Planning and Scheduling in Healthcare Modular Services

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Planning and Scheduling in Healthcare Modular

Services

Master thesis, MSc,

Supply Chain Management

University of Groningen

Faculty of Economics and Business

21

st

of June 2013

Student Name: Yu Zhu

Student Number: S2088495

E-mail: Y.Zhu.4@student.rug.nl

Thesis Supervisors:

Drs. Monique van der Laan

Co-assessor/ university

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2 Abstract

In the introduction part, the main research question is raised as “How can modules be planned and scheduled in a healthcare service setting in order to achieve a proper trade-off between service level and efficient resource use?” The contribution of this research is to provide an insight of planning and scheduling in modular services in healthcare systems. The service modularity is new in service setting especially in healthcare system.

In theoretical framework, the theories from production modularity and modular production planning were explored. The hierarchical planning activities are structured according to manufacturing production planning. The focus of the research fell on the tactical level, on which the modular service planning dealt with the resource management and setting service level from the perspective of patient.

In the methodology part, all the variables are operationalized in the selected case, and the data analysis methods are designed. The case study happened in an elderly service center, the interview and documentary data were collected. These data were analyzed under the hierarchical steps since the higher level results are the input to the next level.

The results showed the less resource use could be achieved by modular service planning. The service offering in modular groups generates flexibility in mixing and matching activities. Meanwhile, efficient resource allocation are concerning to the service level from patient perspective. The monthly plan was designed. In discussion part, the research questions are answered and discussed. The findings of the research are presented.

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1. INTRODUCTION

Health care (HC) service organizations are facing the challenge of balancing high service levels and efficient resource use (De vries; Bertrand and Vissers 1999). The concept of modularity can provide insights by which to answer this balancing problem. Modularity refers to a continuum in which components can be separated and combined to the degree that refers to the tightness of coupling and the mixing and matching of components (Schilling 2000). Designing a service offering in a modular manner influences the planning and scheduling, as modules rather than individual resources need to be planned and scheduled (Böttcher and Klingner 2011). Also, planning and scheduling play an increasingly important role in balancing between high service levels and efficient resource use by avoiding capacity loss and violation of the service agreement to patients (Vissers 1998). Although modularity is gaining attention in health care provision, the influence of a modular supply on planning and scheduling activities has never been systematically described. The aim of this research is to provide deeper insights on planning and scheduling of modules within a health care setting. The literature in planning and scheduling modules has mostly been found in the

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5 flexibility of the service offering, reduces the possibility of parallel service delivery, and increases the resource use in healthcare services (Rossi et al. 2013).

This research will contribute to the theory of service modularity by discussing how modules in a health care setting can be planned and scheduled in a way, such that a proper balance between service level and efficient resource use is achieved. Based on the current researches about modular services provision planning and scheduling activities in healthcare modules should vastly consider the specific advantages of modularity, such as mass customization and improved flexibility. Planning and scheduling care service modules with the goal of less use in resources and high service level leads to the main question of this research:

“How can modules be planned and scheduled in a healthcare service setting in order to achieve a proper trade-off between service level and efficient resource use?”

This research will focus on planning and scheduling modules aiming for an optimal solution for efficient resource use, which is expected to contribute to the field of modular service planning and schedule in health care service system. Because service delivery systems are analogous, with respect to many aspects in manufacturing production processes, the successful applications of modularity in manufacturing will provide theoretical support to service modularity.

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2. THEORETICAL FRAMEWORK

In the theoretical framework, theories on planning and scheduling modules from the

manufacturing field will be explored, as planning and scheduling modules in service settings is relatively new. Due to the differences between services and physical products, the

transformation will be based on the characteristics of service modules. First, the concepts of service modularity will be introduced. Then, the planning and scheduling levels and scope will be discussed. Thereafter, the technology in modular groups is explored in the

manufacturing field and then translated to a service setting. Finally, difficulties of balancing trade-offs between service level and resource use in a service setting will be examined.

2.1 Service Modularity

The main performance objective of service modularity is to achieve low cost customization (Voss and Hsuan 2009). Modules refer to decomposed parts from a complex system. Each module has a specific function and is relatively independent of other modules (Chorpita et al. 2005). The specific function increases the flexibility by allowing a variety of possible

configurations to be involved (Schilling 2000), and reusability by reusing similar modules in different configurations (Bask et al. 2010). The flexibility and reusability in modular service designs contributes to the possibility of planning for the efficient resource allocation to fulfill mass customization (Jiao 2012). Modular service is a package designed based on client needs, standard components can be combined from a menu of options, and adapted during the

service delivery (Blok et al. 2010). Service modularity attempts to develop services by the flexibility of tailoring in an efficient service delivery process (Rahikka et al. 2011).

2.2 Planning and Scheduling Levels

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7 functions and focus on different levels (Wong et al. 2012). The hierarchical nature requires planning and scheduling decision activities on each aggregated level (Qiu and Burch 1997), ranging from long term capacity planning to daily scheduling (Sunmichrast & Burch 1985). In this research the common distinction between three planning and scheduling levels: strategic, tactical and operational is applied (Shen 2012; Vissers et al. 2007). At the strategic level objectives concern the forecast of demand and the corresponding required use of

resources. This strategic plan delivers input for the second level; the tactical plan. The tactical plan involves the decisions on how to utilize the available capacity on relative demand

(Olhager and Johansson 2012) with the consideration of attaining the service level. The tactical plan in its turn provides input for the operational plan, which involves the day to day schedule. The focus of this research lies on the first two levels of planning: the strategic and tactical planning level. The operational schedules deal with loading and sequencing the planned resources based on individual demand (Sunmichrast and Burch 1985). The scheduling policy determines the assignment of slots by matching between patients and available resources.

2.3 Strategic level: Demand Forecast and Required Resource

Developing a strategic production plan in healthcare services starts with the required capacity management based on the demand forecast in order to constantly run the service operations (Shen 2012). Demand forecasting is an interactive process which is important in providing the input for determining the gap relative to the required capacity and the real use of health care practices (Heroman et al. 2012). In a manufacturing setting, required capacity and resources are estimated for the end product demand (Feng et al. 2011). To translate that into modular service means that, the required capacity planning is in modules or modular groups rather than in components. The reason is that modularization reduces the number of

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RQ 1: How can the demand for modules forecasted in a healthcare context? 2.4 Tactical level: Modular Service Groups and Service Level

Modular Service Groups

A service group refers to a set of services facilitating customization by promoting customer value and providing cost-effective services (Moon et al. 2010). The planning based modular service groups provide shared processes or activities with commonality for a variety of customer needs without losing capacity efficiency because of the standardized components in modules (Lin and Pekkarinen 2011). The standardization leaves room for the heterogeneity of healthcare clients, because functional similarity between components and modules indicates a high possibility of mixing and matching while keeping cost under control for patient groups (Blok et al. 2010). Planning modular groups for efficient resource use is done to create variants through rearrangement of existing modules with commonality, which perform more efficient in service design and operations when compared to a combination in individual components (Chen and L. Wang 2008; Lin and Pekkarinen 2011).

By considering the high possibility of mixing and matching in modular groups without over- or under-use of capacity, the associated resources of modules need to be taken into account when forming groups. Group Technology is a philosophy based on similarity in production characteristics between products/services (Kaku and Krajewski 1995). The similar production processes with similar required resources and machines used in products/services are grouped together (Agrawal et al. 2010). The aim of group technology is to improve overall

performance through minimizing machine changeovers and setups, and maximizing the resource use in the cell (Yang et al. 2011; Agrawal et al. 2010).Changeover happens when production switches to produce another product in the same machine (Bardhan et al. 2013), while setup time is the preparation time for a different task (Aydilek et al. 2013).

In HC service setting, machines and equipment are not the primary resources, but care providers (human capacity) are the most important resources. Changeovers and the

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9 services is also patient flow-based which can easily lead to less optimal use of resource

(Vissers 1998). Patient-flow is the process of every patient moving through the health care facilities, while consuming resources and generating cost (Tavakoli et al. 1999). The similarity in used modules between patients is taken into account in patient grouping. Therefore, planning on modular service groups is suggested to consider the route of service delivery and the compositional structure of modules (Böttcher and Klingner 2011). However, to apply the theory of service groups in a service setting is limitedly discussed in literature. The second sub-question is as following:

RQ2: How are modular services be grouped in a healthcare service setting?

Perceived Service Level

In healthcare service planning, since patients are highly aware of the acceptable waiting time and service, it becomes a key issue to balance the high service level and resource use ( De vries et al. 1999). In literature about service levels in health care common indicators are: waiting time (Vissers et al. 2007) , waiting list and in process waiting (De vries et al. 1999). For service providers, the starting point of setting a service level should be to consider the patients’ needs, expectations and preferences concerning their wellbeing and illness (Laan et al. 2012). However, in elderly care, the service level might involve other indicators apart from the general needs of adult patients . For example, elderly people might experience mobility problems and therefore they might prefer a one stop shop in their care provision. Also, elderly patients usually have multiple needs, the flexibility in service provision and diverse care packages are required (Blok et al. 2010). Therefore, elderly care in planning and scheduling need to consider heterogeneous demand in order to achieve a high service level. Since the perceived service level is fully from a patients’ perspective and different from the tradition concept described in literature, it is significant to define perceived service level in elderly care. The definition of perceived service level leads to sub-research question 3.

RQ 3: What are important indicators for the service level in planning elderly care services?

Trade-offs

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10 capacity loss and infeasibility for mixing and matching activities. The capacity loss is caused by peaks and troughs in workload, overcapacity of a resource, and the simultaneous use of resources required (Vissers 1998). The modular service groups in a service offering generate flexibility for mixing and matching, in order to realize efficient resources planning. Period batch control (PBC) is a system of production control to reduce the total throughput time by arranging the sequence of production (Zelenovic & Tesic 1998). PBC constrains all orders to a single fixed cycle length, by using certain length of time, all work for all jobs go through some stages within that period (Steelef & Malhotraj 1997). It also creates overlap between patient groups in order to sufficiently use all the capacity, and meanwhile provides a systematical way of planning.

In healthcare services, to what extend the elderly perceived service levels are met by means of a modular service offering is unknown. The less the resources that are used, which obtained by a flexible service offering. The independent living elderly have multiple needs that differ from each other, and which are subject to change over time (Blok et al. 2010). The trade-offs are made for both less resource use and high service level in modular service planning. Which factors play an important role in healthcare planning to balance those two objectives is

interesting to explore.

RQ4: What factors in planning are balanced with less resource use and high service level?

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3. METHODOLOGY

From the theoretical section, the research scope and topic have been set. In the methodology part, the methods and processes of conducting the research will be developed. First, the setting of the research will be explained. Then, the required variables will be operationalized in the case circumstances. Third, the data collection will describe the way in detail of

collecting the useful information. In the end, a comprehensive analysis will be performed for acquire the results.

3.1 Research Setting

The aim of this research is to provide a deeper insight on how modules in a health care setting need to be planned in order to achieve less resource use and a high service level. This paper explores whether manufacturing methods for planning modules can also be used in a health care setting. This research therefore involves an explorative case study within a health care center which provides care and services for people of 65 years and older, who live

independently. The elderly care delivered by the center involves the intermediate stage

between family doctor and the hospital. Since January 2013 this center started to provide their care and services in a modular manner. The focus of this research is on the planning of

diagnostic modules. The center provides three types of diagnostic modules: basic, minimum and intensive. The basic diagnostic module aims at generating a basic idea of the needs of the elderly people. The minimum diagnostic module is then provided to gain a deeper

understanding of the needs of elderly people in a specific domain (i.e., minimum physical, minimum psycho-social, minimum psycho-cognitive). When during the minimum diagnostic the diagnosis cannot be set, an intensive diagnostic module is offered (i.e., intensive psychic, intensive, cognition, intensive physical).

3.2 Operationalization of Variables

Demand Forecast

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12 time horizon usually spans a few months. In healthcare services, the uncertainty is high, Vissers et al. (2001) suggested 1-3 months is more appropriate for the capacity preparation, since this is a new service, the monthly plan would fit better to the demand.

In a healthcare context, the demand prediction is based on age, sex and historical data regarding a certain disease (Reisman et al. 1980). Demand forecasting is an interactive process that requires trustworthy historical data and good judgment, and based on an estimation of the volume of care required by a given population (Heroman et al. 2012). The forecast method chosen is that of the moving average to allow estimating the mean of the available information (Porras and Dekker 2008; Cattani et al. 2000). The required capacity for modules is calculated. For the work load of human resources, the holidays and vacations need to be excluded.

Service Groups

The modular service groups are categorized by the similarity of components (activities) in the modules, required resources of modules and the patient flow in a modular service sequence. The activities in health care modules require different or shared resources, meanwhile, the processing time also determines whether modules can be mixed and matched. The variance in processing time would cause an interruption for patients going to the next destination of treatment. Setup time and changeover time are expected to be reduced by applying service groups in Group technology. In a healthcare context, the setup time is the preparation time for the care services, and changeover cost is when change happens between services, for example, the room is prepared for conducing surgery for a batch of patients. Small service groups would lead to much changeover and setup time and costs (Vissers et al. 2001), therefore, the batch size should be more than 1and at least be equal to the time length of a scarce resource.

Service Level

The service level is set to add value to products and fulfill the customers’ needs (Kuo & M. Wang 2012). Traditional considered as waiting time which can happen before and during the service delivery. However, to set the service level from a patient’ perspective, the

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13 The all palnning variables and measurement are concluded in the table 1.

Table 1: Planning Variables and Measurement

Level Variables Measurement

Strategic Forecst Demand Yearly demand volume for modules Required Capacity Weekly Work load for each components

Weekly Machine resource use

Tactical Service Groups Module associated resources Service processing time Setup time

Changeover cost Batch size

Service Level The characteristics of the elderly

The specific needs, expectations and requirement

The elderly illness, wellbeing

3.3 Data Collection

The data on demand forecast, required capacity, service groups and service level will be collected during a single case study. This case study involved three interviews with a manger, a planner and a nurse which play key roles in the provision of the diagnostic modules. Also, documents including a detailed description of the modules, current planning method, demand forecast, patient flow sequence and perceived service level were collected.

The focus will be on the diagnostic modules. This care service center records all the modular service performances, which is done by the planner. The documentary resources are the source for the detailed modular service provision processes. The data regarding all of the variables were collected according to the interview protocol (See Appendix A).

Data regarding the demand forecast is collected by means of an interview with the planner and documentation concerning historical data. This historical data involved: a list of all elderly people (65 years or older) provided by a general practitioner, an overview of elderly people who the planner of the center contacted, and to whom the basic, minimum and intensive diagnostic modules were provided to.

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14 Data concerning the service level is collected by the interview with the elderly practitioner nurse and the manager. The interview covers several topics: The characteristics of the elderly in this service center, the expectations and requirement of elderly patient to modular care services, the difficulties in fulfilling patient needs, the preparation time for services and change over frequency during modular services.

The single case study database is from convergence of evidence (Yin, 2009). The source of convergence of evidence is derived in several ways. First, the documentation that refers to the historical data of the modules is needed. Second, the interview will be conducted in a semi-structured way, because both quantitative and qualitative data are needed. Third, the archival records such as census will help to set the standard working days for human resource since it is not clear yet in this new service center. Through the triangulation of field data collection, the reliability of data will be increased because these multiple sources of data are all on the same phenomenon (Karlesson, 2009).

3.4 Data Analysis

Demand Forecast and Required Capacity

The demand forecast is based on historical data and the list of the elderly for the general practitioner. Even though, all of the elderly population is the potential market on the list, due to the emergency of the modular diagnostic modules, not all the patients on the list are expected to be treated in a short time. The yearly demand forecast is based on historical data of the basic modules which is the source for two other following diagnosis. By using Moving average on the near future demand, the next year demand from next month is predicted based on a little part of the available historical data. The required capacity is calculated according to the associated resources of each module. The modular service consists of one and more operations and activities, of which the required human resource and equipment usage will be calculated.

Service Groups

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15 similarity of required resources. Third, the similarity in possible patient flows will also be used to form the service groups. In the end, the possible modular service offering will be formed by using service groups.

Patient Perceived Service

The interview will be conducted to investigate the existing service level from the patients’ perspective. The experienced service providers will be interviewed because their work experience would help to set service levels completely from patients’ needs. In this case, the service level is set aiming to enhance customer satisfaction from the customers’ perspective. Service level is the fulfillment of patients’ expectations in care services. Due to the

characteristics of heterogeneous demand in healthcare services, the difficulties in planning for meeting all kinds of service requirements are expected. Therefore, considering management limitations in capacity and feasibility are necessary.

Trade-offs in Planning

By imposing strict disciplines, the batch of jobs are pushed to each following stage and

finished in a uniform number of periods (Schutt, 2004). Benders & Riezebos (2002) suggested three principles in configuring a planning system. In modular service planning, they are defined as following:

(1) Single cycle ordering: each component in a service module should have the same frequency as the parent module.

(2) Single phase: The starting time of each module or modular groups can be planned at the same time.

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4. RESULTS

Current Planning

Currently, the long term plan is missing, and the modular services are scheduled according to the available capacity on daily basis. There are five service modules being used at this

moment, each type of module consists of different operations and associated resource. The overview of the modules is depicted in table 2. All of the five modules are used in care services (see Appendix B) which start with a call from the planner to the older person as recommended by their family doctors. This first contact is to confirm whether the elderly want to receive a check up at the care service center. The checkup comprises the basic

diagnostic modules which are sent via emails with a questionnaire to elderly people. The basic diagnostic module involves a broad assessment of the elder’s needs, which these older

persons can fill in by themselves. Hence, the older person does not need to come to the care service center. The results from the basic diagnosis suggest a division of patients into five patient profiles ( ZP1 Vital, ZP2 Psychosocial problems, ZP3 and physical mobility problems, ZP4 multi-domain problems, ZP5 Extremely vulnerable). When there appears a problem in the basic diagnostic module, a minimal diagnostic module is offered in three types

(psychic/cognitive, psycho-social and physical). Each minimal diagnostic module consists of an intake with a specialist nurse, dental check and a medical check. When a clear problem appears in the minimal diagnostic module, an advice for treatment is discussed with the patient and the family doctors. In case no clear diagnosis could be set, the intensive diagnostic module is offered. There are also three types of intensive diagnostic modules namely, psychic, cognitive and physical. These modules involve intensive tests by a multidisciplinary team of professionals.

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Overview of Modules

Modules Operations Activities Resource Duration Basic Module

O1 Triage C1 Administratie (PLANNER) 30min O2 Intake Minimal (psychic/cognitive)

O3 Drug screening C2 Apotheker 30min

O4 Dental care check C13 Tandarts 15min

O5 Assessment Findings C6 Huisartsspecialist ouderenzorg (HAO) 15min O6 Screening for cognitive (memory) problems C15 Verpleegkundig specialist (VS) 45min +

15min (preparatio n) O7 Screening for mood / anxiety

O8 Screening for problems in daily life actions O9 Screening for sufficient exercise

O10 Screening for malnutrition / obesity Minimal (psycho-social)

O5 Assessment Findings C6 Huisartsspecialist ouderenzorg (HAO) 15min O7 Screening for mood / anxiety C15 Verpleegkundig specialist (VS) 45min +

15min (preparatio n) O9 Screening for sufficient exercise

O10 Screening for malnutrition / obesity

O11 Screening for coping, grief, acceptance problems O12 Screening for loneliness

Minimal (physical)

O5 Assessment Findings C6 Huisartsspecialist ouderenzorg (HAO) 15min O10 Screening for malnutrition / obesity C15 Verpleegkundig specialist (VS) 45min +

15min (preparatio n) O13 Screening for mobility problems

O14 Screening problems physical fitness O15 Screening force / transfers O16 Screening for fall risk

O17 Screening for dealing in home situation intensive (psychic)

O18 Diagnostics personality C11 Psycholoog 2.5 hour O19 Diagnosis coping with limitations / loss / grief

O20 Diagnostics mood / anxiety

O21 Assessment findings (intensive) C15 Verpleegkundig specialist (VS) 1hour intensive

(cognitive)

O22 Diagnostics cognitive functioning C11 Psycholoog 5.5hour O23 Assessment findings C12 Specialist ouderenverpleegkunde (SOG) 1hour

C15 Verpleegkundig specialist (VS) 1hour intensive

(physical)

O24 mobility C5 Geriatrisch Fysiotherapeut Not Found O25 physical fitness

O26 Force / transfers O27 risk of falling O28 additional diagnostics

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18 RQ 1: How can the demand for modules forecasted in a healthcare context?

On the strategic level, the demand forecast is based on a list of potential patients aged 65 and over, which are provided by a general practitioner (family doctor). Till now, two general practitioners have provided the center with a list of their patients of 65 and over, in which there are 860 elderly people being recommended to the diagnoses. So far, the rejection rate from the older people is 19 out of 276 in the first contact because of many different reasons. Based on the rejection rate, around 800 persons (860*(1-19/276)) will be diagnosed. In addition, for the coming year on the patient list 543 basic modules (800-257) and required resources should be prepared. However, the manager stated: “The elderly in this region is

growing fast; besides, we are cooperating with more GPs who will provide more elderly people’s information to us.” Therefore, 543 basic modules is the minimal capacity for the

coming period. In order to plan enough resource in an efficient way, the more accurate demand forecast was conducted. Moving average was used to perform the forecast of basic modules based on the real operation (production) rate from the month March to May this year (See Appendix C). That is because different than the demand from the market; the demand in this service center is determined by the amount of contacts with the elderly made by the planner. As a result, there are 1118 patients being expected for the coming year according to the growth speed of the first three months. There are also three months historical data of minimal and intensive modules which are provided in Table 3. Since the forecast demand for basic modules are known, the results of patient profile volume can be calculated. Based on the patient flow, the needed modules are retrieved. The results are given in Table 4. The

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Figure 2: Patient flow (source:Zorgprofielen en Modulaire aanbod AHC 20120907) Table 3: Usage of modules

Usage Data of Modules

Basic Minimal Intensive

Jan 12 - - - -

Feb 8 - - - -

Mar 30 Mar 37 Mar 1 Apr 94 Apr 21 Apr 1 May 113 May 12 May 0

Total 257 70 2

Table 4: Modules Forecast Patients and Modules Forecast

Zorgprofiel 1(Vitaal) - - - 179 73% 814 Basic 1118

Zorgprofiel 2(Psychosociaal )

35 16 10 61 25% 277

Mimimal 304

Zorgprofiel 2(Psychisch cognitief) 0% 0

Zorgprofiel 3(Lichamelijk) 3 0 1 4 2% 18

Zorgprofiel 4 (Geriatrie) 1 0 1 2 1% 9

Intensive 9

Zorgprofiel 5(Geriatrie) 0 0 0 0 0% 0

Table 5: Required Capacity Required Capacity

Forecast (yearly)

Work Load

(Monthly) Required Capacity

Required working

hours

Basic 1118 93 Administratie (PLANNER) 46,6

Minimal (all types) 304 25

Apotheker 12,7

Huisartsspecialist ouderenzorg (HAO) 6,4

Tandarts 6,4 Verpleegkundig specialist (VS) 25 intentive (psychic) 9 1 Psycholoog 2,5 Verpleegkundig specialist (VS) 1 intentive (cognitive) Psycholoog 5,5 Verpleegkundig specialist (VS) 1 Specialist ouderenverpleegkunde (SOG) 1

intentive (physical) Geriatrisch Fysiotherapeut N/A

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20 RQ2: How are modular services be grouped in healthcare service setting?

Currently, all the basic modules are offered together as a group based on the patient flow. That is because as a starting point of all the care trajectories, a basic diagnosis must be undergone by every older person regardless of the type of illness. Therefore, there are no differences in service delivery of basic modules between patient profiles (See Table 6). Basic modules are grouped for higher service production rates of planner. The reason is that group technology suggests that modules with similarity in resource use can be grouped for the purpose of reducing setup and changeover cost, and increasing the productivity by economies of scale. Meanwhile, to look beyond the similarity in patient flow, the planner needs to investigate more detailed resource use within modules. Another group is also performed by a specialist nurse as she stated that: “Since the first diagnose is performed by the system, there

are some less reliable results being expected. I can always switch between minimal modules without any problems. It is very flexible”. Three different types of minimal modules sharing

the exact same resources are used as one package. Operations and activities within these modules are interchangeable. As long as the sequence of care is not reversed, the deviation from the standard modules is allowed. The deviation in current service offerings is provided in Table 8. The result shows that around 30% of the modules benefit from the flexibility of service modularity. In order to achieve flexibility, in terms of less resource use, in modular services, planning high possibility of mixing and matching between these modules is very important.

As a result, four modular groups are proposed by means of group technology. The modular groups are given in Table 7. First, all the basic modules are offered as continuous production by the dedicated resource. A similar service produced at one time should achieve low setup and changeover time, which is seen as the setup time of the computer to conduct the surveys via emails. Thus, the resource use of group in planning is more efficient than individual service for every patient. Second, three types of minimal modules offered in one group enhance the chance of switching between these three types. Third, intensive psychic is

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21 Besides the flexibility, another advantage of using the tool of Group Technology is to achieve less setup and changeover time. However, they have not been found. According to the

specialist nurse: “ For every patient I use the same time to read the medical background and

relevant information, there is no reason to use less time to prepare for a batch of them than individuals.” Setups and Changeovers happen equally in every service delivery process. Table 6: Current Grouping

Patient Flow Patient Profile

ZP1 ZP2 (a) ZP2 (b) ZP3 ZP4 ZP5 Basic 1 1 1 1 1 1 Minimal (psychic/cognitive) 1 1 1 Minimal (psycho-social) 1 1 1 Minimal (physical) 1 1 1 intensive (psychic) 1/0 1 1 intensive (cognitive) 1/0 1 1 intensive (physical) 1/0 1 1

Table 7: Group Technology

Group Technology Grouping Required Resource

C1 C2 C3 C4 C5 C6 C7 C8 C9 C10 C11 C12 C13 C14 C15 Basic 1 Minimal (psychic/cognitive) 1 1 1 1 Minimal (psycho-social) 1 1 1 1 Minimal (physical) 1 1 1 1 intensive (psychic) 1 1 intensive (cognitive) 1 1/0 1/0 intensive (physical) 1 1

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Usage Deviation Basic Minimal Intensive

Month Jan Feb Mar Apr May Mar Apr May Mar Apr May

Total 12 8 30 94 113 37 21 12 1 1 0 Geen afwijking ₀ ₀ ₀ ₀ ₀ 24 2 0 0 0 0 100% 100% 100% 100% 100% 64,86% 9,52% 0,00% 0,00% 0,00% n/a Less 0 0 0 0 0 11 10 7 0 0 0 29,73% 47,62% 58,33% 0,00% 0,00% n/a More ₀ ₀ ₀ ₀ ₀ 1 5 5 0 1 0 2,70% 23,81% 41,67% 0,00% 100,00% n/a Flexibiltiy: (total/more) 0,00% 15,71% 50,00%

RQ 3: What are important indicators for service level in planning elderly care services? Currently, the service level in the case company is determined based on the perceived needs of the elderly. During the interview, there were several aspects related to the addressed needs, expectations and preferences. First, the patient characteristics are important to be noticed in the service delivery process. The most recognizable distinction in elderly care services is the mobility issue. The manager of this service center shared that: “The one time visit is an

incomparably convenient service to the elderly, because most the elderly have difficulties in travelling by themselves.” All the examinations and diagnosis are expected to be finished at

one visit which is seen as an indication of high service level to the elderly patients. Second, the planner from the service center pointed out that: “Planning needs to be very flexible and

highly adapted to the preferences of the elderly patients.” Holidays and bad weather (i.e..

snow, heavy rain, strong wind) are barriers in making appointments. The specialist nurse said that: “The elderly people have a very busy schedule, besides the care services we provide are

not for urgent care, therefore, the patient preference in time is very diverse.” The various

patients’ needs require a better plan for keeping patients satisfied when making appointments. When the first call from the planner does not result in an agreement on the time slot with patients for treatment, it is seen as a providing a failed service. Thus, the second indicator of the service level is the fulfillment of the first call appointment.

RQ4: What factors in planning are balanced with less resource use and high service level?

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23 actually planned in the PBC model since there is only one stage in service production. Basic module groups generate economies of scale to reduce the setup time in service preparation, for example the time required to setup a computer and preparing documents, etc. Besides the basic modular group, the other three groups are planned in the PBC model by considering the balance of resource use and service level. According to three principles of PBC, the planning has been done in order to create the overlaps between stages and reduce throughput time. The results are reflected in Appendix D. Group 1 is the plan for minimal modular groups. There are four stages patients need to go through in sequence, and the shortest cycle time is 15min. The current available service offering time is in the morning (approximately from 9:00a.m. to 13:00p.m.). There is maximum of 3 patients that can be treated, and switching between different minimal module types is possible. Group 2 is the plan for the minimal module and intensive psychic. In order to guarantee that the associated resource would not be double planned, there are six stages used for showing the parallel and sequential activities. This group provides the possibility to switch between minimal and intensive psychic, and more time slots options of the intensive modules to patients without planning more extra resources. Group 3 is the plan for intensive psychic and cognitive. These two modules have shared resources in Psychologist, and therefore the flexibility in mixing and matching these two modules is very high.

As the demand is forecasted in months, the monthly plan is performed. The result is reflected in Appendix E. The planner works in a continuous production way to conduct basic modules. The first three weeks are always planned only for minimal and basic modules, since most of the services are about these two modules. The intensive modules only happen once a month, and they are the diagnosis after basic and minimal modules, therefore, all the intensive

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24 resource will be diminished if they are not used. Therefore, the capacity lose is inevitable. The usage level will be at 76% in the monthly plan. 60% of available resources remain free which leaves room for growing business.

Table 9: Resource Use in monthly Plan

Resource Use MAX MIN USE LOSS

C1 Administratie 80 44 44 0

C2 Apotheker 80 26 21 5

C3 Diëtist 0 0 0 0

C4 Ergotherapeut 0 0 0 0

C5 Geriatrisch Fysiotherapeut 0 0 0 0

C6 Huisartsspecialist ouderenzorg (HAO) 80 19,5 6,5 13

C7 Intakeverpleegkundige 0 0 0 0

C8 Mondhygieniste 0 0 0 0

C9 Ouderenadviseur 0 0 0 0

C10 Preventieassistente apotheek 0 0 0 0

C11 Psycholoog *11 11 10,5 0,5

C12 Specialist ouderenverpleegkunde (SOG) *4 4 1 3

C13 Tandarts 80 19,5 6,5 13 C14 Testassistent 0 0 0 0 C15 Verpleegkundig specialist (VS) 80 40 35,5 4,5 Total 415 164 125 39 Usage 40% 76% Note: * These figures could not be provided by the company at this moment.

Scheduling

The schedule is the practical record for services. The input of this schedule is from the tactical plan of modules. In the current situation, the scheduling arrangement principle is first come first serve. In table 10, the daily schedule provides an overview of the available time slot, time duration and percentage of progress in the service process. This is a schedule from a daily work for scheduling patient in modules.

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25 Date Planned Actual % Da te Planne d Actual % # List of Activties

Start Dur Patient Name

Start Dur Done # List of Activties

Start Dur Patient Name

Start Dur Done

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26

5. DISCUSSION

RQ 1: How can the demand for modules forecasted in a healthcare context? The demand forecast conducted in this research is different from the regular healthcare context. That is because, in other healthcare service systems, the patient demand is randomly from the market with very high uncertainty. However, in the case company, patients are all on a list of family doctors. Besides, there is no time limitation for finishing the diagnoses of all the patients, as such that the planner could plan the demand based on an acceptable work load. However, uncertainty still exists in forecasting the demand forecasting at the case company. Not all the patients want to get a checkup, which thereby creates fluctuations in patient demand. With a lower accepted checkup rate, the planned resources would be used less. The demand forecast should focus on modules instead of operations of services. For example, dental checks or medical background diagnosis are not necessary. In a healthcare context, the sequence in patient flow is not reversible. Patient after basic modules will be put into five files which indicate the following modules and treatment which consists of patient flows. The sequence service production in the patient profiles is similar to a BOM (bill of material) structure in end product which makes them similar to the manufacturing field. The patient treatment consists of different modules. The forecasted end products (patients) volume determines how many modules will be used. The BOM of products is the same as the patient flow of different patient profiles. Therefore, the demand forecast focus on patients with different profiles, and needed modules are managed by how many times they appear on the patient flow.

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27 illness, environment and societal issues. Furthermore, new diseases and new technology developments are always responsible for further demand fluctuations.

The demand forecast is the proactive intervention for planning the resource use in an efficient way. In a healthcare context, the resource management mainly focuses on human resources since they are more expensive and perishable than physical resources. The required resources are calculated in hours needed by each module. However, the required working hours are the minimal working time in processing modules. Since this is a human resource, the capacity will be lost if care providers are waiting for the next patient or not in use (busy).

RQ2: How are modular services be grouped in healthcare service setting?

Modular service groups are defined by Group Technology which suggests modules sharing same resources should be produced as a group. However, Group Technology does not provide insights on the sequential dependence between modules, which is very important in a

healthcare service context. The process nature of healthcare services complicates grouping. Therefore, it is wise to consider not only resources, but also the service delivery process. In the grouping process, the modules and their corresponding resources are listed in sequence of the service delivery process (Basic-Minimal-Intensive). Furthermore, the shared resources might not be able to be grouped because of the nature of the care service. In care services, activities are mostly performed by human resources. As being a shared resource they might be needed by different care services which deal with different illness and patient types. For example, the intake process in minimal modules which is performed by specialist nurses also performs the diagnosis in intensive modules. These two activities are very different in service, and therefore it is very likely that different processing times are required for providing the service. Consequently, in planning and grouping modules, shared resources can be used as a criterion to group modules, but economies of scale in service production is not very likely to happen.

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28 paid attention to (see Table 8). The flexibility percentage can also indicate that certain shared resources are highly possible to perform mixing and matching, therefore, the related modules should be grouped.

RQ 3: What are important indicators for service level in planning elderly care services? The service level in the manufacturing field generally means on time delivery. However, in a healthcare context service level mainly indicates waiting time and length of the waiting list. In order to set the service level from a patient’ perspective, the needs and expectations of the elderly were investigated.

First of all, we identified two service level indicators. For service level indicator 1 ( First contact appointment), the waiting time happens mostly in the appointment making step. The Planner makes an appointment with patients. Because of the busy schedule, and various preferences of the elderly, it is very important that enough choices are planned in the service provision. Heterogeneous demands of patients require more resources to be planned to fulfill patients’ preferences, expectations and needs. When the patients required time is not available in the time slots, waiting time is being generated. Patient has to wait for another time slot next time in making an appointment. It is seen as an important issue in elderly care caused by the busy schedule from patients, to enhance the rate of agreement at the first call which can be improved by planning more available resource.

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29 chance to over use the capacity. There is also no inventory of service that can be stored for usage when they are needed; therefore, planning flexibility in service needs to be balanced with a relatively reasonable service level.

RQ4: What factors in planning are balanced with less resource use and high service level?

The aim of doing trade-offs in the monthly plan is to increase the flexibility and reduce the resource use. The higher flexibility is realized by modular group service supply. PBC is used as a tool for planning modular groups with the aim of less throughput time. However, in healthcare service, PBC cannot be used as regularly as in production. That is because the processing time of each of the activities in modules vary, and the sequence of service delivery restricts the arrangement of productive production. PBC provided a theoretical way to plan modular groups according to processing time of each activity. The modular groups are designed in the care service sequence with less processing time in total, and shared resources between modules have no conflicts.

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6. CONCLUSION AND FURTHER RESEARCH

The research question of this thesis is: “How can modules be planned and scheduled in a healthcare service setting in order to achieve a proper trade-off between service level and efficient resource use?” To answer this question, an explorative methodology is developed and a hierarchical planning activity has been performed. The activities in planning and scheduling are comparable in structure with that in the manufacturing field, but modular service planning appears to be more difficult. Strategic planning as a starting point begins with demand forecast in order to identify the matched capacity on a long term. In a healthcare context, uncertainty is also the big issue in care services. It can be caused by uncertain care needs from the patients; it also can appear when the results of diagnosis from practitioners are not very certain, therefore, uncertainty need to be dealt during the rest of the service process, it is inevitable. In healthcare context, patients are forecasted instead of modules. Because patients are comparable to end products, they should be forecasted instead of materials and resources. Needed modules and patients flow (BOM) belongs to capacity management. The modular groups should be planned to pursue high flexibility instead of productivity. Group technology is used to form modular groups. That is because shared resource plays an important role in achieving flexibility. In the manufacturing field, economies of scale are pursued in production to reduce the cost in setup and changeovers. An optimal batch size can balance the demand fulfillment and resource use. Nevertheless, service batches do not share any setup cost, since the setup time of service is depending on the number of patients. All the patients require the same preparation in care service. The setup time might be different due to the complexity of the illness of the patient, not due the volume of the patient batch.

Changeover times cannot prove to be decreasing; despite that it is stated in some researches. Therefore, the use of batch size control did not work out well in a HC service setting. In the end, because shared resource in healthcare context can perform different services, depending on different modules, shared resourced perform differently in one modular group. Therefore, in a shared resource modular group; it is not always possible to achieve economies of scale since the job contents are not same in one group.

In modular service planning, modular groups are planned to achieve flexibility to enhance service level with less resource use. The high service level from elderly care increases the difficulties in planning and scheduling process, because the specific needs from the

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31 people need fewer visits for service and more preferred appointment time. It indicates that several aspects in planner need to be considered. In manufacturing filed, production is planned as certain as possible. On contrast, in healthcare setting, it is important to plan services as flexible as possible. Service modularity can be used to realize high flexibility in service offering. Modular groups are used as a platform to perform service offering because shared resources are the factors that are able to generate flexibility in service process. Therefore, a good plan in terms of less resource use should have well-formed groups which are with more frequently being mixed and matched components between modules. In addition, due to the irreversible sequence of in HC services, capacity loss between patients is not

avoidable. The capacity loss is mainly from the waiting time of service provider waiting for next patient owing to the processing time difference between operations. The considerable benefit from modularity such as flexibility, customization and shared resources makes the possibility in trade-offs between service level and resource use possible.

Practical Implications

First, demand forecasts can be more accurate. In this service center, the planner in the

administrative department has the first contact with patients from the list provided by the GP. Consequently, the demand is not only based on the forecast, instead the uncertainty from the market is reduced. Therefore, in this service center, the demand forecast is controllable by planning to decrease the fluctuation with the aim of fully matching the limited capacity and efficient use of resources. The less uncertainty also means planner could smooth the service offering by contacting with proper amount of patients for check-ups designedly.

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32 Third, to set clear indicators for service levels is important. During this research the specific service requirements form elderly people have been found. Nonetheless, to set all the factors as performance indicators in the service level is not necessary. The plan and schedule could be efficiently in resource use if the service indicators are clear and reasonable.

Limitations and Further researches

The results showed that the main goal of the research has been achieved; however, there are still some unavoidable limitations. This case study happened in only one company, the

modular service in this company is a novel business in a healthcare system. It is reasonable to doubt the generalization of the research. Furthermore,, as this center has just been opened, the documentary records are not sufficient for performing a more detailed research, besides, some of the modules even have never been used or developed very well so far. Therefore, the solution found in this research is expected to have many adjustments according the situation changing in the future.

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Appendix A: Case Study Protocols

Case study topic Source of information Research Question Modules Document Interview

What are the patient-flows from the register point to the end of treatment?

Document Interview

What modules are using at this moment? Document What are operations in modules? and list them

with patient flow sequence and relevant equipment and human resources

Document Interview

What is the processing time of each module? Is there variance or idle time need to be planned for doctors or nurses?

GT Document What is the maximum capacity?

Document What is the current planning period? (week or month?)

Document Interview

Is there any patient group is using and under which principle they are organized?

Capacity Document What is the maximum capacity in next planning period?

Document Interview

What is the preferred equipment utilization level? Please rank the equipment use frequency due to the setup time or other reasons. (To avoid overuse or setup waste)

Document Interview

Please list the available human resource and the utilization level?

Interview What is the cost for idle time of the staff? (From company’s perspective, which cost is related to the operation cost in this company? )

Service Level Interview Please describe what modules are not supposed to be dealt for two times? What are the

expectations from patients in service? How do you deal with patients’ preference for

practitioners?

Interview What is the current service level, or the minimum level the company wants to achieve?

PBC Document What is the basic period in planning?

Interview What are the constraints in organizing patient groups?

Scheduling Document Interview

What are the current scheduling policies? How long should patient register the time for

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Appendix C: Basic Modules Demand Forecast

Basic Modules Demand Forecast

Month Forecast Demand Moving Average

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Appendix D: Period Batch Control

Group 1: Minimal module group

Group 2: Minimal and intensive (psychic) group

Group 3: Intensive psychic and cognitive group

Patient 1 Patient 2 Patient 3

Order Preparation Preparation Preparation

stage N=1 O6+O7+08+O9+O10 O6+O7+08+O9+O10 O6+O7+08+O9+O10

O7+O9+O10+O11+O12 O7+O9+O10+O11+O12 O7+O9+O10+O11+O12

O10+O13+O15+O16+O17 O10+O13+O15+O16+O17 O10+O13+O15+O16+O17

stage N=2 meeting meeting meeting

stage N=3 O4 O4 O4 stage N=4 O5 O5 O5 P=1 P=3 P=1 P P P P P P P P P P P P P P 9:00 10:00 11:00 12:00 13:00 13:45 O3 O3 O3

Minimal 1, Intensive (psychic) 1 Minimal 2 Order Preparation Preparation

stage N=1 O6+O7+08+O9+O10 O6+O7+08+O9+O10

O7+O9+O10+O11+O12 O7+O9+O10+O11+O12

O10+O13+O15+O16+O17 O10+O13+O15+O16+O17

stage N=2 meeting meeting

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Appendix E: Monthly Plan

Minimal modules in the first week of a month

Minimal and Intensive modules in the fourth week of a month

WK1 9 :0 0 1 0 :0 0 1 1 :0 0 1 2 :0 0 1 3 :0 0 1 4 :0 0 1 5 :0 0 1 6 :0 0 1 6 :3 0 9 :0 0 1 0 :0 0 1 1 :0 0 1 2 :0 0 1 3 :0 0 1 4 :0 0 1 5 :0 0 1 6 :0 0 1 6 :3 0 9 :0 0 1 0 :0 0 1 1 :0 0 1 2 :0 0 1 3 :0 0 1 4 :0 0 1 5 :0 0 1 6 :0 0 1 6 :3 0 Planner VS pharmacist Dentist HAO Psycholoog SOG Tuesday Wednesday Maandag WK4 9 :0 0 1 0 :0 0 1 1 :0 0 1 2 :0 0 1 3 :0 0 1 4 :0 0 1 5 :0 0 1 6 :0 0 1 6 :3 0 9 :0 0 1 0 :0 0 1 1 :0 0 1 2 :0 0 1 3 :0 0 1 4 :0 0 1 5 :0 0 1 5 :0 0 1 7 :0 0 Planner VS pharmacist Dentist HAO Psycholoog SOG Thurday Friday

(basic) Sending emails (30 min) (minimal)Preparation time (15 min) (minimal)The first patient intake with VS (minimal)The meeting time (VS and pharmacist)

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43 WK1 9: 00 10 :0 0 11 :0 0 12 :0 0 13 :0 0 14 :0 0 15 :0 0 16 :0 0 16 :3 0 9: 00 10 :0 0 11 :0 0 12 :0 0 13 :0 0 14 :0 0 15 :0 0 16 :0 0 16 :3 0 9: 00 10 :0 0 11 :0 0 12 :0 0 13 :0 0 14 :0 0 15 :0 0 16 :0 0 16 :3 0 9: 00 10 :0 0 11 :0 0 12 :0 0 13 :0 0 14 :0 0 15 :0 0 16 :0 0 16 :3 0 9: 00 10 :0 0 11 :0 0 12 :0 0 13 :0 0 14 :0 0 15 :0 0 16 :0 0 16 :3 0 Planner VS pharmacist Dentist HAO Psycholoog SOG WK2 9: 00 10 :0 0 11 :0 0 12 :0 0 13 :0 0 14 :0 0 15 :0 0 16 :0 0 16 :3 0 9: 00 10 :0 0 11 :0 0 12 :0 0 13 :0 0 14 :0 0 15 :0 0 16 :0 0 16 :3 0 9: 00 10 :0 0 11 :0 0 12 :0 0 13 :0 0 14 :0 0 15 :0 0 16 :0 0 16 :3 0 9: 00 10 :0 0 11 :0 0 12 :0 0 13 :0 0 14 :0 0 15 :0 0 16 :0 0 16 :3 0 9: 00 10 :0 0 11 :0 0 12 :0 0 13 :0 0 14 :0 0 15 :0 0 16 :0 0 16 :3 0 Planner VS pharmacist Dentist HAO Psycholoog SOG WK3 9: 00 10 :0 0 11 :0 0 12 :0 0 13 :0 0 14 :0 0 15 :0 0 16 :0 0 16 :3 0 9: 00 10 :0 0 11 :0 0 12 :0 0 13 :0 0 14 :0 0 15 :0 0 16 :0 0 16 :3 0 9: 00 10 :0 0 11 :0 0 12 :0 0 13 :0 0 14 :0 0 15 :0 0 16 :0 0 16 :3 0 9: 00 10 :0 0 11 :0 0 12 :0 0 13 :0 0 14 :0 0 15 :0 0 16 :0 0 16 :3 0 9: 00 10 :0 0 11 :0 0 12 :0 0 13 :0 0 14 :0 0 15 :0 0 16 :0 0 16 :3 0 Planner VS pharmacist Dentist HAO Psycholoog SOG WK4 9: 00 10 :0 0 11 :0 0 12 :0 0 13 :0 0 14 :0 0 15 :0 0 16 :0 0 16 :3 0 9: 00 10 :0 0 11 :0 0 12 :0 0 13 :0 0 14 :0 0 15 :0 0 16 :0 0 16 :3 0 9: 00 10 :0 0 11 :0 0 12 :0 0 13 :0 0 14 :0 0 15 :0 0 16 :0 0 16 :3 0 9: 00 10 :0 0 11 :0 0 12 :0 0 13 :0 0 14 :0 0 15 :0 0 16 :0 0 16 :3 0 9: 00 10 :0 0 11 :0 0 12 :0 0 13 :0 0 14 :0 0 15 :0 0 15 :0 0 17 :0 0 Planner VS pharmacist Dentist HAO Psycholoog SOG

Tue s day We dne s day Thurday

We dne s day Thurday Friday

M aandag Tue s day

Friday M aandag

We dne s day Thurday Friday

M aandag Tue s day We dne s day Thurday Friday

Planning and Scheduling in Healthcare Modular Services