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Introduction
Anne Arundel Dermatology Clinic (AADC) in Annapolis, Maryland has a current throughput over 7,500 patients per year (30 per day). The clinic was able to provide some specific data, but other data used in this simulation had to be based on management estimates. AADC plans to expand their facility (Figure 1), and with
Single throat
Office Area
Double throat
Office Area
servers in Arena, with the respective queues representing wait lines for check-in or check-out, which was the main focus of this simulation. This simulation runs for an 8-hour day, for a replication of 10 days. The clinic schedules appointments in fifteen-minute intervals, with the first appointment at 8:00am and the last at a time to allow the clinic to close at 5:00pm. The data recording system for the clinic only tracks the appointment times and approximate length, not the exact length of time for the check-in or check-out process, so these times were estimated by the clinic. These estimated times are very important, and a concern for error here is great, given that the data supplied is only a conservative estimate and not recorded by a computer system.
area to the exam rooms, but unfortunately separates the administrative office area from the reception area. The clinic would like to use the layout pictured in Figure 1, as long as wait times and queue lengths are reasonable, and revert to the plan in Figure 2 as an alternative option.
Project Objectives
The purpose of this project is to prepare the clinic for likely results as the number of patient appointments per day increases. The goals of this project are as follows: Confirm that the single throat, in Figure 1, is adequate for a predicted increase in volume Collect and analyze data to predict wait times in check-in and check-out processes Evaluate adequacy of three receptionists, as opposed to two or four as possibilities Advise practice on predictions and probability of wait time, given current data provided by clinic
Problem
The current design supports the current capacity, but with an increase of more than 200% of its current population, the clinic needs to know that three servers for the registration process are adequate. The most ideal design (Figure 1) unfortunately has a single throat between the waiting area and the exam rooms, which also serves as the registration window area; however, this design is the most ideal for the administrative offices, with the office manager, medical records, and reception area all easily accessible. A second layout option is shown in Figure 2, which does have a double throat connecting the waiting
Methodology
Literature Search After searching literary databases, few articles appear to have been written on the specific matter at hand. Most references for discrete-event simulation are focused on scheduling policies and admissions, concluding that admission decision rules for scheduling appointments may
increase utilization of staff and patient throughput (Rising, Baron, & Averill, 1973); however, the option for altering schedule rules was out of the scope of this specific project. Information Sources At the beginning of this project, data from August and September 2010 were collected from the practice managers. This clinic schedules patient appointments every fifteen minutes, but will check them in early if they arrive before appointment time; therefore, the exponential distribution occurs naturally when describing the lengths of the inter-arrival times in a homogeneous Poisson process. However, since this clinic schedules specific appointment times, this does not satisfy the memoryless property, and could possibly fall under another distribution (Alexopoulos, Goldsman, Fontanesi, Kopald, & Wilson, 2008). For simplistic reasons and compatibility with Arena simulation software, all arrivals are estimated to be in a random Poisson distribution. When scheduling, the clinic also may schedule two patients with the same appointment time, so the simulation allows for two patients to arrive simultaneously throughout the day, to account for this higher possibility. The simulation automatically ends Table 1: Arrival Frequency Based on Patient Volume Patient Volume 100 patients 100 patients 80 patients 80 patients 60 patients 60 patients For Testing: 30 patients 30 patients Arriving 1 or 2 at a time? 1 2 1 2 1 2 Frequency 4 min 25 min 5 min 30 min 8 min 60 min
when the 60th, 80th, or 100th patient leaves the system, depending on the model. The estimates of arrival times and frequencies are shown in Table 1. Additional data times supplied, estimated, or agreed upon by the clinic are shown in Table 2, with their respective distributions. Model Building The simulation software Arena was used for this project. The patients were considered entities and the receptionists were the resources of focus. A simplified flowchart of a patients experience is shown in Figure 3. The black background boxes are the processes of focus, where the patient would be in this potential bottleneck area: check-in, walking from wait area to exam room, and check-out. Assumptions are included in the model for a realistic result; three receptionists, versatile for the check-in or check-out process, are each allotted fifteen minutes per hour for other tasks, such as answering phones, scheduling patients, or taking a break. The clinic mails registration forms to patients before their appointment, as an opportunity for a faster check-in; the clinic estimates about half of their patients complete forms prior to appointment Table 2: Process Times (Poisson) Process Check-in (new) Fill out clipboard (new) Return clipboard (new) Check-in (est) Wait in area Med.Asst. walk patient to room Patient in exam room (new) Patient in exam room (est) Check-out (new) Check-out (est) Check-out (accutane) Time assigned Normal (1, 0.22) Normal (10, 22) Tri (2, 4.5, 6) Tri (1, 2, 3) Tri (0, 30, 40) Normal (0.5, 0.12) Tri (15, 45, 90) Tri (10, 30, 45) Tri (0.5, 3, 4) Normal (1, 0.22) Normal (3, 0.22)
1 2
Number of Patients in Process
Check-in
8:00am
10
11
Noon-1pm is Lunch
5:00pm Check-out
time, so the probability used in the simulation is 0.5. In the clinic layout as shown in Figure 1, nine exam rooms are available for use. Two months of clinic data, analyzed by reason for appointment, show the distribution of 18% new patients and 81% established patients. The clinic also wanted to take into consideration Accutane patients, which account for the remaining 1% of the patient population, who take slightly longer to check-out because they must schedule the next appointment. These probabilities are incorporated into the model, and follow the respective process times. Arena also allows the creation of time plots (Figure 4), which were used as a visual for the number of patients in the check-in or check-out process. The x-axis is time, in minutes, beginning at 8:00am; the y-axis is number of patients in the process. Figure 4 is specifically a replication for a 60 patient volume scenario.
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Table 3: Comparison among Potential Patient Volumes
Check-in Check- wait in wait average max 0.137 0.104 0.033 0.005 1.898 1.491 1.037 0.138
Check- Check- out wait out wait average max 0.071 0.055 0.041 0 1.651 1.196 0.892 0
time, as seen in Table 3. These observations are very similar to the current state of the practice, and therefore the model performs adequately well and provides results at the level of accuracy desired for this project. In addition to the other VV&T techniques mentioned above, the simulation was reviewed and discussed with the Chief Executive Officer of Anne Arundel Dermatology Clinic.
expand its application. The simulation could determine optimum utilization of exam rooms or include a possibility of extended hours for this specific clinic. This simulation could also be further reviewed for accuracy once the clinics volume has expanded. Since time was a restricting factor in this project, direct observation was not available as an option for data collection; in the future, direct observation could provide better data estimates. When a simulation expands with more process steps, the room for error increases; this project along with other simulations could be studied to determine if adding a process step, even if only estimated, could prove beneficial to the model. Also, once these wait times are confirmed with the given assumptions, the simulation could be used to report expected wait times based on patient volume in a clinic, in order to establish benchmark data. This model could also be used for other clinics to determine wait lines based on individual clinic daily volume.
Acknowledgements
The author wishes to acknowledge the constant support and advice of David Cowan from the Health Systems Institute of the Georgia Institute of Technology as well as Anne Arundel Dermatology Clinic for supplying data, reviewing the simulation, and approving the use of the information gathered during this research. She would also like to recognize Professor Christos Alexopoulos for his help with the Arena simulation program.
References
Alexopoulos, C., Goldsman, D., Fontanesi, J., Kopald, D., & Wilson, J. (2008). Modeling patient arrivals in community clinics. Omega: The International Journal of Management Science, 36(1), Retrieved from
Next Steps
After the completion of this initial project, many additions could be made to strengthen the model and
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http://www2.isye.gatech.edu/~sman/publications/OM E790_final.pdf Balci, O. (1997). Principles of Simulation Model Validation, Verification, and Testing. Transactions of the Society for Computer Simulation, 14(1), 3-12. Elbeyli, S., & Krishnan, P. (2000). In-patient flow analysis using promodel simulation package. Informally published manuscript, Department of Food and Resource Economics, University of Delaware, Newark, Delaware. Retrieved from https://ageconsearch.umn.edu/bitstream/15827/1/sp00 0002.pdf Rising, E. , Baron, R. , & Averill, B. (1973). Systems analysis of a university-health-service outpatient clinic. Operations Research, 21(5), 1030-1047. Swisher, J., Jacobson, S., Jun, J., & Balci, O. (2001). Modeling and analyzing a physician clinic environment using discrete-event (visual) simulation. Computers & Operations Research, 28(2), doi: 10.1016/S0305-0548(99)00093-3
Biographical Sketch
Tiffany Adams is an Industrial and Systems Engineering student in her senior year at Georgia Institute of Technology. This project was completed as part of her undergraduate research with the Health Systems Institute. Tiffany will graduate in May 2011 with a Bachelors of Engineering and plans to continue her studies by pursuing her Masters of Science degree in Health Systems. Tiffany joined the Institute of Industrial Engineers during her freshman year and Society of Health Systems her junior year with hopes to further her understanding and knowledge of the healthcare system in order to improve the efficiency of the current system. E-mail: tadams7@gatech.edu