inpatient units, approx. average census = 360
• Excludes inpatient psych unit

• The new system will result in:
• Changes in resource management and requirements
• Changes in process and employee roles
• Changes in patient service
|6


Objectives
1. Create a representation of the new food service
delivery process in a simulation environment
2. Use simulation to show how changing system
parameters will affect patient service levels and
resource requirements

3. Through model analysis, create operational
recommendations for the forthcoming system changes

|7


The Internal Logistics Simulation Model
• Captures all support service functions within GMC
• 19 inpatient units
• 33 outpatient clinics
• 51 ancillary service departments

• Captures food delivery to:
• Med/Surg. Units
• Adult critical care units
• Women’s and Children’s

|8


Internal
Logistics
Simulation
Model

2.1 Miles of Hallway
38 Elevators
11 Floors
199 Network Nodes
160 Destinations
35 Transport Groups


Modeling the New Food Services System
• Three delivery zones
• Dispatch timer on carts
• Once the first tray is placed on a cart a timer is set
• The cart will leave when it is full or when the timer
expires, whichever occurs first

• Nearest neighbor delivery route
• Cart and staff resource modeled as one entity

Zone A Zone B Zone JK
AGP4
AICU4
SCU4
AGP5
ICS5
AICU5

GP2
SCU3
SCU5
BP5
BP6
BP7
BP8

WILL1
CH2
CH3
HfAM7
HfAM8

• Always a host to travel with a cart

• Three meals per day
• Approximately 1060 meals served between 5:30am
and 9:30pm

| 10


The Delivery Process
Patient orders
meal

Is there a
cart
waiting for
that zone?

N

Initiate new
cart for the
zone

Y
Add meal to
zone cart

Is cart at
capacity
?

N

Y

Has the
time limit
been
met?

N

Y
Wait for
another meal
or until time
limit met

Send trays for
delivery
| 11


Input Data
• Distribution of meal orders
• Estimate of meal delivery count every 30 minutes
• Patient census snapshot

• Time to serve meal to patient
• Estimated with time studies
• ~59 seconds to serve meal
• ~49 additional seconds for isolation patient
• 10% of patients modeled as isolation status

• Travel speed
• 185 feet/min
| 12


Key Performance Measures
PATIENT SATISFACTION
• Service time

OPERATIONAL EFFICIENCY
• Cart utilization

• Wait time on cart before
routing

• Maximum number of
carts used*

• Percent delivered after
30*, 40, 45 and 50
minutes

• Number of delivery trips
made in a day

* Management chose these two metrics as the most important.
| 13


The Phase 1 Experiment
• Carts modeled as an unlimited resource
• Three dispatch times
• 8, 10, or 12 minutes
• Three cart capacities
• 12, 14 or 18 trays
Which combination of dispatch time and cart
capacities would be most effective?
| 14


Results
Dispatch Timer
Cart Utilization
Service Time
Max # Carts
# Delivery Trips
Service Level

Parameters
Minutes Cart Capacity
8
12
8
14
8
18
10
12
10
14
10
18
12
12
12
14

Parameters
Minutes Cart Capacity
8
12
8
14
8
18
10
12
10
14
10
18
12
12
12
14

Service Time
Average
17.22
17.20
17.23
19.23
19.31
19.31
20.97
21.20

95% CI
Average
95% CI
Average
95% CI
(17.15, 17.29) 16.00 (15.83, 16.17) 242.60 (241.40, 243.80)
(17.13, 17.27) 15.93 (15.66, 16.21) 242.70 (241.39, 244.01)
(17.17, 17.29) 15.90 (15.72, 16.08) 243.23 (241.64, 244.82)
(19.16, 19.30) 14.63 (14.45, 14.82) 206.53 (205.36, 207.70)
(19.23, 19.38) 14.64 (14.46, 14.83) 205.00 (203.77, 206.23)
(19.23, 19.39) 14.37 (14.18, 14.55) 205.43 (204.39, 206.47)
(20.89, 21.04) 13.70 (13.53, 13.87) 179.60 (178.82, 180.38)
(21.11, 21.30) 13.27 (13.10, 13.43) 177.77 (176.79, 178.75)

Cart Utilization
Average
0.3613
0.3086
0.2399
0.4235
0.3660
0.2850
0.4878
0.4238

Max Number of Carts Number of Delivery Trips

95% CI
(0.3597, 0.3629)
(0.3068, 0.3105)
(0.2387, 0.2412)
(0.4210, 0.4259)
(0.3640, 0.3681)
(0.2835, 0.2864)
(0.4856, 0.4899)
(0.4217, 0.4260)

Wait Time on Cart
Before Routing
Average
95% CI
4.78
(4.77, 4.80)
4.80
(4.78, 4.83)
4.80
(4.78, 4.81)
5.80
(5.82, 5.77)
5.83
(5.81, 5.85)
5.85
(5.83, 5.87)
6.72
(6.69, 6.76)
6.81
(6.78, 6.84)

Percent delivered after
30 min
Average
95% CI
2.06
(1.83, 2.29)
2.00
(1.78, 2.21)
2.10
(1.92, 2.29)
5.67
(6.02, 5.32)
6.08
(5.78, 6.38)
5.97
(5.59, 6.35)
10.79 (10.41, 11.16)
12.04 (11.58, 12.49)

Cart Capacity

Cart Utilization


Percent delivered after
40 min
Parameters
Minutes Cart Capacity Average
95% CI
8
12
0
(0, 0)
8
14
0.003 (-0.003, 0.010)
8
18
0.003 (-0.003, 0.010)
10
12
0.061 (0.026, 0.095)
10
14
0.117 (0.073, 0.161)
10
18
0.199 (0.129, 0.270)
Not12 reuse or distribution without permission
for
12
0.231 (0.175, 0.288)
12
14
0.434 (0.310, 0.558)

Percent delivered after Percent delivered after
45 min
50 min
Average
95% CI
Average
95% CI
0
(0, 0)
0
(0, 0)
0
(0, 0)
0
(0, 0)
0
(0, 0)
0
(0, 0)
0
(0, 0)
0
(0, 0)
0
(0, 0)
0
(0, 0)| 15
0.013 (-0.003, 0.028)
0
(0, 0)
0
(0, 0)
0
(0, 0)
0.010 (-0.001, 0.020)
0
(0, 0)

Interpreting the Results
• These trends reveal a broad theme within the meal delivery system:
A trade-off exists between patient service and efficient use of
resources.
• The 8 minute dispatch timer provides the best performance in terms of
percent of meals delivered beyond each of the time intervals.
• As the dispatch timer increases, the results show an improvement in the
efficient use of resources; however, the factors measuring patient
service perform worse as the timer length grows.
• A cart capacity of 12 meal trays provides the highest utilization for each
of the three dispatch timer settings.
– Cart utilization is the only measure significantly affected by a change in cart capacity.
– For this reason, the 12 meal tray carts were selected.

| 16



Results
12-Tray Cart Capacity
Max Number of Carts

Number of Delivery Trips

Cart Utilization

Parameters
Minutes

Average

95% CI

Average

95% CI

Average

95% CI

8

16.00

(15.83, 16.17)

242.60

(241.40, 243.80)

0.3613

(0.3597, 0.3629)

10

14.63

(14.45, 14.82)

206.53

(205.36, 207.70)

0.4235

(0.4210, 0.4259)

12

13.70

(13.53, 13.87)

179.60

(178.82, 180.38)

0.4878

(0.4856, 0.4899)

Parameters
Minutes

Percent delivered after 30
min
Average

8

2.06

95% CI
(1.83, 2.29)

% Delivered after 30 minutes

12
12 Minutes
10

Percent delivered after 40
8
min
6

Average

10 Minutes

95% CI

4

0

(0, 0)
8 Minutes

2

10

5.67

(6.02, 5.32)

0.061

(0.026, 0.095)

12

10.79

(10.41, 11.16)

0.231

14
14.5
(0.175, 0.288)

0
13.5

15
15.5
Max Number of Carts

16

16.5

| 17


Usage Profile for the 12-Tray Cart
18.00%

Percent of Time in Use

16.00%
14.00%
12.00%
10.00%
8.00%

8 Minutes

6.00%

10 Minutes

4.00%

12 Minutes

2.00%
0.00%

1

2

3

4

5

6

7

8

9

10

11

12

13

14

15

16

17

Number of Carts in Use

• Must consider more than just the max number of carts used.
• For example, the 8 minute dispatch timer experiences a count of 17 carts in
use for a period of time in a day, but it is for less than 0.01% of the time.
• A balance must be struck between the need to have a cart available to
deliver meals, and the acceptable limit of time that a meal must wait to be
delivered because it is waiting for a cart.
| 18


Phase 1 Recommendations
• 12 tray cart capacity will provide best cart utilization and
lowest equipment cost
• Depending on dispatch timer setting, trade-offs exist
between:
•
•
•
•

Required number of carts (14-17)
Number of delivery trips (178-244)
Utilization (35%-49%)
Service Level (1.83%-11.16% delivered after 30 min)

• Shorter timer will provide better service level
• Longer timer will sacrifice service level for improved
resource usage
| 19


Phase 2 Model
• The operational staff schedule provided did not provide
enough employee hours to satisfy work requirements
• Utilization is greater than 100%

• Combined delivery and pickup processes determined to
enhance service levels
• Estimated approx. 40% reduction in number of trips required

• Inclusion of return process
• Empty cart swapped with cart full of dirty trays on return route
• Return trip route based on a cyclical zone schedule
• Carts cleaned after each round trip
| 20


Additional Model Assumptions
• Food preparation and cart cleaning time included
• Zone routing for pickup and delivery
• Carts modeled as an unlimited resource
• Cart use limited by number of staff available

• No break times included in resource schedule
• At request of management

• Adjustments made to original order distribution to create
a 7am-7pm order estimate


| 21

Performance Measures
1. Service level
– Percent of carts delivered in 45 minutes or less

2. Resource utilization
– Percent of time resources are in use for
delivery/pickup services

3. Scheduled work hours in one day

| 22


Experimentation Objective
• Determine the optimal staffing schedule,
as well as the most efficient delivery and
pickup routing methods
• Test various daily employee schedules to
determine an hourly schedule which
allows for high service levels and worker
utilization
• Management asked that staff be
scheduled hourly, not by shift
• Ability to flex staff across various tasks

Example Schedule
Time
Staff Count
7am-8am
9
8am-9am
12
9am-10am
12
10am-11am
8
11am-12pm
8
12pm-1pm
13
1pm-2pm
12
2pm-3pm
10
3pm-4pm
9
4-pm-5pm
7
5pm-6pm
9
6pm-7pm
11
7pm-8pm
9
8pm-7am
0

| 23


Delivery and Pickup Routing Scenarios
Testing performed on three scenarios:
A. Standard original operations (3 zones, fixed route
schedule)
B. Modified pickup schedule
•
•

Rotational delivery schedule forces delivery route to begin
from different unit on each trip
Pickup unit is last unit in delivery schedule

C. Six zone facility layout with original operations
Zone

Units

1

2

3

4

5

6

AGP4
AICU4
SCU4

AGP5
AICU5
ICS5

GP02
SCU3
SCU5

BP05
BP06
BP07
BP08

WLL1
CHM2
CHM3

HFAM6
HFAM7
HFAM8

Which of these scenarios do you think will be most effective?
| 24


Scenario Testing
• All scenarios tested in a 24-hour simulation period
• Includes routing and staffing variations

• Seven highest performing scenarios tested in 30-day
simulation period
• Reduction of variability

• Testing to maximize service level and utilization
• Minimization of total employee hours used to break “ties”

| 25


Comparison of Service Level (squares) and Resource Utilization (triangles) for
the 4 best performing staff schedules.
Option A: Shown in green, is the standard routing, 3-zone option.
Option B: Shown in red, is the modified, rotational, 3-zone option.
Option C: Shown in blue, is the standard routing, 6-zone option.

105

100
98
95

96
95
94

90

99
98
97

98
97
96

96
95

90.52
88.4

87.5
Standard Util

85

85
83.7

Standard Service
Rotational Util

80

80.8

80

Rotational Service

79.75

6 Zone Util
6 Zone Service

75.86

75

74.83

74.78

70

69.7

65

120

129

3

7

131

142

60

6

Schedule

5

|
226
6

Six Zone Delivery Layout
98% Service Level  ~20/meals per day delivered after 45 minutes
88.4 % Utilization  114 hours/day busy (129 total)
6 Zone Operation Utilization-Service
Trade-Off
110
105
100

96

98

99

95
90
85

90.52
88.4

80

Utilization

83.7

Service

75
70
65
60
3

7
Schedule

5

* Schedule 6 was eliminated from comparison because it performed
comparable to Schedule 7, however the utilization was slightly lower
and it used additional scheduled work hours


Schedule 7
Time
Staff Count
7am-8am
8
8am-9am
13
9am-10am
12
10am-11am
7
11am-12pm
8
12pm-1pm
13
1pm-2pm
11
2pm-3pm
10
3pm-4pm
8
4-pm-5pm
7
5pm-6pm
10
6pm-7pm
12
7pm-8pm
10
8pm-7am
0

| 27

Conclusions and Recommendations
• Six zone facility layout allows for best service with least
compromise in employee utilization
Zone

Units

1

2

3

4

5

6

AGP4
AICU4
SCU4

AGP5
AICU5
ICS5

GP02
SCU3
SCU5

BP05
BP06
BP07
BP08

WLL1
CHM2
CHM3

HFAM6
HFAM7
HFAM8

• Best found schedule requires 129 hours scheduled for
delivery/pickup services per day
• Break times not included in schedule

| 28


THANK YOU FOR ATTENDING!

WHO HAS QUESTIONS?

Seth Hostetler
Geisinger Health System
sthostetler@geisinger.edu
570-214-7029


| 29

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