The and earliest definition is “services are intangible

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Last updated: March 16, 2019

The central purpose of this document is to discuss the various aspectsof Operations Management related to the Specialist Pre-operation Consultation (SPoCS),a small semi-autonomous unit within the Good Health Hospital (GHH), located inthe UK. The SPoCS’ purpose was to provide an assessment of patients todetermine their fitness for pre-operative anaesthesia. Critical issues will beconsidered and possible solutions will be proposed to address the OM issues. Operationsmanagement involves the applications of business practices to attain thehighest level of efficiency possible within an organization.

(Friedman andMiles 2006). According to Slack et al. (2016 p. 689),”Operations Management is the activities, decisions and responsibilities ofmanaging production and delivery of products and services”.  “It is the systematic design, direction, andcontrol of processes that transform inputs into services and products forinternal, as well as external, customers”. (Ritzman et al. 2007 p.

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3). Theoperations function is central to the organisation because it produces theservices which are its reason for existing. Russell and Taylor (2011) statedthat one of the most pervasive, and earliest definition is “services are intangibleproducts”.The first section will discuss the theoretical background of theproposed framework as well as a proper consideration of its stakeholders andtheir perspectives in relation to their performance and operational issues. Thesecond part will identify the process flow of the patient’s journey in SPoCS. TheOM issues affecting Specialist Pre-operation Consultation Service in the Hospital,along with some OM methods will then be described in the third part of thisstudy.

Finally, the last section will examine valuable suggestions andrecommendations for addressing these OM issues, justifying all of them. Thefocus in this paper has been on addressing the dissatisfaction of patients causedby the long wait hours spent in queues, which lead to a long-time duration ofwork for Doctors (MDs) and Registered Nurses (RNs). This document will refer tothe Theory of queuing for the mathematical treatment of the issue andverification of proposed alternatives for improvement. Due to the complexity ofthe rigorous mathematical treatment for the case of SPoCS, where many sequencesand many servers are presented, this study adopted simplification on thecalculations treating the unit as an overall Section 1: Nature of the Business and itsstakeholders  Although the safety of anaesthesia has improved considerably dueto advancements in technology and research, risks are still present, and GHHoperation room (OR) surgeons, therefore, need to know before surgery that apatient’s system was strong enough to endure anaesthesia. The Good Health Hospital(GHH) is located in the UK, with an outpatient clinic with 12 exam rooms, alab, and a waiting room. Stakeholders, which are “any person or group of peoplewith a significant interest in services provided, or who will be affected byany planning changes” (Friedman and Miles 2006 p.30), can be internal, connected or external to theLocal Health Community, and include staff, patients, trade union, MPs, membersof the public and community groups”. (NHS 2012 p.

9). It can be argued that theinternal stakeholders of the GH Hospital are the employees of the hospital,including Registered Nurses, Laboratory technicians, Anaesthesiologists, andAttendants. In addition, Director of Public Health, the Procurement, theDirector of Nursing, Public Health Management Analyst and Strategists, ResearchScientist, Board committee members and Director of Programmes and Services areclassified as stakeholders of the hospital. The connected stakeholders includeLocal Authority/council, Patients, Customers, Suppliers, Funders, Healthvisitors or school nurses, Media. Lastly, the external stakeholders cover otherparties that can impact on the organization, the most important of which isusually the Government.

From the case study given, it can be argued that both RegisteredNurses (RNs) and Doctors (MDs) are affected about the long wait hours enduredby their patients because they had to stay more time in the hospital in orderto clean queues. They also realized the low level of satisfaction of their patients.Extra hours would result in higher costs for the business and this impact onthe financial prospects, affecting the Management of the Hospital. Furthermore,the high percentage (35%) of the assessment done in the precious spaces of theOR reduces the capacity of the Hospital, influencing its economical results andagain its management.

The level of satisfaction of customers of this service isvery low due to the long-time hours spent in the queue, which tends to be acause of leaving the hospital in the middle of the appointment. Section 2: Process Flow of Patient’s Journey                  Figure 1:Patient’s journey flow diagram      As referring to a service industry, the process involves bothphysical processes and the people that deliver the services to the customer. Aservice process lies on all the routines and tasks that are accomplished todeliver service to customers along with the jobs and training for serviceemployees. Themain inputs of this process are patients, doctors, nurses, building, medical supplies,equipment and laboratories. The transformation process includes examination, surgicalprocedures, administering medication, changes in the location of materials,information of customers, administering patient. The outputs producedinvolve healthy patients. The process included information flows which consistsof the record the patient’s results on an index card attached to their chartand patient chart in the holding bin.

 Section 2.1:  Daily Capacity Calculation     Task Time per min No. of Resources Daily Capacity patient/day Check-in Capacity 4 2 210 Check-out Capacity 5 2 168 Reception Capacity 9 2 93.

3   Lab Capacity 15 2 56.0   RN Assessment Capacity 10 3 126.0 Blood sampling Capacity 5 3 252.0 RN activities Capacity 15 3 84.0 MD Capacity 30 2 28.0    Exam Room Capacity 45 12 112.

0 Figure 2: Daily CapacityCalculation The GoodHealth Hospital’s open time was from 9am to 4pm. However, both RNs and MDsstayed till 7pm to clear queues that had built up during the day. Therefore,the time available in a day was 7 hours, 420 minutes per day, and the doctor’stotal working hours were 9 hours. The cycle times in the process is an average of 69 minutes, which is 1,15hours. The check-in process usually took about 4 minutes per patient, theVitals and ECG’s process averaged about 15 minutes, the nurse took around 20minutes to prepare the patient for examination. Moreover, the anaesthesiologistspent a further 30 minutes on average to examine the patient. In case a patientwould require a blood test, this process would take about 5 minutes. Finally,the check-out phase lasted about 5 minutes.

The throughput of the attendants is 93.3 patients perday, while the maximum capacity of Lab is 56 patients per day; the MD maximumcapacity is 28 patients per day and the Exam Room Capacity is 112 patients perday. Thelead time is 94 minutes for each patient who is also required to do a bloodtest, whereas 79 minutes for a person who does not need to do the blood test. Thetime between the initiation and completion of the check-in process is around 4 minutes,the Vitals and ECG process averaged about 15 minutes per patient.

The patienthas to wait for about 10 minutes to then be assigned in a room. After 5 minutesthe nurse took about 10 minutes to prepare the patient for examination and further30 minutes on average were spent to provide a detailed examination of thepatient. If a patient was required to do a blood test, other 15 minutes were addedon the processing time, divided in 10 minutes of wait and 5 minutes to completethe process. Finally, the check-out process averaged around 5 minutes.  Looking at the daily capacity’s dataof each department of the Hospital, it is evident that the bottleneck in the system can befound in the MD Capacity.

Waits and delays are caused due to the insufficientstaff, which lead to interrupt the natural flow and hinders movement along thecare pathway. It can be argued that process type choice is strategic because it canrepresent a large amount of capital investment in terms of equipment and workforce.The process type used in the system is the service shop process, which operatewith a medium amount of variety and volume. It is characterised by having acertain amount of customization of the service and a mix of staff and equipmentused to deliver the service. There is an emphasis both on the service deliveryprocess itself and any tangible items that are associated with the service.Service shops can be distinguished by a high degree of customer involvement inthe process of generating the service. It may be subdivided into those that lieon the professional service boundary relating to professional services.

Professionalservice processes operate with high variety and low volume. They arecharacterized by high levels of customization in that each service deliverywill be tailored to meet individual customer needs.  This customization requires communicationbetween the service provider and customer and so professional services arecharacterized by high levels of customer contact and a relatively highproportion of staff supplying the service in relation to customers. Theemphasis here is on producing a service through personal attention to thecustomer.Lovelock (1992) developed analternative service process type classification: The Service Process Mix, basedon the degree of labour intensity against the degree of interaction andcustomization.

In this model, labour intensity refers to the ratio of labourcost incurred in relation to the value of plants and equipment used to deliverthe service. The degree of interaction and customization refers to a jointmeasure of the degree to which the customer interacts with the service processand the degree to which the service is customized. Professional services are definedas having a high degree of both variables and include doctors; service shopsare defined as having high labour intensity and low interaction and includeshospitals. (A. Greasley, 2013).The layout type choice is linked to the process typechoice and so provides the context around which the operation performs acrossits performance objectives.

The layout concerns the physical placement ofresources such as equipment and storage facilities and is designed tofacilitate the efficient flow of customers or materials through the operationssystem. Layout is important because it can have a significant effect on thecost and efficiency of an operations and can entail substantial investment intime and money. Process Layout, also termed afunctional layout, is one in which resources which have similar processes orfunctions are grouped together. Process layouts are used when there is a largevariety in the products or services being delivered and it may not be feasibleto dedicate facilities to each individual product or service. It allows theproducts or customers to move to each group of resources in turn, based ontheir individual requirements.

One advantage is that they allow a wide varietyof routes that may be chosen by customers depending on their needs. Anotheradvantage is that the service range may be extended and, as long as no newresources are required, may be accommodated within the current layout. However,an issue related with process layouts is the management of the flow of servicesbetween the resource groups.

In addition, the transportation between processgroup can be a significant factor in terms of transformation time and thenumber of services involved and the fact that each service can follow anindividual route between the process groups makes it difficult to provide whena particular product will be delivered or a service completed. This is becauseat certain times the number of customers arriving at a particular process groupexceeds its capacity and so a queue might be formed until resources areavailable. This behaviour can lead to long throughput time, which is the timetaken for a product or customer to progress through the layout. … the processis characterized by six sequences: Check-in, Vital Measurement, RN Assessment,MD Assessment and Check-out, with an optional phase of blood test.

In addition,there are 4 service categories: ATT, LT, , RN and MD, and there are more thanone server per each category.  Section 3: OM Methods Before expanding the capacity of anyprocess, it is critical to ensure that existing resources are used efficientlyand effectively. The fundamental idea underlying the Theory of Constraints(TOC) is to focus on bottleneck resources because increasing their outputincreases the output of the entire process. Managers should minimize the idletime lost at bottlenecks because jobs or customers are delayed at upstreamoperations in the process. They should also minimize the time spentunproductively for setup time, which is changing over from one service toanother. When a changeover is made at a bottleneck operation, the number ofunits or customers processed before the next changeover should be largecompared to the number processed at less critical operations.Optimised Production Technology(OPT) is an operations control system based on the identification ofbottlenecks within the production process.

According to Goldratt (1997), thesebottlenecks are “any resource whose capacity is less than or equal to the demandplaced on it”.  Analysing where thebottleneck is helps an organisation to identify the area in which changes mustbe made in order to improve the process. As described before, the bottleneckin the system is the MDs Capacity and the best way to remove the bottleneckwould be complete the work shortly or addressing the work to the …Furthermore, another methoduseful to control the size of the queues at processes is the Input – outputcontrol. The method measures the actual flow of work into a work centre and theactual flow of work from that work station. The difference will result in theamount of work-in-progress (WIP) at that process.

By monitoring these figuresusing input/output reports, capacity is adjusted in order to ensure queues donot become too large and average actual lead time equals planned lead time asclosely as possible.Six Sigma isanother OM method that can be considered in order to address the SPoCS’soperations problems. It is a comprehensive and flexible system for achieving,sustaining, and maximizing business success by minimizing defects andvariability in processes.

LeanSix Sigma is a mindset for solving specific problems surrounding the threedemons of quality: delay, defects and devotion (Arthur 2016). It is driven by a close understanding of customerneeds (Ritzman, L.P., et al. 2007). Itcan be argued that it is easy to get a better hospital using a few key toolsfrom Six Sigma. …  Section 4: Methodology The data given from the casestudy shown that additional 2 hours are required to clear queues that had builtup during the day. Therefore, the service processed 36 patients per day(28*9/7).

It is important to remember that the service processed only the 65%of desired clients and the other 35% took the assessment directly in the OR.The actual patients per day,without taking account of the commercial developments or recover of the peoplewho left the hospital, are 55. (36/0.65). Section 4.1: Evaluation of the Queuing TheoryIt may be useful to evaluate theimprovement in performances, increasing the number of Doctors from 2 to 4.Results are summarized in the following table.

  4 doctors ? = average users arrival rate 7.9 users/h µ = average capacity 8 users/h p = utilization 98.9% L = average users into the service 90 Lq = average users queing 89.01 W = average time in the service 682 min Wq = average time in the queues 675 min  Having 4 doctors allows to alignthe lab capacity with the MDs capacity, resulting on achieving the benefits interms of cost of service and increasing the utilisation rates of the subservices. Subsequently, anevaluation of the benefits derived from the extension of the open hours of theservice will be discuss.It can be argued that despite theincrease of resources, the utilization is very high and service delivery timeand queuing time are too high. In addition, the number of rooms seemsinadequate at this rate.

Based on observations we checkthe model for 6 MD. Results are in the following table  6 doctors ? = average users arrival rate 8.571428571 users/h µ = average capacity 12 users/h p = utilization 71.4% L = average users into the service 2.5 Lq = average users queing 1.79 W = average time in the service 18 min Wq = average time in the queues 12.

50 min The daily customers subject to operations are55/0.44= 126. This number is relevant because if SPoCs will performefficiently, these can use the time to do operations rather than assessment andthey can do other operations in the recovered time. Therefore, x + y = 44% *126     x = 35% ( x+ y) so x is 19.

4 andthis number represent the assessments done in OR. If the assessments last halfof the operation it can be argued that 11 operations per day can be recovered,therefore 44% * 11= 5 patient each lab. RN capacity is now equal to MD capacity.It seems that an increase of the LT capacity from 56 to 84 p/day is needed.Therefore, a third technician is needed but in this case space for lab and labequipment have to be verified. In general term, the solution consists touniform the capacity of various servers (ATTs, RNs, MDs) avoiding idling timeof the high designed and increasing the overall capacity attending the lowestcost.  There is a trade-off between theutilization, waiting queues and costs.

It seems that a low utilisation leads tolow cost but the average users queuing is high. When utilisation is high, theaverage of users queuing decreases but costs arise. ORONLY WRITE: With simple calculations, it is possible to show that with thisassumption the additional number of patients for the SPOCS is 5 per day.Image 4: Queuing TheoryBasic  Patients wait for long time in the hospital before they areattended to by the health personnel. It seems that this trend is increasing andthat it is a potential threat to healthcare services. Specialist, teaching andgeneral hospitals with large number of patients have cases where patients maynot be attended to on time while others may end up going home without receivingmedical attention. (Obulur and Eke 2016).

The appointment queuing systemdetermines major utilization of resources and reduces patients waiting times inthe general outpatient department before consultation with the RegisteredNurses and Doctors. The term of “appointment” refer to the periodof time allocated in the schedule to a particular patient’s visit and “servicetime” refer to the amount the physician actually spends with the patient (Mardiahand Basri). According to Collier and Evans (2007), queueing theory is theanalytical study of waiting lines. Long waiting queues are symptomatic ofinefficiency in hospital services. (QUEUING theory). Also, the use of queuinganalysis and simulation to enhance performance at various hospital departmentshas been widely researched (Green, 2002), (Kim et al., 1999).

This establishedtheory helps us to quantify the appropriate service capacity to meet thepatient demand, balancing system utilization and the patient’s wait time. Itconsiders four key factors that affect the patient’s wait time: average patientdemand, average service rate and the variation in both.  (PROQUESTDOCUMENTS 4.26) Section 5: ProcessImprovement Solution It can be stated thata good solution would be to extend the span of time in which the service isopen.

For instance, delivering services not only from 9am to 4pm but from 6amto 10pm with two shifts, using a different organisation of the personnel: onthe first shift, 6am to 2pm, 1 attendant, 2 nurses and 1 anaesthesiologist; onthe second shift (2pm to 10 pm) 1 attendant, 1 nurse and 1 anaesthesiologistand the attendant for calls and general office work will keep working on dailybasis. This strategy allows to reduce drastically the number of patients perhour and then avoid queuing for limited rooms available. A first step in this proposal could beto extend timing on Saturday but the result wouldn’t be of the necessarymagnitude. The revamp available is only 20 % (6/5 = +20 % ) that doesn’t lookenough to address substantially the SPoCs problem. Thefirst modification to investigate is the possibility to shorten the cycle timeincreasing the efficiency of the various server or using the resource that arenot fully utilized to support the job of the current bottlenecks. Looking atthe data of the problem it seems that the Assessment of MD could be made onlyby them and they cannot be replaced by RN. Then the other possible area ofimprovement consists in the modification of the worktime and opening time.

It is possible to conceive theservice opening 6.00am and closing at 10.00pm with the existing personnel intwo shifts. Unfortunately, this modification has the only benefit to reduce theutilization of the exam rooms but being the bottlenecks the numbers of MD theoverall capacity would not be impacted.Thereforealso in the situation with the increased number of MD and LT the change ofshift doesn’t improve sensibly the quality of service.

The quality is alreadygood with the labor on daily basis and utilization of the Exam rooms is not thebottleneck also now. Improve communicationbetween Surgeons department in order to plan better activities in SPoCs as poorcommunication in surgeon assessment resulted in surgeon appointments madewithout recourse to SPoCS availability. As a result, Hospitalsare usually adopting electronic medicalrecord (EMR) systems. EMR systems record all the information generated bythe health care facility and its patients in electronic form. The doctor uses atablet PC or a wireless PDS instead of a paper-based medical chart for eachpatient. It allows to reduce costs, improve administrative efficiency as wellas clinical efficiency and partner care.

(Collier and Evans 2007). However, itis not always easy to adopt these systems and one challenge of the EMR involvesgetting a large medical staff trained in the use of the EMR. (Alpert 2016). Thehigh cost of these systems is another disadvantage for hospitals.

 The best solution would be toincrease the MRs working in the hospital from two to six. As discussed before,the MRs daily capacity is not sufficient, compared to the other divisions, toprocess the system. Two doctors are able only to 28.0 patients per day and Workforcescheduling aims to ensure that available staff are deployed to maximise thequality of service delivery to the customer. The amount of staff available needto be determined by long-term and more strategic decisions taken on the amountof staff required. This recommendation has various impact on stakeholders. Interms of customers, their satisfaction will increase due to the decrease of thetimes spent on queues.

However, the utilisation will arise and therefore thecosts will increas

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