Massachusetts General Hospital's Pre-Admission Testing Area (PATA)

Jireh Philip B. Acabal

Bachelor of Science in Accountancy - III

Daverah M. Banagodos
Bachelor of Science in Accountancy – II

Carla Marie F. Primicias

Bachelor of Science in Accountancy - III

Gyle Angela V. Sabacahan

Bachelor of Science in Accountancy - II

Vnzichro V. Sarno
Bachelor of Science in Accountancy - III

Aileen E. Suminguit
Bachelor of Science in Accountancy - III

Mr. Earl Z. Calingacion

Management 31 - C

April 26, 2017

I. Brief Description

The Massachusetts General Hospital was founded in 1811 and has been committed to
delivering standard-setting medical care. The hospital has 907 beds in a 4.6 million square foot
campus as one of the largest hospitals in America. Also, it consistently ranked as one of the top
five hospitals in the country. It is considered the cradle of anesthesia since it was there in the
Ether Dome where the ether was first supplied during a surgical procedure in the year 1846. The
Department of Anesthesia, Critical Care and Pain Management (DACCPM) was accredited in
1938 and since then has maintained a leading position in the field of innovation and research of
anesthesiology. They have 278 physicians and 198 nurses in the hospital. The department is able
to support patients before, during and after their surgery.

With that, the hospital has a Pre Admission Testing Area (PATA), where they are
responsible for outpatients having 43% of that had undergone surgery. They are ones who
evaluate safety anesthesia before surgery, who inform the patients, and who obtains the legal
acknowledgment and consent from the patients. The purpose of PATA was to thoroughly
evaluate each patient To determine if they could withstand anesthesia during the operation and
perform all laboratory tests prior to surgery.

PATA was an outpatient clinic with 12 exam rooms, a lab, and a waiting room. Patients
typically spent about 80-90 minutes of face time with providers in PATA, but even in the best-
case scenario, appointments lasted at least two hours. The average appointment was two-and-a-
half hours and many patients spent over four hours in PATA. Long waiting times were
particularly troubling due to the goal of high quality patient- and family-focused care that MGH
espoused.
The system they have used until today has proven to be ineffective which creates a rather
tense situation for patients and employees and has repercussions in turn In the surgery
department. The group exerted their efforts to settle this case until a letter forwarded from the
president’s office emphasizing that the problem is not getting any better. Patients spend long
hours waiting to be evaluated and staff needs to work long hours to be able to serve the large
number of patients. PATA had been struggling with inefficiencies and long patient wait times for
over two years.
II. Central Problem

The Pre-Admission Testing Area (PATA) of the Massachusetts General Hospital has
been struggling with their inefficiencies. Patients would be waiting for a long time, and this has
been happening for the past two years. They would be in the clinic for four hours, but in that
span the patients only have one hour and a half of face time. With that, patients are frustrated and
providers would have to overtime to cater the patients’ needs. This long wait was due to the
clinic’s goal of having high quality patient and family focused care that the Massachusetts
General Hospital aim.

III. Minor Problem

Due to the long wait problem of PATA, it caused a domino effect where other areas are
affected.

One of these minor problems is when registered nurses and medical doctors have to work
overtime. Instead of finishing their work by 5:00 pm, they have to stay and finish their jobs as
late as 7:00 pm or 8:00 pm.

Surgeons are also affected in the PATA’s dilemma of long wait, another minor problem
for the clinic. They are tasked to book the patient’s appointments in the PATA. Since the clinic’s
capacity is limited, they had to make priority for complex cases, but their lack of guidelines often
resulted to sick patients not being sent to the PATA.

Another minor problem is the presence of many unhappy patients that would walk out
with no screening, and would show up on the day of surgery, resulting to delays and backlog on
the surgeon’s schedule.

Lastly, a minor problem caused by the long time wait is that the clinic isn’t able to bring
in any revenue that made it even harder to justify additional resources. The operating room
director would cancel surgeries, resulting to upsetting patients. And fewer surgeries result to less
revenues.
IV. Key Analysis

SWOT ANALYSIS

STRENGTH WEAKNESS
• The quality of care and • Long wait time
concern for the patients' • Insufficient number of
safety was very high. rooms, physicians and
• The staff remained nurses
committed to thorough
pre-admission work-ups
to ensure a safe and
uneventful surgery

OPPORTUNITY
• Considered as one of the
top five hospitals
• Known as the birthplace
of anesthesia
THREATS
• Due to long waits, other
potential patients would
rather go to other clinic.
 PROCESS FLOW DIAGRAM AND CAPACITY

Arrival rate = 8 pts/hr 7 am-12 and 2-3pm

Arrival rate = 4 pts/hr 12-2pm (Lunch)

Calculating PATA Process Capacities

1. Check-in: 2. Vitals + EKG in Lab: 3. RN Visit:

 Service time = 2 min/pt  Service time =10 min/pt  Service time =43 min/pt

 Service rate = 30 pt/h  Service rate =6 pt/h o Chart review = 5 min/pt

 m = 1 attendant  m = 2 technicians o Visit with patient = 27

 Capacity = 30 pts/hr  Capacity = 12 pt/hr min/pt

o Chart write-up = 11 min/pt
 (lunch: 6 pt/hr)
 Service rate = 1.4 pt/h
 m = 5 nurses
 Capacity = 7 pt/hr
 (lunch: 2.8 pt/hr)
4. MD Visit: 5. Blood Work in Lab: 6. Check-out:

 Service time = 64 min/pt  Service time = 6 min/pt  Service time = 1 min/pt

o Chart review = 10 min/pt  Service rate = 10 pt/h  Service rate = 60 pt/h
o Visit with patient = 37  m = 3 technicians  m=1 attendant
min/pt  Capacity = 30 pt/hr  Capacity = 60 pt/hr
o Chart write-up = 17 min/pt  (lunch: 20 pt/hr)
 Service rate = 0.94 pt/h
 m = 8 MDs
 Capacity = 7.5 pt/hr
 (lunch: 3.75 pt/hr)

PROCESS CAPACITIES

Non-Lunch Lunch
Service
Service # of Capacity # of Capacity
Step Time
Rate (pts/hr) Employees (pts/hr) Employees (pts/hr)
(min/pt)
Check-in 2 30 1 30 1 30
Vitals + EKG in Lab 10 6 2 12 1 6
RN Visit 43 1.40 5 7 2 2.8
MD Visit 64 0.94 8 7.5 4 3.75
Blood Work in Lab 6 10 3 30 2 20
Check-out 1 60 1 60 1 60

The Registered nurses are the bottleneck.

PROCESS FLOW DIAGRAM AND CAPACITY (BOTTLENECK)

Bottleneck

Before the registered nurse step, the patients can flow through at the arrival rate until the
waiting room is full. The capacity of the waiting room was not mentioned; therefore it was
assumed that it is large that it never fills up. Then the flow rate at steps before the registered
nurse is eight patients per hour in non-lunch times and four patients per hour during lunch.

During the registered nurse step and afterwards, the RN capacity limits flow, thus the
flow rate would be seven patients per hour in non-lunch times and 2.8 patients per hour during
lunch.
 UTILIZATION ANALYSIS

Non-Lunch Lunch
Flow Flow
# of Capacity # of Capacity
Step Rate Util. Rate Util.
Employees (pts/hr) Employees (pts/hr)
(pts/hr) (pts/hr)
Check-in 8 1 30 0.27 4 1 30 0.13
Vitals+EKG in Lab 8 2 12 0.67 4 1 6 0.67
RN Visit 7 5 7 1.00 2.8 2 2.8 1.00
MD Visit 7 8 7.5 0.93 2.8 4 3.75 0.74
Blood Work in Lab 7 3 30 0.23 2.8 2 20 0.14
Check-out 7 1 60 0.12 2.8 1 60 0.05

In this process, the registered nurses are overloaded. They build up a backlog of work and
would only work after the patients would stop arriving. With the use of the inventory build-up
diagrams, it can be easily analyzed the backlog of the registered nurses.

Analyzing Inventory Buildup at the Registered Nurse Station

Capacity Thus, the backlog accumulates at

7 am – 12 pm: 7 patients per hour 7 am –12 pm: 1 patients per hour
12 pm – 2 pm: 2.8 patients per hour 12 pm –2 pm: 1.2 patients per hour
2 pm – end of day: 7 patients per hour 2 pm – 3pm: 1 patients per hour
3 pm+: -7 patients per hour
Arrivals
7 am – 12 pm: 8 patients per hour
12 pm – 2 pm: 4 patients per hour
2 pm – 3 pm: 8 patients per hour
After 3 pm: 0 patients per hour
INVENTORY BUILD UP DIAGRAM

Average Inventory at RN Station

Time Length (hours) Start Inventory End Inventory Avg Inventory
7 am - 12 pm 5 0 5 2.5
12 pm - 2 pm 2 5 7.4 6.2
2 pm - 3 pm 1 7.4 8.4 7.9
3 pm - 4:12 pm 1.2 8.4 0 4.2
Grand Average 4.11
Thus the average patients that are waiting is 4.11.

Average Patient Waiting Time

Average flow rate (out of RN queue)
 7 patients/hour from 7 am to 12 pm (5 hours)
 2.8 patients/hour from 12 pm to 2 pm (2 hours)
 7 patients/hour from 2 pm to 4:12 pm (2.2
hours)
 Weighted average = 6.1 patients/hour
Average patient waiting time
 Little’s Law:
Inventory = Flow Rate x Flow Time
 Flow Time = Inventory/Flow Rate
 Waiting Time = (4.11 pts) / (6.1 pts/hr) =
0.67 hrs = 40 min

The average patient waits for 40 minutes at registered nurse station.

Other stations have utilizations less than 1. Waiting times in front of other stations will be driven
by randomness in arrivals/processing. This can be analyzed using queueing tools.

Waiting at Vitals + EKG (Queue 1, 9 am to 12 pm only)

Arrivals
 Arrival rate = 1/a = 8 patients/hr
 Average Interarrival time = a = 60/8 = 7.5 minutes
 Std Dev of Interarrival Times from 9 am to 12 pm (Fig 2a) = 8.9 min
 CVa = Std Dev/Mean = 8.9/7.5 = 1.2
Service
 Average Processing Time = 10 min (case p. 10)
 Std Dev of Processing Time = 3.5 min (case p. 10 footnote 9)
 CVp = Std Dev/Mean = 3.5/10 = 0.35
 Number of Technicians/Stations = m = 2

u = p/ma = 10/(2x7.5) = 0.667

Tq= 6.4 minutes
Waiting Time Analysis at MD & Blood Work
Vitals + EKG MD Blood Work
a [min] 7.5 8.6 8.6
Std Dev a [min] 8.9 1.7 3.4

CVa 1.2 0.2 0.4

p [min] 10 64 6
Std Dev p [min] 3.5 29 2

CVp 0.35 0.45 0.33

m 2 8 3
u 0.67 0.93 0.23

Tq [min] 6.38 11.77 0.02

Queue 1 Queue 3 Queue 4

The arrival rate (1/a) after registered nurse equals the capacity at RN is 7/60 which is equal to
1/8.6. Thus, the total waiting time from queueing effects is about 18 minutes.
 PROCESS FLOW DIAGRAM AND TOTAL FLOW TIMES

This diagram shows that the total wait time is 58 minutes, 98 minutes for total service time, and
an average flow time of 156 minutes.
V. Alternative Course of Action

1. Extend hours to 6:30 pm and increase the time between appointments to 45 minutes.
The current system’s schedule of appointments during non-lunch times is 4
arrivals for every 30 minutes, which is equivalent to 8 patients per hour. While during
lunch, there is an estimate of 2 arrivals for every 30 minutes deriving to 4 patients per
hour. The new proposed schedule of appointments during non-lunch times will have 5.3
patients per hour as a result of 4 arrivals for every 45 minutes, and 2 arrivals for every 30
minutes resulting to 2.67 patients per hour during lunch time. Thus, with the new
proposed schedule of appointments, there is a need to extend scheduled arrivals from 3
pm to 6:30 pm to maintain the same number of total arrivals (56) in 1 day.

Advantage: The new proposal eliminates build-up at the registered

Disadvantage:
Eliminates build-up at RN only queueing times remain
waiting time at RN is not zero!
Reduces queueing waiting times at other steps (lower arrival rate)
Total average waiting time is down from about 1 hour to less than 15 minutes
2. Patent

Advantage:
Disadvantage:

3. Add an Anesthesiologist (MD).

The current medical doctor utilization is 93% causing queuing delays due to
randomness. The present average wait time is 12 minutes per patient. If the hospital will
add 1 medical doctor, it should focus more on non-lunch times (9 am- 12 pm) which will
result to a decrease in utilization rate of 83%.
Hiring anesthesiologists are expensive but this will help lessen the waiting time of
each patient. Waiting time will drop to 2.68 minutes.
 Advantage:
Disadvantage:

4. Letting

Advantage:
Disadvantage:

VI. Implementation Strategy

The hospital should hire additional registered nurses to avoid nurse fatigue. The present
utilization rate of nurses in MGH is 100%. They have been working past their normal shifts
risking their own health leading to inefficiency in their workplace. Hiring additional nurses will
lead to the elimination of inventory buildup (bottleneck) in the registered nurse visit. Due to
increase in capacity of patients per hour in the registered nurse visit, the bottleneck in the
operations is now passed on to the medical doctor visit. To eliminate this patient build up, they
should hire medical doctors to increase their capacity of patients per hour. Currently, the medical
doctors have a utilization rate of 93%, and adding medical doctors will reduce waiting time to
2.68 minutes per patient.

Timeline:

Eliminate
The medical
Hire inventory
doctor visit is Hire medical doctors
registered buildup in the
now the (Anesthesiaologist)
nurses registered
bottleneck
nurse visit

VII. Conclusion
VIII. Recommendations

Financial Analysis

Alternative Course of Action

Immediate changes
• Establish shared responsibility for operations among the staff. Reduce burden on Charge Nurse
• Situate Lab Technicians close to front-desk to expedite EKG and Vitals
• Recommend having MDs and RNs use the same operating room
Long term changes
• Add 3 additional RNs to match the number of MDs
• Proactively display current wait times to patients in the waiting room

Implementation Strategy

Conclusion

Recommendation

 Key analysis (Fishbone diagram, SWOT matrix, STEEPLE, Porter’s Five Forces, Environmental
scanning, or any other business tools, technique, or theories to help you in your analysis; a brief
analysis should be included)

 Alternative Course of Action (the ideas should come from the different key analysis, it may not
be the possible but can be of consideration)

 Implementation strategy (should be based on the ACA and a timeline should be given which
would include the operational and marketing strategy)