Master thesis
The applicability of one-stop-shops with the use of
combined appointments
University of Groningen
Faculty of Economics and Business
Master Supply Chain Management
Student
Jeen Duipmans S2397234
Supervisor
Taco van der Vaart
Co-assessor
Mariette Zweers
Abstract
The one-stop-shop concept is increasingly applied in the health care environment. The concept is used in order to increase patient flow performance and to improve patient care. A care process usually consists of several process steps and multiple visits of the patient to a hospital. By clustering multiple process steps on the same day, the number of visits can be decreased. It is unclear which characteristics of health care processes inhibit or facilitate the application of one-stop-shops and what the effect is on patient flow performance and resource utilization. Therefore, the purpose of this study is to assess the relation between the application of one-stop-shops and hospital performance with the moderating effect of characteristics of healthcare processes. In order to assess this relation, we conducted a multiple case-study in a regional hospital in the north of the Netherlands. Within case and cross case analyses were conducted and showed that the presence of variability, shared resources and a short time window for delivery can have a negative effect on the relation between the one-stop-shop application and hospital performance. A high variety in the required process steps for a patient group can limit the applicability of a one-stop-shop. However, variety does not need to limit the application of a one-stop-shop when the predictability of the required process steps is high. After the application of a one-stop-shop, the patient flow performance can increase when the one-stop-shop is properly designed. During one visit, the patient can take several subsequent process steps. The utilization rate on the other hand, could decrease as a result of a one-stop-shop implementation. When the actually needed process steps appear to be different than predicted, capacity may remain unused.
Acknowledgment
The master thesis is the last step in completing the master Supply Chain Management. During the process of writing this master thesis, I had the pleasure to work with several people who contributed to the establishment of my master thesis. I would like to use this opportunity to express my appreciation for the collaboration with the people involved in this project.
Firstly I would like to thank my supervisor dr. Van der Vaart for the given insights and the patience during the process. Constructive feedback was continuously provided during the process of writing the thesis. Although attention points and possible directions were given, I always got the opportunity to determine autonomously how the follow up should look like.
Next I would like to extent gratitude to co-assessor Mariette Zweers who, provided me with helpful feedback during the process. The asked questions about my delivered work triggered me to rethink the elements of my thesis which resulted in new insights.
Special thanks go to the logistic manager of the hospital, who did not only contributed by elaborating on the practical matters in the hospital but also contributed by thinking along the scientific angle of the project. The new insights I gathered with thanks to our discussions were helpful for the progression of the project. Furthermore I would like to thank all involved participants of the hospital where I conducted my research. In order to guarantee the anonymity of the hospital, I will not expose the names of the involved persons.
Lastly I would like to thank Meindert van Rij for his input during the project. We both conducted research within the same research theme. Our conversations and discussions were helpful in creating an in depth understanding of the subject.
TABLE OF CONTENTS
1. INTRODUCTION ... 4
2. THEORETICAL BACKGROUND ... 7
2.1 The one-stop-shop concept ... 7
2.2 Healthcare process characteristics ... 7
2.3 Hospital performance; patient flow and resource utilization ... 10
2.4 Conceptual model ... 11 3. METHODOLOGY ... 14 3.1 Research design ... 14 3.2 Case selection ... 14 3.3 Data collection ... 15 3.3.1 Qualitative data ... 15 3.3.2 Quantitative data ... 16 3.4 Measuring variables ... 17 3.5 Data analyses ... 18 4. RESULTS ... 19 4.1 Within-case analyses ... 19
4.1.1 Orthopedic pre-operative screening OSS ... 20
4.1.2 The inguinal hernia repair pre-operative screening OSS ... 27
4.1.3 Vascular surgery OSS ... 30
4.1.4 Spirometry OSS ... 35 4.1.5 Clinimetrics OSS ... 40 4.2 Cross-case analyses ... 42 5. DISCUSSION ... 48 5.1 Characteristics ... 48 5.2 Hospital performance ... 51 6. CONLCUSSION ... 52 REFERENCES ... 54
1. INTRODUCTION
The one-stop-shop concept is increasingly applied in the health care environment. Salam et al. (2006) state that the one-stop-shop (OSS) concept is used in order to increase patient flow performance and to improve patient care. A care process usually consists of several process steps and multiple visits of the patient to a hospital. By clustering multiple process steps on the same day, the number of visits can be decreased.
OSSs can be established with help of different mechanisms. For example, a walk-in policy can be used through making use of overcapacity of resources. Furthermore, the mechanism of combined appointments can be applied. Drupsteen, Van der Vaart and Van Donk (2013) define combined appointments as an integration mechanism which arranges and executes multiple steps in a care process on the same day. The same reasoning is used by Romero, Dellaert and Van der Geer (2013), who state that capacity needs to be reserved through appointing timeslots for the one-stop-shop in advance. Appointment slots for different steps of the healthcare process are held open so subsequent steps in the care process can be combined. A patient can undergo subsequent process steps on the same day by making use of the available timeslots. In literature and practice combined appointments are majorly used in order to set-up OSSs. In this paper we explore in which situations the implementation of OSSs with help of combined appointments is desirable and what impact these OSS implementations have on patient flow performance and resource utilization.
Butler, Karwan and Sweigart (1992) argue that the hospital operations planning should fit with the facility lay-out or characteristics of the healthcare process. When planning to set-up a OSS, the characteristics of the healthcare process could be assessed in order to determine if a OSS is applicable. The characteristics of the patient and healthcare process can be identified with help of the DWV model. The model developed by Christopher and Towill (2000) is applied in the healthcare environment and uses five characteristics. The following characteristics can be distinguished; life cycle duration; time window for delivery; volume; variability and variety. The DWV model has been used for the identification of healthcare processes in several articles and gives a complete picture of healthcare process.
the process. In some circumstances the use of OSSs can be applicable, although the characteristics of the process could limit the effectiveness of the OSS.
Both healthcare characteristics and effects of one-stop-shop implementations have been separately researched in literature. The influence of process and patient characteristics on the implementation of one-stop-shops and mutual effects have not been addressed in literature until so far. It is unclear in which situations the implementation of a one-stop-shop is applicable and desirable. It can be beneficial for healthcare decision makers to have a guideline which helps them decide if a one-stop-shop is desirable under specific circumstances. This study contributes by covering this gap. Furthermore, side effects as a result of the implementation of one-stop-shops are unclear. Additional required planning efforts and the availability of resources for other departments and patient groups (displacement effects) could be influenced as a result of one-stop-shop implementations. Displacement effects might occur when the capacity is reserved specifically for the OSS, which decreases the available capacity for departments and patient groups who are not making use of the OSS. Information about these effects is desirable so decision makers can determine if implementing a one-stop-shop would contribute to achieve the hospital goals.
In this research we examine how process and patient characteristics influence the implementation of one-stop-shops with the focus on the use of combined appointments. Resulting in the following research questions;
RQ 1: Which characteristics of a healthcare process facilitate or inhibit the implementation of a one-stop-shop?
RQ 2: What is the effect of implementing a one-stop-shop on patient flow performance and resource utilization?
2. THEORETICAL BACKGROUND
2.1 The one-stop-shop concept
In literature several labels are used in order to refer to the one-stop-shop (OSS) concept. Authors ((Tagge et al., (1999), Spencera et al. (2003) and Gupta et al. (2004)) use the following definitions; one-stop surgery, one-stop clinic or see and treat clinic. The concept were these authors are referring to is similar. In this paper we use the label one-stop-shop. We define the one-stop-shop as a concept in which the patient undergoes two or more subsequent appointments during a visit on one day. When we mention the OSS concept in our paper, we refer to the OSS realized with the combined appointment mechanism.
The OSS concept can be designed with the application of combined appointments. Drupsteen et al. (2013) state that the combined appointment is a mechanism in which subsequent process steps are planned together, where these steps can be fulfilled on the same day. Capacity of several process steps is combined, which should result in a reduction of the non-value-added activities as the number of queues is decreased. Romero et al. (2013) argue that admission and capacity planning is of great importance for a feasible application of a combined appointment. It should be clear which process steps will be taken and in which sequence these steps will be done. Besides, the expected time consumption per step and the expected number of admissions should be calculated. Based on these calculations, slots can be reserved for the different process steps of the OSS. The capacity should be reserved in such a way that subsequent process steps can be combined on the same day. Reserving slots for a OSS comes with the risk that capacity can remain unused because it is unsure if the reserved OSS slots will be used.
2.2 Healthcare process characteristics
that for each type of healthcare service, different approaches of organizing and managing a service can be defined. After conducting our research, a distinction in two types of healthcare processes could be made based on the earlier named characteristics. Healthcare processes that are more suited for OSSs and healthcare processes that are less suited for OSSs.
How the five variables can be interpreted in a healthcare environment is explained by Towill et al. (2005). The authors state that life cycle duration is related to the phase of the activity in a healthcare process. Different phases which can be distinguished are diagnosis, treatment and convalescence. A one-stop-shop can be set-up in one of these stages (e.g. the diagnose phase, as investigated by Murray et al. (2000) and Witcher, Williams and Howlett (2007)) or involve multiple phases for the same one-stop-shop (e.g. diagnose and subsequent surgical treatment on the same day as investigated by Jutte et al. (2010) and Voorbrood et al. (2013)). Depending on the phase (and the coherent variety in this phase) in which the OSS is implemented, the effectiveness of the OSS could be influenced.
Variety deals with the different routings and sequence a patient can go through a healthcare process. Vissers et al. (2001) state that the variety also depends on the earlier discussed life cycle duration. In the diagnostic phase, still little is known about the patient and the process steps which are going to be taken, this could cause more variety.
Time window for delivery aims at the moment action is needed for treating the patient. The time window for delivery is related with the urgency the patient needs care. A patient with a high urgency needs to deal with a short time window because of the quick response which is needed to treat the patient. The arrival pattern and the required care of patients who need to be treated on a short notice is rather unpredictable. Reserving capacity for these patients is therefore difficult. The application of a OSS and therewith making reservations for the different appointments in advance, might therefore not be applicable.
is reserved in advance. When the number of patients appear to be less than estimated, reserved capacity could remain unused.
Except the influence of variability on the applicability of OSSs, the application of a OSS can also interact with variability. Without the applications of OSSs, the appointments of all patients in a patient group are organized in a similar way. All appointments are scheduled sequentially and patients are therefore placed in one single queue for an appointment. When shared resources are present in a health care process, capacity for the appointments needs to be reserved in advance for the required appointments. Because of the application of OSSs, capacity is separately reserved for regular patients and separately for the fulfillment of OSSs. Two parallel queues are distinguished for patients taking regular appointments and patients attending the OSS. Because of splitting up the queue in two parts, variability can increase. Hopp (2008) reasons that extreme values, both high and low, in demand can cause variability. Cattani and Schmidt (2005) state that pooling of customer demands, along with pooling of the resources used to fulfill those demands, may yield operational improvements. Applied in our case, this would imply that pooling queues for both the OSS and regular appointments could balance extreme values out. When capacity is unpooled, the situation might occur that demand for the regular appointments is low while demand for the OSS is high. Capacity reserved for regular appointments might remain unused while a lack of capacity might be available for patients attending the OSS. In this scenario patients who would like to attend the OSS deal with a high access time while capacity allocated to the regular patients remains unused. According to Vanberkel et al. (2010) economies of scale can be achieved by pooling capacity. When capacity and queues are pooled, all patients will achieve shorter waiting times in comparison with unpooled capacity and queues. From this perspective the implementation of a OSS (unpooling capacity and queues) could come with the undesirable side effect of increased number of outliers and longer access times.
conflicting interests. In the one-stop-shop multiple appointments need to be fulfilled on the same day. The resources needed in order to fulfill the appointments could already be allocated to another department which constraints the proper implementation of a one-stop-shop. Reserving capacity of these shared resources in advance is therefore of great importance.
2.3 Hospital performance; patient flow and resource utilization
In order to judge if the implementation of a one-stop-shop contributes to the hospital goals, patient flow performance can be used as a measure. Hopp (2008) operationalizes flow performance with the rate at which entities move through the system. Haradsen and Resar (2004) argue that patient flow performance can be improved by reorganizing a healthcare process without the need of additional resources. The application of combined appointments in a one-stop-shop can help to reorganize the healthcare process. The implementation of a one-stop-shop influences the patient flow performance. Salam et al., (2006) and Romero et al., (2013) found that the patient flow performance can increase after implementing a one-stop-shop. Drupsteen et al. (2013) argue that with help of combined appointments, capacity of several process steps is combined, which should result in a reduction of the non-value-added activities as the number of queues is decreased. The increase of performance is the result of diminishing waiting time between the subsequent process steps (Salam et al., (2006)), as they are planned on the same day. After a patient makes an appointment for the first hospital visit (e.g. taking a diagnosis), time elapses before the diagnosis can be conducted. After the diagnosis the patient makes a new appointment for the actual treatment, after which the patient is again put on the waiting list. With help of the one-stop-shop, waiting time between subsequent stages is decreased to a minimum, which has a big impact on the patient flow performance.
The timeslots reserved for the one-stop-shop can also be needed for regular treatments or, in case of shared resources (Visser et al. (2001)), for other departments. These regular treatments can only be planned during the timeslots which are not reserved for the one-stop-shop. This makes the planning of the regular treatments more rigid as only the timeslots which are left open can be allocated. As a result, the throughput time of the patients opting for a regular treatment could increase when too much capacity is allocated to the OSSs. These are the so-called displacement effects of the implementation of a one-stop-shop.
Hans, Van Houdenhoven and Hulshof (2011) conducted research about healthcare planning and control. The researchers state that different departments in the hospital are often managed autonomously and independently. In a lot of cases, different departments are involved with the fulfillment of the different appointments embedded in the OSS. In these cases the departments are forced to give up a part of their autonomously in order to make the OSS work. Capacity needs to be kept aside and reserved for the fulfillment of the OSS in order to guarantee a smooth collaboration between the different departments. Because of the different involved independent departments, more planning efforts might be needed in order to guarantee a successful OSS. The departments involved with the OSS, might need to interact more often with each other. Especially when changes occur in available capacity in one department, all other involved departments might be influenced because of the interrelationship between the departments. When changes occur in one department, collaboration and additional planning efforts are needed in order to adjust the schedules of the other departments involved.
2.4 Conceptual model
Our conceptual model (Figure 1) is based on the discussed literature in the earlier paragraphs. The variables which potentially influence one another are depicted in the model. We should mention that the model constructed in this stage is based on the in the literature section explored theories and on coherent educated-guess assumptions.
When a healthcare process is characterized with a high variety, the OSS concept might be less applicable. Vissers and Beech (2005) argue that structural and operational flexibility is required in order to cope with high variety of routings. When applying the OSS concept, capacity is reserved in advance and dedicated to the OSS. This reduces the operational flexibility and therewith the applicability of OSSs.
Hyer, Wemmerlöv and Morris (2009) state that a higher volume of patients can result in economies of scale and a more efficient healthcare process. Nevers (2002) states that high volumes are needed in order to establish efficient new healthcare concepts. Therefore we assume a positive relation between volume and the establishment of the one-stop-shop concept with help of combined appointments. Patient flow performance can increase as a result of the economies of scale of a higher volume of patients.
Variability of inflow of the patients can have a negative impact on the applicability of OSSs. Because of variability, it is difficult to predict how many patients will be attending the OSS and how many coherent slots need to be reserved. As a result of variability, access time can go up or capacity can remain unused.
Although variability and variety are different per process, one can argue that variability and variety are more likely to be high in the first stages of the healthcare process. In the first phase of the healthcare process (e.g. diagnosis), still little is known about the patient. As a result of the limited knowledge about the patient and the process steps which need to be taken, variety goes up in the first phase. Besides, the inflow of patients is insecure in this stage. New applications for diagnosis can occur at all times. In later stages of the process, more is known about the patient and better estimations of follow up visits and inflow of patients can be made. In order to establish a one-stop-shop and apply combined appointments, timeslots need to be reserved for the patients attending the one-stop-shop. The chance of gaps between the reserved and actual needed timeslots is higher in case of high variety and variability of demand. This could result in low utilization rates because of overcapacity which needs to be built in to cover fluctuations. However, the question remains if a phase of life cycle duration has a fixed relation with values of variability and variety and therewith the applicability of OSSs. We will elaborate on this issue further on in this paper.
Shared resources could trouble the establishment of a OSS because of the limited availability of resources. The lung function department and the radiology department deliver medical services (e.g. spirometry tests and ultrasound exams) which are used by several outpatient departments. Because of the concern of different departments for these shared resources, conflicting interests might occur. In order to allocate the capacity between the different departments, slots for the expected amount of patients can be reserved per outpatient department for these shared resources as stated by Drupsteen et al. (2013). Because of the distinction in different queues for these resources, economies of scale diminish according to Vanberkel et al. (2010). With the application of a OSS, additional queues need to be distinguished. A queue for regular patients and a queue for patients attending the OSS. Because of the distinction in different queues, economies of scale are lost. Outliers in demand might not be balancing out among the different queues. The variability makes it more difficult to predict the amount of required slot reservations which might affect the resource utilization negatively as a result of wrong predictions. Reserved capacity might remain unused because of the increased variability.
After the reservations of slots for the OSS, other departments could be restricted in the access to a resource as a side effect. When a high amount of slots are reserved for the OSS, less slots might be available for other patient groups. Displacement effects could occur, implying that other users of the resources have limited access. Which means that these departments need to cope with a decrease in patient flow performance.
3. METHODOLOGY
3.1 Research design
In our research we applied a multiple-case study in a regional hospital in the north of the Netherlands. Only limited knowledge is available about the applicability of OSSs in hospitals. Therefore we conducted a case study about the relation between healthcare process characteristics and the application of one-stop-shops. After which we assessed the impact of OSSs on hospital performance. Voss, Tsikriktsis and Frohlich (2002) state that a case study is an appropriate choice when rich and deep insights are required in order to develop theory which can be applied in service operations. With conducting a case study, how and why questions can be answered according to Stuart et al. (2002). As this research aims at answering the question in which situations one-stop-shops are desirable (characteristics of the process) and the question what the impact of the implementation of a OSS is on hospital performance, a case study seems to be the right research design. Multiple-cases are assessed in order to enhance external validity and to increase generalizability of the findings. Besides, Voss et al. (2002) argue that observer bias can be prevented when using multiple-cases.
3.2 Case selection
five cases are selected in this case study. In chapter four we elaborate on the selected cases. Therefore we displayed the selected cases with the values of the different characteristics in Table 2 in chapter four.
3.3 Data collection
Eisenhardt (1989) argues that a case-study can be fulfilled with collecting quantitative data, qualitative data or both. Using both data sources has the advantage that synergy effects can emerge. With help of a quantitative approach, unexpected relations could be revealed. While with a qualitative approach this relation can be further analyzed in order to understand a found construct. In this research, both qualitative and quantitative methods are applied because of the synergy effects which can emerge after combining both approaches. Besides, Eisenhardt (1989) and Yin (2003) argue that the use of different data sources contribute to triangulation of the study.
3.3.1 Qualitative data
Qualitative data is gathered with help of semi-structured interviews. Interviews with actors involved in the implementation and fulfilment of combined appointments were held. Semi-structured interviews give the opportunity to retrieve the targeted information in a more guided way compared to unstructured interviews. This has the benefit that the data is easier to compare between different cases. Sousa et al. (2008) argue that semi-structured interviews give deeper insights than surveys. Information acquired with the conducted interviews reveal which characteristics of a healthcare process facilitate the implementation of combined appointments. Effects of utilization rates are also determined with help of qualitative data because of the limited reliability of quantitative data. Differences in the utilization rates are not only the result of OSS applications but are dependent on a high number of different aspects. Changes of utilization rates can be the result of capacity adjustments, changes in demand, (un)availability of medical staff, etc. Qualitative data is a good source in order to get an overview of the utilization rates as the involved actors have a good sense of the effects of the OSS implementations and can also allocate other triggers of adjustments in utilization, which are not revealed with plain data.
held with the logistic manager, the manager outpatient department and the outpatient coordinators of the different departments. These first interviews had an explorative character and were held in order to determine which OSSs are offered in the hospital. Each interview took at average one hour. The outcomes of the interviews gave us a general overview of the 60 different combined appointments used in the hospital to offer OSSs.
After the earlier described case selection, 5 combined appointments were selected for the thoroughly within case analyses. In order to get a complete and detailed picture of the OSS (designed with the combined appointments), multiple actors involved with the implementation and application per OSS were interviewed. Physicians, nurse practitioners and outpatient coordinators are interviewed during this phase in order to acquire a complete understanding of the OSSs and the circumstances. The outpatient coordinators are interviewed twice. Firstly in the explorative phase of the research in order to get a general understanding of the different outpatient departments and all the different used combined appointments within these departments. A second interview with these coordinators was held in order to discuss and to elaborate on the selected cases in detail. Appendix 1 entails the interview protocol used for the interviews.
The interviews in the explorative phase of the study were held by two researchers. Both researchers conduct a study about the OSS concept, while both researchers use different angles of analyzing the concept. Because of similarities between the research design of both researchers, the held interviews in the explorative phase were held together. Conducting interviews with multiple researchers brings the advantage of an increased reliability of the retrieved data. Vos et al. (2002) argue that a debate between the researchers after an interview can increase the understanding and can give new insights of the retrieved information. Eisenhardt (1989) follows the same reasoning and states that interpretations after the held interviews can be verified by interaction between the researchers. After these explorative interviews, both researches distinguished from each other by focusing on cases applicable for their own research. The follow up interviews after the explorative phase were held with one researcher. All the interviewees allowed us the record the conversations. All held interviews were recorded with help of digital devices. These recordings and field notes were the input for the within-case and cross-case analyses.
3.3.2 Quantitative data
records of patients attending a OSS in the period between 1 January 2013 and 31 December 2013 were collected. With this data, the average amount of patients per week attending a OSS was calculated. The average amount of patients and the measures per week were compared after which the deviation and coherent standard deviation was calculated in order to assess the variability. The coefficient of variation is also calculated in order to be able to interpret the ratio between the standard deviation and the average amount of patients.
3.4 Measuring variables
After the data was collected, the outcomes per OSS are compared with each other. The characteristics are ranked on the scale low, mediate and high. The rankings of the different OSSs and all characteristics will be displayed in table 2 in chapter 4. Ranking the characteristics based on a three point scale instead of on raw data increases the comparability between the different cases. Miles and Huberman (1994) state that the reduction of data into categories is important in order to increase the comprehensibility and comparability between the different cases. The used rankings and coherent ratio’s for the characteristics volume, variability and variety are displayed in table 1. The boundaries of the rankings low, mediate and high are based on the ratings of these characteristics. The threshold values for the ratios of variability are based on the findings of Hopp (2008) and are expressed with the coefficient of variation. Hopp (2008) suggests to use the threshold values 0,75 and 1,33 for the coefficient of variation, which we also use in table 1. Volume is measured with the average demand of patients for a OSS per week. The threshold values are determined based on a comparison between the volumes of the different offered treatments within the hospital. Both variability and volume characteristics are determined with help of data from the hospital information system. Variety is measured with help of the number of different routings distinguished in the OSS. Different routings within a OSS exist when patients (based on the patient’s medical situation) can take different process steps or sequence within the same OSS. These different routings are determined based on the different registrations of the OSS which are registered in the hospital information system. These distinctions of routings were also verified during the conducted interviews. The threshold values are based on the comparison between the 60 combined appointments.
senior laboratory worker at the lung function department and a secretary at the radiology department) involved per OSS are asked the same questions about these characteristics in order to verify if the given classification are correct.
Table 1. Ranking of characteristics
Characteristics Ranking Rating
Volume
(measured in number of patients per week)
Low Mediate High
Equal or lower than 1 Between 1 and 7 Equal or more than 7
Variability
(measured with coefficient of variation)
Low Mediate High
Equal or lower than 0,75 Between 0,75 and 1,33 Equal or more than 1,33
Variety
(measured with the number of different patient categories) Low Mediate High Equal to 1 Equal to 2
Equal or more than 3
3.5 Data analyses
4. RESULTS
As discussed in the paragraph case selection, 5 out of the 60 combined appointments were selected for the within-case and cross-case analyses. During the explorative phase of our research, we got the basic insights of all combined appointments applied within the hospital. Of all 60 considered combined appointments, all combined appointments had a high time window for delivery. Different outpatient coordinators argued that the OSS slots are already filled a few (depending on the combined appointment) weeks in advance. This implies that when a patient needs to be treated in the OSS and wants to make an appointment, it can take a few weeks before the treatment takes place. Patients who need an urgent treatment, cannot wait a few weeks until the slots of a OSS are available. Patients with a low time window for delivery are therefore less suitable for a treatment in the OSS. Coherently the researched hospital is not offering any OSSs for these patients. Although we did not found different values for time window for delivery, we did found differentiations in values for life cycle duration, volume, variability and variety, number of steps and the combination of different disciplines in the OSS.
Based on these criteria the following cases were selected; the orthopedic pre-operative screening OSS; the inguinal hernia repair pre-operative screening OSS; the vascular surgery OSS; the spirometry OSS and the clinimetrics OSS. In this chapter we discuss the different cases. We start with a within-case analyses after which a cross-case analyses is followed.
4.1 Within-case analyses
Table 2. Characteristics of the One-Stop-Shops
4.1.1 Orthopedic pre-operative screening OSS
The orthopedics OSS is applied for the pre-operative screening of patients who need a total knee, hip or shoulder replacement. The aim of this OSS is to conduct a complete screening of the patient within one day and therewith increasing the convenience and experienced service of the patient. Instead of attending the hospital multiple times for going through the process of pre-operative screening, the patient visits the hospital ones to finish all the steps. The reason to offer the OSS concept for this specific patient group within the orthopedic department is the relatively high number of patients and the expected growth of number of patients within the orthopedic department for this patient group. Because of the high number of patients, economies of scale can be achieved. The results after the efforts of designing and setting up the OSS are beneficial for a high number of patients. Before a OSS can be offered, the different involved process steps need to be analyzed in order to determine if these steps can be grouped on the same day. The orthopedic OSS entails (as described in the next paragraph) a high number of different process steps and different departments. In order to have a smooth collaboration between these different stakeholders, more research efforts are required in order to set-up a proper OSS. During the design of the combined appointment, it needs to be planned how the different disciplines should cooperate and interact with each other during the
Life cycle duration Time window for delivery Volume Varia-bility Variety Shared Resources
Orthopedic OSS Pre-operative screening
High High Low High Present
Inguinal hernia repair OSS
Pre-operative screening
High Low High Low Present
Vascular surgery OSS Diagnoses High Mediate Mediate High Present
Spirometry OSS After diagnosis High High Mediate Low Present
day. The more patients using the OSS concept, the more worthwhile the time spend for the design of the OSS.
Within the OSS seven steps are combined on one day, of which four are included for all patients while three steps are optional. During the first consult, the patient visits the hospital for an appointment with the orthopedic surgeon. If the orthopedic surgeon determines that the patient needs a knee, hip or shoulder replacement in order to cure the patient, an appointment is made for the pre-operative screening of the patient which is organized via an OSS.
Three categories of patients and three corresponding routings can be distinguished within this OSS. The healthcare process for the different patient categories is displayed in figure 2.The first category of patients need a total knee or hip replacement and are diagnosed to have a higher risk of delirium after the operation. The second category of patients need a regular total knee or hip replacement and are not expected to have any issues with delirium based on medical history. The third category of patients need an orthopedic treatment which consists of different steps than a knee or hip replacement. For example patients who need a shoulder replacement or patients who attend the hospital for a revision of their replaced knee or hip. A revision contains a treatment for patients who get a replaced knee or hip for the second time.
Figure 2. Process steps orthopedic OSS
Characteristics
The different characteristics of the healthcare process for knee, hip and shoulder patients are described in table 3. The OSS takes place in the pre-assessment stage of the process. Three patient categories are distinguished because of variety in the healthcare process in this stage. The required steps for the different patient categories are slightly different. Before the patient can take the pre-operative screening, a diagnoses is needed in advance. For this reason the patient attends the hospital already before the screening day. After the diagnosis it is determined which process steps are required and to which patient category the patient belongs. The predictability of the required care steps is high after the diagnosis. When the situation of the patient is clear, it is easy to determine which steps are appropriate because similar steps are needed within each patient category. Only the possible seventh step (the consult with the geriatric nurse practitioner) for the first category of patients, is difficult to predict. During an earlier visit of the patient to the hospital, the orthopedic surgeon estimates if there is an increased risk of delirium after the operation. But only while conducting the screening day, a better indication of the need of a consult with the geriatric nurse practitioner becomes clear. During the screening day, a better view of the patient can be obtained after the consult with the orthopedic nurse practitioner. During this consult additional questions are asked in order to determine the mental and physical situation of the patient and the need of a consult with the geriatric nurse practitioner.
1.Informational session 1.Informational session 3.Consult anesthetist 2.Consult pharmacist 2.Consult pharmacist 3.Consult anesthetist 4.Consult nurse practitioner anesthesiology 4.Consult nurse practitioner anesthesiology 2.Consult pharmacist 3.Consult anesthetist 4.Consult nurse practitioner anesthesiology 5.Consult nurse practitioner orthopedics 6.Consult physio-therapist 7.Consult geriatric nurse practitioner1 5.Consult nurse practitioner orthopedics 6.Consult physio-therapist 5.Consult nurse practitioner orthopedics Patient category 2 1
The seventh step is optional for the patients in the first category. A consult can be taken with the geriatric nurse practitioner if it appears to be needed during the day
Patient category 1
Patient category 3
The average demand of patients for the one-stop-shop per week is 7,30 with a standard deviation of 4,70. The data reveals that the demand of patients is lower during the summer time than during the rest of the year. During an interview, the orthopedic nurse practitioner argued that the variability of the used combined appointment could be explained as a result of seasonal fluctuations in demand. Because of the low urgency of the required treatment, patients can decide their own treatment date. Patients could prefer not to be treated in the hospital during the summer, which results in a low number of knee, hip and shoulder operations in this period.
The pharmacist and the anesthetist can be considered as shared resources which are used by a high number of different patient groups. A high number of different specialties are reserving capacity of these resources which might reduce the availability of capacity for the OSS. However the reservation of slots for the OSS in advance guarantees the availability of these shared resources.
Table 3 Characteristics of the Orthopedic OSS
Life cycle duration
Time window for delivery
Volume Variability Variety Shared Resources
Pre-operative screening
High – The care is not urgent Demand of 7,30 patients per week SD = 4,70 CV = 0,64 Depending on patient four, six or seven steps need to be fulfilled Pharmacy and Anesthesiology are shared with a high number of different patient groups
Design of the One-Stop-Shop
The mechanism used to facilitate the orthopedic OSS is the combined appointment. Every week slots for 10 patients are reserved for the OSS in advance. When less than 10 patients need the reserved slots for the OSS, the capacity is released 24 hours before the execution of the appointments. These empty slots are not dedicated to the OSS anymore and can be used by other disciplines. Patients of other disciplines can still fill up these empty slots in time.
day. In figure 2 the reserved time per step is displayed. Patients with an increased chance on delirium are allocated on this day. However it is still unpredictable if the patient will need the appointment with the geriatric nurse practitioner. For that reason capacity of the geriatric nurse practitioner is not reserved in advance in order to prevent unutilized slots. The geriatric nurse practitioner is aware of the possible need of offering consults on this specific day but is not keeping capacity aside for these patients. If needed, the geriatric nurse practitioner will see the patient between the regular appointments. The patients who possibly need a consult with the geriatric nurse practitioner are planned on Monday because the regular appointments at the geriatric department on Monday are designed with slack because of the nature of the appointments. This makes it easier to anticipate on the additional required appointments for the orthopedic patients.
The second category of patients is planned on the Thursday afternoon. Slots for the six steps of the process are all reserved in advance. Timeslots for four patients are reserved. In the case when more than four patients of the second category need to take a screening, these patients can be planned on Monday with the patients of the first category. With the difference that these patients do not need a consult with the geriatric nurse practitioner. The first category of patients however is dedicated to take the screening on Monday and cannot be switched with the patients on Thursday.
Two slots are available on Friday for the third category of patients. The slots for the four steps which need to be fulfilled are all reserved in advance. There is not held an informational session on this day because of the limited amount of two patients on Friday. Therefore information is not supplied during an informational session but during an extended consult with the orthopedic nurse practitioner. Patients of the third category do not need the consult of a physiotherapist and can therefore only be scheduled on Friday. Scheduling these patients on Monday or Thursday is not possible because of the reserved capacity at the physiotherapist.
Effects
information about patients between the different disciplines can be done in an efficient and effective way.
As a result of the implementation of the OSS, different queues are distinguished. In the first place a queue for the regular patients and a queue for patients attending the OSS. Besides, different queues are distinguished within the OSS for the different patient categories. Because of the distinction of different queues, variability cannot be balanced out among the different queues. This implies that economies of scale of working with a larger patient group are lost. A result could be a lack of capacity for patients in one queue and therewith an increased access time, while another queue might have overcapacity and unused slots. In order to reduce the chance of unused slots, reservations of slots for the OSS are released 24 hours before the appointment. After the release, the reserved slots are used for separate appointments with a single discipline. The orthopedic nurse practitioner stated that a separate slot will still be filled within 24 hours in the majority of the cases. A separate slot is easier to fill because the slot is not dedicated to the OSS, but can be used for all kind of patients.
Variability of the number of needed treatments per week can also have an effect on the access time. When more than the expected amount of patients need a pre-operative screening, access time might increase as a result of limited reserved capacity. In order to prevent excessive access times, appointments can be booked separately. In this case, the orthopedic secretary will book the five or six appointments sequentially. The secretary searches for each separate appointment in the system separately and tries to find a day on which all five or six disciplines have an empty spot in the agenda. In this situation the access time increases rapidly because of conflicts between the agendas of the different disciplines. One discipline could have empty slots only available on Tuesday while the other discipline could only have empty slots on Wednesday. It is hard to find one day on which all disciplines are available. In these situations the separate appointments can be booked over different days. The patient needs to visit the hospital multiple times in this situation but can finish the pre-operative screening earlier. The orthopedic secretary complains about scheduling sequentially because of the increase in required manual steps which need to be taken to make all the separate appointments. The situation in which capacity is reserved in advance makes it much more convenient to schedule the different steps. With one action the appointments are booked in the different agendas.
be supplied on the same day as the day the screening is conducted. For patient that do not qualify for the OSS, the different appointments are planned on the different days of the week. Information needs to be transferred during individual appointments. The time needed to inform the patients is multiplied with four in this case. Another advantage of working with the informational sessions is that patients can also retrieve insights as a result of interactions with the other patients. A question of another patient during the informational session can also be of help for the other patients.
All appointments are all planned closely together. After one appointment is finished, the patient is expected to attend the next appointment straight away. The time needed to finish an appointments can differ per patient, depending on the physical status and additional asked questions of a patient. When more time is needed than planned, a delay can occur. A delay at the first appointment implies that all subsequent appointments can also be affected because of the interrelation between all steps in the process. Especially the time needed for the appointment with the anesthetist fluctuates because of the unpredictability of the needed time during the consult. This impacts the efficiency of the whole OSS. Besides, the specialist time of the anesthetist is a shared resource which is shared with a high number of different patient groups. During the afternoon the OSS is offered, the anesthetist switches between different patient groups. After having a consult with a patient in the orthopedic OSS, the anesthetist might have a consult with a patient from another patient group after which the anesthetist has a consult in the OSS again. Because the anesthetist is switching between the different patient groups, the chance of delays increases. The orthopedic nurse practitioner and the physiotherapist active in the OSS, both perceive these delays as a negative side effect of working with the OSS. Because of the scarcity of the resource, no or limited slack is incorporated in order to prevent delays. Both actors do not see a way of organizing this differently but do not see this as reason to stop offering the OSS because of the advantages involved with the offered concept.
Another issue which is perceived as a disadvantage is the decreased flexibility of the moment on which the appointments can be fulfilled. Time is reserved on the Monday, Thursday and Friday afternoon. The patient has only the opportunity to fulfill the screening day (depending on the category the patient is placed in) on one of these moments. The patient cannot choose for other moments to take the screening than the ones which are reserved.
To conclude it can be stated the OSS has been successfully implemented and brings several advantages. The orthopedic nurse practitioner states that offering the OSS concept is important in order to deliver the patient a high service. Besides, economies of scale can be achieved by grouping several patients in the informational session. Economies of scale are lost on the other hand by splitting up different queues for the OSS. The physiotherapist argued that the increased chance of delays in the OSS can also be seen as a drawback. At the same time, the interaction between the medical staff during the day the OSS is offered is made more effective. The barrier to approach colleagues in order to discuss the medical situation of a patient is lowered as a result of the application of the OSS.
4.1.2 The inguinal hernia repair pre-operative screening OSS
Figure 3. Process steps inguinal hernia repair OSS
Characteristics
The OSS is offered in the pre-operative screening stage for patients who need surgery for their inguinal hernia, this can also be read from table 4. The steps which need to be taken before the patient can take surgery are highly predictable when the patient does not have a complicated medical history. The three steps mentioned earlier are required for all these patients. Patients with a complicated medical history might need additional healthcare process steps. Because of unpredictability, appointments for these patients are not scheduled in the OSS but are scheduled sequentially. After each appointment the required next steps can be determined and scheduled.
Patients which need a inguinal hernia repair experience inconveniences because of their injury but are not majorly limited in their daily activities. The treatment of a inguinal hernia repair is therewith appointed as non-urgent care. At average the demand is 0,42 patients per week with a standard deviation of 1,63. Although there is a low number of patients and a high variability in the inflow, the OSS is still offered in order to increase the service for the patient. The surgery outpatient coordinator explained that variability of the number of patients is not a problem because of the release of empty slots a few days before the day of fulfillment.
The pharmacist and the anesthetist can be considered as shared resources which are used by a high number of different patient groups. A high number of different specialties are reserving capacity of these resources which might reduce the availability of capacity for the OSS. However the reservation of slots for the OSS in advance guarantees the availability of these shared resources.
1.Consult surgeon 3.Consult anesthetist 2.Consult pharmacist
(10 minutes) (10 minutes) (10 minutes)
Table 4. Characteristics of the inguinal hernia repair pre-operative screening OSS
Design
Every week slots are reserved for two patients who can attend the OSS, one on Tuesday and one on Thursday. The subsequent process steps need to be done in a fixed sequence, because the dependencies between the different steps. The number of reserved slots can be easily adjusted, which is important, because of the high variability of the number of patients attending the OSS. When demand appears to be lower than two for a week, the coordinator can release the reservation with one press on the button. The reserved slots can now be used for separate appointments which will be filled much easier. In the case of more demand than expected, the waiting time for the patient can increase. The amount of slots reserved can be increased in case demand is higher for several weeks in a row. This was not needed until so far however.
Effects
The surgeon states that although a low number of patients are referred to the OSS, this low volume does not hinder the effectiveness of the OSS. The aim of increasing the service for the patient is achieved. The number of treated patients is not a measure for the success of the OSS and does not constrain the design of the OSS.
Because of variability in demand, the schedule needs to be adjusted when demand appears to be different than expected. When a few days are left and it is not likely that the reserved slots for the OSS are going to be used, the surgery outpatient coordinator releases the reservations so the slots can be used for separate appointments. The coordinator determines
Life cycle duration
Time window for delivery
Volume Variability Variety Shared Resources
Pre-operative screening High – The care is not urgent Demand of 0,42 Patients per week SD = 1,63 CV = 3,93
The three steps are required for
all patients
attending the OSS
(based on the actual demand and capacity) if it is likely that the slots are still going to be filled. Based on this check the slots can be released. This check is not done with a regular interval but on an ad hoc basis. According to the surgery outpatient coordinator the slots still get filled for separate appointments after the release of the slots. Although practically all slots still get filled after release, additional planning efforts are required in order to fill all slots.
The surgery outpatient coordinator stated that it happens in a few cases that during the consult with the surgeon it appears that the issue of the patients is actually not caused by an inguinal hernia. The general practitioner could have made a wrong estimation of the medical situation of the patient. In this situation the consult with the pharmacist and the consult with the anesthetist are canceled just after the appointment with the surgeon. This implies that the reserved capacity for the appointments with the pharmacist and the anesthetist remains unused. The consults however only takes 10 minutes, usually the pharmacist and anesthetist find other (administrative) tasks to do during these empty slots.
The different process steps embedded in the OSS are interrelated with each other. As the day proceeds, it is likely that the surgeon faces delays. A delay at the first appointment can also result in a delay for the subsequent steps. In order to prevent excessive delays for the subsequent appointments, there has been built in slack of 30 minutes between the consult with the surgeon and the consult with the pharmacist. Some delays cover more than 30 minutes which therefore still affects the other two appointments. In this situations, the pharmacist and anesthetist are informed about the delay. If possible the pharmacist and anesthetist will see other patients first in order to prevent delays affecting other patients.
4.1.3 Vascular surgery OSS
Patients allocated to category 2 and 3 both undergo a duplex ultrasound exam. Patients who need a duplex ultrasound exam and have single sided symptoms are appointed to patient category 2. Patients who need a duplex ultrasound exam but who have double sided symptoms are placed in the third category. The difference between both categories can be expressed with the time needed to take the duplex ultrasound exam. Patients in category 2 undergo an exam with the length of 45 minutes while patients in the third category will receive an extended exam with the length of 75 minutes.
Figure 4. Process steps vascular surgery OSS
Characteristics
The process steps of the OSS are within the diagnostic phase of the healthcare process. The process steps are predictable up to a certain extend. As displayed in figure 4 there is variety in the steps which need to be taken. With help of the triage questionnaire, the required steps can be predicted. The Doppler ultrasound exam is required for everyone attending the OSS. The Duplex ultrasound exam however, is needed for a smaller group of patients. The triage questionnaire can help to predict the need of the Duplex ultrasound exam. However, the actual need of the Duplex can only be determined at the moment the results of the Doppler ultrasound exam are known. The results of the Doppler exam give a complete insight in the situation of the patient. With help of these insights, the need of an Duplex exam can be determined. 1.Blood test 1.Blood test 3.Consult nurse practitioner 2.Doppler ultrasound exam 2.Doppler ultrasound exam 3.Consult nurse practitioner 4.Duplex ultrasound exam (45 min) 4.Consult vascular surgeon (5 min) 2.Doppler ultrasound exam 3.Consult nurse practitioner 4.Duplex ultrasound exam (75 min) 5.Consult vascular surgeon 5.Consult vascular surgeon Patient category 2 Patient category 1 Patient
category 3 1.Blood test
(5 minutes) (60 minutes) (25 minutes) (5 minutes)
Different than in the other cases, there was no data available of this OSS covering the period between the 1st of January 2013 and the 31st of December 2013. Therefore we needed to adjust the analyzed period for this case. In the period between 16th of April 2013 and the 16th of April 2014, at average 2,11 patients per week in the first category demanded the service of the OSS with a standard deviation of 1,85. For the second and third category of patients (the categories which include a Duplex exam), only data of treatments between the 2nd of April and the 10th of June is available. During this period at average 3,2 patients had demand for the OSS with a standard deviation of 1,35.
For the fulfillment of the OSS, the surgery department collaborates with the radiology department and the laboratory. The blood tests are conducted at the laboratory, while the ultrasound exams are conducted at the radiology department. The departments interact with each other in order to determine at which moment the OSS can be offered.
Table 5. Characteristics of the vascular surgery OSS
Life cycle duration
Time window for delivery
Volume Variability Variety Shared Resources
Diagnoses Patients who
need non urgent care are treated in the OSS 1st category: 2,11 per week 2nd and 3rd category: 3,2 per week 1st category: SD = 2,01 CV = 0,95 2nd and 3rd category: SD = 1,35 CV = 0,42 Three different routes can be distinguished within the OSS
The laboratory and
the radiology
department are shared with a high number of different patient groups
Design
when 9,7 slots are reserved. Therefore the reservations of number of slots was determined by the average number of patients added up with the standard deviation. Based on the normal distribution this would imply that 84,1% of the patients could be seen within one week. During the implementation, slots were reserved on Monday, Tuesday and Thursday in order to facilitate the diagnoses in the OSS. Before the implementation, no data was available about the ratio between the diagnosis in which only a Doppler was included and the diagnosis in which also a duplex was included. With help of an educated guess a 50/50 ratio was determined. In 50% of the reservations OSSs the Doppler and Duplex ultrasound exam was included while in the other 50% only the Doppler was included. Based on these ratio, slots for the OSS were reserved.
Effects
With the implementation of the OSS, the patient can take a Doppler and Duplex ultrasound exam on the same day. This while the need of the Duplex ultrasound exam is dependent on the outcomes of the Doppler exam. The capacity of the Duplex exam is limited, therefore capacity needs to be reserved in advance. In order to determine the amount of capacity which need to be reserved for the Duplex exam, the triage questionnaire is used. However, the actual need of the Duplex ultrasound exam is determined with the results of the Doppler ultrasound exam. The surgery outpatient coordinator and the vascular surgeon explained that it can appear that the predicted need of the Duplex ultrasound exam is not corresponding with the actual need of the exam. This would mean that the reservation of the Duplex ultrasound exam is canceled just before the scheduled exam. This can result in unused capacity for both the Duplex ultrasound gear and the employee conducting the exam. The employees of the radiology department are responsible for multiple tasks. The secretary of the radiology department stated that in some cases the employee can spend the scheduled time for another task within the department. In other cases no other tasks are available, which implies that capacity remains unused. (Data about the numbers of cases the capacity is used or remains unused is not available.) As a result of the canceled Duplex exam the capacity of the Duplex ultrasound exam gear can also remain unused. The utilization of resources decreases as a result of the OSS application, the vascular surgeon argues that the increased service for the patient however is worth this utilization loss.
department needed to cancel the reserved OSS slots, because of a lack of employees at the radiology department on a day. The radiology department did not communicate about the capacity lack with the surgery department in advance. With the result that the surgery department was still planning to schedule patients on that day. In a later stage the surgery department discovered the gap in the schedule and needed to adjust the planning. The secretary of the radiology department also perceives communication issues. In some cases the surgery department uses the reserved slots allocated to the OSS for regular appointments. This while the secretary of the radiology department is not informed about these adjustments. Capacity of the Doppler and Duplex exams at the radiology department remains therefore reserved for the OSS. In a later stage, the capacity is released for regular appointments. In these situations the capacity is still filled for regular appointments. A lack of communication between the departments can result in inconveniences for both patients and schedulers.
up to six weeks. This could be partly the result of peaks in demand. The radiology secretary and the surgery outpatient coordinator also stated that a lack of capacity is contributing to the high access times. Up to five appointments are combined in the OSS. When only one of the actors involved with one of the appointments is unavailable (for a congress, holiday, etc.), the complete OSS cannot be offered. In these situations, the reserved slots for the OSS are released. The available OSS positions where patients are placed on, can therefore be limited. When the appointments are scheduled sequentially, the access time would cover only a few weeks. In the situation of big differences between the access time for the OSS and the access time for sequentially scheduled appointments, the patient is asked if he/she prefers to be helped within a few weeks, but with the need of multiple visits to the hospital. The other option is to wait six weeks for the appointments, with the advantage of only one needed visit. Dependent on the urge of the diagnosis and the preference of the patient, one of these options is chosen. By spreading the patients among both options, the queues get more balanced.
To conclude, the logistic manager, the manager outpatient departments and the outpatient surgery coordinator are content with the OSS offered for the first category of patients. They are content with this way of working because of the increased service they can offer to the patients with help of OSSs. They are however not satisfied with the OSS offered for the second and third category of patients, because of the increased chance of a loss in capacity of the Duplex ultrasound exam. In their opinion this scarce resource should only be scheduled when the need for this exam is absolutely certain. The vascular surgeon and the secretary of the radiology department are satisfied with the OSSs offered for all three patient categories. These actors state that wrong predictions of the need of the Duplex exam are not occurring very often (exact numbers are not available.) These actors do not see the possible loss of capacity as a big problem. In their opinion the service offered to the customers by decreasing the number of visits is more important than the possible loss of capacity. In order to have consensus between all actors, the current procedure might be evaluated. The adjustment of the triage questionnaire could help in predicting the need of the Duplex exam.
4.1.4 Spirometry OSS
follow up, which is needed to monitor the development of the lung disease. The reason for combining these two appointments is to offer the patient a higher service level. Instead of visiting the hospital twice for the separate appointments, now one visit is sufficient to cover both steps.
Figure 5. Process steps spirometry OSS
Characteristics
As described earlier, the diagnosis of asthma or COPD has already been done. This combined appointment takes place after the diagnosis, the pulmonologist decides on the need and urge of the follow up appointment based on medical conditions of the patient. If needed, a follow up appointment is planned. During this follow up visit to the hospital, the patient will first take a spirometry test at the lung function department. With help of this test the volume and speed of air which can be inhaled and exhaled can be measured, which reveals the lung function of the patient. Straight after the spirometry test, a consult is held with the pulmonologist. During the consult, the results of the test and the development of the lung disease are discussed.
The predictability of the need of the appointment is relatively high. In all cases a consult with the pulmonologist is needed in order to assess the wellbeing of the patient. The spirometry test however, is not needed in all situations. At the moment the appointment is made, it is unclear how the medical condition of the patient will develop. In case the patient is facing increased problems with shortness of breath, a spirometry test cannot be conducted. In order to take the test, the patient should take a deep breath after which should be exhaled into the spirometry sensor for at least six seconds. In case of shortness of breath, the patient could not be capable of maintaining exhalation for six seconds. The employees who conducts the spirometry test at the lung function department are capable of determining if the patient is in the position to take the spirometry test. In some cases this means that the appointment for the spirometry test is canceled at the moment the patient is attending the lung function department. However, no exact numbers are available, the senior laboratory worker at the
1.Spirometry test
2.Consult pulmonologist
(15 minutes) (10 minutes)
