:Optimizing patient flow planning

Transcription

1 Optimizing patient flow planning Bachelor Thesis Organization & Strategy Name :Elleke Swaanenburg ANR : Year :2010 Supervisor :A.E. Kramer Study Program :Business Studies Title: :Optimizing patient flow planning Number of words :8.287

2 Management Summary This literature review focuses on the problem statement: how can hospitals optimize their patient flow planning, while taking uncertainty into account? In order to resolve this problem statement, three research questions are formulated. Each research question is answered in one chapter. The first research question is: Which factors influence patient flow planning in hospitals? The answer to this question, first there is explained which patients can be present in a hospital. Patients can either be elective or non-elective, these groups can be divided into emergent and non-emergent patients and last of all there can be made a difference between inpatient patients and outpatient patients. Not all groups are equally likely to occur. After the possible groups of patients are explained, the factors that influence patient flow planning are explained. These factors are divided into factors with a negative and factors with a positive influence on the planning efficiency. Negative factors are: complexity, variability, limited resources and uncertainty. The factor uncertainty is appointed to be the most important one to deal with. The positive factors are: number of elective patients, advancement of IT systems and level of cooperation between departments. The second research question is: How do hospitals manage their patient planning? This question is answered by explaining the two main patient scheduling methods, namely the open scheduling method and the block scheduling method, and a combination of these two, named the modified scheduling method. The difference is that the open scheduling method is overall more appropriate for elective patients and the block scheduling method and the modified block scheduling method is mainly more appropriate for non-elective patients. The third research question is formulated as: How can the level of efficiency of patient flow planning be improved? This question is answered first by explaining what exactly efficiency is, namely: the best use of resources in production. Second, the main categories of measuring efficiency are explained, which are: cost-based measures, time-based measures, congestion measures, fairness measures and other measures. Final, the Lean Thinking approach is explained as a way to improve efficiency, because this method focuses on the aspects that are being experienced as real important by patients. All these answers together provide the answer to the problem statement, namely that hospitals are encouraged to use the Lean Thinking approach to improve efficiency. Hospitals have to identify the factors which influence their patient flow, then measure the impact of these factors and finally identify where possible bottlenecks are located that influence efficiency. After making a clear overview of the whole process, efficiency can be improved. The note that has to be made is that it is very important to keep evaluating Lean Thinking, because it is a quite new method for improving planning efficiency in hospitals, in the manufacturing businesses it is used much longer. 1

3 Table of contents Chapter 1: Introduction Problem indication Problem Statement Research questions Research methods Structure thesis... 5 Chapter 2: Factors influencing patient flow planning Planning Patient flow Elective versus non-elective Emergent versus non-emergent Inpatient versus outpatient Factors that have a negative influence on patient flow planning Complexity Variability Limited resources Uncertainty Factors that have a positive influence on patient flow planning Number of elective patients Advancement IT systems Level of cooperation between departments Summary Chapter 3: Managing patient flows Patient Planning methods Open scheduling strategy Advantage Open scheduling strategy Disadvantage Open scheduling strategy Block scheduling strategy Advantage Block scheduling strategy Disadvantage Block scheduling strategy Modified block scheduling strategy

4 Advantage Modified block scheduling strategy Disadvantage Modified block scheduling strategy Different patients, different methods Elective patients and open scheduling method Elective patients and block scheduling method Elective patients and modified block scheduling method Non-elective patients and open scheduling method Non-elective patients and block scheduling method Non-elective patients and modified block scheduling method Summary Chapter 4: Improving planning efficiency Efficiency of planning Measuring efficiency Cost-based measures Time-based measures Congestion measures Fairness measures Other measures Improving planning efficiency Lean Thinking Lean Thinking, how does it work? Benefits of Lean Thinking Thresholds of Lean Thinking Summary Chapter 5: Conclusion and recommendations Conclusion and discussion Recommendations Limitations Reference list

5 Chapter 1: Introduction This chapter provides an overview of what will be discussed in this literature review. There is given a problem indication to make clear why this topic is accurate and what lead to choosing this particular subject. The problem statement and accompanying research questions give direction for this literature review. In paragraph four, the research methods are given. Finally, the last paragraph provides an overview of the remaining chapters. 1.1 Problem indication More and more hospitals are nowadays focused on making their internal processes as efficient as possible, so that time and money are optimally used (Beaudry et all., 2010; Cardoen, et al., 2009). Furthermore, they have to improve quality of the services provided to keep them competing within the industry, as is said by Cayirli & Veral (2003). According to Haraden and Resar (2004), one of the ways to accomplish this is by optimizing the patient flow planning aspect by understanding this process better. Focus lies on the patient flow planning aspect of logistics within a hospital. This aspect is very important in making sure waste of time and money is minimized. While making the planning of patient flows more efficient, it is important to keep in mind the quality of the care as is mentioned by Enthoven and Tollen (2005). In other words, care has to stay at a minimum level, otherwise it can have severe consequences. Sawhey (2005) believes that a very important factor influencing patient flow planning is the uncertainty aspect. More clearly, the number of patients arriving in any given time period is subject to substantial variability, a large part of which is unpredictable as has been stated by Gaynor and Anderson (1991). Therefore, there will be looked at the different factors that influence patient flow planning and how to deal with these factors influencing the efficiency of patient flow planning. According to Harper (2002), the variable uncertainty is not the only one which influences the efficiency of patient flow logistics planning in hospitals, but there will be focused mainly on the influence of this variable. 1.2 Problem Statement Following from the problem indication, the problem statement has been stated as follows: how can hospitals optimize their patient flow planning, while taking uncertainty into account? 1.3 Research questions To answer the problem statement, three research questions will be answered in chapters two, three and four. The research questions are formulated as follows: 4

6 Which factors influence patient flow planning in hospitals? How do hospitals manage their patient planning? How can the level of efficiency of patient flow planning be improved? 1.4 Research methods The research in this thesis will be a descriptive study, which will be carried out by conducting a literature review. As has been stated by Sekaran (2003) a descriptive study is a study that is undertaken in order to ascertain and be able to describe the characteristics of the variables of interest in a situation. A literature review, according to Sekaran (2003), is a clear and logical presentation of the relevant research work done thus far in the area of investigation. Secondary data, which will consist of academic articles, will be used to answer the research questions. The literature that will be used will mainly consist of books and articles from academic journals. Web of Science and ABI/Inform global will be used as a starting point of searching for online academic articles, because they provide academic articles of high level, with the ability to search in designated areas. The keywords will be uncertainty in hospital planning; patient flow; efficiency of patient planning in hospitals; patient planning; and health care planning. 1.5 Structure thesis The next chapter will describe the different kinds of patients that can be present in a hospital and different factors, negative as well as positive, that influence patient flow planning. Chapter 3 will take a look at the way hospitals manage their patient planning and which method is appropriate for which group of patients. In chapter 4 will be about efficiency and how to improve the efficiency of planning. First efficiency will be explained, second how to measure efficiency and final, a method to improve patient flow planning efficiency in hospitals. In the final chapter, chapter 5, conclusions and recommendations will be made to improve the efficiency of patient flow logistics planning in hospitals. 5

7 Chapter 2: Factors influencing patient flow planning This chapter gives more insight into the different patients that can be present in a hospital and the different factors that influence patient flow planning. According to Harper (2002), factors can either have a negative influence or a positive influence on the level of planning efficiency. When a factor has a positive influence on the level of efficiency, it means that the higher the existence of this factor, the more efficient the planning will become. For a negative factor it means the exact opposite, the existence of this factor will decrease the efficiency level. This chapter provides an answer to the first research question, namely: which factors influence patient flow planning in hospitals? 2.1 Planning Before looking at factors that influence patient flow planning in hospitals, it is important to know the definition of planning. With planning, the process of reconciling supply and demand is meant, as has been said by Cardoen, et al., (2009). Planning is a broad concept that covers many different kinds of planning, such as patient flow planning or workforce planning. There will be focused on the planning of patient flows. The supply side consists of the hospital services, for example, the doctors that give the treatment and the demand side, consists of the patient, who needs to receive the treatment. Reconciling supply and demand in an efficient way, therefore means, that patients receive the right treatment from the right doctor with minimal waiting time for the treatment to take place after it was requested for. Or, as has been said by Haraden and Resar (2004): optimal care can only be delivered when the right patient is in the right place with the right provider and the right information at the right time. 2.2 Patient flow According to Cayirli and Veral (2003), patient flow-time is the total time a patient spends in a hospital, including the service time. With service time is meant, the actual time the treatment takes place. Since the problem statement of this thesis is: how can hospitals optimize their patient flow planning, while taking uncertainty into account? It is important to critically evaluate the patient flow time and identifying possible bottlenecks in the process, to be able to improve the efficiency. As has been stated by Haraden and Resar (2004); reducing delays and unclogging bottlenecks depend on assessing and improving flow between and among these departments. To asses this flow, it is important to look at different factors that influence patient flow planning, to determine where the possible bottlenecks are and therefore to know which part or parts of the process can be improved, to eventually have a 6

8 more efficient planning. First, is made clear which kinds of patients theree are possible. Note that not all categories have the same number of patients. The different kinds of patients are clarified in the following figure: Figure 3: Kinds of patients, the differences between non-elective, elective, emergent and non-emergent patients Elective versus non-elective According to Visser (1994), there are two ways for a patient to enter a hospital, one is on referral from a general practitioner, the other one is through the emergency department. According to Adan, et al., (2009); Cardoen, et al., (2009) and McIntosh, et al., (2006), once they have entered the hospital, they can be divided into two categories, namely: elective and non-elective patients. Elective patients are patients for whom the surgery can be well planned in advance, whereas for non-elective patients a surgery is unexpected and hence needs to be performed urgently. The last group makes it more difficult to plan in advance and because of not knowing how many non-elective patients there will come to a hospital and what kind of patients will come in advance, it makes it hard to maximize the efficiency of patient flow planning Emergent versus non-emergent Another distinction that can be made is the difference between emergent and non-emergent patients. First, one has to realize that elective and non-elective patients are not equal to emergent and non-emergent patients. From Cardoen, et al. (2009) it follows that the difference between them is that when a patient enters a hospital (which can be done on referral or not), it is an elective patient when an appointment was being made in advance; and a non-elective patient, when this was not the case. When the patient is a non-elective patient, it can be either an emergent patient or a non-emergent patient. According to Adan, et al. (2009) and Cardoen, et al. (2009), a patient is an emergent patient, when he or she needs treatment within two hours of arrival at the hospital, otherwise he or she is a non-emergent patient. Again, it can be divided in a group that is more difficult to plan, namely emergent, 7

9 and a group that is somewhat less difficult to plan, namely non-emergent. The higher degree of non-emergency, the easier it becomes to plan, because the treatment does not have to take place immediately Inpatient versus outpatient Eventually patients can be divided into inpatient and outpatient care patients, as is said by Adan, et al. (2009); Cardoen et al. (2009) and Vissers (1994). According to them, inpatient care means that a patient stays in the hospital while receiving treatment, for instance when a patient is receiving surgery and stays overnight to recover. Outpatient care is described by them as a patient that comes to the hospital for receiving treatment, but leaves immediately after the treatment, so for instance when a patient has to get his blood examined or has to be treated for simple fractures. Inpatient patients spend a longer time in the hospital, because they stay in the hospital after they have received their surgery, outpatient patients immediately go home after their treatment, and therefore have a shorter total flow-time than inpatient patients. 2.3 Factors that have a negative influence on patient flow planning As has been stated earlier, there are factors that influence the efficiency level of patient flow planning in a negative way and there are factors with a positive influence. This section looks at factors that have a negative influence, meaning the higher the existence of this factor, the lower the efficiency level of patient flow planning will become. Factors that influence the efficiency of patient flow planning in a negative way are according to Harper (2002): complexity, variability, limited resources and uncertainty, as is shown in the figure below. These factors are visualized in the following graph and will be explained in the accompanying sub sections. Variability Uncertainty Efficiency of patient flow planning Complexity Limited Resources Figure 1: factors that have a negative influence on the efficiency of patient flow planning. 8

10 2.3.1 Complexity The first factor influencing the efficiency level of patient flow planning in a negative way is complexity. Examples of complexity are according to Harper (2002): rules governing patient admissions into the hospital, patient-flows through the hospital and constraints imposed by other hospital services. With rules, he gives the example of always keeping some beds available for emergency patients. Complexity concerning patient-flows through the hospital, is explained by Harper (2002) as referring a patient to a different department, when there is no available bed at the department where the patient needs to receive its treatment. With constraints imposed by other hospital services, Harper (2002) gives the explanation of not having any beds available for a patient to recover after surgery and therefore not letting a patient go into surgery. These examples show that the factor complexity, makes it more difficult to plan patient flows efficiently, because there are a lot of external factors that indirectly influence patients flow planning. Not just the kind of patient, but also indirect factors as where the patient can stay after the surgery have to be taken into account when planning patient flows. Complexity can be dealt with by a high level of cooperation between departments, as the following has been said by Ludwig, et al. (2008): more efficient hospitals also are better organized, have a better cooperation with other health care providers, and are more patient friendly. The more cooperation between departments, the more information will be available not only about the patients, but also about the number of beds that are still available at the hospital and at which department Variability According to Adan, et al. (2009); Haraden and Resar (2004); Harper (2002) and McManus, et al. (2003), another factor influencing patient flow planning efficiency is variability. Haraden and Resar (2004) and Adan, et al. (2009), state that there are two kinds of variation, namely natural and artificial variation. Natural variation is for example the variation from the randomness of the disease, which can be managed by looking at data from previous years. Artificial variation, and Adan, et al. (2009), is more difficult to manage, because according to Haraden and Resar (2004): it consists of variation based on personal preferences and beliefs of individual surgeons. The both kinds of variation each have a negative impact on the efficiency of patient flow planning. The higher the total amount of variation, for instance the more random the diseases are and the more preferences that have to be taken into account, the more difficult it will become for a hospital to plan their patient flows and thus to make this planning efficient. 9

11 2.3.3 Limited resources Third, there is the factor limited resources. According to Harper (2002), this variable emphasises that not all resources are unlimitedly available. For example, hospitals want to help every patient that comes in, but this amount of patients can be larger than the number of available beds for instance, whereas a bed is a limited resource. Harper (2002) therefore states: There is a need to efficiently and effectively plan and manage all hospital resources, with particular emphasis on inpatient beds, operating rooms, hospital workforce, and expensive critical care resources. Or, as Vermeulen, et al. (2007) state: Even a short vacation or illness of the calendar supervisor leads to immediate and significant deterioration of the resource efficiency. With this is meant that it is important to keep an overview of what is available and what is needed, so there will not be mayor delays, because of bad management. Another example according to Harper (2002): there are not enough doctors at work, while the operating room is free, the patient is waiting to receive treatment and there is a inpatient bed available for the patient to recover after the surgery. In conclusion, the higher the amount of limited resources, and more resources, such as for example sterile equipment or inpatient beds are not available, the longer the patient has to wait to receive treatment, the lower the efficiency of patient flow planning will become Uncertainty Sawhey (2005); Gaynor and Anderson (1991) and Harper (2002) believe that a very important factor influencing patient flow planning is the uncertainty aspect. Cardoen, et al. (2009) stated that there are four different kinds of uncertainty that have a negative influence on the efficiency of patient flow planning, namely: arrival uncertainty, duration uncertainty, uncertainty in the estimated contribution margin of surgeons and resource uncertainty. With arrival uncertainty Cardoen, et al. (2009) and Min, Yih (2010), give the example of not knowing when emergency patients will arrive. This not knowing exactly, makes hospitals need to predict arrivals, to make a planning, but it is impossible to always be accurate and therefore arrival uncertainty influences the planning efficiency in a negative way. With duration uncertainty according to Cardoen, et al. (2009) and Min, Yih (2010), the length of stay in the hospital can be an example of which. Not knowing when the patient is able to leave the hospital, will again give uncertainty about when the resources, for example an inpatient bed, occupied by this patient will be free again to be used for another patient. The third one, uncertainty in the estimated contribution margin of surgeons, is explained by them as not knowing how many and what kind of surgeons there are needed. Resource uncertainty are, according to Cardoen, et al. (2009) for instance resource breakdowns, such as not having enough sterile equipment. When there are not enough resources available needed to perform a surgery, this surgery cannot take place, even though the patient and 10

12 doctor might be both at the right place. As has been stated before by Haraden and Resar (2004); optimal care can only be delivered when the right patient is in the right place with the right provider and the right information at the right time. When looking at the factors explained before, there can be said that situations are not precisely influenced by one factor, but there is an overlap between variables. According to Harper (2002) a hospital has to deal with an unknown number of patients coming to the hospital. This not knowing is uncertainty and because of this uncertainty, it is difficult to always plan the exact amount of doctors needed to provide proper treatment to the patients. It could be that not enough doctors are available to provide proper treatment and then this will be the factor of limited resources again. Cardoen, et al. (2009) also state: One can question why the majority of the papers focuses on elective patients and ignores the problems caused by non-elective patients. This observation is even more striking when one realizes that the larger degree of uncertainty is the main reason why operating room scheduling urges other scheduling methodologies than the machine scheduling procedures developed for industrial systems. This stresses even more that the uncertainty factor is very important, as not the most important one to keep in mind, when trying to improve the efficiency of planning patient flows in a hospital. 2.4 Factors that have a positive influence on patient flow planning All the previous mentioned factors have a negative effect on the efficiency level of patient flow planning, but of course there are also factors which have a positive influence on the efficiency level of planning. In the coming sections, three of them will be explained, namely: the number of elective patients; the advancement of IT-systems and the level of cooperation between departments. These factors are shown in figure 2. Number of elective patients Efficiency of patient flow planning Advancement IT-Systems Level of cooperation between departments Figure 2: Factors that have a positive influence on the efficiency of patient flow planning. 11

13 2.4.1 Number of elective patients As has been mentioned before, there are different kinds of patients that a hospital needs to provide with treatment. For this subsection, only elective and non-elective patients are taken into account, because these are the main categories. According to Adan, et al. (2009) and Cardoen, et al. (2009), elective patients are patients for whom a surgery can be well planned in advanced, for non-elective this is not the case. For non-elective patients however, planning is more difficult, because it was not known in advance that they were coming to the hospital. Therefore, the higher the number of elective patients, compared to the number of non-elective patients, the lower the uncertainty of not knowing how many patients will come and what kind of treatments they will need, the easier it becomes to make a planning and thus a more efficient planning. Hence, this shows the positive influence of this factor on the efficiency of patient flow planning Advancement IT systems The next factor to be discussed is the advancement of information technology (IT) systems. IT systems are systems that store and provide information about patients, such as the number of patients and the results from an x-ray scan, as has been said by Menon, et al. (2000). They also state that the use of IT capital has positive influence on the production of output and thus the efficiency of the planning. The more advanced the IT facilities of a hospital are, the better available the information about the patients and kinds of patients become for the entire hospital, and therefore the better the overview of knowing which patients are where and what treatment have they received and need to receive. All this information and overview, makes it easier to plan what, where, who and when. In the end this enables a more efficient planning. The advancement of IT systems and alongside the better available the information about patients therefore has a positive influence on the efficiency of patient flow planning Level of cooperation between departments The last factor that has a positive influence on the efficiency of patient flow planning is according to Ludwig, et al. (2008), the level of cooperation between departments. They claim that the interest of hospital departments is currently not in line with the interests of the entire hospital. This means that not all departments work in the best interest of the whole hospital, but more in the best interest of their own department. The efficiency of hospitals is a hot issue, as stated by Ludwig, et al. (2008); Beaudry, et al. (2010) and Cardoen, et al. (2009), therefore cooperation should be of high importance to the sub departments of a hospital. When departments share more information with each other, and thus cooperate more, a more efficient planning can be made, because of this cooperation more information can be 12

14 shared and can improve both individual department planning efficiency and total planning efficiency. As Ludwig, et al. (2008) also state: Results show that cooperation is a key issue in achieving high efficiency in both departmental and the total hospital organisation, this shows the positive effect of cooperation within a hospital on the efficiency of patient flow planning. 2.5 Summary The research question that has to be answered in this chapter is: which factors influence patient flow planning in hospitals? In this chapter there have been given four factors that have a negative influence on the efficiency of patient flow planning, namely: complexity, variability, limited resources and uncertainty and three factors that have a positive influence, namely the number of elective patients, the advancement of IT systems and the level of cooperation between departments. When looking at the above described negative and positive factors, it is important to notice that they also influence each other. 13

15 Chapter 3: Managing patient flows This chapter will take a look at the way patient flows are planned in hospitals. In paragraph one, different planning methods will be given, together with their advantages and disadvantages. In the second paragraph, for each kind of patient, the most used method(s) from paragraph two will be given. These paragraphs together will come to the answer for the second research question, namely: how do hospitals manage their patient planning? 3.1 Patient Planning methods This section gives more insight into methods that are used by hospitals to plan patient flows. According to Augusto, et al. (2009) and Fei, et al. (2009), there are two main planning strategies that are used in hospitals, namely: open scheduling strategy, block scheduling strategy, furthermore there is a third strategy that is a combination of the first two, called modified block scheduling strategy. In their article, Fei, et al. (2009) make a very important overall conclusion: if the staff can collaborate well to fulfill the proposed surgery schedule, considerable operating costs of the operating theatre can be saved. These costs can be saved, because the operating rooms are being used more efficiently. The following sub sections will explain three different strategies for operating room planning, but with this also the other aspects of patient planning, such as patient planning for the x-ray department, are meant Open scheduling strategy The open scheduling strategy is explained by Fei, et al. (2009) as a first-come-first-served strategy, where is a fixed schedule made in advance. According to Dexter, et al. (2003), this method of planning consists of surgeons and patients who together decide at which date the treatment should take place, the other staff will be adjusted to achieve maximum efficiency. Therefore, this method is most appropriate for treatments that can be well planned in advance, hence elective patients. This method can also be called the queue discipline according to Cayirli and Veral (2003). McManus, et al. (2004) describe the queuing method as: in appropriate systems, it enables managers to calculate the optimal supply of fixed resources necessary to meet a variable demand. The supply of fixed resources are for example the surgeons that have to provide the treatment and the inpatient beds, the demand is the patient who needs to receive treatment. The advantages and disadvantages of using this method for patient flow planning will be described in the following two sub sections: 14

16 Advantage Open scheduling strategy The advantages of using this strategy are the expectations of surgeons and patient s wishes, as Dexter, et al. (2003) already stated, they for example set a date for the surgery together. Furthermore it is a method that can be a very efficient planning method, because the appointments are being made in advance, the fixed resources necessary can be calculated and therefore the planning is as optimal as possible. In conclusion every minute can be optimally used, because unlike the block scheduling strategy (Fei et al. 2009; Blake, et al., 2002), every minute of the operating room can be reserved separately Disadvantage Open scheduling strategy The largest disadvantage of using the open scheduling strategy is that it is less appropriate for handling large amounts of non-elective emergency patients. Fei, et al.(2009) and Dexter, et al. (2003) both stated that the open scheduling strategy is used to plan treatment for the (near) future and most importantly respects surgeons and patient s wishes, something that cannot always be done if the patient needs to receive treatment emergently. Besides that, this strategy follows a first-come-first-serve approach according to Fei, et al. (2009) and McIntosh, et al. (2006). When all patients are equally in need of treatment, this can be done, but when this is not the case, patients should receive treatment in order of emergency Block scheduling strategy The second one, according to Fei, et al. (2009) is the block scheduling strategy and is clarified as assigning surgeons or groups of surgeons to a set of time blocks in which they can arrange their surgical cases. Furthermore, they state: these surgeons own this time block and that it cannot be used for other purposes even though not everything will be used constantly. From the article written by Fei, et al. (2009), it becomes clear that there are four steps in the decision making process for making a planning. The first step has been described by them as forecasting demand based on experiences from the past, which can also be called patient classification. According to Cayirly and Verdal (2003), patient classification can be described as: a realistic application requires that the patients are classified into manageable number of groups and that they are assigned to pre-marked slots when they call for appointments. With this they mean that there will be made a preliminary planning based on historical data, with slots that can be divided among the actual patients. The second step according to Fei, et al. (2009) is allocating blocks of time and schedule staff, which will be done about a month prior to the actual day. According to Blake, et al. (2002): surgeons are typically allocated block time in which they are able to book elective cases. Block booking rules permit an elective case to be scheduled only if it can reasonably be expected to be completed during the regularly scheduled hours of OR time. With block 15

17 time, a day is divided into blocks of for instance one hour, and one or multiple of these blocks can be booked, as Blake, et al. (2002) mentioned, for instance by surgeons. The third step described by Fei, et al. (2009) is constructing the case schedule and optimizing this schedule, given a specific scenario, which will be done about 1 to 2 weeks prior to the actual day. Fei, et al. (2009) explain the final step, as the actual execution of the schedule based on the actual patients needing to receive treatment on that same day. With actual patients is meant both elective patients for whom the treatment was already planned, as well as the non-elective emergency patients, who need to receive treatment that same day Advantage Block scheduling strategy This strategy is more flexible than open scheduling strategy, because it can deal better with non-elective patients. It determines forecasts based on results from the past, as is said by Cayirly and Verdal (2003). By doing this, the hospital is better prepared to handle nonelective patients, because they have estimated how many and what kind of patients will come to the hospital Disadvantage Block scheduling strategy The main disadvantage of this method consists of loss or underutilization, because blocks might be blocked, although they are actually not in use. To be sure there is enough time, surgeons will reserve blocks of time, large enough to finish the surgery, but in reality, it could be the case that the surgery ends sooner, or not even takes place at all Modified block scheduling strategy The last strategy is described by Fei, et al. (2009) and Augusto, et al. (2009) as a strategy that is more flexible than normal block scheduling, because it combines this method with the open scheduling method. This strategy follows the same steps as described for the block scheduling strategy, but in addition to that, Fei, et al. (2009) state: it leaves more space open to be flexible in scheduling emergency patients and / or releases unused blocks a few hours before the actual beginning of the block, to be used for other surgeries. Or, as Augusto, et al. (2009) state it: First the weekly planning is divided into time slots. Two strategies are commonly used: (i) some time slots are allocated to surgeons, surgeon teams or medical specialties, and the remaining time slots are common (unassigned block); (ii) after a given time (block release time), unaffected time slots are re-assigned in order to maximize the operating theatre utilization. Both examples show that the modified block scheduling strategy is a mixture of the two main strategies, it mainly follows the block scheduling strategy, but leaves some blocks open for the open scheduling strategy. 16

18 Advantage Modified block scheduling strategy Because it combines the two main strategies, this strategy is more flexible to deal with different kinds of patients. On the one hand it can deal with elective patients, because the surgeon can reserve a block of time in advance, on the other hand, it is flexible to emergent patients, because there are always some blocks left open for these patients Disadvantage Modified block scheduling strategy According to Fei, et al. (2009), only a few hours before actual beginning of the block there it is clear whether the block is occupied or not. Because there are always some blocks kept open for emergency patients, it can be the case that there are too many blocks unoccupied, which will lead to inefficiency. This can result from reserved blocks that were released at the last moment in addition to the already reserved blocks. 3.2 Different patients, different methods Once knowing which kinds of patients can be present in a hospital and what kind of methods there are being used for planning, it is important to look at the different ways of making a planning for different kinds of patients. There has to be made a difference between elective and non-elective patients. As has been stated before by Cardoen, et al. (2009), it is easier to plan elective patients, than to make a planning for non-elective patients. The high level of not knowing how many and what kind of non-elective patients are going to come to the hospital, in other words the high level of uncertainty, makes it more difficult and therefore needs a different approach to planning, compared to planning for elective patients, therefore the two categories has been separated into the following six sub sections. In these sections there is assumed that the patient group characteristics are as described in and the scheduling characteristics are as described in Elective patients and open scheduling method Characteristics of elective patients are that they can be well planned in advance. The open scheduling strategy has the characteristic to plan the date, time and surgeon in advance, as has been said by Fei, et al. (2009). Therefore it is a very appropriate strategy to use for planning non-emergency elective patients Elective patients and block scheduling method Planning non-emergent elective patients is possible by using the block scheduling strategy, but the difference from the open scheduling strategy is that only the date will be set in advance and the other elements such as time will be set later on. 17

19 3.2.3 Elective patients and modified block scheduling method This last scheduling strategy is the one least appropriate for elective patients, because this strategy leaves some blocks open for last-minute patients. Because elective patients are all planned in advance, it is a waste of time, money and resources to leave for instance operating rooms empty Non-elective patients and open scheduling method When non-elective patients are non-emergent, they can be planned for another day and thus makes them an elective patient. As has been stated before, non-emergent elective patients are possible to plan in advance and thus be planned via the open scheduling strategy Non-elective patients and block scheduling method When non-elective patients are non-emergent, they can also be planned via the block scheduling strategy, because the treatment does not have to take place immediately. The characteristic of block scheduling strategy again is that only the date will be announced to the patient and the other elements such as time and the name of the surgeon will be announced later on Non-elective patients and modified block scheduling method For non-elective emergent patients however, the need to receive treatment fast is high as is stated by Cardoen, et al. (2009). This can be dealt with by a modified block scheduling strategy if the necessary treatment is for instance rare. 3.3 Summary This chapter made clear there are different methods to plan patient flow throughout the hospital and that there are different kinds of patients to plan treatment for. There has to be made a difference between non-emergent elective patients, non-emergent non-elective patients and emergent non-elective patients. These kinds of patients can be scheduled via the two main strategies, open scheduling and block scheduling, or via the combination of these two, modified block scheduling. 18

20 Chapter 4: Improving planning efficiency Chapter three gave more insight into the different strategies of planning that are used in hospitals for planning treatment for those patients. Since it is of interest to improve the level of efficiency of planning, it is important to know how to measure the efficiency in the first place. The first paragraph will explain what is meant with efficiency and the measurements of efficiency, also called performance measurements, will be discussed in the second paragraph. After knowing what the level of efficiency of planning is, it is important to look how to improve this efficiency. This will therefore be done in the third paragraph. In the final paragraph, the other ones will be used to answer the research question: how can the level of efficiency of patient flow planning be improved? 4.1 Efficiency of planning When talking about efficiency it first needs to be made clear what is meant with efficiency. According to Hollingsworth, et al. (1998), efficiency refers to the best use of resources in production and consists of two parts, namely technical efficiency and allocative efficiency, together it is called overall efficiency. Hollingsworth, et al. (1998) and Worthington (2004) describe technical efficiency as producing a maximum amount of output, from a given amount of input. With this they mean, treating as much patients as are waiting to receive treatment. Allocative efficiency is according to Hollingsworth, et al. (1998): minimizing costs given input mix and input prices or maximizing revenue given output mix and output prices. This can be explained as, choosing the right mix of treatments for minimizing costs or maximizing revenue. Efficiency of patient flow planning is important, because according to Worthington (2004), inefficiency of planning contributes to rising costs of healthcare. Furthermore, an insufficient patient flow can lead to dissatisfaction among patients, as is stated by Blomberg, et al. (2009). Striving for efficiency is therefore for multiple reasons of high importance for hospitals. 4.2 Measuring efficiency This paragraph will look at ways to measure efficiency. Measuring efficiency can be done by means of performance measurements, as is stated by Hollingsworth, et al. (1998). According to Heineke (1995), organizational performance consists of financial and operational performance, but important to notice is that separating this can have negative consequences. Heineke (1995) stated: it tends to focus managers and the workforce in different directions, producing divergent goals and role conflicts. But in professional service organizations, managers are still most often evaluated in light of financial performance and technical professionals on the basis of their technical output. With this he means that it is important to 19

21 see the bigger picture and not just look at either financial or technical facts. To measure the efficiency of patient flows in hospitals, there are several performance measurements. According to Cayirli and Veral (2003), there are five categories of performance measurements, namely: cost-based measures, time-based measures, congestion measures, fairness measures and other measures, which will be explained in the following sections: Cost-based measures In this category, Cayirli and Veral (2003) find the most important performance measurements are the costs of for instance patient waiting time and the costs of overtime of doctors. With patient waiting time, the costs of the time a patient has to wait for receiving treatment is meant, for example the costs of nursing a patient while he has to wait on the intensive care department for receiving surgery Time-based measures Cayirli and Veral (2003) describe that it is very useful for determining the level of efficiency to measure variables of interest, such as the means: maximums, standard deviations and frequency distributions of patients waiting time, doctors idle time, doctors overtime and percentage of patients seen within a set time of their original appointment. By evaluating the different times of different above mentioned aspects there will be a better overview of what is happening and had happened, which can be used for making better predictions for the future as mentioned by Cardoen, et al. (2009) and Min, Yih (2010). For instance for predicting the time a patient has to wait before he can have an x-ray taken more precise, will enable it to make a better planning Congestion measures These measurements are described by Cayirli and Veral (2003) as measuring variables of interest, such as mean and frequency distribution with respect to the number of patients in who are in the queue for receiving treatment and the ones who are already in the system of receiving treatment. If a certain department of a hospital is overcrowded many times a day or a week, it is important to take action and resolve this, because overcrowding of departments means there is a longer waiting time and therefore a longer total patient flow time Fairness measures According to Cayirli and Veral (2003), fairness measures can be defined as the uniformity of performance of an appointment system across patients. With this is meant how well the appointment system works and how long the queue is when the patient makes an appointment. According to Jaeger and Rossler (2009) and Min and Yih (2009), there can be 20

22 made a difference between what is fair for patients who are already in line, and what is fair based on the severity of the condition, the patient needs to receive treatment for. This balancing needs to be done constantly by the hospital staff, in order to make the planning as fair as possible Other measures Other measurements are according to Cayirli and Veral (2003) for instance doctors productivity and mean doctor utilization. There can be a difference in productivity between doctors and also some doctors are more occupied during the day than others. With measuring these variables, there can be seen which aspects can be improved, such as better planning for doctors, to make more efficient use of their presence. 4.3 Improving planning efficiency After having defined how to measure efficiency, it is important to look at a method to improve the efficiency of planning patient-flows in a hospital. According to Van Lent, et al. (2008), in the past different methods were used in trying to improve the efficiency of patient flow planning, such as benchmarking, business process reengineering and total quality management, but the one proven to be most effectively was the Lean Thinking method, this opinion is being shared by King, et al. (2006). Ben-Tovim, et al. (2007) state that Lean Thinking can play a very important role in reforming health care planning. Moreover, Kim, et al. (2006) state that manufacturing and service sector companies both have encountered enormous successes in improving both quality and efficiency and that the time has come for the healthcare sector. Therefore in the following paragraph the Lean Thinking method will be explained Lean Thinking This method is explained by King, et al. (2006) as an approach to the organization of complex processes that derives from industrial manufacturing experience. Furthermore, they state: A key element in Lean Thinking is the practice of starting, not with a potential solution, but with the development of a detailed understanding of how a complex process is actually undertaken. Or as Harrison and van Hoek (2005) describe: Lean Thinking is based around the simple philosophy of eliminating waste. With this they mean that in the Lean Thinking approach it is of interest to look at the total patient flow, not only within several departments, but in the whole hospital, to understand where the efficiency can be improved. 21

23 Lean Thinking, how does it work? The Lean Thinking approach has according to Harrison and van Hoek (2005) four steps to achieve the final step of perfection. These steps are: specifying value, identifying the value stream, making value flow, pull scheduling and seeking perfection. When looking at making the patient flow planning more efficient, the first step will be specifying what each department will do for the patient. The second step is identifying the treatment each department can give. The third step is about optimizing the flow. The fourth step is to react on patients wishes. The final step is about making no mistakes, which means still keeping the quality of treatment high Benefits of Lean Thinking According to Jones and Mitchel (2006), Lean focuses the improvement effort on things that matter to patients and clinicians, and on the things that cause them stress and get in the way of care. Furthermore he states that there are four categories of improvements that can be made by using the Lean Thinking approach, namely: quality and safety, delivery, throughput and accelerating momentum. This last one can be explained according to Jones and Mitchel (2006), as having a working environment that is stable and has clear standardised procedures, to keep improving. Of course the third category is of most importance for this literature review, a higher throughput means that patients flow quicker through the hospital and thus the flow-time becomes smaller Thresholds of Lean Thinking Lean Thinking has been developed in the manufacturing sector after the Second World War, as has been stated by Ben-Tovim, et al. (2007). But Lean Thinking is still a very new concept in the healthcare industry, as has been said by Kim, et al. (2006), therefore it is of importance to keep evaluating whether this method really makes a difference in making the patient flow planning process more efficient. 4.4 Summary This chapter revolved around the research question: how can the level of efficiency of patient flow planning be improved? After having seen what exactly efficiency is, there was explained which main categories there are to measure efficiency, namely: cost-based measures, timebased measures, congestion measures, fairness measures and other measures. The last paragraph has described the Lean thinking method to improve patient flow planning efficiency. Therefore, the answer to the research question is implementing Lean Thinking will improve efficiency of patient flow planning. 22