Appointment scheduling policies for multiple patient groups
in a short-stay nursing ward
The effective use of bed locations
Master Thesis
MSc. Technology & Operations Management
University of Groningen, Faculty of Economics and Business
26 June, 2017
S.L. Mulder
S2353393
s.l.mulder@student.rug.nl
Supervisor University of Groningen
dr. ir. D.J. van der Zee
Co-assessor University of Groningen
dr. ir. S. Fazi
Company Supervisors University Medical Center Groningen
M. G. Nuus
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Abstract
Purpose: Hospitals are under pressure due to a changing environment. They need to improve their quality and produce better patient outcomes and care. Resources need to be used as effectively as possible. The purpose of this research is to design appointment scheduling policies for a short-stay nursing ward with multiple patient groups. New policies will be necessary to use the bed locations more effectively, in such a way that the occupancy will be equal all time. This means avoiding situations with too many patients for the number of bed locations or no patients at all. The scheduling policies will enable a better patient flow, and therefore less workload peaks which cause quality loss and work stress for the nurses.
Method: In this study, a design science research method is used. The short-stay nursing ward of the endoscopy centre of the gastroenterology and hepatology department of the University Medical Center Groningen serves as a case example. Literature provides insights on how to setup effective appointment scheduling policies. The decisions of Ahmadi-Javid, et al. (2017) give insight in, how to classify the patients, when they stay in the short-stay nursing ward, and how they should be divided among the available capacity and appointment slots. Empirical data of the appointment scheduling system of the endoscopy centre and data of the short-stay nursing ward are used to define these decisions and classify the patient groups. In the appointment scheduling system classified groups can be managed. The fluctuation of the bed location occupancy will decrease, because each group has his own time slot.
Findings: The short-stay nursing ward includes multiple patient groups. The current performance of the short-stay nursing ward is low; the occupancy rate of the bed locations is 38.5%. Graphs of daily bed location use show two peaks at 11.00 A.M. and 3.00 P.M., referring to the fluctuations which the nurses complain about. The schedule of the bed location use also shows a lot of empty slots. The schedule of the short-stay nursing ward is a deposited schedule from the endoscopy centre without considering bed availability. Another cause of the low performance is the difference in length of stay (LOS) of each patient group. Besides, sedation is not considered, when scheduling beds are dedicated for infusion and video-capsule patients and patients’ preferences get too high a priority.
Scheduling policies are defined. First, the multiple patient groups must be classified, together with the LOS at the endoscopy centre and the short-stay nursing ward. Second, the patients need to be distributed more equally during the day. Since the schedule is dependent on the availability of the specialist, most improvement can be reached by planning infusion patients in empty slots. Moreover, integration of the schedules with all the involved units is useful and needs to be coordinated by the planning department. Then the bed availability can be checked before scheduling.
Conclusion: Using an integrated schedule for the endoscopy centre and the short-stay nursing ward including the multiple patient groups can result in a better patient flow. With scheduling policies and coordination between the units, the patients will be distributed more equally through the day. More patients can be served, so the bed location occupancy rate will also increase.
Preface
This master thesis is the final project for my Master of Science in Technology and Operations Management at the University of Groningen. The research based on a real case scenario of the UMCG was a great undertaking. The collaboration of the people at the UMCG was a pleasant experience. I would like to thank drs. ing. I.A. van der Weide, Mrs. M.G. Nuus, Mrs. J. Haakma-Jovanovic and all nurses of the short-stay nursing ward for the sharing of information and valuable insights they gave me.
I would like to thank my supervisor dr. ir. D.J. van der Zee for his guidance, support, feedback and knowledge sharing during the writing of my thesis. The meetings with him and my fellow students were very structured, organized by him and useful for the writing of my thesis. Also, the feedback and support from my fellow students helped me, I’d like to say a huge thank you to all of them. I also want to thank my co-assessor dr. ir. S. Fazi for the feedback on earlier drafts of my thesis.
Finally, I would like to thank my family and friends for support during writing of my thesis and especially my roommate Cornelieke Werkman for checking my thesis time to time.
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Content
1. Introduction ... 6
2. Problem statement and research design ... 8
2.1 Problem background ... 8 2.2 Research objective ... 8 2.3 Conceptual model ... 8 2.4 Research design ... 9 2.4.1 System description ... 10 2.4.2 System analysis ... 10 2.4.3 Design ... 10 2.4.4 Testing ... 10 2.4.5 Case essentials ... 10 2.4.6 Data sources ... 10 3. Literature review ... 11
3.1 Service of a short-stay nursing wards of outpatient clinics ... 11
3.1.1 Outpatient clinic ... 11
3.1.2 Short-stay nursing ward ... 11
3.1.3 Appointment scheduling system for healthcare service ... 12
3.2 Appointment scheduling system ... 12
3.2.1 Classification patient groups of a short-stay nursing ward ... 12
3.2.2 Slot policy ... 13
3.2.3 Adjustments for variability reduction ... 14
3.3 Summary... 14
4. System description ... 15
4.1 System overview ... 15
4.1.1 Outpatient clinic ... 16
4.1.2 Short-stay nursing ward ... 16
4.2 Patient classification ... 16
4.2.1 Classification categories ... 17
4.2.2 Categories short stay nursing ward ... 17
4.3 Available resources and services ... 18
4.3.1 Specialists and nurses ... 18
4.3.2 Services ... 19
4.3.3 Medical equipment ... 20
4.4 Appointment scheduling system ... 21
4.4.2 Priority rules ... 21
4.5 Summary... 22
5. System Analysis ... 23
5.1 Approach ... 23
5.2 Performance short-stay nursing ward ... 24
5.3 Root causes of performance ... 25
5.3.1 Allocation of capacity ... 26 5.3.2 Patient classification ... 27 5.3.3 Schedule policy ... 27 5.4 Findings... 28 5.5 Summary... 28 6. Design ... 29 6.1 Approach ... 29
6.2 Classification of the patients ... 29
6.2.1 Allocation of capacity to classified patient groups ... 30
6.2.2 Appointment interval (slot) ... 30
6.3 Scheduling policies ... 31
6.3.1 Levelling the patient flow ... 31
6.3.2 Integration of schedules ... 32 6.3.3 Emergencies slots ... 32 6.4 Coordination ... 32 7. Discussion ... 34 7.1 Main findings ... 34 7.2 Limitations ... 35 8. Conclusion ... 36 8.1 Concluding remarks ... 36 8.2 Future research ... 36 References ... 37
Appendix I Table of Ahmadi-Javid, et al. (2017) ... 39
Appendix II Patients categorized ... 40
Appendix III Occupancy rate... 42
Appendix IV Current schedules short-stay nursing ward ... 44
Appendix V Number of scheduled patients in 2016 ... 45
Appendix VI Classification of the patients ... 48
Appendix VII Shifting infusion patients ... 49
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1. Introduction
Today, the healthcare sector is interested in defining ‘quality improvement’, i.e., changes that result in better patient outcomes (health) and better system performance (care) (Batalden and Davidoff, 2007). This research will focus on ‘better system performance’, including the coherence between available resources and patient planning. White et al. (2011) previously stated that quality improvement represents an operational challenge, as it reflects the larger objective of coordinating capacity and demand. Appointment scheduling systems are instrumental in coordinating capacity and demand in healthcare (Cayirli and Veral, 2003).
This research is motivated by the short-stay nursing ward of the endoscopy centre of the gastroenterology and hepatology department of the University Medical Center Groningen (UMCG). The new short-stay nursing ward is opened in July 2016 and has 14 bed locations for multiple patient groups. This includes patients served by the endoscopy centre, four bed locations which can be used for infusion patients who stay 2-3 hours, and sometimes a bed location is reserved for video-capsule patients who use a bed a whole day. This short-stay nursing ward is introduced to shorten the patient length of stay (LOS) at the endoscopy centre and to allow the pooling of synergies by clustering patients from various other departments. Some preparation and recovery can be supported by a nurse at the short-stay nursing ward.
The bed location occupancy in the short-stay nursing ward appears to fluctuate strongly. This influences the workload of nursing personnel, the waiting time for patients and delays at the endoscopy centre. Bed location occupancy rate can be defined as: measurement of the percentage of time that bed locations are occupied (Cunningham et al., 2006). The fluctuations occur since the appointment scheduling system for the endoscopy centre does not consider demands set on bed location capacity. By dedicating capacity to patients from other departments rather than sharing capacity among patient groups, also an ineffective way of using staff capacity and resources results. Different departments with separate groups are involved. Integrating planning functions in hospitals helps to address this problem (Vissers and Beech, 2005; Aronsson et al., 2011; Drupsteen et al., 2016). It is important to use the bed locations and the personnel as effectively as possible, because bed occupancy rates have been proposed as measures that reflect the ability of a hospital to provide proper care for patients (Usman et al., 2015). Appointment scheduling systems lie at the intersection of efficiency and timely access to health services (Gupta and Denton, 2008). Master surgical schedule (MSS) is such a system that can level the bed occupancy at a ward (Guerriero and Guido, 2011). Besides, Drakousi’s (2016) thesis shows that less research is done on multiple patient groups in short-stay nursing wards. This research will extend the study of Drakousi by analysing the performance of the new introduced short-stay nursing ward and the needed appointment scheduling policies with multiple patient groups. To develop effective planning and scheduling procedures, profound knowledge is required. This knowledge about the effects on the appointment scheduling system leads to the following research objective:
Design appointment scheduling policies for a short-stay nursing ward with multiple patient groups.
‘Policies’ is defined as a set of guidelines, formulated after an analysis of factors that affect the performance. Considered factors are the faced multiple patient groups, the current appointment scheduling system and scheduling policies.The guidelines direct the decisions and actions of the short-stay nursing ward to achieve objectives and long-term goals. More effective means that the bed locations are used with a high and equally distributed bed location occupancy.
about multiple patient groups in a short-stay nursing ward. In the next step, the regulative cycle of van Strien (1997) will be used: (1) system description, (2) system analysis, (3) design and (4) testing. This research will add theoretical and practical knowledge to the literature. First, the multiple patient groups of a short-stay nursing ward will be classified and subsequently divided in time slots using policies. Second, this research will obtain knowledge about effective appointment scheduling policies. Altogether, it will provide guidelines to plan the patients in an appointment scheduling system effectively, which will hopefully result in a more effective use of the bed locations at a short-stay nursing ward. The design of the appointment scheduling policies can be implemented at short-stay nursing wards of outpatient clinics, and is therefore very applicable.
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2. Problem statement and research design
This chapter provides an overview of the content, scope and methodology of this research. Section 2.1 describes the problem background. In section 2.2 the objective of this research is defined. In section 2.3 the conceptual model of the research is shown. Finally, section 2.4 discusses the research design.
2.1 Problem background
Nowadays, hospitals and short-stay nursing wards face the problem of a growing number of patients and less proper appointment scheduling systems (Cayirli and Veral, 2003; Gupta and Denton, 2008). This may cause a lack of capacity in a short-stay nursing ward in peak hours. This issue becomes even bigger in a short-stay nursing ward with multiple patient groups. Multiple patient groups have distinctive needs and treatment times. To serve these multiple patient groups in one short-stay nursing ward effectively, appointment scheduling policies are required.
To avoid overloads or underutilization of the nursing ward, coordination is required between the departments referring patients to the ward. The short-stay nursing ward of the endoscopy centre clearly experienced consequences of the absence of such coordination. The problem is that a short-stay nursing ward faces multiple patient groups, but does not have schedule policies. Currently, a pooling resources (beds) notion is introduced, to achieve higher efficiency in the endoscopy centre. However, these effects have not been accomplished yet. It is observed that the new short-stay nursing ward is not used efficiently to serve all groups, since problems such as frequent peaks or idle time are still present in the short-stay nursing ward. The inefficient use of the short-stay nursing ward will create obstacles especially in peak hours, when patients might experience longer waiting times for their allocation due to scarce availability of bed locations and nurses. Design of new appointment scheduling policies for the short-stay nursing ward is considered to prevent these issues.
2.2 Research objective
The objective of this research is to design appointment scheduling policies for a short-stay nursing ward with multiple patient groups.
‘Effective’ is defined as a high and equally distributed bed location occupancy rate. An effective short-stay nursing ward can result in better work circumstances for nurses, shorter waiting times for patients and less delays at the endoscopy centre. The bed location occupancy rate is defined as the average number of occupied bed locations divided by the number of available bed locations (Bruin et al., 2010). The multiple patient groups need to be classified, so that specific scheduling rules can be defined for each group. This can be accomplished using slot policies according to these rules.
2.3 Conceptual model
Figure 1. Conceptual model.
The conceptual model shows the patient flow: the moment they are accepted for treatment, the stay at the short-stay nursing ward and/or the outpatient clinic, and their departure from the system. In the conceptual model, the information flows will also be clarified. For the design of appointment scheduling policies of a short-stay nursing ward three criteria are displayed. First, the patients need to be classified into separate groups. It will be determined which patients stay when at a short-stay nursing ward, and what their characteristics are. After that, the settings of Ahmadi-Javid et al. (2017) are used: the available resources and the number of bed locations, need to be divided among these separate groups, which will result in appointment time slots. These time slots can be used by defining scheduling rules which will be used when designing appointment scheduling policies.
2.4 Research design
In order to address the main research objective, a design science approach will be used. This method supports solving problems in practice and generalizing the findings (Holmström et al., 2009). This method will support the research objective while it solves practical knowledge problems. Methodologies like a survey or a case study are not creating an artefact, and are therefore not useful for this research.
Possible solutions are only valuable if they are assessed within a broader perspective. Because of that, this research starts with reviewing the literature about existing theories and gathering information about the current system and policies. After that, the barriers and opportunities for scheduling in a short-stay nursing ward are identified and addressed, resulting in configurations that fit the hospital context.The short-stay nursing ward of the endoscopy centre of the UMCG is being used as a case example.
By using a design science approach, the literature will be reviewed first to provide a theoretical background, a solid base for this research. It will typify and classify the problem of the research and reveal the research gap. After this, the design steps of the regulative cycle of van Strien (1997), will be taken into account by doing this research. An overview of the four steps, (1) system description, (2) system analysis, (3) design and (4) testing, on this research will shortly be presented.
• Classification of patient groups • Allocation of capacity to patient groups • Appointment interval (slot) Patients Patients Patients Appointment scheduling system
short-stay nursing ward
Appointment scheduling system outpatient clinic
Short-stay nursing ward Patients Outpatient clinic
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2.4.1 System description
To investigate the effects of the situation in a short-stay nursing ward, it is necessary to know more about the current appointment scheduling system and its functioning. This chapter (4) will give an overview of the used appointment scheduling policies, the characteristics of a short-stay nursing ward and the multiple patient groups. Documents from the involved hospital and unstructured interviews with personnel of the short-stay nursing ward will be used to get a good insight into the ongoing business.
2.4.2 System analysis
The system analysis describes and discusses the current performance of a short-stay nursing ward. The causes and the problems of the performance will be investigated. The relations between the fluctuations, the high workload and an appointment scheduling system of multiple patient groups, will be investigated. Theories and tools that are described before will be used to get a good insight in the results. To obtain better understanding about the causes, quantitative and qualitative data will be gathered, by searching the literature for theories and from the short-stay nursing ward and the involved units by doing interviews. This chapter (5) will conclude in issues that need to be addressed in the design phase.
2.4.3 Design
In this phase of the research, the considered causes of the problem will be taken into account and used to improve an appointment scheduling system of a short-stay nursing ward. The findings of the system analysis will be used and result in suggestions for appointment scheduling policies that are possible solutions for improvement, to get a better appointment scheduling system. It will be clarified how the multiple patient groups are classified and which appointment scheduling policies fit these groups. The purpose of these suggestions is to design an appointment scheduling system that introduces effective scheduling policies regarding the bed location occupancy, for all the multiple classified patient groups.
2.4.4 Testing
The last step of the regulative cycle of van Strien (1997), is to evaluate and test the suggested appointment scheduling policies. By using the suggestions, it can be assumed what possible performance improvements will be reached for the short-stay nursing ward. Moreover, how the schedule of the short-stay nursing ward is changed. Analytical deterministic techniques can be used to test the suggestions. The performance of the suggested policies can be compared with the current situation and the different future situations, to find the best policies to make an appointment scheduling system. The effects and improvements can be used to recommend the best appointment scheduling policies to the management of a short-stay nursing ward.
2.4.5 Case essentials
At the endoscopy centre of the UMCG 11.552 patients are treated in 2016, including 5.380 of these patients served at the short-stay nursing ward. These patients need preparation and recovery by their treatment or are video-capsule patients. Moreover, there are 1.445 infusion patients who stay at one of the 14 bed locations. Therefore, in total the short-stay nursing ward served 6.825 patients in 2016.
2.4.6 Data sources
3. Literature review
The aim of this research is to design appointment scheduling policies for a short-stay nursing ward with multiple patient groups of outpatient clinics, with the goal to use the bed locations more effectively. This chapter offers a theoretical background to this subject by reviewing literature.
Section 3.1 discusses the services of a short-stay nursing ward and how these services are linked to outpatient clinics. Section 3.2 will zoom in further into the characteristics of an appointment scheduling system, to discover what needs to be known before designing policies. In the final section, 3.3, the chapter will be summarized.
3.1 Service of a short-stay nursing wards of outpatient clinics
This section will describe what is shown in the conceptual model in figure 2. Firstly, what is meant by an outpatient clinic. Secondly, the characteristics of a short-stay nursing ward are introduced as well as their role in a hospital. This will conclude in the characteristics of an appointment scheduling system for a short-stay nursing ward.
Figure 2. Conceptual model.
3.1.1 Outpatient clinic
“Outpatient services are gradually becoming an essential component in healthcare” (Cayirli and Veral, 2003). The services that are offered in an outpatient clinic are examinations and treatments, which can cover common activities as: intakes, treatment and follow-up of patients (Zonderland, 2014). Zonderland (2014) also stated that outpatient clinics usually are multidisciplinary, thus involving several specialities.
3.1.2 Short-stay nursing ward
A short-stay nursing ward is a ward where beds are available for short periods of stay (Dallos and Mouzas, 1981). This is for observation, preparation of an operation as well as postoperative care (Dallos and Mouzas, 1981). To make a short-stay nursing ward efficient, the capacity should be scheduled carefully to serve the patients in time and simultaneously reduce the operational costs. The available short-stay nursing ward capacity is in fact the number of available bed locations with a staffing ratio per bed location (de Bruin et al., 2010). Besides, well-timed service can also decrease the
• Classification of patient groups • Allocation of capacity to patient groups • Appointment interval (slot) Patients Patients Patients Appointment scheduling system
short-stay nursing ward
Appointment scheduling system outpatient clinic
Short-stay nursing ward Patients Outpatient clinic
12 workload of the nurses and subsequently lead to an increase of their performance (van Essen et al.,
2014).
3.1.3 Appointment scheduling system for healthcare service
For the use of the healthcare services in a short-stay nursing ward, a good system between the treatments and the stay of patients in a short-stay nursing ward is necessary. Coordination of several and various activities in an uncertain environment is a key feature (Guerriero and Guido, 2011). The effective use of a ward depends on this coordination: the bed allocation and scheduling decisions. A cycle timetable with time slots (which also will be discussed in 3.2.2) is called either “Operating room block allocation table” or master surgical schedule (MSS) can accomplish this. It defines number and type of available operating rooms, the open hours and the availability of the specialists. Besides, it also envisages some randomness of the process such as the number of patients assigned to each time slot and LOS of the patient to level the bed location occupancy (Guerriero and Guido, 2011). The use of an MSS shows great benefits for hospitals because it creates more predictable flows of patients from the operating rooms to short-stay nursing wards (Evers, et al., 2010).
3.2 Appointment scheduling system
Cayirli and Veral (2003) designed a framework with three basic elements for an appointment scheduling system. This framework is used for matching the patients’ inflow and the capacity, and the resources and services of the system. These elements are patient classification, slot policies and the considerable planning adjustments.
Patient classification is defined as a group of patients that has the same demand or is known to be the same in terms of various attributes (Cayirli and Veral, 2003). Slot policies are allocated time slots for the multiple patient groups that are present in a short-stay nursing ward to schedule all patients in an effective way. These policies are a combination of the decisions about the multiple patient groups, patient classification, and how the patients will be divided among the time slots. The third element are the adjustments the planner should consider. This includes dealing with emergencies, no-shows and walk-ins, during the design of appointment scheduling policies (Cayirli and Veral, 2003).
3.2.1 Classification patient groups of a short-stay nursing ward
The first criterion displayed in the conceptual model in figure 2 is the classification of multiple patient groups that are present at an outpatient clinic. Each treatment has different preparations and recoveries with different times of staying in a short-stay nursing ward. According to Cayirli et al. (2006), most literature studies assume that appointment scheduling systems cover no patient classification. They wondered if classification of patient groups of different departments will improve an appointment scheduling system.
To make it easier to plan the multiple patient groups in a MSS, they need to be classified. Marshall and McClean (2004) stated that grouping patients will assist healthcare providers to take better decisions on the overall management of a stay nursing ward. By allocating the resources better, a short-stay nursing ward will become more efficient (Marshall and McClean, 2004). In previous studies (Marshall and McClean, 2004; Cayirli et al., 2006; Gupta and Denton, 2008; Cayirli et al., 2008; de Bruin et al., 2010; Zonderland, 2014) some characteristics are found which could support the clustering of patients: the LOS of the patients in a short-stay nursing ward, the sort of preparation or recovery the patient gets and a new-return classification. The first two characteristics are relevant for this research, and will thus be discussed separately.
Length of stay
(Cayirli et al., 2008; Gupta and Denton, 2008; Zonderland, 2014). The LOS can be influenced by delays during the care process in a short-stay nursing ward, what may result in a negative influence on the occupancy of the bed locations and the workload of the nurses in a short-stay nursing ward. Using the LOS classification, future admissions of the multiple patient groups can be identified (Marshall and McClean, 2004). In the article of Vollebregt (2011), it is demonstrated that if patient groups are not well determined, LOS will become unstable, which will lead to a bad utilization of a short-stay nursing ward. Bad utilization will then result in longer waiting times, higher workload for nurses and idleness of the resources in a short-stay nursing ward
.
Procedure type
The next characteristic was introduced as the ‘sort of preparation or recovery’, what also can be called the procedure type. Every patient requires specific resources and care in a short-stay nursing ward, that can be characterized as a procedure type classification (Cayirli et al., 2006). According to Gupta and Denton (2008), patients with the same diagnosis and characteristics cannot have significantly different needs. Therefore, patients can be classified by treatment or by type of procedure. Most studies focus on process types of the patient which are related to a specific illness. They do not cluster the patients by process similarity regardless of the speciality (Vissers et al., 2001). In a short-stay nursing ward, which serves a different outpatient clinic for the same speciality, the patients need to be clustered on examination.
All the mentioned characteristics assume that classifying patients into separate groups will be beneficial and that for every classified patient group an average preparation time and an average recovery time at a short-stay nursing ward can be defined. These times have to be taken into account when designing appointment scheduling policies. However, the literature that supports these theories is still scarce. Some pitfalls need to be considered. When patients are classified in separate groups they allow less flexibility to the planner to allocate individual patients in slots, as the time slots are reserved for the groups (Cayirli and Veral, 2003).
3.2.2 Slot policy
By designing an appointment scheduling system for outpatient clinics, policies are necessary. The policy of an appointment scheduling system and the multiple patient flow configurations affect the efficiency of the clinic (White et al., 2011). The department needs to determine which policies will be implemented. Policies for the design of the appointment scheduling system for a short-stay nursing ward can be classified according to the outpatient appointment system decisions/settings of Ahmadi-Javid et al. (2017).
In table A displayed in Appendix I, two kinds of decisions are stated for making policies: design and plan decisions. These decisions need to be made at the strategic, tactical and operational level. According to the conceptual model in figure 2, the decisions that need to be made are clear. First, the
allocation of capacity to patient groups, how the available capacity should be divided among the
classified patient groups (Ahmadi-Javid et al., 2017). Second, the appointment interval (slot) is defined as the interval between two successive appointment times (Cayirli and Veral, 2003). Classified patient groups need to be assigned according to pre-marked time slots (Cayirli et al., 2008). An appointment scheduling system plans a defined block of time for the multiple classified patient groups, which is called an appointment slot (Zonderland, 2014).
14 interval between two consecutive appointments. These slot policy variables can change over time and
give possible appointment rules (Cayirli and Veral, 2003).
3.2.3 Adjustments for variability reduction
Another issue that should be considered when patients will be scheduled, is the uncertainty that might arise from the patients’ unknown decisions and arrival times. This is about the number of walk-ins, emergency cases that come in between, and patients that do not show up at the appointment (Cayirli and Veral, 2003). When planners are scheduling they encounter these variabilities by established adjustments. They use for example priority rules and reserve time slots for the acute patients. This is more challenging in this research, because of the multiple patient groups.
3.3 Summary
4. System description
This chapter describes the short-stay nursing ward of the endoscopy centre of the gastroenterology and hepatology department of the UMCG. In the first section, 4.1, an overview of the system is given, to display the flow of patients. Section 4.2 describes how the patients of the short-stay nursing ward are classified, what the characteristics are and how they can be divided into separate groups. Section 4.3 elaborates on which resources and services are necessary to make this process possible. After that, in section 4.4 the current appointment scheduling system of the endoscopy centre is described, including the found characteristics of the appointment scheduling system of the short-stay nursing ward. Together this will be summarized in the final section 4.5.
(1) ‘What is the set-up of the current appointment scheduling system?’
4.1 System overview
The process that is going to be reviewed in this research is about the short-stay nursing ward of the endoscopy centre. Since the planning depends on the schedule of the outpatient clinic, this one is also taken into account and shortly described.
Figure 3. System description outpatient clinic endoscopy centre UMCG.
Figure 3 shows an overview of the current situation. The process starts with the arrival of a patient. The patient may arrive from one of the involved departments. He has a certain urgency level and needs a specific treatment at the endoscopy centre and/or at the short-stay nursing ward. Based on the urgency level and the available time slots the patient will be helped, scheduled or refused. The specialist can decide to refuse a patient when the patient does not need a treatment at the endoscopy centre, as the UMCG only provides services for highly complex cases. An accepted patient should be scheduled for an appointment within 6 weeks (Dutch law), or within 7 days for an urgent patient (UMCG norm).
The first three groups in the short-stay nursing ward in figure 3 are also served at the endoscopy centre. The time and number of visits can be taken from the schedule of the endoscopy centre out of the
Patients arrive - Urgency level - Required treatment Resources - Specialists - Nurses - Bed locations - Medical equipment Refused patients Available resources, endoscopy rooms Schedule Appointment scheduling system endoscopy centre
16 appointment scheduling system. The schedule will be used to look at which patients need a sedation
for the treatment at the endoscopy centre. The video-capsule patients have a short visit at the endoscopy centre and are then observed a whole day at the short-stay nursing ward. The infusion patients are only served by the short-stay nursing ward for 2-3 hours. A separate appointment scheduling system is used to plan these patients at one of the four reserved bed locations. The resources to make this process possible are: specialists and nurses, bed locations and medical equipment. These resources will be discussed in the section 4.3.
4.1.1 Outpatient clinic
The endoscopy centre is the main examination and treatment clinic of the gastroenterology and hepatology department. The centre is open five days a week (Mon-Fri) from 8:00 A.M. till 4:00 P.M. However, since the introduction of the short-stay nursing ward, the departments lung examination, oncology and emergencies are also part of the outpatient clinic, and deliver patients for endoscopy treatments. The endoscopy centre contains six operating rooms and a short-stay nursing ward. Various treatments can be performed in the operating rooms at a diagnostic and therapeutic minimal invasive level. It covers intramural examination, doing biopsy and removing polyps.
4.1.2 Short-stay nursing ward
Currently, the short-stay nursing ward is established as a part of the endoscopy centre. 14 bed locations are available at the short-stay nursing ward. The short-stay nursing ward serves patients who need sedation for their treatment at the endoscopy centre. Since the preparations are done before the treatment at the endoscopy centre and the recovery is afterwards, on most days the short-stay nursing ward is open from 7:30 A.M. until 6:00 P.M. Moreover, infusion and video-capsule patients are also served. Four bed locations are dedicated for these patient groups, who stay a couple of hours or the whole day.
During the whole day patients from all the multiple patient groups are arriving and leaving. The care and LOS differs per classified patient group. Every patient gets his own bed at the short-stay nursing ward and when he is transported he will move together with his bed to the endoscopy centre. At that moment, the bed location will be free for the next patient with a new bed.
4.2 Patient classification
Table 1. Classification categories.
Referral department Urgency level Endoscopy treatments
Short-stay nursing ward
Emergency Emergency (same day) Gastroscopy Preparation patients
Oncology Urgent (3 days) ERCP Recovery patients
- Propofol - Anaesthesia - Midazolam
Lung In between (1 week) Balloon scanning
Gastroenterology and Hepatology
Elective patients (just regular)
Colonoscopy
Children Endo-echo Video-capsule patients
Endo-Echo (Lung) Infusion patients Sigmoidoscopy
PEG Lungscopy Video-capsule
4.2.1 Classification categories
First, the patients can be referred from five different departments for a treatment at the endoscopy centre. Second, all these patients have a different urgency level. Three types of groups exist when using ‘urgency’ as criterion: elective patients, urgent patients and patients in between (Zonderland, 2014). The patients at the endoscopy centre are classified as elective patients, since their treatment or consultation can be planned some time in advance, and they need care within a certain amount of time (Zonderland, 2014). However, as mentioned by Zonderland (2014), a difference in urgency by planning the patients in the appointment scheduling system exists within these elective patients. The urgency classifications for the endoscopy centre are urgent; including the same day; in 3 days or in 1 week, or regular, in the order of arrival.
The third characteristic, the type of treatment, is also of great importance to this research. As stated in the literature review, patient groups can be classified by procedure types, and divided by which part of the body needs examination. Because all patients at the endoscopy centre need a treatment in the same part of their body, it is necessary to zoom in to determine what kind of treatment the patient gets. Furthermore, it must be known if their treatment needs sedation and thus preparation and recovery at the short-stay nursing ward. Table 1 shows that the patients in that case belongs to the first two groups of the short-stay nursing ward. The fourth characteristic is the short-stay nursing ward, which includes next to sedation, the video-capsule and infusion patients
.
4.2.2 Categories short stay nursing ward
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Table 2. Number of patients of each classified group per week.
Preparation Recovery Midazolam Recovery Propofol Recovery Anaesthesia Video-capsule Infusion Total patients in the ward Monday 19,25 13,75 4,25 1,25 0,75 6,25 26,25 Tuesday 22 16,75 2 3,25 0,5 4,5 27 Wednesday 18 17,75 0,25 0 1 4,75 23,75 Thursday 24,25 16,5 1,5 6,25 0,75 7 32 Friday 21,75 15,25 5,5 1 1 7 29,75 Sedation patients
First, the patients of the endoscopy centre who need sedation are discussed. Every sedation can be used for most of the treatments. The sedation which should be used is determined by the referring doctor. The endoscopy centre patients who get sedation, Midazolam, Propofol or Anaesthesia, are taken into account in this research because they are important for the patient flow at the short-stay nursing ward. The average preparation time at the short-stay nursing ward is 15 minutes and the average recovery time is between 1 and 2,5 hours.
Video-capsule patients
Second, as mentioned, the video-capsule patients also have a short visit of 15 minutes at the endoscopy centre. 80% of these patients swallow the capsule and 20% need a gastroscopy at the endoscopy centre to get the capsule inside. The patient will be monitored for the rest of the day. The patient can move through the hospital but needs to stay nearby. For this reason, a bed location for a video-capsule patient is reserved for the whole day. When it becomes suddenly very busy at the short-stay nursing ward, it can happen that the video-capsule patient is asked to take place in the waiting room, but that is not preferable.
Infusion patients
Last, besides the patients that need endoscopy treatments, infusion patients stay at the short-stay nursing ward. As well any moment, a maximum of four patients can be served because of the four dedicated time slots in the short-stay nursing ward. It is considered important that these patients can be planned into reserved time slots, because they return on average every 8 weeks for a couple of years. A consultation for an infusion patient takes on average 2-3 hours. At the moment, the short-stay nursing ward has a group of about 270 patients that need to be served. On Monday and Thursday these patients are also served in the evening.
The UMCG uses a triage system to categorize the patients based on their needs and disease type. Urgent patients get the priority over less urgent patients.
4.3 Available resources and services
In the process various resources and services are involved at the short-stay nursing ward and the endoscopy centre, as shown in figure 3 at the beginning of this chapter. For services delivered by specialists and nurses, available bed locations, rooms and medical equipment are required. How these resources in the UMCG will be used is discussed separately in this section.
4.3.1 Specialists and nurses
supervise 2 or 3 residents at the same time. Beside these different specialists, nurses are needed during the treatment in the operating rooms. Two supporting nurses are present in a common situation; one for the instruction of the patient and one for the support of the specialist.
The specialists and the nurses are divided into one of the operating teams, on average four each day, scheduled among the six operating rooms. In table 3 it is shown which team completes which treatment category. The endoscopy centre has a fixed basic schedule for the specialist and teams. That is why specific treatments are upfront divided in time slots, meaning that the classified patient groups need to be scheduled into this basic schedule
.
Table 3. Operating teams versus the treatment category.
Teams Schedule / Treatment category
Team 1 A/GASTROSCOPIE DIA EN THER
Team 2 B/COLON/SIGMOIDOSCOPIE
Team 3 C/BRONCHOSCOPIE + PUNCTIE
Team 4 D/ENDO-ECHO ONDERZOEK
Team 5 E/FUNCTIE-ONDERZOEK
Team 6 F/ANESTHESIEPROGRAMMA
Team 7 G/NE PROGRAMMA
Team 8 H/BALLON ENTEROSCOPIE
Team 9 I/VIDEOCAPSULE
Team 10 J/EXTRA PROGRAMMA
Team 11 K/OK, ODBC
Emergency team SPOEDTEAM
Next to the nurses at the operating rooms at the endoscopy centre, nurses are also present at the short-stay nursing ward. At the short-stay nursing ward four nurses work each day. In table 4 a schedule is shown of the number of present nurses per day. The nurses are all trained to deliver care to all patients that can arrive at the short-stay nursing ward of the endoscopy centre.
Table 4. Number of nurses serving at the short-stay nursing ward in timeframe.
Monday/Thursday Tuesday/Wednesday/Friday #Nurses
7:30 A.M. – 12:00 P.M. 7:30 A.M. – 10:00 A.M. 2
12:00 P.M. – 4:00 P.M. 10:00 A.M. – 4:00 P.M. 4
4:00 P.M. – 9:00 P.M. 4:00 P.M. – 6:00 P.M. 2
4.3.2 Services
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Figure 4. Pathway of the sedation patients.
As shown in figure 4, the sedation patient arrives at the short-stay nursing ward before the treatment in the endoscopy operating room will take place. The patient gets information about the treatment and will be injected so that the infusion of the sedation can be connected directly when the patient arrives at the operating room. Sometimes the patient also needs to undress at the short-stay nursing ward or takes laxatives, depending on the treatment. After the treatment at the endoscopy centre, the patient comes back to the short-stay nursing ward and will be cared by the nurses until they are brisk enough to go home. The nurse will check the status of the patient every ten minutes. With the help of the monitor, the heartbeat, blood pressure, etc. can be checked. Depending on the sedation and the treatment the patient had, or the treatments he further will get in the hospital, the nurse serves something to drink and eat after a certain amount of time. After that, the nurse will discharge the patient and they will go home or will be moved to another department in the hospital.
Figure 5. pathway of infusion and video-capsule patients.
The service of infusion and the video-capsule patients is more complicated. Figure 5 summarizes the pathway of these patient groups. First both will be checked: blood control and questions about their health. Thereafter, the infusion will be prepared and injected into the patient. Subsequently, the patient lies on the bed for 2-3 hours and the nurse checks only regularly. Besides, the nurse has to do some administrative work at the beginning of the stay. This also applies for the video-capsule patient. Most of the work can only be done at the endoscopy centre at the beginning of the intake, such as swallowing the capsule. Thereafter, the patient stays at the short-stay nursing ward the whole day, but is allowed to walk around the hospital. Finally, both patient groups will be decoupled and the results will be checked.
4.3.3 Medical equipment
used for patients that need to be in sleep more than the common sedation can reach. There is also one fluoroscope at the endoscopy centre that can be used by X-ray specialists.
In the short stay nursing ward 14 bed locations are available. It is called ‘bed locations’ and not ‘beds’, because the beds move together with the patients. So, for the short-stay nursing ward more than 14 beds are available. The beds that are not used at a certain moment, will be cleaned and stored in the corridor. Each bed location includes medical equipment to monitor patients during the recovery of the treatment. Medical equipment for removing the injection needle and materials to clean up the beds after the patient is discharged are also present.
4.4 Appointment scheduling system
In this section, the current appointment scheduling system of the endoscopy centre will be discussed, including the used priority rules. Besides, it will be described what part of the system can be used for the design of the appointment scheduling policies of the short-stay nursing ward.
4.4.1 Current appointment scheduling system of the endoscopy centre
The current appointment scheduling system at the endoscopy centre is X-care from McKesson. The treatment requests are coming in via different media inside and outside the UMCG. Intern requests appear digitally via the X-care planning system. The extern requests are delivered on paper and need to be planned manually in X-care. Decisions in the planning and administrative functions are focused on the managing of the primary process. The available resources and services need to fulfill the demand of the patient flow. The planning of the endoscopy centre has a strong focus on the availability of the endoscopy specialists. In other words, the initiating capacity is the bottleneck of the process. The planning system uses block-scheduling, that implies assignment of individual surgeons or surgical groups to blocks of the endoscopy centre periodic schedule (Gupta and Denton, 2008). The specialists are only available at the days and time slots that are described in a basic fixed schedule. This means that for each classified patient group which requires specific treatments certain hours are dedicated, which cannot be shared with other patient groups (Zonderland, 2014).
The nurses of the short-stay nursing ward use the schedule of the endoscopy centre to derive their planning for the next day. All patients of the endoscopy centre who need preparation or recovery will be picked out from the X-care and printed on a list. The list with the appointment time, treatment and name of the patient will be written on the white board in the hall. In this way, the nurses know how and at what time the patients need to be prepared for their treatment at the endoscopy centre.
4.4.2 Priority rules
Besides the dedicated time slots, the planners of the endoscopy centre use priority rules to schedule the patients in the appointment scheduling system. The patients receive a priority number, which they get according to some priority rules. For the planning four basic scheduling rules are used according to the urgency level of the patient, shown in table 5.
Table 5. Scheduling rules for planning in appointment scheduling system.
Number Scheduling rule Situation that it is used
1. Urgent, same day Priority rule -urgent patients
2. Priority in 3 days Priority rule -all groups
3. Priority within a week Priority rule -all groups
4. FCFS Same for all groups regular situations norm 6-8
22 The first three rules are defined on the level of urgency. The indication of the urgency and time space
to treatment will be done by a doctor. If the patient has something like bleeding, the first rule will be used. When the patient has another appointment at the UMCG, doctors request the patient to undertake endoscopy at the same day to improve the patient’s satisfaction. FCFS (first come first serve) is mostly used when patients have complaints but are not referred to urgent.
When the patients have a priority number they can be scheduled into the appointment scheduling system. The planners use the priority to plan the patients in the best possible time slot near the indicated day. Most of the time the more urgent patients are allocated before other urgent cases. Sometimes the number of patients exceeds the capacity, making it necessary for the specialists and planners to find another solution.
4.5 Summary
In this chapter the short-stay nursing ward is described. The short-stay nursing ward of the endoscopy centre is currently largely dependent on the schedule of the endoscopy centre. The planning of the endoscopy centre serves all the discussed referral departments into one schedule. The resources of the short-stay nursing ward and the endoscopy centre are also strongly connected. The beds are one of these resources, because they move with the patient through the system. Another example is the availability of the specialist, nurses and the operating rooms, because the number of patients that need to be served at the short-stay nursing ward depends on these availabilities.
5. System Analysis
This chapter analyzes the current scheduling system, which is described in chapter 4, and the performance of the short-stay nursing ward. The approach underlying the system analysis is discussed in section 5.1. Section 5.2 reflects the performance of the short-stay nursing ward. The causes of the stated performance will be discussed in section 5.3. After these processes are analyzed, the main findings are discussed in section 5.4. Section 5.5 will summarize the whole chapter.
5.1 Approach
The set-up of the current short-stay nursing ward might influence the design of the appointment scheduling policies for the short-stay nursing ward. To provide a structured analysis of this, the following questions are taken into account:
(2) ‘What is the performance of the current short-stay nursing ward? (3) Which findings are identified for the design of appointment scheduling policies?’
This performance is measured using the fluctuations in current occupancy rate of the bed locations of the short-stay nursing ward. This means the calculations are based on the patients that are served at the short-stay nursing ward. These are the patients that are served at the endoscopy centre and need preparation before and recovery after the treatment, including video-capsule and infusion patients. Data of all patients served at the short-stay nursing ward and the endoscopy centre in 2016 are used. It is assumed that the short-stay nursing ward serves from 8:00 A.M. till 6:00 P.M, from Monday till Friday. The occupancy rate is the time the 14 bed locations of the short-stay nursing ward are used, divided by the available time.
The waiting times of the patients and delays at the endoscopy centre are indicators of the performance of the short-stay nursing ward as well. However, due to the lack of data of these factors, it can only be determined as: the waiting times and delays are not extreme, but can be improved. By levelling the flow of patients in the short-stay nursing ward, these factors would also become better.
All patients of the short-stay nursing ward are categorized according to their treatment in Appendix II in table B, visualized in figure A, and further categorized in table 6. A total of 6.825 patients are served. The patients from the marked categories remain only at the short-stay nursing ward.
Table 6. Number of patients per category in 2016.
24 The category function means the infusion patients. Since, as mentioned in chapter 4, only for the
schedule of the infusion patients the bed location availability is checked, the influence of this schedule can be measured.
Besides the numbers of patients and calculations of the performance, the experiences of the nurses are also considered. The causes of the performance are linked to the main characteristics that the appointment scheduling system should have, as discussed in the literature review in the conceptual model, figure 2. This model showed three criteria: classification patient groups, allocation of capacity to patient groups and appointment interval (slots). It is examined how these criteria can be causes for the low bed occupancy rate in the current situation. The causes and effects are conclusions from informal interviews with planners of the endoscopy centre.
5.2 Performance short-stay nursing ward
The performance of the short-stay nursing ward can be described by the occupancy rate of the bed locations. As mentioned in the literature review, occupancy rate means: measurement of the percentage of time that bed locations are occupied (Cunningham et al., 2006). Data of the year 2016 shows that the occupancy rate of the bed locations at the short-stay nursing ward is 38.5%. To get a better understanding of the fluctuations, two tables are composed; table 7 shows the average monthly occupancy rates and table 8 shows the averages of each day of the week. The occupancy rates of Saturday and Sunday are very low since the short-stay nursing ward is closed, except for emergency cases. Therefore these days are not taken into account in the monthly and overall calculated occupancy rates.
Table 7. Monthly bed location occupancy rates.
Months January 40,7% February 40,7% March 37,3% April 37,8% May 38,2% June 38,4% July 39,4% August 32,3% September 40,6% October 38,8% November 38,6% December 40,2%
Table 8. Daily bed location occupancy rates.
Days Monday 37.4% Tuesday 36.8% Wednesday 37.2% Thursday 41.4% Friday 39.9% Saturday 6.2% Sunday 3.7%
Figure 6. Bed location occupancy rate of Thursday the 14th of January 2016.
The average occupancy rate of 38.5% is indicated as low. De Bruin et al. (2010) mentioned that an average of 85% occupancy is the norm for most wards. That seems unreachable for this short-stay nursing ward because the nurses talked about a high workload already, and only an occupancy rate of 85% is reached at the peaks. The internal manager of the gastroenterology and hepatology department suggest therefore that an occupancy rate of 60% is appropriate. This way, the short-stay nursing ward will be used as effectively as possible.
The workload experiences of the nurses are interesting and seems to differ per nurse. Some encounter it only at the peak moments. Other nurses experience a heavy workload all the time because since the introduction of the short-stay nursing ward, they need to do more proceedings per patient. In addition to this, table 4 shows that the number of serving nurse is also in conflict with the two peaks that appears each day. When the first peak arises at 11:00 A.M. on Monday and Thursday just 2 nurses are in the short-stay nursing ward present. And when the second peak is decreasing, at 4:00 P.M., two nurses already go home, so again two nurses remain. That only two nurses are present at the short-stay nursing ward at overloaded moments can exaggerate the workload experience. The workload experience cannot be expressed in numbers, so cannot be considered in the performance calculations. However, it can be assumed that when two nurses are present at peak moments, the workload is high.
5.3 Root causes of performance
The approach discusses how the fishbone diagram in figure 7 is set-up. It links the performances that are discussed in the previous section to the main causes that result in the low bed occupancy.
26
Figure 7. Root causes of the performance of the short-stay nursing ward.
5.3.1 Allocation of capacity
As mentioned before, the planners of the endoscopy centre do not pay attention to the availability of the bed locations of the short-stay nursing ward while they are planning the patients which need sedation. The schedule of the infusion patients is not checked, although these patients can reserve four bed locations. Furthermore, video-capsule patients, who stay the whole day, are not checked but have a reserved bed location. These reservations that get priority over sedation patients can thus be assumed as a fixed number, which indicates a loss of pooling synergy.
Figure E in Appendix IV visualizes a schedule of infusion patient at the current moment in the short-stay nursing ward. As shown, these four bed locations have a lot of empty time slots. This suggests that the bed locations are not used optimal. Besides, figure K in Appendix V shows that the infusion peak lies between 12:00 P.M. and 1:00 P.M. The parabola in the graph confirm that most patients are scheduled somewhere in the afternoon. Because the infusion patients stay for 2-3 hours, it can be concluded that they contribute to the second peak, shown in figure 6 and the figures B-D in Appendix III.
However, on the one hand the patients of the endoscopy centre are scheduled within the defined time slots of the endoscopy centre, according to the availability of the specialist. On the other hand, which of these scheduled patients get a sedation, and thus need to stay at the short-stay nursing ward is not taken into account. Additionally, the time slots are based on the amount of operating teams, but that number changes every day.
All these causes result in a lack of careful allocation of the patients in the current short-stay nursing ward, which causes the high fluctuations of the occupancy. The graph in figure 8 shows how many patients are currently scheduled in a certain timeframe. This is visualized per category in Appendix V in figures F-L. It becomes clear that the peaks at 11:00 A.M. and 3:00 P.M. are explainable because around those times most sedation patients are scheduled.
Bed availability is not taken into account by scheduling for the endoscopy centre
LOS at the endoscopy centre
differs per group LOS at the short
stay-nursing ward for each sedation differs per group
1 dedicated bed for video-capsule patient
Max 4 dedicated beds for infusion patients
Serving emergency patients
Sedation of patients taken into account
Influences of patient preferences Allocation
of capacity
Figure 8. Total number of patients with present in specific timeframes at the short-stay nursing ward in 2016.
5.3.2 Patient classification
The short-stay nursing ward serves multiple patient groups: preparation, recovery, infusion and video-capsule patients. Recovery patients can have three different sedations: Anaesthesia, Midazolam and Propofol. The characteristics differ between and within the separate groups. The time of coming back to recover at the short-stay nursing ward and the LOS differ per patient group. This means that the moment of recovering of the sedation patients is not only treatment dependant but also sedation dependant. These variations in time cannot be changed, but should be taken into account by the design of the appointment scheduling policies.
5.3.3 Schedule policy
The planners of the endoscopy centre are planning the patients according to the scheduling rules stated in table 5, section 4.4.2. At the moment, emergencies are only reserved at the endoscopy centre. These patients are not taken into account in the short-stay nursing ward. It is possible that emergency cases result in overtimes for specialists and nurses in order to serve all the urgent cases. Interviews confirmed and revealed that there is little attention for the patients who need to stay at the short-stay nursing ward. When possible within the defined time slot of the endoscopy centre, patients with and without sedation are planned alternately. However, the scheduling rules get priority. Besides, it is only checked whether the treatment is with or without sedation, so this only regulates the planning of the patients a little in the preparation phase in the short-stay nursing ward and not at the recovery phase.
Furthermore, the scheduling of the infusion patients has no strict rules. Four pre-reserved beds can be used, but for this is also no underpinning. The interviewees have made it clear that patients have a great influence. Next to the regularity of a certain week in which the treatment needs to take place, the preference of day and time gets high priority while scheduling. The schedule of the sedation patients of the endoscopy centre is not taken into account at all.
0 250 500 750 1000 1250 1500 1750 2000 2250 2500 2750 3000
#pa
ti
en
ts
Total in short-stay nursng ward
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5.4 Findings
The causes mentioned above show two clear aspects which the short-stay nursing ward currently lacks. First, there is a lack of an integrated schedule. As mentioned before, there is a schedule for the endoscopy centre and a schedule for the infusion patients that stay at the short-stay nursing ward. However, the 10 (or 14 in the absence of infusion patients) beds that are available at the short-stay nursing ward have no schedule. What subsequently happens is that the endoscopy centre schedule is deposited and the short-stay nursing ward must deal with it. At the moment, the nurses only complain about the bad schedule, but give no real feedback that can lead to solutions.
The second aspect is the lack of coordination. With the introduction of the short-stay nursing ward, cooperation and communication with the endoscopy centre is necessary. About half of the endoscopy centre patients are being served by the short-stay nursing ward. The multiple patient groups can make the organisation complex. To get proper insight into the short-stay nursing ward, communication with the nurses is important. The flow of these patients should be coordinated by the planning department as well as the pooling of the 14 bed locations.
5.5 Summary
The performance of the current short-stay nursing ward is low and the occupancy rate of the bed locations varies over time. This is shown with graphs and schedules of the current system. The causes of these performances are the bad allocation of capacity, no classification of the multiple patient groups and the scarcity of scheduling policies.
The main findings are that the lack of in integrated schedule and good coordination between the short-stay nursing ward, the endoscopy centre and the planning department result in the low performances of the short-stay nursing ward.
6. Design
In this chapter, the possible design options will be discussed. In section 6.1 the approach for the design is sketched. It considers the main causes and the way of considering them. The other sections will discuss each one of the solutions for the design. 6.2 discusses the classification of patients and 6.3 consider the scarcity of scheduling policies for the short-stay nursing ward. The appointment scheduling system: the empty slots, the peaks and the integration with the endoscopy centre will be argued. Lastly, in 6.4 the finding of lack of coordination between the involved units will be discussed.
6.1 Approach
In chapter 5, the analysis is performed for the short-stay nursing ward and the causes of these performances are discussed. The causes are justified with calculations and informal interviews with staff of the endoscopy centre. The causes and findings are linked to three questions that will be discussed in this chapter. The two causes: patient classification and allocation of capacity as shown in the fishbone diagram are linked to:
(4) How can the multiple patient groups be classified?
For the classification of the patients it is necessary to discuss two decisions following Ahmadi-Javid et al. (2017). As mentioned in the conceptual model, figure 2, and in chapter 3 in the literature review, this is about allocation of capacity to patient groups and appointment interval (slots). When considering data from the UMCG, it becomes clear how patients can be classified and can be allocated into time slots. The important characteristics for good appointment scheduling policies for a short-stay nursing ward that faces multiple patient groups are discussed.
The third cause of the fishbone diagram is scarcity of schedule policies and linked to the question:
(5) What are necessary scheduling policies for the appointment scheduling system?
The cause of scarcity of scheduling policies will be discussed and come to the core of the problem: the fluctuations of the short-stay nursing ward. Suggestions for levelling the patient flow, using integrated schedules and considering the emergency cases by making the appointment scheduling policies for the short-stay nursing ward are made.
The last question of this chapter will discuss the options to deal with the findings concluded in section 5.4. The lack of integration will be covered in the suggestion for scheduling policies, because policies are necessary for the right way of integrating appointment scheduling systems. The findings of lack of coordination are linked to:
(6) How should coordination be addressed at the planning department?’
6.2 Classification of the patients
The classification proposes the important characteristics about patient groups. This makes it possible to design effective scheduling policies for a short-stay nursing ward which faces multiple patient groups.
