Master thesis GUIDELINES FOR THE DESIGN OF A FACILITY LAYOUT FOR AN ORTHOPAEDIC OUTPATIENT CLINIC

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GUIDELINES FOR THE DESIGN OF A FACILITY LAYOUT

FOR AN ORTHOPAEDIC OUTPATIENT CLINIC

Master thesis

MSc Technology & Operations Management

University of Groningen, Faculty of Economics and Business

January 29, 2018

J.W.F. Doeksen

S2441098

j.w.f.doeksen@student.rug.nl

Supervisor / university:

dr. ir. D.J. van der Zee

Co-assessor / university

dr. J.A.C. Bokhorst

Supervisor / field of study:

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ABSTRACT

Purpose – Well-designed facility layouts, based on design guidelines, can increase the efficiency of outpatient clinics. This study emphasizes on orthopaedic outpatient clinics, which have to deal with high levels of uncertainty and complex health care delivery systems. No specific guidelines for orthopaedic outpatient clinics are set and therefore this study’s contribution to the research is to provide such guidelines on the layout of orthopaedic outpatient clinics that ensures tolerable patient turnaround time, affordable investments in consultation, and consultation speed.

Method – A design-science research approach at the orthopaedic outpatient clinic of Nij Smellinghe hospital is developed. Literature on facility layout planning for outpatient clinics is first reviewed to identify insights on important issues such as proposed existing guidelines. Next, the current system is described and analysed, and design options are formulated and tested with the use of a hybrid research approach. Simulation tools and a deterministic approach are used to assess alternative facility layouts for orthopaedic outpatient clinics. Individual effects and possible interaction effects are analysed.

Findings – The literature review reveals proposed guidelines for (1) the clinic’s room planning (2) healthcare staff planning, and (3) resource allocation planning. However, the proposed guidelines do not solve all the main (under) performance issues encountered in orthopaedic outpatient clinics. Therefore, new guidelines are added to the current set of guidelines to improve on and extend existing guidelines. The simulation results show that a 2:1 ratio of treatment rooms to doctors should be implemented to achieve minimal patient-turnaround time and that a doctor-to-patient policy should be avoided, as this leads to higher patient turnaround time. Interestingly, if the guideline is implemented in combination with a 3:1 ratio of treatments rooms to doctors, this effect on the patient turnaround time is mitigated. The deterministic approach demonstrates that, for instance, the implementation of “shared rooms” positively influences the consultation resource investments. A sensitivity analysis reveals high levels of uncertainty (i.e. disturbances of the orthopaedists) significantly influence patient turnaround time.

Conclusions – Several guidelines should be implemented (or not) to safeguard tolerable turnaround time, affordable investments of consultation resources, and consultation speed. Each guideline will improve layout on one or more of the performance measures, and should therefore be implemented in the clinic. Furthermore, this study recommends minimizing uncertainty for orthopaedic outpatient clinics, as it significantly impacts turnaround time.

Keywords - Orthopaedic outpatient clinic, design guidelines, facility layout design, layout improvement,

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PREFACE

This master thesis is the final step towards the completion of the MSc Technology and Operations Management at the University of Groningen. The goal of this thesis was to develop guidelines for the design of a facility layout for an orthopaedic outpatient clinic. Insights on different layout configurations were obtained by doing a case based study within the Nij Smellinghe Hospital in Drachten.

Performing research based on a real-life case, as explained above, has been a great and challenging experience to me. I’ve gained a considerable amount of knowledge over the last few months. This would not have been possible without the help and contribution of the following people. In the first place I would like to thank Mr. P. Buwalda MSc and all the medical staff from the orthopedic outpatient clinic from the Nij Smellinghe Hospital for their constructive feedback and valuable insights on the complexity of hospital practice. Their advice and involvement in setting up the analysis and the development of the simulation models helped me enormously.

Furthermore, I would like to thank my supervisor dr. ir. D.J. van der Zee for making available so much of his time, the discussion about the content and also the feedback on the progress was very motivating and contributed substantially to this thesis. Also, the quick response to my questions made the communication easy. Finally, I thank my co-assessor dr. J.A.C. Bokhorst and my fellow students of the healthcare thesis group for their feedback on earlier drafts of this thesis.

Groningen/Drachten, January 2018

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1. INTRODUCTION

The operating costs of providing medical care in hospitals have been steadily increasing over the past decade (Winpenny et al. 2017). To safeguard the provision of healthcare at an affordable level, hospitals are have been trying to improve efficiency in their health service operations (Hamrock et al. 2013, Vanberkel et al. 2012). However, significant challenges to increasing effectiveness and efficiency in the delivery of care remain, and these challenges push hospitals to review their operational and planning activities (Vahdatzad, Griffin 2016). Well-designed facility layouts can increase efficiency in the delivery of care (Sepúlveda et al. 1999). As such, this study focusses on outpatient clinics, as this area of care is experiencing some of the strongest growth in the healthcare industry (Cote 2000). Orthopaedic outpatient clinics (OOCs), especially, deal with high levels of uncertainty and complex healthcare delivery systems (Rohleder et al. 2011).

This study is motivated by a layout-planning problem faced by the orthopaedic outpatient clinic (OOC) of the Nij Smellinghe hospital in Drachten. Initial analysis of the current layout and its use indicates, among others, that office floor space is not being fully used and that patient lead time could be shortened; furthermore, attention to the privacy and well-being of the patients could be improved. Budget and facility plans would allow for a reconfiguration of the department rooms. The main questions focus on how to design and operate the new layout, given the process characteristics and criteria set for patient lead time, along with the costs of providing care services.

The literature provides several guidelines for designing the layout of an outpatient clinic. Examples of existing guidelines focus on the clinic’s room planning (e.g. two available doctors per treatment room is an upper limit), maximising utilisation of staff by sharing treatment rooms, and improving resource-allocation planning. Several authors have shown how a well-designed facility layout based on design guidelines improves the service and efficiency of outpatient clinics (Badri, Hollingsworth 1993, Berg et al. 2010). However, no specific guidelines exist for OOCs. Moreover, the specific application of existing guidelines for outpatient clinics to orthopaedic clinics has not yet been validated or refined. Rohleder et al. (2011) have studied OOCs with a view to improving performance; however, that study did not focus on layout-related issues.

Therefore, this study develops guidelines for designing OOC facility layout, aiming to secure three ends:

tolerable patient turnaround time, affordable investments of consultation resources, and consultation speed. The first regards the time patients spend in the clinic, including waiting time. The second is based

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2. RESEARCH OBJECTIVE AND DESIGN

This chapter discusses the research objective and the design of the study. In Section 2.1 the problem background and the study’s deliverables are described. Section 2.2 presents the research objectives. Section 2.3 explains the conceptual model. Sections 2.4 and 2.5 detail the study’s research design and data sources, respectively.

2.1 P

ROBLEM BACKGROUND

Since 2004, all Dutch healthcare institutions have been obliged to draw up a long-term housing plan (LTHP) and to update it every four years. An LTHP is a strategic policy document in which the healthcare institution evaluates its housing capabilities on the basis of its care vision to determine investment needs (Huisman et al. 2009).

This research is motivated by Nij Smellinghe hospital, where the board has set out a housing plan for the coming years. A considerable part of the LTHP of Nij Smellinghe concerns improvement of the operational performance of the OOC. Clinic-room use and patient lead time at the hospital are not optimal, and the wide variation in these measures significantly impacts the hospital’s performance, as well as patient and staff satisfaction. The management of the hospital has struggled with the issue of developing a more efficient and effective layout. The hospital is considering various alternative layouts for the setup of the OOC, thereby aiming to increase efficiency and use of building space optimally, thereby safeguarding the privacy and comfort of the patients and medical staff.

Current guidelines for designing the layout of outpatient clinics focus, for example, on the clinic’s room planning (e.g. two available doctors per treatment room is an upper limit), maximal use of staff through sharing treatment rooms, and improved resource-allocation planning with regard to organisation of processes. However, no specific guidelines exist for OOCs. Moreover, the specific application of existing guidelines for outpatient clinics to orthopaedic clinics has not yet been validated or refined.

2.2 R

ESEARCH OBJECTIVE

This study’s primary objective is as follows: Develop guidelines for designing a facility layout for an

OOC that safeguards tolerable patient turnaround time, affordable consultation resource investments, and consultation speed.

The guidelines for designing facility layout for an OOC derive from a set of alternative generic guidelines, defined as prescriptions for the logistic design of an OOC. Existing guidelines for outpatient clinics (applied to the orthopaedic setting) and potential new guidelines are tested to show the performance impact.

Tolerable patient turnaround time regards the time patients spend in the clinic, including waiting time

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2007), and particular attention is paid to minimising the delay of consultations so that the average number of patients served per hour can be increased.

Performance trade-offs must be considered in approaching the research objective. For instance, efficiency improvements for hospital resources may have a negative impact on the performance measures valued by patients. In this thesis, trade-offs are accounted for and further elaborated in the discussion.

2.3 C

ONCEPTUAL MODEL

The conceptual model (see Figure 1) presents the studied system. Patient inflow, and thus the arrival of the patients, occurs by appointment. The performance is the result of the patient inflow and the selected guidelines for the design of a facility layout in the OOC.

Figure 1: Conceptual model

The guidelines for the design of an outpatient clinic are categorised into (1) the clinic’s room planning, (2) healthcare staff planning, and (3) resource allocation planning. This study assumes that all patients follow the same routing, and all the patients entering the OOC follow the same sequence of activities. For physical layout, walking distances are typically short, both for patients and for medical staff, and they are therefore not considered.

Three cost-based and time-based related performance measures figure in the measurement of the effects of layout planning; these quantify the impact that any changes to the clinics’ processes might have (Norouzzadeh et al. 2015, Cote 2000, Stoy, Kytzia 2005, Kopach et al. 2007):

- Tolerable patient turnaround time: total time a patient spends in the clinic (turnaround time),

including waiting time;

- Affordable consultation resource investments: occupation rate of rooms and total capacity of

office work space in the facility; and

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The patients’ satisfaction levels are measured by a proxy measure (i.e. waiting time of the patient, as reduced waiting time for the patient will lead to an overall increase in the level of satisfaction with outpatient services (Manaf, Nooi 2009). Although the staff’s level of satisfaction is an important part of the overall success of the design of the clinic, this research does not include an analysis of staff satisfaction, because the design was not implemented in a real-life situation. Such an analysis would be possible only after a design has been realised.

2.4 R

ESEARCH DESIGN

This study applies design science research within the Nij Smellinghe in Drachten. This approach is based on the creation of an artefact in order to develop general knowledge (Holmström et al. 2009). The hospital is considering a reconfiguration of the department rooms. The question, however, is how to design the new layout, given the process characteristics and criteria set on patient lead time, while considering the associated costs.

Holmström et al. (2009) designed a framework consisting of four research phases: (1) solution incubation, (2) solution refinement, (3) explanation I – substantive theory, and (4) formal theories. However, in this study, only the first three phases will be used, as the last phase concerns developing theories that can be used regardless of context, which is not the case in this study. In Table 1, all steps are addressed and linked to the corresponding chapter in the thesis. A more detailed description of the research phases can be found below.

Table 1: Research phase and corresponding chapter

Phase 1: Solution incubation. In this phase the problem is framed and an initial solution is designed. First, the current facility layout design is described. In order to investigate the effects of facility layout planning on the performance of the OOC, it is necessary to know more about the current as-is situation within Nij Smellinghe. Nij Smellinghe hospital in Drachten serves as our research vehicle, providing a typical example of an OOC. The characteristics of the system and operational procedures are investigated, as this investigation creates a starting point from which further research should take place. The complete primary process in the OOC is also described. After the as-is situation is described, the current performance is analysed and discussed according to the criteria mentioned in Section 2.3. Finally, an initial solution is designed based on the retrieved and analysed data.

Phase (Holmström et al., 2009)

Chapter

1. SOLUTION INCUBATION 4. System description 5. Analysis

6. Redesign 2. SOLUTION REFINEMENT 6. Redesign

7. Evaluation of alternative layouts 3. EXPLANATION I – SUBSTANTIVE THEORY 8. Discussion

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Phase 2: Solution refinement. In this phase, the performance of the designed alternative facility layouts is tested and refined. The alternative layouts, each having a specific focus area (i.e. architectural efficiency) will be described in detail in section 6.2. The various layouts are tested by means of a hybrid research approach. A simulation study is performed first, in order to demonstrate the effects of the different redesigns. The simulation can cope with variability, interconnectedness, and complexity (Robinson 2008), and it is thus suited for high levels of uncertainty and complex healthcare delivery systems (Rohleder et al. 2011) related to OOCs. The simulation includes the facility layout redesigns and accounts for the performance indicators mentioned in Section 2.3. Secondly, a deterministic approach is used, in which the output of the model is fully determined by the parameter values and the initial conditions. The guidelines that cannot be tested by the simulation study are tested by the deterministic approach.

The various layouts must be compared to and evaluated against the current layout. Furthermore, the general findings of Phase 2 can suggest new or refined guidelines and any implications for (orthopaedic) outpatient clinics.

Phase 3: Explanation I – Substantive theory. In the last phase, the obtained insights regarding facility layout design are generalised to make a theoretical contribution. The insights relate to the validation, refinement, and new development of guidelines for the design of a facility layout for an OOC. The theoretical relevance of the design solution will be established by means of evaluating and examining the insights from a theoretical point of view (Holmström et al. 2009). The generalisation of the insights makes them suitable for other OOCs or other outpatient clinics with similar characteristics.

2.5 D

ATA SOURCES

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3. THEORETICAL BACKGROUND

This chapter reviews the literature on how facility layouts can be designed in (orthopaedic) outpatient clinics to increase overall performance. Section 3.1 addresses the growth of outpatient clinics and the needs for re-construction. In Section 3.2, the concept of facility layout planning and its applications in (orthopaedic) outpatient clinics are explained. A review of the proposed guidelines for designing OOCs is provided in Section 3.3. Finally, Section 3.4 concludes the main findings.

3.1 O

UTPATIENT CLINICS

:

G

ROWTH AND NEEDS FOR RE

-

CONSTRUCTION

Healthcare systems are experiencing a continuous drop in the number of beds required for inpatients: Inpatient care is decreasing as outpatient healthcare increases (Carr 2010). The growing demand for outpatient care results from more effective ambulatory care treatments and the overall growth of healthcare demand (Hulshof et al. 2012). Therefore, managers of outpatient clinics are emphasising the efficient use of scarce resources, doctors’ time, and facility space (Cote 2000, Hulshof et al. 2012). As a result, many hospitals are redesigning their outpatient clinics (Hulshof et al. 2012).

An outpatient clinic is a specialist clinic in a general hospital (Hong et al. 2013). In the past, outpatient clinics have mainly been used as diagnosis and treatment centres, but currently they also serve many other functions. For example, patients who are admitted for inpatient services are screened in outpatient clinics, and patients who are discharged from the inpatient clinic receive follow-up treatment in the outpatient clinic (Hong, Shang et al. 2013). One advantage of outpatient clinics is that they are less expensive to build and operate than inpatient clinics, as there is no space required for overnight accommodation and accompanying areas such as housekeeping. Furthermore, there is no need to shift the work of the staff, as the clinics are closed at night and on weekends (Hong, Shang et al. 2013, Carr 2010).

Many hospitals already encompass outpatient diagnostics and treatment facilities. These outpatient construction projects are a result of the increased workload at outpatient clinics (Carr 2010). The introduction of market competition in 2005 has led to an increase in the average costs of inpatient diagnosis treatment combinations: “Market competition in the Dutch healthcare market implies that insurers and hospitals are allowed to negotiate freely about healthcare volume, price and quality, and to contract selectively” (Krabbe-Alkemade et al. 2017). This leads to hospitals looking for possible efficiency improvements in predominantly outpatient care clinics, while the outpatient clinics have to maintain high standards for quality of care(Krabbe-Alkemade et al. 2017).

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3.2 F

ACILITY LAYOUT PLANNING

Facility layout planning in outpatient clinics is defined as “the placement of facilities, whereby placement is defined as the arrangement of everything that is needed for the delivery of services” (Drira et al. 2007).

Effective facility layout planning systems must be able to improve the utilisation of the doctors, other staff,

and other resources, at the same time reducing waiting times for patients (Cayirli, Veral 2003, Jun et al. 1999).

As explained in Section 3.1, numerous uncertainties arise within healthcare. It is therefore particularly important to assess process characteristics when assessing layout. Variations in clinical practice are common features of healthcare systems (Andersen, Mooney 1990). First of all, an (orthopaedic) outpatient clinic increasingly has to deal with disturbances in the operational process (Creemers, Lambrecht 2011). A disturbance occurs, for example, when a doctor is called for a second opinion in the plaster room, but disturbances also include events that can be avoided, such as administrative issues. Secondly, the duration

of the consultation can vary widely due to the complexity of the process in OOCs (O'neill et al. 2003).

Patients have different characteristics, and although the consultation time can be estimated in advance, in the end it ranges from two to 23 minutes. Finally, the preparation time of patients can differ significantly (Greenfield et al. 1985). For some patients, the doctor needs only a brief look at an X-ray, whereas for other patients, second opinions from other doctors are necessary in the preparation phase.

The common layout for an outpatient clinic consists of treatment and consultation rooms, providers’ working areas, waiting areas, and a reception area. One must incorporate all viewpoints and the activities of all stakeholders when identifying a new, effectively organised layout (Vahdatzad, Griffin 2016). Patients may wish to limit the distance between the waiting area and treatment rooms, and providers may wish to minimise distances between their working areas and the treatment rooms—the performance trade-off. The outpatient department is usually on the ground floor of the hospitals, with a parking lot, X-ray facilities, laboratories, a pharmacy, and a medical record office nearby (Kunders 2004).

3.3 P

ROPOSED GUIDELINES FOR OUTPATIENT CLINIC FACILITY DESIGN

Outpatient clinics currently face growing competition. For outpatient clinics, it is crucial to attract new patients, but also to retain the current patients (Jun et al. 1999). Therefore, specific guidelines have been proposed for outpatient clinics to increase efficiency in the delivery of care. In outpatient clinics, resource allocation is divided into guidelines for (1) the clinic’s room planning, (2) healthcare staff planning (Hong et al. 2013), and (3) resource allocation planning for the organisation of processes (Hulshof et al. 2012). No specific guidelines address patient and staff satisfaction, but satisfaction must be considered in the overall performance of the outpatient clinic (Blizzard 2009) (for further, see Sections 3.3.1–3.3.4).

3.3.1 C

LINIC

’

S ROOM PLANNING

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orthopaedists should not be greater than 2:1, as exceeding this ratio could lead to lower treatment room utilisation without an increase in patient lead time.

Another finding was to allocate the treatment rooms more flexibly and dynamically among the OOCs (Santibáñez et al. 2009). The sharing of treatment rooms will improve the utilisation of the available capacity (Baril et al. 2014). In most situations, each room is assigned to a specific physician for an entire session, referred to as a “dedicated” room assignment. Alternatively, all rooms can be shared among all practising physicians, and patients may be visited in any available room, referred to as “shared” room allocation (Vahdatzat, Griffin 2016).

Furthermore, according to Carr (2010) multi-purpose spaces should be created so that efficient use of space is made. Regarding flexibility, it is important to use established standard room sizes and plans as much as possible and to follow modular concepts of facility planning and layout. Proper planning of the number of treatment rooms during the clinics’ setup is important, as generally it is easier to hire medical staff than to add space later on (Hong et al. 2013).

Sepulveda et al. (1999) simulated a cancer treatment centre with the objective of improving patient flow process and increasing the capacity of the facility. They modelled the new clinic with a 100% increase in capacity, and by identifying key bottlenecks, they identified that the limited accommodation of the waiting room was responsible for the inefficiency in patient flow.

3.3.2 H

EALTHCARE STAFF PLANNING

Groothuis et al. (2002) studied the effect of relocating a phlebotomy department in a hospital. The most important bottlenecks identified were too little capacity at the reception desk (only one nurse, which does not provide sufficient privacy), and the process of calling a patient and having a nurse guide that patient from the waiting room to the cubicles, which is time consuming. Based on the bottlenecks, a new floor plan of the phlebotomy area was made. They found that relocating the department would enable a reduction of 33% in patients’ turnaround time (Groothuis et al. 2002).

Rohleder et al. (2011) tested different solutions to determine the appropriate schedules that would ensure improvement in the performance of the OOC and more efficient use of human resources. The most important improvements were implemented, optimising levels of staff and emphasising staff punctuality. After implementation, the average time for a patient in the outpatient clinic decreased by 33%. The measurements regarded patient waiting times and total length of stay of patients in the outpatient clinic.

3.3.3 R

ESOURCE ALLOCATION PLANNING

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the room). Lastly, “when the doctor finishes consultation with the (n − 1)th_{patient, and the nth patient has} not entered a room yet, the doctor transfers to an empty room when one becomes available, and waits there for the nth patient” (Hulshof et al. 2012).

3.3.4 S

ETTING REQUIREMENTS ON PATIENT AND STAFF SATISFACTION

Several factors influence patient satisfaction. These include clear communication from the healthcare provider and accessibility to the service, but more importantly time spent in the encounter (Levesque et al. 2000). Long OOC visits are typical of many outpatient clinics and frequently cause complaints: Patients are less satisfied not only when the original appointment time runs out but also when the appointment takes longer than expected (Levesque et al. 2000). Outpatient clinics typically schedule appointments for patients in advance, and patients arrive at the clinic expecting service to begin at the scheduled time. However, due to variation in patients’ arrival times and service times, patients find themselves waiting even though they have reserved time slots (Rohleder et al. 2011, Noon et al. 2003). Noon et al. (2003) found that the reduction of arrival and service time variance yields a substantial reduction in waiting time.

The literature finds that for healthcare systems where patients have a choice of different outpatient clinics, shorter wait times can be seen as a competitive advantage (Rohleder et al. 2011, Blizzard 2009). For of several reasons, wait times have negative effects on patients, doctors, and other staff. First, they lead to discomfort and to patients distrusting the functioning of the outpatient clinic. Second, as patient complaints increase, so do staff stress levels. Third, doctors feel pressure both to reduce consultation times and to increase quality of service (Rohleder et al. 2011, Zhu et al. 2012). Hong et al. (2013) found that patient satisfaction levels correlate strongly with wait times and overall outpatient satisfaction. Reduced wait times for patients leads an increase in overall satisfaction with outpatient services (Manaf, Nooi 2009). Even when the quality of the treatment is high, long wait times produce dissatisfaction among patients (Rohleder et al. 2011).

Furthermore, research has shown that an increase of 50–90% of a doctor’s workload can cause patients’ wait times to increase by 10.5 minutes (per patient with appointment), as is supported by queueing theory. This finding shows that a realistic clinical load for a doctor is critical in outpatient clinics (Hong et al. 2013), as is ensuring that a certain level of satisfaction is achieved by staff.

The guidelines for layout issues for outpatient clinics discussed in Sections 3.3.1–3.3.4 are summarised in Table 2.

Table 2: Important guidelines for outpatient clinics

Layout issue Guidelines for outpatient clinics By whom

Clinic’s room planning

(Section 3.3.1)

Maintain a maximum ratio of 2:1 treatment rooms to doctors to prevent insufficient utilisation of treatment rooms

Baril et al. (2014); Berg et al. (2010); Cote et al. (1999) More flexible and dynamic rooms (e.g. shared rooms) to

improve the utilisation of the available capacity

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Multi-purpose spaces in the outpatient clinic to optimise use of space

Carr (2010)

More accommodation in the waiting room to eliminate inefficiencies in the patient flow

Sepulveda et al. (1999)

Healthcare staff planning

(Section 3.3.2)

Enough available capacity at the reception desk (i.e. to accommodate more than one nurse)

Groothuis et al. (2002)

Prevent patient calling by nurses, as this is very time consuming in outpatient clinics

Groothuis et al. (2002)

Optimisation of staff levels and staff punctuality to increase performance

Rohleder et al. (2011)

Resource allocation planning

(Section 3.3.3)

A doctor-to-patient (DtP) policy for an outpatient clinic, under certain assumptions

Baril et al. (2014); Hulshof et al. (2012)

Patient level of satisfaction

(Section 3.3.4)

Reduced waiting times, to increase satisfaction of the patients

Levesque et al. (2000); Rohleder et al. (2011); Blizzard (2009); Manaf et al. (2009)

Enough privacy (i.e. at the reception desk) Groothuis et al. (2002)

Staff level of satisfaction

(Section 3.3.4)

Realistic clinical load of medical staff should be applied Hong et al. (2013); Fetter & Thompson (1966)

3.4 S

UMMARY OF FINDINGS

With less inpatient care, outpatient healthcare is on the rise. Existing outpatient facilities have to enhance their performance to compete with others in the current competitive climate. The redesign of facility layout is to increase the performance of health service operations. Meanwhile, outpatient clinics must maintain high standards for quality of care. Resource allocation for facility layout planning in outpatient clinics is categorised into guidelines for (1) planning of clinic rooms, (2) planning for healthcare staff, and (3) planning for resource allocation. No specific guidelines exist for patient and staff satisfaction, but these must be considered to improve the overall performance of an outpatient clinic. Patient satisfaction is measured, for example, by waiting time in the outpatient clinic. Performance trade-offs must also be considered, as efficiency improvements for hospital resources may negatively impact the performance measures valued by patients.

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4. SYSTEM DESCRIPTION

This chapter describes the primary process of the OOC of Nij Smellinghe, the department under study. Section 4.1 provides an overall system description of the OOC. Sections 4.2 and 4.3 describe the patient characteristics and the care services. Section 4.4 explains the associated (staff) resources, and Section 4.5 addresses planning and control of OOCs.

4.1 S

YSTEM DESCRIPTION

Figure 2 presents an overview of the elements of an OOC. The process begins with the arrival of a patient. The patient inflow is organised with the use of an appointment schedule, according to which different time slots are assigned to different patient characteristics. Once a patient is admitted, the patient will undergo treatment. From a systematic point of view, this means that the patient is using the resources of the clinic for a certain amount of time. These resources can be subdivided into (1) the clinic’s room planning, (2) healthcare staff planning, and (3) resource allocation planning. After the treatment is completed, the patient leaves the clinic. In Figure 2, each element shows the section in which that element will be discussed in detail.

Figure 2: System overview

4.2 P

ATIENT CHARACTERISTICS

Orthopaedics deals with the posture and the musculoskeletal system; related problems can occur at any age. The most common conditions are injuries of the knee (meniscus, cruciate ligament, or cartilage damage) and the shoulder (bursa, tendonitis, and instability). In addition, many patients are seen with hip or back complaints. Stubborn complaints of the foot and ankle (flat foot, hallux valgus, hammertoes, etc.) are also common. Orthopaedics make much use of imaging technology, of which the classic X-ray is the most common. Ultrasound, computed tomography (CT) and magnetic resonance imaging (MRI) scans are also in common.

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 new patients,

 new patients from the emergency department,

 repeat patients returning for review of their progress with either surgical or non-surgical treatment, and

 patients returning for a check-up.

Most patients visit the clinic multiple times in the course of their orthopaedic care. The clinic has had an average weekly volume of 380 appointments, with some variations in recent years. The clinic is generally open from 08:30–16:30, Monday through Friday. All patients follow the same path through the clinic’s management system. In short, the patient must go to radiology before meeting with the orthopaedist. Then the patient meets the orthopaedist, and a follow-up meeting is planned by the medical staff, if necessary.

4.3 C

ARE SERVICES

Figure 3 displays an overview of the key elements of the patient flow in an OOC.

The care services are split into three services, namely pre-consultation, consultation, and post-consultation. (1) Pre-consultation

Once the patient has completed the radiology examination, the patient continues to the OOC and registers at the reception desk, which can serve only one patient at a time. The medical assistant checks the patient into the system, provides information, answers questions, and requests that the patient take a seat in the waiting room (Buffer 1). Next, the patient is called to one of the treatment rooms by the medical staff. The patient waits in the treatment room (Buffer 2) before the orthopaedist enters. While the patient waits in the treatment room, the orthopaedist is usually busy with another patient in the second treatment room or is preparing for the patient.

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(2) Consultation

A consultation is a scheduled meeting with an orthopaedist (e.g. to seek advice for problems pertaining to the patient’s joints or bones). An orthopaedist may be assisted in a consultation by a nurse, who might prepare injections, bandages, and so on. During the consultation, a patient may want to see a previous X-ray, in which case the patient is invited to the orthopaedist’s private room. In most cases, however, the consultation takes place in the treatment room.

(3) Post-consultation

After the scheduled meeting, the orthopaedist decides on the next step for the patient. Several options are available for the completion of the consultation. If an injection is needed, it is in most cases administered directly. If an additional examination is needed, the patient is sent to the radiology department. When finished, the patient must go through the entire process again. The completion of the consultation is either a repeat visit, physiotherapy, a pharmacy prescription, an MRI scan appointment, the planning of an operation, or a short explanation of educational or informational material. New appointments are made on the computers in the hallway. One computer is available for each medical assistant (responsible for the consultation). After the completion of the consultation, the patient leaves the clinic.

While the patient is waiting, the orthopaedist is simultaneously preparing for the patient. After the consultation, the orthopaedist leaves the treatment room, informs the medical assistant in the hallway about the follow-up, and moves to his own private room to record all new information about the patient in the computer system and to prepare for the next patient. The main tasks of the orthopaedists during the consultation consist of (1) preparing for the patient, (2) consulting with the patient, and (3) recording new information about the patient in the computer system. The preparation of a patient and recording of patients’ details takes place in the private room of the orthopaedist. The orthopaedist is very often disturbed while in his private room; these disturbances are taken into account in the simulation.

4.4 A

SSOCIATED

(

STAFF

)

RESOURCES

Two orthopaedists staff the clinic at any given time during the week, each with a specific area of focus. All orthopaedists are able to treat patients who have ordinary problems, but complex cases can be treated only by orthopaedists with the relevant specialisation. While the orthopaedists drive the operations of the clinic, the staff and resources indicated in Table 3 are also key elements of the clinic’s operations.

Table 3: Key elements of clinics’ operations

Resources Operation of task

Clinics room planning

Four treatment rooms  For examination of patients Two private orthopaedist rooms  For preparation of patients

 To carry out administrative tasks One reception desk

One waiting space

Two computers in hallway  To make follow-up appointments

Health care staff planning

Two orthopaedists Each with two treatment rooms

Two members of medical office staff One member of medical office staff for each orthopaedist

 Complete consultations (placing patients on waiting lists for operation, booking follow-up appointments, providing brief explanations of educational material)  Prepare injections, etc.

(21)

In total the clinic has four treatment rooms, and five orthopaedists work there. Every week the consulting periods are reserved to specific orthopaedists, two per day. The weekly schedule is constructed according to each orthopaedist’s surgery schedule. Every consulting period is managed by an orthopaedist using two treatment rooms and working with one nurse. The weekly number of consulting rooms and nurses required by an orthopaedist depends on his or her patient caseload.

While the patients’ paths vary significantly through all clinic resources, the orthopaedists are the busiest members of clinic staff by a significant margin, as essentially all patients see the orthopaedists.

All X-rays are pre-ordered and completed before a patient is invited into a treatment room, so that the orthopaedist can make a diagnosis and therefore start a treatment directly. As displayed in Figure 3, all patients that need an CT scan will have already made this at a special location in the hospital, not being in the orthopaedic department. Since the X-rays are not made inside the orthopaedic clinic this resource is not considered in the rest of this research.

Indicating the way in which the resources are allocated, the floor plan of the current OOC (including the dominant pathway) is shown in Figure 4.

Legend:

1. The patient enters the clinic.* 2. The patient checks in at the

reception desk.

3. The patient waits in the

designated waiting room.

4. The patient goes to treatment

room 4.1, 4.2, 4.3 or 4.4.

5. The patient schedules a

follow-up meeting, if necessary, on either computer (5.1) or computer (5.2) in the hallway.

6. The patient leaves the clinic.

*Indicating physical patient path (i.e. step 1 to step 2). For the remaining steps the same procedure is followed.

(22)

4.5 P

LANNING AND CONTROL

The number and type of patients scheduled daily varies according to the number of consulting rooms and the number of available orthopaedists. Generally, each patient has an appointment with a specific orthopaedist, and the consulting periods assigned to each orthopaedist are known in advance. Appointment schedules for each orthopaedist cover a three-month period. The appointment scheduling rule currently used by the OOC consists of scheduling the patients according to type, so either five or 10 minutes (Table 4). The day is split up in two parts, with a lunch break in between. Patients are scheduled from 08:30–12:05 in the morning and from 13:30–15:40 in the afternoon, so delays in the process are incorporated. Most of the patients are therefore scheduled in the morning. No walk-in patients are admitted to the clinic (i.e. patients without a prescheduled appointment).

Table 4: Treatment duration according to patient characteristics

Patient characteristics Treatment duration

New patients 10 min

New patient from the emergency department 5 min

Repeat patients returning for review of progress (discuss results) 10 min

Repeat patient for a check 5 min

(23)

5. ANALYSIS

In this chapter, the current facility layout of the OOC is analysed. Section 5.1 elaborates on the approach of the analysis and the data collection. Section 5.2 assesses turnaround time and waiting time, Section 5.3 assesses the occupation rate of rooms and of total capacity, and Section 5.4 assesses the average number of patients served per hour.

5.1 A

PPROACH AND DATA COLLECTION

The current facility layout is assessed according to the performance criteria presented in the conceptual model of Section 2.3:

- total time a patient spends in the clinic (turnaround time), including waiting time, - occupation rate of rooms and total capacity of office work space in the facility, and - average number of patients examined per hour.

The main purpose of this assessment is to clarify the current scores on relevant performance measures and to show that these performance measures underpin the need to reconsider the layout of the clinic.

Data was collected over a period of three months: October, November, and December 2017. Accurate data on over 120 patients seen by four doctors were collected over this time period for the following categories: (1) patient arrival times and (2) service times for all the resources. After each patient entered the clinic, time passages were observed and manually recorded with the use of a tracking form. The observation is made at the beginning and end of each service (i.e. pre-consultation, waiting in waiting room, waiting in treatment room, consult, post-consultation) the patient received. The data on each service was collected for the same number of patients during separate calendar-weeks. For each service, whole weeks are observed to account for a divergence in influx and occupancy. Because the observation for each service is made on similar days and for a similar amount of time, the data used should be comparable.

5.2 T

URNAROUND AND WAITING TIMES

All service times, starting when the patients enter the clinic, are visualised in Figure 5 to give an overview of the total turnaround time from a patient’s point of view.

Figure 5: Service times in the orthopaedic outpatient clinic (OOC) from a patient point of view

Waiting times were divided into two categories (Figure 5): time spent waiting in the actual waiting room and time spent waiting in the treatment room. Patients often arrived too early for their appointments, but waiting time was defined as the time from the planned start of the scheduled appointment to the actual start of that appointment.

(24)

Redesign is needed where waiting time could be decreased. The times provided in Table 5 include patient transfer times in the clinic (which are negligible) for over 120 patients. In Appendix C, a graph visualises the breakdown of the total turnaround time of several patients during one day.

Table 5: Breakdown of total patient turnaround time

Time (in minutes) Percentages

1. Pre-consultation 0.415 minutes 0.75%

2. Wait in waiting room 26.49 minutes 49.47%

3. Wait in treatment room 16.18 minutes 29.84%

4. Consultation duration 7.100 minutes 12.79%

5. Post-consultation 3.950 minutes 7.12%

Total turnaround time patient 54.14 minutes 100%

For each element of the patient stay listed in Table 5, minimum, maximum, mean, standard deviation, and the coefficient of variation are presented in Table 6.

Table 6: Analysis of different service time measures (in minutes)

Parameter

Pre-consultation

Consultation duration Post-consultation Wait in waiting room Wait in treatment room Min-value 0.083 2.150 0.000* 0.000 0.200 Max-value 1.967 13.167 15.617** 59.460 24.812 Mean 0.415 7.100 3.950 26.490 16.180 Standard deviation 0.354 2.912 2.468 15.934 6.560 Coefficient of variation 0.85 0.4 0.63 0.54 0.43

*For an average 27% of the patients the post-consultation is equal to zero (no future appointment needed) **Max. time is reached when someone must be placed on the waiting list for an operation

The coefficient of variation is an indicator of the spread of the data. More detail on the spread of the pre-consultation, consultation duration, and post-consultation can be found in the histograms provided in Appendix F.

(25)

Figure 6: Spread of waiting times and spread throughout the day (waiting room)

Figure 7: Spread of waiting times and spread throughout the day (treatment room)

As explained in Section 4.3, the main tasks of the orthopaedists during the consultation consist of (1) preparing for a patient, (2) consulting with a patient, and (3) recording new information about a patient in the computer system. The preparation of a patient and the recording of patient information takes place in the private room of the orthopaedist, who is often disturbed in this room, which also causes delay. Delays during preparation, consultation, and post-consultation are thus the main cause of longer wait times. Some of the specific causes of lengthened wait times are (1) longer preparation time; (2) extended consultation, and (3) the unavailability of a doctor due to disturbances.

0 10 20 30 40 50 60 70 1 4 7 10 13 16 19 22 25 28 31 34 37 Min u tes

Patients throughout one day 0 2 4 6 8 10 12 14 16 <10 min 10-15 min 15-20 min 20-25 min 25-30 min 30-35 min 35-40 min 40-45 min >45 min N u m b er o f p at ie n ts

Spread of waiting times in the waiting

room

0 5 10 15 20 25 30 35 40

<5 min 5-10 min 10-15 min 15-20 min > 20 min

N u mb er o f p atien ts

Spread of waiting times in the treatment

room

0 5 10 15 20 25 30 1 4 7 10 13 16 19 22 25 28 31 34 37 Min u tes

(26)

5.3 O

CCUPATION RATE OF ROOMS AND OF TOTAL CAPACITY

In this section, the occupation rate of rooms and the occupation rate of total capacity are analysed.

5.3.1 O

CCUPATION RATE OF ROOMS

In the current situation, the following rooms are used for the consultation under the premise that two orthopaedists are available. The occupancy in the current situation is shown in Table 7.

Table 7: Occupancy of resources used

Occupancy (%)

Reception desk 2%

Treatment rooms 1–4 86%

Treatment rooms 1–4 (excluding waiting) 27%

Private orthopaedist rooms 46%

Post-consultation hallway 26%

The reception desk, where pre-consultation takes place, is occupied by patients only 2% of the time. In redesigns, the occupation rate at the reception desk does not necessarily need to increase to boost performance. However, since reception is only in effective use 2% of the time, human and physical resources could be spent more effectively the other 98% of the time.

The occupancy of treatment rooms, including waiting time, is 86%; excluding waiting time, this percentage is reduced to 27%. Therefore, only 27% of the time is spent on actually treating patients, whereas both patient and orthopaedists are present in the treatment room. In the development of a redesign, attention should be paid to improving the occupancy rate of the treatment room.

The occupancy of the orthopaedist room is at 46%. Occupancy is calculated by the time an orthopaedist is in her own room either preparing patients or recording new information about the (n −1)th_{patient in the} computer system. Occupancy also includes disturbances over 5 min. Although this research strives to increase occupancy in all rooms, an increase in occupancy of orthopaedist room does not necessarily leads to an improvement, since time spend by the orthopaedist in the orthopaedist room leads to less time spend with patients. Therefore, the redesign should simultaneously increase the occupancy while not increasing the time spend per orthopaedist.

(27)

5.3.2 O

CCUPATION RATE OF TOTAL CAPACITY

The total capacity of the OOC is 315.1 m2_{. Table 8 shows the total capacity of the other work spaces of the} facility.

Table 8: Total capacity of office work space of the facility (in square metres) Square metres (𝒎𝟐) Total available capacity layout 315.1 𝑚2

Waiting area 193.1 𝑚2

Reception desk 25.4 𝑚2

Treatment rooms 1–4 35.5 𝑚2 (each 9.125 𝑚2)

Private rooms orthopaedists 60.1 𝑚2 (each 15.025 𝑚2)

Hallway (passage of the surface) 21.9 𝑚2 Total capacity used in current situation 305.25 𝑚2

There are four private orthopaedist rooms, but most of the time only two of the rooms are occupied. The total capacity used in current situation is not equal to the total available capacity in the layout (Table 8), since four private orthopaedist’s rooms are available, but only two at most are used throughout the day, as only two orthopaedists are working on regular days. This shows there is room to improve the layout by, for example, establishing “shared rooms” to increase this percentage.

Therefore, the occupation rate of the total capacity can be represented as follows: 𝑈𝑠𝑒𝑑 𝑐𝑎𝑝𝑎𝑐𝑖𝑡𝑦

𝑇𝑜𝑡𝑎𝑙 𝑐𝑎𝑝𝑎𝑐𝑖𝑡𝑦=

193.1 + 25.4 + 35.5 +60.1_{2 + 21.9}

315.1 ∗ 100 = 97.1%

Table 8 displays the total workspace of each area. Some workspaces cover a large space (e.g. the reception desk), although they receive little use (e.g. the reception desk is only occupied 2% of the time). Thus, the proportions of occupancy versus available capacity should be more streamlined in the redesign. This streamlining can be accomplished either by increasing the occupation rate of the resources or by decreasing the occupation rate of the total capacity, so that this space can be used for other tasks or departments in the hospital. Such an adjustment would ensure that the largest areas are also occupied for the largest amount of time and that the available capacity is used as effectively as possible.

5.4 A

VERAGE NUMBER OF PATIENTS SERVED PER HOUR

(28)

6. REDESIGN

This chapter aims to describe the alternative configurations to be tested at the OOC of Nij Smellinghe. Section 6.1 gives an overview of the key elements in the redesign for the OOC. Section 6.2 provides a detailed description of the various alternative layouts.

6.1 K

EY ELEMENTS IN REDESIGN

Based on the findings for (under) performance in section 5: (1) waiting due to a longer duration of the pre-consultation, consultation and post-consultation; (2) a low occupation rate at the reception desk; (3) low occupation rates of treatment rooms; (4) low occupancy of the orthopaedist rooms; (5) overcrowded hallways, which also reduces the privacy of patients and doctors and; (6) available capacity is not used as effective as possible, guidelines are tested as they might serve as potential solutions to the before mentioned findings.

Existing guidelines for outpatient clinics will be validated or refined for OOCs. The total set of existing guidelines have already been displayed in Table 2. Most of these guidelines suggest improvements applicable to OOCs. However, the complete list of guidelines is not tested in this case study. The decisions as to which existing guidelines are tested are based on advice from domain experts. In short, Section 5.1.1 provides an explanation of which guidelines of Table 2 will be tested or not. Some inefficiencies in the current situation are not solved by the existing guidelines, so these will be made complete by adding potential new guidelines (Section 5.1.2). Combining both existing and new guidelines creates a set of guidelines for OOCs (Figure 8).

Figure 8: Breakdown of guidelines for orthopaedic outpatient clinics (OOCs)

6.1.1 E

XISTING GUIDELINES FOR OUTPATIENT CLINICS

The current guidelines are subdivided into different categories (as in Table 2). Each category with the matching guideline(s) is discussed below:

Clinics’ room planning

 A maximum ratio of 2:1 of treatment rooms to doctors to prevent under-utilisation of treatment

rooms is expected to have a higher occupation rate of rooms in comparison with other ratios. Other

ratios will be implemented to prove this (see section 6.1.2). In the current situation, Nij Smellinghe already applies a 2:1 ratio. Therefore, including the guideline will not address a current issue but the effect of the guideline could be used as comparison to other ratios.

 More flexible and dynamic rooms to improve the utilisation of the available capacity will be tested to prove they are valid for the orthopaedic setting. To solve the issue that available capacity is not used as effective as possible more flexible and dynamic rooms will be implemented by using shared rooms. It is expected that implementation will positively affect the occupation rate of total capacity (m2_).

EXISTING GUIDELINES FOR OUTPATIENT CLINICS POTENTIAL NEW GUIDELINES

(29)

 Multi-purpose spaces to increase efficiency in use of space to improve on the occupancy of the orthopaedist room. This guideline is tested by the implementation of a shared orthopaedist room (1 room per 2 orthopaedists) in which orthopaedists perform multiple tasks (i.e. pre-consultation, post-consultation). The guideline is expected to increase the occupation rate of (orthopaedist) rooms without decreasing the time spend with patients.

 Limited accommodation in the waiting room will lead to inefficiencies in the patient flow will not be tested but will be a constraint to not decrease the area of the waiting room in the various designs. Health care staff planning

 There must be enough available capacity at the reception desk. This guideline is not tested in the model as it is assumed that there should, at all times, be enough available capacity.

 Patient calling by nurses is very time consuming in outpatient clinics is not tested since no current option is available to change this process. In future studies, when new technological solutions are available, it could be tested whether changes lead to improved efficiency.

 The guideline: optimising staff levels and punctuality of staff lead to increased performance of an

outpatient clinic is not tested. In this research staff levels are assumed to be fixed and punctuality

of staff is assumed to be optimal. Resource allocation planning

 The guideline: a Doctor to Patient policy (DtP) is preferable under certain assumptions will be implemented to test the effect on the performance of the clinic. The implementation of this guideline is likely to reduce the patients’ turnaround time. It is expected that a DtP policy will decrease the patients’ turnaround time and therefore possibly reduce the waiting time. In a DtP policy the movement of the patient is minimized whereas the doctor is moving continuously and thus will the post-consult always be done in the treatment room. So when a doctor is finished with the (n -1)th_{patient, the doctor can already move to the next treatment room while a medical assistant} moves in to the treatment room to do the post-consult. It is expected that this way of working saves time as it is more efficient and will possibly decrease the patient waiting time. Moreover, the occupation rate of the treatment rooms will increase as the post-consult is executed in the same room. Finally, as the turnaround and waiting time might decrease, the expected average number of patients served per hour will increase.

Patient level of satisfaction

 Reduced waiting times will lead to an increased level of satisfaction is not seen as an input in the model but rather as a goal of the redesign and is therefore not tested.

(30)

Staff level of satisfaction

 The guideline: realistic clinical load of medical staff should be applied is not tested as it is assumed fixed, because of rules set in consultation with hospitals, clinics and unions.

Table 9 summarizes the points mentioned in Section 6.1.1, including the issues the enacted guidelines might solve and the expected effect of specific guidelines on the performance measures.

Table 9: The expected effect of existing guidelines on the performance measures and the issues they might solve Performance

measure 1

Performance measure 2 Performance

measure 3

Layout issue Issue (section 5) Guideline Turnaround and waiting times Occupation rate of rooms Occupation rate of total capacity Average number of patients served per hour Clinics’ room planning

_-

Implementation of a 2:1 ratio of treatment rooms to doctors to prevent under-utilisation of treatment rooms

+

-Available capacity is

not used as effective as possible.

More flexible and dynamic rooms (e.g. shared rooms) to improve the utilisation of the available capacity

+

Health care

staff planning

-Low occupancy of the orthopaedist rooms

Multi-purpose spaces to increase

efficiency in use of space

+

Resource allocation planning

-Waiting due to a longer duration of the pre-consult, consult and post-consult -Low occupancy of treatment rooms

A doctor-to-patient (DtP) policy is preferable, under certain

assumptions

-

+

6.1.2 P

OTENTIAL NEW GUIDELINES

The existing guidelines mentioned in Table 2 do not solve all the issues encountered in OOCs. This research proposes additions to the current set of guidelines found in the literature to improve on and extend existing guidelines. Furthermore, because this research focusses solely on OOCs the newly developed guidelines tackle underperforming elements in these specific clinics.

Clinics’ room planning

 The guideline: implementation of a 3:1 ratio of treatment rooms to doctors to prevent the

under-utilisation of treatment rooms is tested to verify if the 2:1 ratio is a valid guideline. By testing the

3:1 ratio, the 2:1 can be benchmarked against the new result. The ratio could not be extended further to, for instance, a ratio of 4 to 1 due to capacity constraints.

 To solve the issue of an overcrowded hallway, which reduces patient and doctor privacy, a second new guideline is added: invest in a special post-consultation room for scheduling new

appointments instead of scheduling them in the hallway. In the current situation the hallway is used

(31)

Health care staff planning

 The issue a low occupation of the reception could be solved by the guideline: implementation of a

hostess function is more efficient than a reception desk. This specific guideline should tackle the

low occupation rate of the reception desk described in section 5.3.1. As noted before, the redesign tries to ensure that the largest areas are also being occupied for the largest amount of time and that the available capacity is used as effective as possible. By implementing a hostess (including a check-in terminal) instead of a reception desk, less physical space is needed to fill the pre-consultation function. Patients can check in electronically with their hospital cards. This method might be more efficient and would require less staff for the reception desk and less space, so it will have a positive influence on the occupation rate of total capacity.

Table 10 summarizes the points mentioned in Section 6.1.2. It therefore includes the issue the guidelines might solve and the expected effect of specific guidelines on performance measures.

Table 10: The expected effect of new guidelines on the performance measures and the issues they might solve Performance

measure 1

Performance measure 2 Performance

measure 3

Layout issue Issue (Section 5) Guideline Turnaround and waiting times Occupation rate of rooms Occupation rate of total capacity Average number of patients served per hour Clinic’s room planning -A low occupation of treatment rooms Implementation of a 3:1 ratio of treatment rooms to doctors to prevent the under-utilisation of treatment rooms

−

-Overcrowded hallway, which also reduces patient and doctor privacy

Investment in a special post-consultation room to schedule new appointments instead of in the hallway: privacy focussed

− Healthcare staff planning -A low occupation of the reception desk Implementation of a hostess function (including a check-in terminal) instead of a reception desk, to increase efficiency in terms of capacity

+

There could be other new guidelines that might also apply to orthopaedic clinics. However, this research focusses on the underperforming elements at Nij Smellinghe, and it is expected that the used guidelines all influence the current efficiency issues. To conclude Sections 6.1.1 and 6.1.2, Table 11 shows the summary of key elements (both existing and new guidelines), incorporating the constrains to be tested for OOCs.

Table 11: Key elements to be tested for orthopaedic outpatient clinics (OOCs)

Layout issue Guidelines to be refined for OOCs

Existing guidelines Clinic’s room planning

- Implementation of a 2:1 ratio of treatment rooms to doctors to prevent under-utilisation of treatment rooms

- More flexible and dynamic rooms (e.g. shared rooms) to improve the utilisation of the available capacity

- Multi-purpose spaces to increase efficiency in use of space Resource allocation

planning

(32)

New guidelines Clinic’s room planning

- Implementation of a 3:1 ratio of treatment rooms to doctors to prevent the under-utilisation of treatment rooms

- Investment in a special post-consultation room to schedule new appointments instead of in the hallway: privacy focussed Healthcare staff

planning

- Implementation of a hostess function (including a check-in terminal) instead of a reception desk, to increase efficiency in terms of capacity

Constraints 1. No decrease in waiting room seating 2. Realistic clinical load of medical staff

6.2 D

ESCRIPTION OF ALTERNATIVE LAYOUTS

In this research, all identified guidelines are evaluated individually to assess whether they actually influence one or more of the performance measures. Also, following a request from OOC Nij Smellighe, multiple possible layouts are tested to investigate which layout would be the optimal choice and whether any interaction effects of guidelines would occur. Other OOCs could implement separate guidelines based on the individual research or implement an instant improvement package by choosing a layout. The alternative layouts are classified in different so called “scenarios”, and this section explains how to arrive at the scenarios. Table 12 provides an overview of which guidelines (refined or new) are implemented in which scenario.

Table 12: Overview of guidelines implemented in the different scenarios Guidelines to be tested Current

situation:

Scenario 1: Scenario 2: Scenario 3: Scenario 4: Scenario 5:

Implementation of a 2:1 ratio of treatment rooms to doctors to prevent

under-utilisation of treatment rooms

x

Implementation of a doctor-to-patient (DtP) policy preferable, under certain assumptions

x

Implementation of a 3:1 ratio of treatment rooms to doctors to prevent

under-utilisation of treatment rooms

x

Investment in a special post-consultation room to schedule new appointments instead of in the hallway: privacy focussed

x

More flexible and dynamic rooms (e.g. shared rooms) expected to improve the utilisation of the available capacity

x

Multi-purpose spaces in the outpatient clinic expected to increase efficiency of use of space

x

Implementation of a hostess function (including a check-in terminal)

(33)

Five scenarios are provided, so that each guideline can be tested both individually and in combination each other. Due to the capacity constraints of the building, as the building space cannot be expanded, these scenarios represent the only possibilities. Each scenario has a main focus, and several explicit guidelines are implemented that encourage this. Each scenario is compared to the current situation. Appendix A shows the staff and resources needed for each scenario.

Scenario 1: The focus in this scenario is on patient privacy. Two guidelines are chosen that stimulate patient privacy. This floor plan of Scenario 1 is shown in Appendix D.

Scenario 2: The focus in this scenario is on architectural efficiency. Two extra guidelines are implemented on top of the guidelines implemented for Scenario 1 that will enhance the efficiency of the building. The floor plan of Scenario 2 is shown in Appendix D.

Scenario 3: The focus in this scenario is on patient convenience. In this scenario, patients do not have to move during the visit in the clinic, so the movement of patients is minimized, at the expense of doctors. Two guidelines are implemented, in comparison with the current situation, that stimulate patient convenience. The floor plan of Scenario 3 is shown in Appendix D.

Scenario 4: The focus in this scenario is patient flow. This scenario is similar to Scenario 3, except for the fact that a 3:1 ratio of treatment rooms to doctors is implemented to see the effect on patient turnaround time and the average number of patients served per hour. The floor plan of Scenario 4 is shown in Appendix D.

Master thesis GUIDELINES FOR THE DESIGN OF A FACILITY LAYOUT FOR AN ORTHOPAEDIC OUTPATIENT CLINIC

GUIDELINES FOR THE DESIGN OF A FACILITY LAYOUT

FOR AN ORTHOPAEDIC OUTPATIENT CLINIC

Master thesis

MSc Technology & Operations Management

University of Groningen, Faculty of Economics and Business

January 29, 2018

J.W.F. Doeksen

S2441098

j.w.f.doeksen@student.rug.nl

Supervisor / university:

dr. ir. D.J. van der Zee

Co-assessor / university

dr. J.A.C. Bokhorst

Supervisor / field of study:

ABSTRACT

PREFACE

TABLE OF CONTENTS

1. INTRODUCTION

2. RESEARCH OBJECTIVE AND DESIGN

2.1

P

2.2

R

2.3

C

2.4

R

Phase (Holmström et al., 2009)

Chapter

2.5

D

3. THEORETICAL BACKGROUND

3.1

O

:

G

-

3.2

F

3.3

P

3.3.1

C

’

3.3.2

H

3.3.3

R

3.3.4

S

3.4

S

4. SYSTEM DESCRIPTION

4.1

S

4.2

P

4.3

C

4.4

A

(

)

4.5

P

5. ANALYSIS

5.1

A

5.2

T

Spread of waiting times in the waiting

room

Spread of waiting times in the treatment

room

5.3

O

5.3.1

O

5.3.2

_-