Date: Dec 7, 2010

To: Sanjeev Bordoloi

From: Luke Thielen, Jon Kaplan, Steve Ackerson, Todd Thul
Re: OPMT 610, University Health Services Case Study Answers

(1).The new system is not an improvement. The process diagrams that follow indicate the different
paths and processing times across these paths. The table that follows the diagrams summarizes the
processing times and wait times for each path in the pre-triage and triage systems. As it shows,
processing time went up significantly for treatment by specified and non-specified doctors and for non-
specified nurse practitioners (NPs). The only processing time that went down, is for treatment by
specified NPs which makes up only 5% of patient volume.

UHS Pre-triage process

Recept.

Sign-in (AVF)
- request
record
2 min
Record

Retrieve &
clerk

send records
8.5 min
Med clerk

Check record Specific MD,

Y Queue Spec NP
5 min NP?
24.5 min

N
Able to Treat patient
Y
treat? 32.8 min
NP

Queue N
7.5 min
Evaluation time
10 min

Queue
Spec MD 10 min
MD

Treat patient
19.4 min

Page 1 of 6
 UHS Triage process

Recept.
Sign-in (AVF)
- request
record
2 min
Record

Retrieve &
clerk

send records
8.5 min
Med clerk

Check record
5 min

Triage Triage patient MD or NP Queue Treat patient

NP
Queue 3.5 min NP? 6.7 min 32.8 min
RN/NP

4.2 min Specific: 33.8

MD

MD Queue
25.2 min
Specific: 33.8

Treat patient
MD

19.4 min

System Time and Waiting Time Comparisons

Pre-triage Triage
Treatment Option System Time Wait Time* System Time Wait Time* Difference
Treated by MD 52.4 33 67.8 48.4 15.4
Treated by NP 55.8 23 62.7 29.9 6.9
Treated by specified MD 59.4 40 67.8 48.4 8.4
Treated by specified NP 72.8 40 62.7 29.9 -10.1

*Wait time is defined here as any time not receiving treatment from MD or NP

Page 2 of 6
(2). Current Analysis

MD' Capacity per

Time of Day Arrivals per hour s NP's hour Capacity - arrival differential Utilization rate
8-9 a.m. 18.2 2 2 9.8 -8.4 186%
9-10 a.m. 17.6 2.5 4 14.95 -2.65 118%
10-11 a.m. 16.8 5 4 22.7 5.9 74%
11-12 p.m. 15.2 3 4 16.5 1.3 92%
12-1 p.m. 11.8 3 2.5 13.8 2 86%
1-2 p.m. 16.9 3 2.5 13.8 -3.1 122%
2-3 p.m. 16.2 3 4 16.5 0.3 98%
3-4 p.m. 15.9 4 4 19.6 3.7 81%
4-5 p.m. 11.6 3 2.5 13.8 2.2 84%
5-6 p.m. 2.8 1 2 6.7 3.9 42%
Totals 143 29.5 31.5 148.15 Std Dev = 4.20145808 97%

Above is a look at an average Monday at UHS. We chose to look at Monday as it is the busiest
day of the week and thus would require the most staff. To get to an even better answer UHS
could over the next year take a look at patient arrival per hour per day. This would provide them
with the most accurate information on patient trends and would allow them to staff most
appropriately and thus staff most appropriately. It is clear that the busiest time of the day for the
clinic is 8-9 a.m. and then it decreases throughout the day with the low points being 12-1 p.m., 4-
5 p.m. and obviously 5-6 p.m. as they admit the last patient at 5:30. It is clear they are not using
the appropriate staff at appropriate times. After looking more closely it was simple that they
needed to get both MD’s and NP’s to the office earlier in the morning and not have as much staff
on in the last few hours of the day when the demand (arrivals) are less than earlier in the day.
Below is an example of a redistribution of staff to better cover more critical early hours when the
clinic is it’s busiest. Doing this has also decreased the standard deviation of the capacity/demand
differential. As we have learned this has helped the clinic run more on lean principals and has
taken much of the variation out of the equation.

Projected/Anticipated Analysis

Arrivals per MD' Capacity - arrival

Time of Day hour s NP's Capacity per hour differential Utilization rate
8-9 a.m. 18.2 4 3 17.8 -0.4 102%
9-10 a.m. 17.6 4 3.5 18.7 1.1 94%
10-11 a.m. 16.8 3 4 16.5 -0.3 102%
11-12 p.m. 15.2 3 4 16.5 1.3 92%
12-1 p.m. 11.8 2.5 2.5 12.25 0.45 96%
1-2 p.m. 16.9 4 2.5 16.9 0 100%
2-3 p.m. 16.2 3 4 16.5 0.3 98%
3-4 p.m. 15.9 3 4 16.5 0.6 96%
4-5 p.m. 11.6 2 3 11.6 0 100%
5-6 p.m. 2.8 1 1 4.9 2.1 57%
Totals 143 29.5 31.5 148.15 Std Dev = 0.786006079 97%

Page 3 of 6
(3)This analysis takes into account two major factors, the median salary of a doctor and nurse
and the service rate of a doctor vs. a nurse. Without taking service into account, but taking hours
into account, the doctors’ hourly rate is close to twice that of a nurse. If each patient is
considered, however, the salary per process time of the patient becomes significantly smaller
between doctor and nurse because the doctor can serve patients at a much faster clip than nurses.
Even though it is still more expensive for a doctor to service a patient than a nurse, it is only 76
cents more per patient. My conclusion is based on whether the specific work can be passed on
from the doctor to a nurse without affecting the patients’ experience. If both are equally capable
of performing it at close to the same level, then more work should be off-loaded to nurses,
because it is still is less expensive for a nurse to treat the patient even taking the service rate into
account. However, for any treatments that can be more proficiently handled by the doctors, the
cost difference does not merit off-loading and doctors should continue to perform them.

Doctors Nurses
Median salary per professional (including prorated benefits)(1): 53325 24885
Number of hours per year (2): 1840 1610
Professionals salary per hour: 28.98 15.46
Service (process time per customer as a % of an hour) (3,4): .32 .56
Cost per patient served (based on service time): 9.35 8.59

(1) The median doctor salary is 45k per year and a nurse is 21k, these calculations also take into
account an additional 18.5% for benefits.

(2) The number of hours per year per doctor is based on 40 hours for a 46 week year for the entire
UHS system, per the case. I made the same assumption for the nurses for number of weeks but
took into account a one hour lunch, for 35 hours.

(3) The process time is based on the service rate of a doctor and nurse for one patient as a % of an
hour. (6o minutes/3.1 patients per hour for doctor, 60/1.8 for nurses).

(4) This analysis is not directly taking waiting costs into account because waiting costs are separate
from the cost of labor, which is being analyzed here. Even though the cost of waiting is
important, in this part only process time is being measured in the comparison of how fast a
doctor or nurse can actually serve a patient.

(4) 5 MD's, 14.3/hr 5 MD's, 14.87/hr 6 MD's, 14.87/hr

λ - arrival rate (per hour) 14.3 14.872 14.872
μ - service rate (per hour) 3.1 3.1 3.1
ρ - arrival rate/service rate (C/U) 4.61 4.80 4.80
S - # of doctors 5 5 6
Average Idle Time (minutes per hour) -216.8 -227.8 -227.8
Lq - average patients waiting 9.33 21.64 2.07
L - average number in system -1.28 -1.26 -1.26
Wq - wait time (minutes) 39.15 87.31 8.35
Processing Time (minutes) 19.35 19.35 19.35
Waiting + Processing Time (minutes) 58.50 106.66 27.71

Page 4 of 6
The waiting time dramatically increases when the arrival rate only slightly increases. It is
evident the incremental 4% has pushed the system over the break point. With 5 MD’s and an
arrival rate of 14.3 patients per hour (average of 143 patients per day, 10 hour day), the wait time
is 39.15 minutes. In combination with processing time of 19.35 minutes, it brings the total wait
plus process time to 58.50 minutes.

When the arrival rate increases by a small percentage (4%), which is the equivalent of one half of
a person per hour, it greatly influences the wait time of the M/M/S system. Lq increases from
9.33 to 21.64, a large increase especially relative to the small increase in the arrival rate. Wait
time launches to 87.31 minutes, when combined with the same processing time of 19.35 minutes
results in a total wait plus process time of 106.66 minutes.

To show the extreme change in wait time relative to the minor change in arrival rate, we decided
to see the impact of adding another doctor to the system. If we add a sixth MD, the Lq drops
significantly to 2.07, which in turn reduces the wait time even more substantially to 8.35
minutes. Obviously there is a cost component to this application but we wanted to contrast the
impact of 1 MD versus the impact of only a 4% increase in the arrival rate.

(5)We can make the assumption that wait time for business executives is much more of a
concern than for students. The primary reason is that for a business executive, time is literally
money, as they work for a salary and must utilize their free time for personal interests, or use
paid time off. Conversely, a student is not bound by the same constraints. Time may still be
money in the literal sense that they are paying for education and time away from studies could be
viewed as lost opportunity. But there may not be the same direct correlation and most likely
there is the social perception that a business executive will value time more than a student.

Further, a business executive will have more options. We can assume they will be more mobile,
and therefore have access to more choices for health care service. A student on the other hand is
contained to the University campus, and more likely to be ‘land-locked,’ or at least less mobile
and operating within a smaller zone of access to health care.

If our concern is the satisfaction of the business executive, we must find a way to minimize the
number of patients waiting in the system, as well as the actual waiting time of those patients. We
propose the clinic should add more MD’s in this scenario, which is the more efficient use of time
in terms of service provided.

(6A)The issue is not for them specifically, if a doctor is being specifically utilized by a patient,
then the first come first serve method is being compromised. The extra 8.6 minutes of waiting
for a doctor or 27.1 minutes for a nurse does have an effect on people who come in after those
patients.
(6B)
 There is no reason for the nurses to have specific patients’; the issue in the case is with
doctors, so that should be the first practice eliminated.
 It is stated in the case that the triage nurse does not have to specifically give them the
option of seeing a specific doctor or nurse. For this or any other practices already
decided on in the case, enforcement is very important. It is very easy to go into bad
habits if they are not.

Page 5 of 6
 The case mentions that Doctors can’t be dictated to, yet it does not seem that
Dr.Zuromskis, who sees 33 specific patients every three weeks, needs to be told that this
is a bad practice when he says “…Our aim is not and should not be to provide an
atmosphere reminiscent of the country doctors office, but rather to provide the best
possible care to all patients.” If Dr. Zuromskis is indicative of other doctors, then
perhaps explaining to doctors that this is a bad practice will get them to reduce the
incidences on their own. Perhaps doctors like Zuromskis would be happy to explain that
this practice should be reserved for specific appointment time that all (or most) doctors
have.
 Not assigning rooms for physicians might discourage them from this practice.
 Education of walk in patients is critical. If they are made to understand what the function
of a walk in clinic is, and they are taught they are doing a disservice to the system, that
may be a good way to get patients to voluntarily abandon the notion.
 It is mentioned that the triage nurse can determine if an appointment or referral to another
UHS service would be better for the patient’s situation. Give them the ability to make an
appointment for a doctor in such cases.
 If nurses are given lists of patients who are given permission to see doctors, that can
reduce the random nature of this practice and potentially reduce the incidences of it
occuring.

(7)
 Manage Capacity-Staffing more nurses or doctors, if feasible will reduce waiting times
for patients. If that is not feasible, then exhibit 10 in the case shows 11 doctors who are
in the walk in clinic less then 20 hours every three weeks, see if they can allocate more
hours to the walk in clinic. We included some information of how increasing the walk in
by one doctor has a pronounced effect on Wq and Lq when answering the question about
increasing arrival rates from question 4. Similarly, in question 2, we show how changing
the pattern of doctors and nurses has a pronounced positive impact on utilization balance.
 Manage Capacity- Have a system where the patients can bring in an AVF form ahead of
time or give the information over the phone on a hotline, if they are planning on coming
in the next day. The clerk can get the information directly, and take care of all the
responsibilities prior to the information going into a triage pile. When the patient comes
in, they can go right into the chronological pile. This will save practitioners from
responsibilities clerks can perform, and will give patients incentive to handle this ahead
of time, so they do not have to be placed on an initial queue. Additionally, if they have a
reason to come in that the walk in clinic does not cover, the patients can be told ahead of
time, thereby reducing some unneeded arrivals. For any patient that goes through this
procedure, over 15 minutes can be allocated to clerks ahead of time, as shown in exhibit 5
of the case: (sign in/AVF form, record retrieval and record check).
 Manage Capacity- The triage nurses can’t be just asked to stop the MD/NP classification,
they must be insisted on.
 Manage Demand- Advertise all the services, giving patients the knowledge of the options
available to them.
 Manage waiting experience- (1) Install a quiet room for study. (2)Add a television in the
waiting room. (3) Move the patients to a doctor’s office as soon as that becomes feasible.

Page 6 of 6