Designing an appointment scheduling system for short-stay
nursing wards serving multiple patient groups
Master Thesis
M.Sc. Technology and Operations Management
University of Groningen, Faculty of Economics and Business
June 20, 2016
Paraskevi Drakousi
Student number: 2738597
Supervisor: University of Groningen
dr. ir.D.J. van der Zee
Co – assessor: University of Groningen
Prof. dr. J. Wijngaard
Company supervisors: University Medical Center Groningen
R.P. Borgers
G. Planting
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Abstract
Purpose: The purpose of this study is to design an appointment scheduling system which will improve the bed occupancy while guaranteeing the timely service of multiple patient groups in short-stay nursing wards. The ward will operate under the notion of pooling synergy. The insights gained in this study will help professionals to design slot policies which are better suited for serving multiple patient groups in a pooled ward, by allocating the proper number of resources to each group and by organizing more efficient the ward planning.
Method: A design science approach is used for attaining knowledge regarding the basic elements of the appointment scheduling system design. Literature is reviewed to identify these basic elements. Informal interviews, observations, data acquisition and literature are used to describe, analyze and design the ward scheduling system built in the Gastroenterology and Hepatology Department of the University Medical Center of Groningen. The proposals are tested using spreadsheets where possible.
Findings: The current appointment scheduling system that is implemented in the endoscopy center influences the ward’s performance in terms of bed occupancy, which turns out to be less than 40%. A lot of peaks and valleys and scattered empty slots are observed in the ward per day. Timely service of patients is more or less in line with the Dutch law obligations. Root causes analysis revealed main reasons for this poor performance that may be relevant for the set-up of the new ward scheduling system. Planners do not pay attention to bed availability when scheduling appointments and do not consider the required LoS of patients in the ward. Informal scheduling and a large number of planners involved in decision making were identified. Furthermore there seems to be lack of communication between planners from different (sub)-departments who are responsible to schedule patient appointments in the ward. Finally, there are no dedicated/ reserved beds for specific classes of patients in the ward.
Pooling synergy gains are identified in the new ward in accordance with literature. The realization of pooling synergy requires the design of the appointment scheduling system. A combination of number of slots, their type and position including scheduling rules are proposed. Improvements on organizing the ward planning are introduced concerning staff requirements, communication barriers, number of planners and data collection
Conclusion: The testing of the proposed solutions revealed improvement of bed occupancy, smoothing of the workflow and decrease in idleness of resources.
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Preface
This master thesis is the final project for my MSc in Technology and Operations Management at the University of Groningen.
Performing a research based on a real case of UMCG has been a creative challenge to me. I would like to thank Mr. Borgers, Mrs. Planting, Mrs. Hintzen and Mrs. Nuus from UMCG for their valuable insights on the complexity of hospital practice and their cooperation.
I would like to thank my supervisor dr. ir. Durk-Jouke van der Zee for his guidance in order to set up this research and throughout the thesis as well as his valuable and constructive feedback during our meetings.
In addition I would like to thank my co-assessor prof. dr. J. Wijngaard and my fellow students of the healthcare thesis team group for their feedback on my research proposal and on earlier drafts of this thesis respectively.
Finally I would like to thank my family and friends for their support during this difficult and challenging process.
Page | 4 Table of Contents
Abstract ...2
Preface ...3
1. Introduction ...7
2. Problem statement and research design...9
2.1. Problem background ...9
2.2. Research οbjective ...10
2.3. Conceptual model ...10
2.4. Research design ...12
2.5. Data sources ...14
3. Appointment scheduling for nursing wards- a literature review ...15
3.1. Basic elements of appointment scheduling system ...15
3.2. Nursing wards ...16
3.3. Slot policy ...17
3.3.1. Capacity allocation ...17
3.3.2. Appointment scheduling ...17
3.4. Adjustments for variability reduction ...18
3.5. Patients’ classification ...19 3.6. Performance criteria ...21 3.7. Summary ...22 4. System description ...23 4.1. System overview ...23 4.2. Patient characteristics ...24
4.3. Process: ward care services and resources ...25
4.4. Appointment scheduling for the endoscopy center and ward ...27
4.4.1. Patient scheduling ...27
4.4.2. Slot policy ...29
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4.4.2.2. Appointment scheduling for endoscopy center ...31
4.5. Adjustments to reduce variability’s effect ...32
4.6. Discharge and transportation process ...33
4.7. Summary ...33
5. System Analysis ...34
5.1. Approach ...34
5.2. Current performance of the ward ...34
5.3. Root causes of current ward performance ...37
5.3.1. Slot policy capacity allocation ...38
5.3.2. Slot policy appointment scheduling ...38
5.3.3. Patient classification ...39
5.3.4. Planners ...39
5.4. Opportunities for pooling beds at the new ward ...40
5.5. Barriers for pooling for the new ward ...40
5.6. Summary ...41
6. Solution directions of the appointment scheduling system for the new ward ...42
6.1. Approach ...42
6.2. Benefits from pooling synergy realization in the new ward ...42
6.3. Appointment scheduling system ...42
6.3.1. Patient classification for the new ward ...43
6.3.2 Slot policy ...44
6.3.2.1 Capacity allocation ...44
6.3.2.2. Appointment scheduling ...45
6.4. Organizing the ward planning ...46
6.5. Performance improvement ...47
7. Discussion ...49
7.1. Main findings ...49
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8. Conclusion and future research directions ...51
8.1. Conclusions ...51
8.2. Future research directions ...51
References ...53
Appedix A ...56
Appedix B ...57
Appendix C ...61
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1. Introduction
In recent years, an increased demand for healthcare resources has been observed (Bekker et al., 2011). Hence managers struggle for their more efficient and effective allocation (Cayirli et al., 2003). As part of the hospitals, nursing wards are facing the same pressure. A parameter that increases this pressure in wards is the need to service an increasing variety of patient needs for care. An effective way to address the above issues is through the use of an appointment scheduling system (Gupta et al., 2008; Cayirli et al., 2003).
This research is motivated by a planning challenge faced by the gastroenterology and hepatology department’s (GHD) short-stay nursing ward, within the University Medical Center of Groningen (UMCG). A new ward, with increased capacity of operational beds, is being built at the moment within GHD, which will share its facilities with other departments under the concept of pooling. Pooling synergy is expected to increase ward utilization, decrease idle times of resources and waiting times of patients. Overall the new ward will serve three main different groups, each of them with distinctive care needs regarding their treatment, their length of stay (LoS), or the uncertainty of their LoS and their urgency level. Here a challenge is raised for the planner in order to serve and satisfy all patient groups within the new ward, while smoothing its utilization. This study investigates how appointment scheduling system could be designed to efficiently allocate the multiple patient groups to the available resources, while ensuring timely service to all groups. In particular it investigates the effective allocation of patient groups to the operational beds resource (i.e. the bed plus the staff that is dedicated for each bed) which is observed to highly fluctuate throughout the day.
Most of the literature regarding appointment scheduling systems focuses on “homogeneous
patients” (i.e. single patient groups), as it is easier for the planner to schedule their
Page | 8 These few examples suggest the positive influence of classifying patients. However, to the best of my knowledge, there has been done scarce research regarding appointment scheduling considering multiple patient groups and their optimal allocation in nursing wards. In particular, there were no studies found considering bed occupancy and timely service for multiple groups, which are important criteria for ward utilization and patient satisfaction (Bruin et al., 2009). Hence the current research will try to contribute to this research gap.
The main contribution of this research is twofold. Initially, it will contribute scientifically to the limited studies which investigate the effect on serving multiple patient groups in nursing wards through appointment scheduling improvements. Furthermore, the research will focus on finding the means (slot policies) for designing an appointment scheduling system for improving wards’ performance, considering the timely service of the groups through a design science approach. Secondly, it makes a managerial contribution, as it will use a real case planning problem that the UMCG faces and will provide suggestions of appointment rules (known as slot policies) for this case.
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2. Problem statement and research design
This chapter gives an overview of the content, the scope and the methodology of this research. Section 2.1, describes the problem background. Section 2.2, describes the research objective and questions arising from the objective. Section 2.3, discusses the research design. Section 2.4 mentions the data sources.
2.1. Problem background
In general, one of the problems that hospitals and short-stay wards face derives from the growing number of patients and a less proper appointment scheduling (Cayirli et al, 2003; Gupta et al, 2008). In turn, this may cause a lack of capacity in the wards in peak times. This issue becomes even greater in nursing wards where different patient groups should be allocated, simultaneously. The patient groups have distinctive needs according, for example, to their treatment, procedure type (need for specialized resources e.g. x-rays) or LoS. Consequently to serve these patient groups shared capacity is needed regarding the operational beds of the ward. In order to allocate effectively these patient groups in the ward, without unnecessary waiting times, an appointment scheduling system is required.
The UMCG-GHD future ward is representative regarding the upper mentioned challenges. It is going to operate under the pooling resources (beds) notion, which seeks to reduce variability of the ward and succeed its higher efficiency. Also, it can be characterized representative for other wards which confront the same issues by applying the pooling approach not only within UMCG but also in other academic hospitals, as similar problems may occur in every ward.
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2.2. Research οbjective
The objective of this study is to design a slot policy which will improve the bed occupancy while guaranteeing the timely service of multiple patient groups in short-stay nursing wards.
Bed occupancy is defined as the average number of occupied beds divided by the number of
available beds (Bruin et al., 2009).
Timely service is defined in the current study as the admission of patients for treatment within the timeframe set by the Dutch Law. Admission time is measured from the time the patient calls for an appointment till the day the appointment is scheduled (Gupta et al., 2008). In the current case is of high priority to timely service the endoscopy patients which need preparation and recovery in the ward and secondly the other patient groups. The endoscopy patients should be treated within 6 weeks (legislation) with the exception of urgent patients who need to be scheduled within 7 days (UMCG norm).
Slot policy is used to address the problem of scheduling-allocating patients to available time slots (Schütz and Kolisch (2012)). This allocation in the current study will be performed under the assumption of known and fixed doctors’ schedule per week which is not easily changed in this case. The doctors’ fixed schedule is used in this study only because their availability guides the design of the current appointment scheduling system and defines the available time slots.
2.3. Conceptual model
Page | 11 Figure 2.1 shows the patients flow from the moment they are accepted for treatment. It shows also the information flow regarding the patients’ scheduling on how they will be served. Moreover, this figure serves the purpose of introducing the multiple patient groups’ classification according to their characteristics such as the patients' arrival time, the treatment required and subsequently their LoS. Each patient group is distinguished by the perspective of its symptoms and illnesses, as from the urgency of its situation, too. The urgency requires short admission times and priority over the other patients; hence it is added separately. The main focus will be given on the endoscopy group, due to its demanding scheduling.
In addition patients from the urology department will be allocated in the ward for recovery once or twice per week but only when all the previous groups are allocated and free slots are available. Urology patients are out of the research scope of the current study and will not be considered further.
Page | 12 Figure 2.1 introduces also the performance criteria which will be used for measuring the current performance of the ward in order to obtain knowledge of what could influence the envisioned ward.
2.4. Research design
In order to address the main research objective a design-science approach will be used. As Hevner et al., (2004) mention the objective of a design science approach is to create an artifact. This means that the main purpose of this approach is to solve practical knowledge problems and this is the reason it was chosen.
The first step of this research design is to provide a literature review in order to typify and classify the problem being studied and reveal research gaps (Chapter 3). Afterwards the next design steps are shortly presented according to the regulative cycle of Van Strien (1997) and are further explained in table 2.1. Eventually, the last chapters will discuss the results of the research and future research opportunities will be suggested (Chapters 7-8).
Steps according to
Van Strien 1997 Chapter Questions
1. System
description
4 What will be the envisioned set-up of the UMCH-GHD nursing ward and what are the starting points for setting up a new ward planning system?
2. Analysis of the system
5 What is the performance of the current appointment scheduling system, what causes this performance and how it could influence the new ward’s performance? 3. Solution
Directions
6 How could the set-up of the new appointment scheduling system be designed, so as to enhance the performance of the new ward concerning priority to the endoscopy group’s needs through pooling synergy realization?
To what extent does the pooling synergy for the new ward enhance its performance?
Page | 13 Step 1: System description
In this first step, the description of the envisioned ward will be introduced. In order to investigate the future ward and the effects the new appointment scheduling system will bring out, it is necessary to introduce the situation of the current ward and the changes it will bring to the new ward. The characteristics of the system, which may influence the performance of the new ward, will be described. The appointment rules that apply in the current ward will be defined as they might influence the new ward. The conceptual model and the literature review will help decide which data gathered from the current system is important for the new one as well as the starting points of the latter. This data will be based on the patient groups and their classifications, the ward resources and the appointment rules which are used currently. The execution of this step will include observations; data acquisition of the department’s planning database and informal interviews with the ward administrator of the endoscopy center and a planner.
Step 2: Analysis
The second step is the analysis of the envisioned system from the perspective of realizing pooling synergy for the combined ward and revealing root causes which may raise problems to the new ward. Due to the fact that the current study’s vehicle is a future ward the analysis will not be expanded due to non-existence of its performance. Important aspects of the current system of the endoscopy center will be analyzed as it influences directly the new ward, which is its integral part. Quantitative and qualitative data will be gathered and analyzed in order to find root causes with regard to bed occupancy and timely service that affect the current system and might be bottlenecks of a high performance of the new ward too. Additionally, literature and informal interviews with the manager and/or planners will be used to obtain a better understanding of the causes of the current ward performance.
Step 3: Solution Directions
Page | 14 Possible assumptions in order to deal with uncertainties of the suggested scenarios might be introduced. Analytic deterministic techniques will be used to assess the suggestions. The tool used to test, where possible, the proposals and the performance improvement will be spreadsheets and a comparison will be made with the current performance in order to assess the degree of improvement. Even though simulation seems a more appropriate tool to test the suggestions due to time constraints the spreadsheets tool is selected.
2.5. Data sources
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3. Appointment scheduling for nursing wards- a literature review
This chapter gives an overview of literature in appointment scheduling systems and their basic elements, with a focus on scheduling systems serving multiple patient groups. Figure 3.1 provides an overview of these elements that will be discussed in this chapter. Particular attention will be paid to literature for patient classification.
Figure 3.1 Basic elements of the appointment scheduling system design –conceptual model
In particular section 3.1 gives an overview of the basic elements of an appointment scheduling system for nursing wards which are presented to the conceptual model for clarity reasons. Section 3.2 presents the variety of nursing wards. Section 3.3 discusses the slot policy. Section 3.4 describes the possible adjustments of the system. Section 3.5 discusses the patient classifications found in literature, which are used for heterogeneous demand of patients. Section 3.6 describes the performance criteria. Section 3.7 summarizes the main findings.
3.1. Basic elements of appointment scheduling system
Page | 16 elements, considering Cayirli et al., (2003)’s framework. However, some adjustments will be made in order to serve the current study more effectively; the conceptual model (figure 3.1), provides guidance on these adjustments.
The first element is the slot policy and can be classified further in three elements, i.e. block size, begin-block, and appointment interval. The block size states the number of patients seen per block. The begin-block states the number of patients that arrive at the beginning of a block and the appointment interval specifies the length of time per block. These elements or a combination of them may create different appointment scheduling rules, although some of these combinations have not yet been widely applied in studies. An example is the use of tailored appointment intervals according to different patient types, which would fit in our research as well and have only been used by Cayirli et al., (2008). However, the slot policy has been defined in more detail from other researchers and will be described in another subsection considering the nursing wards.
The second element is the patient classification, which is often used for patient groups with heterogeneous demand. This will balance the quantity and the types of the patient groups served at a specific time in the ward-system.
The third element includes the adjustments the planner should consider such as emergencies, no-shows and walk-ins in order to alleviate the smooth flow of patients without long idle
times for the nurses.
The fourth element consists of the performance criteria that every system uses to measure its efficiency. For example timely treatment is one important criterion used to measure patient satisfaction (Gupta et al., 2008) and also required by Dutch regulations.
Although the above elements summarize the overall appointment scheduling system, because the scope of this study is focusing on multiple patient groups and slot policy design, the next sections will cover these elements in more detail. Initially, though the nursing ward element will be elaborated on.
3.2. Nursing wards
Page | 17 and reduce operational costs simultaneously. The available ward capacity is basically the number of available operational beds (Bruin et al., 2009). As mentioned in the previous sections, the inefficient utilization of a ward may play a critical role in operating rooms as lack of an operational bed may lead to a surgery cancellation or to patient admission refusal (Bekker et al., 2011; Hulshof et al., 2012). On the contrary, an improved utilization of the ward may decrease waiting times in the ward, smooth the workflow, improve bed occupancy and provide timely services to the patients. The timely service could also decrease the stress of the nurses and subsequently lead to and increase of their performance (van Essen et al., 2014).
3.3. Slot policy
The slot policy consists of three parts, the capacity allocation, the appointment scheduling and the short-term decisions on the actual day of service. The study in hand will focus on capacity allocation and appointment scheduling.
3.3.1. Capacity allocation
At capacity allocation level decisions are taken regarding the resources to be allocated to each patient group (Patrick et al., 2008). Different patients require different capacity and timeslots. Moreover, pooling patients from different patient groups in the same timeslot is a decision also taken at this stage and is called type of slot. Therefore, this decision is important for the current study which combines multiple patient groups.
Klassen and Rohleder(2004) suggest that the position of the slots can give better results when planned uneven, in the case the number of patients that arrive are not stable. Otherwise a normal distribution could provide good results.
Another issue that needs special attention with regard to capacity allocation is the variability of urgent patients’ demand. At Klassen and Rohleder (1996) study it is observed the difficulty to reserve a sufficient number of slots and the correct time-slots for urgent patients and regular patients simultaneously. They observe that the more slots are reserved for this group the less slots for other patient groups remain free, which causes delays on the latter patient groups’ treatment. Nursing wards are also facing the above issues when the planners have to decide on the number of patients and the different patients groups that have to be scheduled and allocated in operational beds, while considering their LoS simultaneously.
3.3.2. Appointment scheduling
Page | 18 The main purpose of the appointment scheduling is to minimize waiting times for patients and/or improve resource utilization e.g. level bed occupancy and smooth/balance workflow (Hulshof et al., 2012; Gupta et al., 2008). The above goals of scheduling are vital for the nursing wards, as a lack of bed in the ward can lead to a surgery cancellation or to a refused admission (Bekker et al., 2011). Thus appointment scheduling of the wards should be carefully planned. The main concern of this study is which patient group receives which slot.
A wide variety of appointment scheduling rules have been studied, trying to solve the above concerns, mainly with focus on waiting times of patients or to balance the trade-off between patient waiting times and care provider idle times (Klassen and Rohleder 1996). In more detail, according to Cayirli et al., (2003), the most common and easily applicable rule is the FCFS (first come first served) rule which is used when the planner schedules patients with no distinctive needs. Another well known rule is the “Bailey’s rule” where two patients are allocated together in the same time slot at the begin-block (Bailey 1952).
Furthermore, recent studies found that a scheduling rule called “dome-shape” can perform better in most of the cases than most of the known rules. The “dome shape” rule suggests using short slots early in the session, followed by longer ones and eventually the session closes with short slots again (Cayirli et al., 2006; Klassen and Yoogalingam 2009). Moreover, it is worth mentioning that Penneys (2000) reports that the block scheduling rule i.e. specific slots that are reserved for specific number of patients, has better results on the timely service of patients and reduces overtimes contrary to sequencing rules e.g. FCFS.
Although there is a variety of scheduling rules, most of them have not been studied on multiple patient groups, with the exception of Klassen and Rohleder (1996) mentioned above and Cayirli et al., (2006). However both studies only focus on the waiting –idle time trade-off between patients-doctors respectively. Thus, there is a necessity of further empirical investigation of appointment rules that could guarantee the timely service of multiple patients groups while improving the resource utilization of the ward.
3.4. Adjustments for variability reduction
Page | 19 the planners schedule priority rules for dealing with acute patients and reserve slots for them. This process is more challenging in the current research because of the distinctive needs of the patient groups.
3.5. Patients’ classification
According to Cayirli et al., (2003) the use of patient classification is one of the four main elements for the design of an appointment scheduling system. Even if there is a lot of literature dealing with healthcare appointment scheduling systems, most of it assumes homogeneity of patients in order to facilitate the scheduling process (Cayirli et al., 2003; Ho and Lau 1992; Fries and Marathe 1981). Hence, the planner is able to allocate patients simply by following the FCFS rule, as there is no variability in patient needs. However, some papers suggest that grouping patients might have positive influence (e.g. in terms of service time and costs of waiting) on the performance of the appointment scheduling systems and to the available resources of the ward (Cayirli et al., 2003). Some studies (Georgoulakis 2003; El-Darzi et al., 2009) support that there is not a single best way for grouping patients, but it depends on each case and by extension this grouping may be implemented to similar cases as well. According to that, this section discusses some of the characteristics, already found in previous studies, and which could assist in the clustering of patients in this study.
Length of stay
The time a patient has to stay in a ward is called length of stay (LoS) (Bruin et al., 2009). According to Bruin et al., (2009) LoS might be affected by delays and congestions in the care process. Thus it might negatively influence the patient satisfaction and the occupancy of the ward (beds and staff). Marshall et al., (2004) discuss the importance of clustering patients with LoS classification. In the same article Marshall et al., (2004) argue that grouping patients will assist care providers to take better decisions on the overall management of the ward. This means that the ward could become more efficient by better allocating its resources. Moreover, Marshall et al., (2004) recommend the LoS classification usage in order to forecast future admissions of other patient groups. Vollebregt (2011) provide evidence, (for balancing ward workload in a Dutch hospital), that if patient groups are not well determined, LoS will become unstable, which will lead to bad utilization of the ward. Bad utilization would lead to extended waiting times for patients and possible overtimes of the nursing staff or even idleness of resources.
Page | 20 patient satisfaction. Although these initial studies exist and give some indications on the necessity of LoS, further empirical evidence is needed to support its importance.
Procedure type
The patient requirements for specific resources and services can be characterized as a procedure type classification (Cayirli et al., 2006). The procedure type could be divided according to the part of the body that needs examination e.g. head, stomach, or bowels (Cayirli et al., 2006). Vanden Bosch and Dietz (2000) study optimal scheduling and scheduling rules under procedure type classification (types of patients A, B and C). They conclude that there is no easy rule for optimal sequence and that results cannot be generalized easily when sequencing patients by service times means or variances. The limitation of Vanden Bosch and Dietz (2000) is that the study was based entirely in retiree patients, which could be characterized a class itself and thus have specific characteristics, which might not apply to other classes. Thus, it would be wise when classifying patients under procedure type to carefully choose the elements to sequence the patients, which will allow easy generalizability.
In order to illustrate the use of procedure type classification an example is given regarding the need of x-rays for patients. If this procedure is offered specific hours per day then it is wise to schedule the admissions for preparation in the ward during the hours that this is available. This means, that the admission time in the ward will have to be scheduled appropriately and not reserve a slot for these patients too early in the session. It is also observed that most of the studies focus on process type of patients which is related with a specific illness. For example hospitals classify chronic patients or diabetics but they do not consider clustering patients through process similarity regardless of the specialty (Vissers et al., 2001).However it might be a good idea to get the most out of the resources when they are available.
Under this light, the procedure type seems important to be included in patient classification as there is a high possibility some of the patient groups of the current study to be subject to this category.
New- return
Page | 21 in the hospital, return patients with new symptoms) who need less average service time. Cayirli et al., (2008) are the first who investigate under this classification not only sequencing rules effects such as Cayirli et al., (2006), but also the effects from tailor-made appointment intervals to match the service time of the different patient groups. The results of Cayirli et al., (2008) show that there is an amount of appointment schedules which perform in favor of patients’ time including combinations of sequence rules and adjusted intervals. The benefit of this study is that its use can be expanded into more than two patient groups, which is in line with the current study.
From the above it may be concluded that some attempts have been already made in literature to classify patients in groups as the benefits from this action are well recognized. However, there are still a lot to explore on that field as the related literature is still scarce.
Even if there are benefits from patient classification there are some pitfalls as well, that should be mentioned. One of them is that they allow less flexibility to the planners to allocate individual patients in slots, as the time slots are reserved for the groups (Cayirli et al., 2003). Also, Klassen and Rohleder (1996) prove in their study with two groups, that if more time slots are reserved for one group the performance of the other group will decrease and this is a trade-off to be considered.
3.6. Performance criteria
In order to assess the performance of the ward regarding appointment scheduling, where the patients and the ward resources are scheduled in advance, performance metrics have been introduced in literature. Bruin et al., (2009) suggest the bed occupancy indicator as it is an effective metric to meet production targets, when costs are tight. Cardoen et al., (2010) discuss the patient waiting time indicator, which is an important metric for patient satisfaction and timely service. Regarding the timely service and LoS, the number of admissions and discharges could be valuable measures, too (Bruin et al., 2009). In order to analyze and propose suggestions for the current study a combination of performance indicators will be used for serving the heterogeneous groups of patients with distinctive needs.
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3.7. Summary
This chapter has reviewed the literature which is related to the appointment scheduling system for wards. Basic elements of the appointment scheduling system are presented in the conceptual model (figure 3.1). Furthermore the slot policy, i.e. the scheduling problem of patients’ allocation to available appointments, which consists of capacity allocation, appointment scheduling and short-term daily decision, was introduced. It is also discussed the difficulty of designing an appointment scheduling system when the planner has to schedule patient groups with distinctive needs. To the author’s best knowledge there is scarce literature for serving multiple patient needs with distinctive needs.
Also, it was described the necessity of designing the appointment scheduling system by considering the availability of the ward’s operational beds. The performance criteria of bed occupancy and timely service are found to be of great importance regarding the measurement of the ward utilization and are not widely used in literature for appointment scheduling which serves multiple patient groups.
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4. System description
This chapter describes the envisioned short-stay ward. Essentially, the new ward is an extension of the current ward for the endoscopy center (EC) that will also host alternative patient groups. Core parts of this chapter thus reflect the current ward for the endoscopy center and its scheduling. Extensions foreseen for the new ward are highlighted. The question addressed at this chapter is:
What will be the envisioned set-up of the UMCH-GHD nursing ward and what are the starting points for setting up a new ward planning system?
4.1. System overview
Page | 24
Figure 4.1 System description GHD envisioned nursing ward
When a patient is accepted in the ward, resources will be used for therapy, diagnosis, preparation and/or recovery. The resources in the ward are: beds, nurses and equipment. Doctors and endoscopy rooms are only mentioned because the scheduled endoscopies influence directly the ward utilization. After the end of the treatment the patient will be discharged from the ward or moved to another ward if extra recovery time is needed, i.e. overnight ward.
4.2. Patient characteristics
In chapter 2 were introduced the different patient groups: endoscopy, urgent and infusion. The distinction was made because of the different type of service they receive in the ward and in the EC overall. The UMCG uses the triage system to categorize the patients based on their needs and disease type.
Page | 25 might need diagnosis in the ward (videocapsule) or a diagnostic endoscopy in an ER e.g. colonoscopy and gastroscopy or therapeutic e.g. bronchoscope and ERCP.
Urgent patients are actually a subgroup of the endoscopy. However due to their urgency it has been decided to refer to them separately, as it is a distinction the department considers too. The most important criterion for these patients is the short admission time as their symptoms are acute and they need immediate allocation.
Infusion patients are chronic patients from another (sub)-department who will return regularly to the ward for therapy for the rest of their lives.
4.3. Process: ward care services and resources
The ward care services, the staff and the physical resources of the envisioned ward in comparison, where possible, with the current one are described here.
Care services: The new ward will serve different patient groups and it will be open from 8 am till 6 pm; overtimes will take place if needed. Care services will be provided only after the patients are admitted in the short-stay ward and EC in general. These patient groups will be treated by following different routings.
In the current ward the preparation of the patients before the endoscopy procedure takes place in the ERs and not in the ward. Only the recovery of the endoscopy patients takes place in the current ward.
On the contrary, in the new ward expanded services will be offered for the endoscopy and urgent patients as their preparation for the endoscopies will be offered there. The endoscopy and urgent patients might need preparation and recovery (Appendix A shows that more than half of these patients need preparation and recovery) in the ward before or after undergoing an endoscopy in ER. Patients who need recovery return to the ward or are transferred to their initial department, otherwise they are discharged. In case they need a longer recovery they will be transferred in an overnight ward.
Page | 26 The ward will provide therapeutic care services for the infusion patients, who will arrive from another sub-department of GHD. They will be admitted in the ward for their treatment and afterwards they will be discharged. No further information is known for their process at the moment.
Nurses: In the current ward the fixed number of 4 nurses is used per shift and all of them are trained to serve all patients.
All full-time nurses in the new ward will be trained in order to undertake all care services. According to the ward administrator, the nurses will be enough and trained to serve all patient groups. Their number required for the new ward is still unknown, as it is still under construction and the future demand for all groups is still not precisely known. However their number will be increased due to increase in the number of beds.
Doctors: The number of doctors and their schedule are taken as fixed in the current study. It is a resource that is important especially for the endoscopy group. They do not and will not be involved in the ward services directly except when an emergency takes place. They operate in the 6 ERs within the EC. The ward’s input depends mostly on the number of endoscopies they undertake per day. There are 13 doctors that will undertake the endoscopies and 11 trainee doctors, who perform endoscopies only under a doctor’s supervision. These doctors are divided in ten operational teams with regard to their availability and expertise. However not all of them are able to undertake all endoscopies.
Equipment and beds: The number of beds will increase at the new ward from ten to fourteen. The beds in the current ward can be used from all patient groups in the EC. In the new one the current patients and the new groups will be allocated. Equipment is also transferable for all beds and all patients groups.
Table 4.1 below summarizes the resources and the changes between the two wards.
Resources New ward Current ward
Care services
Diagnosis, therapy, preparation & recovery
Diagnosis & recovery
Beds 14 10
Equipment No restraints No restraints
Doctors for 6 ERs 13 doctors 11 trainees 10 teams 13 doctors 11 trainees 10 teams
Nurses No restraints 4 per shift
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constraint be performed at the ward; recovery
and treatment for new groups
patients takes place in ER; only endoscopy patients treated
Table 4.1 Resources related to the new and current ward allocated in the endoscopy center
4.4. Appointment scheduling for the endoscopy center and ward
The current and the future ward are part of the endoscopy center and their patient inflow variability is affected highly from the ERs’ schedule, determining start of patient preparation at the ward, and his/her recovery afterwards at the ward – after being treated at the ER. Currently attention is paid only to the scheduling on the ERs and not directly to the ward. This section describes the scheduling system of the EC which encompasses the ward scheduling indirectly. It also introduces the information for the patient groups’ demand in the new scheduling system.
4.4.1. Patient scheduling Endoscopy patients
According to the manager of the GHD this is going to be the more demanding group of the new ward, which means that patients, from this group, have priority regarding the other groups, with the exception of urgent cases.
Endoscopy patients have to be served within 6 weeks; most of them will need preparation and recovery in the ward before and after the endoscopy, respectively. Strict timeliness issues are revealed when it comes to preparing the patients in time for the endoscopy and trying to avoid long waiting times and delays. Diagnostic procedures-endoscopies mostly take place in the morning session in the ER and therapeutic procedures are mostly performed in the afternoon session in the ER, according to information from planners and the leading planner. The existence of an available bed during both phases is vital in order for the patient to undertake the endoscopy. The LoS though differs for the two phases and if it is not scheduled carefully the workflow might create lack of available operational beds.
Videocapsule patients are allocated when there is an available bed in the ward but the planning is to allocate 3 or 4 per week; their LoS is 8 hours. They are allowed to leave the ward, but forbidden to leave the hospital before the end of the process.
Urgent patients
Page | 28 admission time as their symptoms are more acute. In the current ward there are no dedicated/reserved beds for urgent patients, however the scheduling of the envisioned ward will ensure reserved/dedicated beds for them.
Infusion patients
Infusion patients will be allocated in the ward only if there are free timeslots and available beds after the scheduling of the above groups. The lead planner mentioned that at the beginning all patients need around 3 hours in the ward but after a number of consultations some of them get used to the treatment and need around 2 hours. In the new ward maximum 4 patients per day are estimated to be served. Thus it is important to ensure a free timeslot for them when they return for therapy (every 6-8 weeks for a lifetime).
Currently the patients are clustering in two ways as it is described in the table 4.2 below. An estimation of the amount of the patients in a normal week that need ward allocation is presented in the same table. The estimation for most groups was based on the 2015 demand as provided from the GHD manager (Appendix A) combined with the appointment scheduling from January 2016. It is important to highlight that the 2015 demand is also estimated as during 2015 there was no indicator (label) to measure the exact number of patients who needed ward allocation. The hospital does not keep relevant records. The infusion patients will be a totally new group for allocation thus their number is just an assumption.
Urgent Treatment No Low priority Yes High priority Endoscopy 90 5-8 Videocapsule(endoscopy sub-group) 3-4 0-1
Infusion (new group) 15-20 0
Table 4.2 Clustering & estimation of patients’ number for ward allocation per week
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Patient type LoS Patient type LoS
Video-capsule patients
8hr slot Recovery patients from endoscopies
1-2 hrs
Infusion patients 2hrs -3hrs Preparation patients for endoscopies
15-30 minutes
Table 4.3 LoS for patient types
Patients’ origin
Most of the groups follow a specific process when entering the ward (Figure 4.1). The endoscopy and urgent groups have priority for admission in the ward as a possible irregular allocation of them will create non availability of beds for the other groups. The other departments are then informed about the number of patients they are allowed to allocate in the ward. The different origin of the patient groups that the GHD will have to serve is presented below.
Patient group
Enters the ward based on
Main need What is important?
Endoscopy and
videocapsule
GP, another hospital or department (before/ after endoscopy usually), after triage process Preparation and recovery Videocapsule : Diagnosis only Timeliness service Urgent patients GP, another hospital or department (before / after endoscopy usually), after triage process
Preparation and recovery
Short admission time
Infusion From another
sub-department
Treatment Timeliness service, Regular visits
Table 4.4 Patient classification and origin
4.4.2. Slot policy
4.4.2.1. Capacity allocation
At this point the dedicated and reserved slots of the current schedule blueprint will be presented. The number of slots per week may alter depending on the number of urgencies or the duration of an endoscopy.
Page | 30 Number of slots of the endoscopy center
For this study a week’s window planning will be used. The planning for endoscopy patients will provide a good indication on how many patients from this group arrive in the ward within a week. However as the total number of available slots differ every day, only the dedicated and the reserved slots can be determined. Appendix C provides a real week’s planning of the teams that were mentioned. A table with dedicated and reserved slots per team and their shifts is presented in the same appendix due to space limitation. Table 4.5 below presents the number of slots per endoscopy type and how many of them require ward allocation in order to provide an overview of the number of patients who need preparation and recovery in the ward per day. The data derived from the appointment scheduling of January 2016 and from interview information.
Day Type of slot
Number of slots per endoscopy type Total number for ward allocation Gastro scopies Colono scopies Endo-echo ERCP-Xrays Video capsule Monday Dedicated 1 6 4 1 17-18 Reserved 7 6-7 Tuesday Dedicated 2 2-3 2-3 20 Reserved 7 9 Wednesday Dedicated 1 2-3 2 1 17 Reserved 8 9 Thursday Dedicated 2 2-3 3-4 1 19-20 Reserved 5-6 7 Friday Dedicated 4 6 2-3 1 20-21 Reserved Amount varies assume 2 Amount varies assume 7
Table 4.5 Dedicated and reserved slots per endoscopy type and number of ward allocation
Page | 31 4.4.2.2. Appointment scheduling for endoscopy center
The current ward’s input of patients is based on the scheduling rules that apply on the appointments of the endoscopies. In January 2016, it was introduced an agenda (called x-care) which records the patients that need recovery after the endoscopies. This seems to be the first step towards improving ward allocation. Even so this agenda does not apply on all patients and teams (e.g. team 3 pulmonary endoscopies) and certainly not on the groups from other sub-departments (e.g. infusion). Overall there are six basic scheduling rules that the planners use according to the urgency level of the patients (table 4.6).
As mentioned, UMCG uses the triage system to categorize the patients regarding their needs. During the triage process the doctors decide whether or not the patients need to receive an appointment in GHD. The triage doctor determines the urgency of a patient's examination as well as his/her admission date (same day, 3 days, etc).
The FCFS is usually implemented when patients with complaints are referred but are not urgent. These patients should be allocated within 6 -8 weeks at most. The long FCFS is implemented for all endoscopies where doctors indicate a long term allocation, i.e. after two months scheduling.
The “same-day” rule is implemented when urgencies occur such as bleeding. The fourth, fifth and sixth rules indicate also urgency of patients but with a less strict time frame. The 3 days and 7 days rules apply when patients’ symptoms and complaints are severe but without bleedings or more acute symptoms. The doctor’s choice rule applies mostly to patients that arrive to UMCG for another appointment and the doctor requests the patient to undertake the endoscopy the same day to improve patient’s satisfaction.
No
Scheduling
rules Situation used
1 FCFS
Same for all groups regular situations norm 6weeks -8 weeks mostly diagnostic processes
2
Same day or the next day planning
Priority rule- Urgent patients
3 Long FCFS Indication for allocation later than 2 months 4
Priority in 3
days Priority rule-All groups -urgency level 5 Within a week Priority rule -All groups
6
Doctor choice
of the day Priority rule -All groups, depend from doctor's instruction
Page | 32 When all patients receive priority number the planners ought to place them in available timeslots on the weekly schedule, as close as possible to the doctor’s indication. However, the planners’ experience reveals an unofficial priority rule for urgent patients. The more urgent patients have certain disease based characteristics that distinguish them and lead the planners to allocate them before other less urgent cases.
Through observation of the planning process for urgent patients a second unofficial rule is revealed. It could be called the “note” rule. The “note” rule is literally a written note that is given by the doctors or nurses to the planners in order to pay attention and allocate first certain more “sensitive” patients Lastly, if the number of the urgent patients exceeds the number of available slots, the doctor needs to interfere and resolve the situation, either by allocating all the patients on the same day in sequence or by indicating the most severe cases.
The above rules regulate the patients’ allocation in the ward, thus they are described at this point in order to provide an overview on how the ward scheduling should be planned. There is no buffer of patients from the previous day admitted in the ward.
4.5. Adjustments to reduce variability’s effect
Walk-ins
The GHD’s ward does not accept patients who refer themselves; walk-ins are not allowed, as the ward administrator mentioned; this rule will remain in the new ward.
No-shows
The ward planners and administrator stated that the number of no-shows is insignificant throughout the year. Thus it may be assumed that the same will occur in the new ward too. In the GHD-database, the total no-shows number for 2015 was 94 patients which is less than a week’s total number of patients.
Emergencies-urgent cases
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4.6. Discharge and transportation process
Officially after their recovery the patients are discharged immediately or if they need more time to recover they are transferred in another ward or to the hospital they arrived from. In order to discharge or transfer patients, the relatives of the patients must arrive punctually and assist them as due to sedation their consciousness is still low. Depending on the transportation, an ambulance or a gurney are also important at some cases.
4.7. Summary
As the new ward is not ready yet a full description of its set-up cannot be presented. The new ward will function under the “pooling beds” notion. Its resources will be shared with patients from other departments. Nevertheless the current study gives priority to the endoscopy, including urgencies, group as it the most demanding and challenging group for ward allocation comparing with the others.
Patients currently are clustering in non-urgent endoscopy patients, urgent endoscopies and videocapsule. There are dedicated and reserved slots for patients who need to undergo endoscopies per day and most of these patients need ward allocation. Also the scheduling rules that currently guide the patient allocation in the ward derive from the rules that apply for the ERs. Priority rules apply for urgent classification and FCFS rule for regular patients. Informal scheduling exists also.
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5. System Analysis
The purpose of this chapter is to analyze the scheduling process and the performance of the UMCG-GHD ward as described in chapter 4 and identify opportunities and barriers for the envisioned ward.
5.1. Approach
In order to provide a structured analysis of the current appointment scheduling system, which might influence the appointment scheduling of the new ward the following question is the subject of the chapter:
What is the performance of the current appointment scheduling system, what causes this performance and how it could influence the new ward’s performance?
It is chosen to focus on the analysis of the endoscopy patient group including the urgent classification, because it is the largest and most difficult group to allocate in the ward. As it can be observed in Appendix A patients from this group vary a lot in the quantity and length of treatment. When these patients are not scheduled carefully they cause peaks and valleys in the ward and lead to low ward performance. The other patient groups have stable LoS, thus they can be allocated easier without creating unbalances. The analysis will be short due to scarcity of data as the performance of the current ward is not regularly measured. The envisioned ward provides no data.
The first step in the analysis is to assess the current performance of the ward in terms of bed occupancy and timely service of the patients. Data were provided from the ward administrator (scorecard) and the manager. The second step is to explore the root causes of the indentified performance. Observations and informal interviews were performed to obtain information. A cause and effect diagram is used to depict the root causes and their effects. The third step explores opportunities for pooling for the future ward considering also the results of the previous steps. The fourth step describes the possible barriers from the pooling synergy combining them with the current situation.
5.2. Current performance of the ward
Bed occupancy
Page | 36
Page | 37
Timeliness of service
The management team raised the issue of the timely service of the patients and especially of the endoscopy group of the ward. The GHD is obliged to serve all patients within 6 weeks according to the Dutch law decrees. An exception is the urgency group, which needs to be served within 7 days maximum. In the opinion of the GHD manager the latter is met. Also, he mentioned the timely service of patients who are sent from other hospitals (treated within 48 hours). However according to him it might be the case that is not possible to serve all patients timely within the 6 weeks deadline. The manager and the planner mentioned that the law is being followed on average, however if a patient arrives only with complaints his allocation might take up to 8 weeks due to lack of available appointment; only a doctor’s intervention could change this appointment. In addition, it has been observed that some patients are allocated to a specific doctor exclusively. In these cases the GHD seems to prioritize the quality of treatment and not the smooth workflow of the ward. Unfortunately, this criterion cannot be verified, as there are no recorded data for patients.
5.3. Root causes of current ward performance
The new ward’s performance could be poor if the policies implemented in the current ward and EC are to be adopted unchanged. An overview of causes that derived from interviews and observations of the current system and cause the low and unstable utilization of the ward are presented below (figure 5.2).
Page | 38 5.3.1. Slot policy capacity allocation
An issue that arose during interviews is that the planners do not pay attention whether there is an available bed in the ward or not, they do not ask/check the availability of beds before planning. In addition, there are no dedicated/reserved beds for different patient groups (ward administrator) officially. Hence every patient is allocated randomly in the ward which causes the appearance of both empty beds and full occupancy of beds within a day (in different hours). The poor bed utilization might deteriorate in the new ward where more patient groups will be allocated.
However, there are some dedicated and reserved slots for the ERs, according to the doctors’ availability and shifts. It has been observed that some physicians need to examine specific patients; hence the planners allocate to their shift as many patients as they can. There is no limit to the number of patients per day. The unstable number of admissions leads to unstable bed occupancy in the ward (Bekker et al., 2011).Furthermore, the number of operational teams per day fluctuates greatly and only two teams are stable and functional every day. For example on Monday there are more teams working than any other weekday, which could affect the new ward’s workload.
It can be concluded that at the moment there is lack of careful consideration and allocation of capacity in the current ward.
5.3.2. Slot policy appointment scheduling
It is found that no attention is paid on the order of the allocation of the patients according to their needs for bed occupancy in the ward. There are days in the schedule where the patients who need recovery were scheduled the one after the other. Interviewees confirmed the lack of consideration for slot availability, and if there are available slots patients are randomly being allocated to them. It is common practice not to consider the patient LoS in the ward, as it appears that the single rule for scheduling the patients in the ward is to follow the exact scheduling set by the doctors for the performance of the endoscopy procedures (Bekker et al., 2011).
Page | 39 needs. Furthermore the low utilization of the ward can be attributed to the scheduling rule is used for the ER planning of urgent cases. This is the same day or next day planning rule: For this rule there are no limits to the number of cases that arrive. It is unethical not to serve an urgent bleeding patient. Unfortunately there are no data recorded concerning urgent patients and thus it is not possible to forecast their number or plan which timeslots would be better to be reserved for them. Lastly one of the main causes that create unbalances are the informal rules that influence negatively the official scheduling in the EC and therefore in the ward.
5.3.3. Patient classification
It has been observed that the LoS per patient group and even within one patient group differs and special consideration is not given to this characteristic. The LoS is not regularly recorded to obtain a complete picture of the patients needs. Also it has been observed that within the endoscopy group the greatest number of patients derives from colonoscopies and gastroscopies thus an improved allocation of them could smoothen the workflow in the ward. Once again this requires the recording of data concerning LoS for preparation, recovery and treatment in ER if applicable.
5.3.4. Planners
Lack of communication: There is a lack of communication and cooperation between the planners from the different (sub)-departments who need to schedule patients that use the ward. Each planner knows the situation in his department and schedules his own patients. As a result there is no information exchange of how many slots the endoscopy patients let available so as to allocate the other groups. This might decrease the patients’ satisfaction, increase admission times and influence bed occupancy.
In addition, not all planners are able to schedule all patients due to the complexity of the number of codes and rules applicable. More complex and urgent patients are scheduled only from specific planners. Also it has been observed that there is an excess number of planners more than 3 for scheduling appointments in one ward and 6 endoscopy rooms.
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5.4. Opportunities for pooling beds at the new ward
The bed occupancy, the visual representation of the ward and the causes have revealed that there is room for improvement with respect to the use of the ward capacity; Bruin et al., (2009) discuss that the norm is 85% occupancy rate in wards. Also from figure 5.1 it can be seen that the scheduling process can be improved as there are many scattered empty slots. This is a consequence of not efficient scheduling and can be solved through reallocation of the capacity which is part of the slot policy. However, empty slots can be filled with patients with similar needs and LoS from other departments. Hence, the new ward will attempt to achieve a better utilization of its resources and economies of scale through the pooling capacity or “pooling idleness” notion (Van Dijk et al., 2009) i.e. shared its resources (beds) with other departments.
Resource pooling is an opportunity to reduce the variability as the facilities of the ward will be available to a larger number of patients; thus it is an opportunity to succeed a higher occupancy of the ward (Vanberkel et al., 2012; Bruin et al., 2009) and reduce idle times of its staff as well. In addition it can decrease the waiting times of patients especially when they arrive from fully occupied wards.
5.5. Barriers for pooling for the new ward
The below mentioned barriers may affect the scheduling and the performance of the new ward.
Lack of integrated agenda: It would provide information on which patient needs ward allocation or not. As it is mentioned above, in the demand of 2015 for endoscopies there were some patients, for example from a specific team of endoscopies, who use the ward but there is no official information on the scheduling in order to forecast their demand for bed occupancy. The planners know again from experience, which need allocation. This might create in the new ward occupancy fluctuation as well.
Staff: It should be ensured that the nurses will be trained not only for the current groups but also for patients who might need special care from the other departments, with whom the nurses are still not familiar.
Page | 41 the day. He should be the point of contact for other departments that wish to use the resources of the new ward. This requires improved communication among all relevant stakeholders.
5.6. Summary
The performance of the current ward in terms of bed occupancy is found to be low and its workflow unstable due to multiple causes. Also it has been observed that the bed occupancy could vary a lot because the appointment scheduling process for ERs does not take into consideration factors such as available beds in the ward or LoS of patients. In addition the sequencing rules that are currently used create fluctuating utilization, which further deteriorates due to the use of informal rules. The excessive number of planners and the lack of experience from some planners in scheduling all processes are identified as causes, too.
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6. Solution directions of the appointment scheduling system for the new ward 6.1. Approach
This chapter provides solution directions for the new ward appointment scheduling system which will operate under pooling synergy. In order to provide constructive directions for the operation of the new ward, the following question is going to be answered:
How could the set-up of the new appointment scheduling system be designed, so as to enhance the performance of the new ward concerning priority to the endoscopy group’s needs through pooling synergy realization?
The first important step is to reveal the gains that are expected from realizing pooling synergy in the new ward. The gains are identified with the use of literature and the analysis chapter results. Afterwards the application of pooling will be accomplished through a proposal for the setting up of the appointment scheduling system. In addition, as discussed in the analysis chapter, a rigorous consideration should be given to the organisation of the planning of the new ward.
6.2. Benefits from pooling synergy realization in the new ward
Pooling synergy is used often in hospitals in recent years in order to offer a more patient-centered service (Villa et al., 2009). The gains from pooling synergy in the new ward will be multiple. It could enhance the performance as its capacity will be used more efficiently and higher bed occupancy will be achieved (Vanberkel et al., 2012; Bruin et al., 2009). Simultaneously it will decrease idleness of the ward resources (Van Dijk et al., 2009); the scattered empty slots that exist currently will be reduced thus the variability of the ward’s workflow will be decreased too. Lastly, in line with the patient centered service, the application of pooling could decrease waiting times of patients who need allocation in a busy ward resulting in increased patient satisfaction (Vanberkel et al., 2012).
These benefits will be realized firstly through the design of an efficient appointment scheduling system and secondly through a change in the organization of the planning of the ward.
6.3. Appointment scheduling system
