1. What is activity utilization at every step in the process? What is the direct labor utilization?

An operation is composed of processes designed to add value by transforming inputs into useful outputs. Inputs may be materials, labor, energy, and capital equipment. Output may be a physical product or a service. A metric used to measure the rate at which potential output levels are being met or used. Displayed as a percentage, capacity utilization levels give insight into the overall slack that is in the economy or a firm at a given point in time. Using the data provided in the case, we are able to compile all data necessary to compute the capacity utilization at the clinic. 1. Front Desk = a. Registration b. Verification 2. Radiology Department = a. X-ray imaging b. Development of X-rat c. Diagnostic reading and comments 3. Hand-off X-ray to Clinic = a. Collection of X-ray b. Filing/exam room prep 4. Examination Room = a. Surgeon b. Resident c. Cast technician The activity utilization at every step in the process is as follows: 1- Its an automatic activity 2- There are two senior resident students, but in a current time only one of them is working 3-4-5 The current available time (in total) for these activities is: a. = 1440; b. 1440; c. = 720. But since Paediatric Orthopaedic Clinic use these activities only 2/3 of the total time they are available we have these numbers: a. = 960; b. 960; c. = 480 6-7- This activity is performed by the same staff as in 1- b. 8- Its an automatic process

9- This activity is performed by the same staff as in 1- b. We can add that the utilization of this part of staff, three nurses is: 1.b + 3.a = 62 % + 19 % = 81 % 10- Utilization for every step in the process is calculated: Utilization=Total time needed for an activity/ Total available time for an activity x 100 % The direct resources of the clinic are: 1 surgeon, 2 senior resident students, 3 clerks, 4 nurses and 1 cast technician. The total time that the clinic has through these resources is: 540 + 765 + 255 + 255 + 255 + 255= 2325 minutes The total time needed to fulfill clinics activities is: 400 + 480 + 145.6 + 160 + 281.6 + 235.2 + 229.6 = 1932 minutes Note: we are not counting the time utilized from the Radiology department since its not a direct resource of the clinic. With these numbers we can calculate the direct resource utilization of the clinic: Direct resource utilization = Total time for activities/ Total available time for activities x 100= 1932/2325 x 100= 83 % The utilization of direct resources of the clinic is 83%.

2. How is variability affecting capacity at the clinic? How can variability be controlled? Many factors affect the performance of appointment systems including arrival and service time variability, patient and provider preferences, available information technology and the experience level of the scheduling staff. In addition, a critical bottleneck lays in the application of Industrial Engineering and Operations Research (IE/OR) techniques. The most common types of health care delivery systems are described in this article with particular attention on the factors that make appointmentschedulingchallenging.Foreachenvironmentrelevantdecisionsrangingfr omasetofrulesthatguideschedulersto real-time responses to deviations from plans are described.

3. Where is the bottleneck in the process? What are the capacity constraints at
the clinic?

A bottleneck is any part of the system where patient flow is obstructed causing waits and delays. It interrupts the natural flow and hinders movement along the care pathway, determining the pace at which the whole process works.The bottleneck in the process is in wait times and utilization rates. From the case, we can determine that there may be bottlenecks in the radiology department and the examination room. In the radiology department, the patient wait time is almost double that of the other wait time. Patients are required to wait in reception area of radiology department until X-ray machine is available. Depending on the type of Xray image, machine has to be adjusted and to adjust the machine from one extremity to other it took several minutes. After X-ray, Patient again has to wait to collect the X-ray image on film. The radiology department is also being used by Urology, Pediatrics and Chest clinic. Exceptions are frequently made for some patients from Emergency who required an X-ray urgently on short notice. Hence we can find high volume of patient in radiology department which has significantly increased the wait times in the radiology department. In the examination room, it was observed that the staffs are over utilized or close to being utilized. Either the surgeon or one of the senior residents performed the medical examination of the patient. The surgeon examined all the new patients and about 30% of follow up patients with greater complexity. A senior resident examined the remaining follow-up patients. The bottleneck has been determined to be the examination room, where the surgeon in particular has been working over capacity at over 110%. Because of high wait times, queue starts to appear. In Fig 1a, the queue appears to grow almost continually, with slight short-term variation in length. This is the one situation where demand clearly exceeds capacity. Each day, more patients are added to the list than are taken off and so the queue increases. By contrast, in Fig 1b, the

queue fluctuates around an average and, viewed over a long time, the queue is actually stable. This is where demand and capacity variation create short-term overand under-supply of capacity, generating queues. Figure 1c shows how a queue would behave if demand and capacity variation could be smoothed the queue reduces greatly without an increase in capacity. It can therefore be suggested that a shortage of capacity is only indicated when queues continually worsen, and even then existing capacity should not be wasted before more capacity is added to the system.

Fig (1)

4. What is the economic cost of wait times? The case Pediatrics Orthopedic Clinic At The Childrens Hospital Of Western Ontario mainly deals with the long time wait in the clinic for the patients during their new check up or follow ups. There are a number of events that goes within the clinic for each and every patient. These events are: a) Front Desk: Registrations and verification of documentsb) Radiology Department c) Hand Off X-ray to Clinic d) Examination Room The Outcome of the survey performed showed the following data: Event Performed New Patients Average Time (Minutes) 30 58 3 38 Follow up Patients Average Time (Minutes) 25 58 3 33

Front Desk Radiology Department Hand Off X-ray to Clinic Examination Room

From the survey outcomes we can say that most of the time spend in the clinic is normally in Radiology department. For the case analysis as well as from some experience we have, the normal time to perform any activity under Radiology Department is around 5-10 minutes to take X-ray, around 20-30 minutes for the preparation of film and 5-10 minutes for radiologist reviews and annotation of the image for further task to perform. Thus, there is a long duration of time lag in Radiologist department as well as front desk tasks are also consuming a lot of time. The front desk operation normally does not add any value to the service that the clinic performs. From this analysis, in an average a patient spends around 2hrs in a clinic. Out of this, 2 hrs around 80% of the time is meaningful time spend in the clinic, rest 20% is just the wait time thus this time has a great impact in economic term for both an individual as well as for the clinics perspective. In this way around 24 minutes per patient is the waste time in the clinic. It is found that an individual earns 20 Canadian Dollars per hours in an average. Thus for an individual around 10 C$ is the opportunity cost that he is missing going to the clinic. From the clinics perspective, it is able to provide service to around 80 patients each half day i.e. working 4 hours and 15 minutes. Now if is able to minimize the wait

time and make it efficient then it can save a lot of time so that it can cater to around 10 more patients. In this way we can see the economic cost of the wait time in a clinic.

5. What recommendations would you make and why? In order to reduce the wait times in the exam room both of the residents could be allowed to exam patients in parallel. This would lead to an increase in staff availability time by 255 minutes and definitely reduce the wait time. Further, to keep the resident learning experience the surgeon could only call in the resident for exams that he/she feels necessary. Similarly the second concern is about the radiology area with 35 minutes wait time. To reduce this wait time, purchase of new X-ray machine could be very effective. Doing so the wait time can be reduced by 25% causing the wait time to be of 26.25 minutes and this reduction would show up as a significant reduction in the total wait time.