Operations Management Engr. Augusto Arguelles Quirino Memorial Medical Center Obstetrics Out-Patient Department June 13-July 4, 2011 Tanbonliong, Beatrix Hannah Chua Parco, Matthew David Sun

Waiting Line Analyses 1 The patient comes early in the morning and falls in line with all the rest of the OPD patients for the encoder. 2 The encoder gives the patient a “green card”, which she presents to the Nurse OIC, who then takes the patient’s vital signs. The patient returns to her seat and wait until the Junior Interns (Clerks) arrive (9:00 AM) from ward work. 3 The Junior Interns then call a patient and interviews her regarding her History (Medical and Obstetric). New patients entail a longer time for History taking (x = 30 minutes), while Follow-Up patients entail a fairly short time for History taking (x = 5-10 minutes). 4 Patient again falls in line for the second part of the Check-Up: the Actual Physical Examination performed by the OB residents.

Waiting Line Analyses Arrivals in the OB-OPD happens in an entirely randomized fashion. The average number of patients arriving inside the OB-OPD facility for History taking is approx. 8 patients in one hour (l), while the service rate is 12 patients in one hour () and the number of Junior Interns simultaneously serving is about six (M). System utilization is about 0.11, using p= l/M. Average number of customers (r)being served is 0.67 in one hour, using l/m. The average number of customers in the line waiting for service is 1.33. The average number of customers in the system is 2, using Ls = Lq + r. The average time customers spend waiting in line is Wq=Lq/l, is 0.16 hour, or 9 minutes. The average time customers are in the system is 0.24 hour, or 14.6 minutes. 1 The patient comes early in the morning and falls in line with all the rest of the OPD patients for the encoder. 2 The encoder gives the patient a “green card”, which she presents to the Nurse OIC, who then takes the patient’s vital signs. The patient returns to her seat and wait until the Junior Interns (Clerks) arrive (9:00 AM) from ward work. 3 The Junior Interns then call a patient and interviews her regarding her History (Medical and Obstetric). New patients entail a longer time for History taking (x = 30 minutes), while Follow-Up patients entail a fairly short time for History taking (x = 5-10 minutes). 4 Patient again falls in line for the second part of the Check-Up: the Actual Physical Examination performed by the OB residents.

Process Analysis of Px Flow in OB-OPD Patient enters OB-OPD/OB-ER with “green card / passport” Patient’s History is obtained by a Clerk / Junior Intern Patient proceeds to queue for the Physical Examination to be conducted by the OB Resident. Patient herself is examined. Patient is presenting with conditions that might endanger fetus. Send to OB-ER for further evaluation and monitoring Sent home. YES NO Patient still has very high blood pressure after 30 minutes or has a cervix opened more than four cm. Admit to LR.

Project Management Pure Project. Each employee has their own job and work schedule to follow so as to move the patients within the triage. All objectives are based on seeing the most number of patients in the shortest possible time. The oldest resident on duty is usually the head and makes the decisions for the difficult patient cases, has full authority and everyone is required to report to her, thus, making the decision-making process faster. Employees are limited to their field, no room for promotional success and employees are likely to be doing the same thing they have been doing since the first day of their job. Whenever a phase of the project is absent/lacking, the whole organization will be deemed insufficient.

Work Breakdown Structure Nursing Department - to identify and encode patients, retrieve records and take their vital signs Junior Medical Interns - interview the patients for their relevant clinical history, advise prenatal health and write requests for the diagnostic tests that they might need OB Residents - consult the patients based on both their given history and physical examination.

Service Processes Professional Service Organization defined by the training that the employees get prior to employment no matter how extensive the training, the system is still based on the degree of contact with patients. the patient will always be the one to dictate the time of demand and quantity of service received. Reactive System infiltrated the patients and responsive to patient requirements Face-to-Face Total Customization little innovation that can be done given that this is a medical field and diagnoses cannot be done without patient-doctor interaction. Service Guarantee Professional Regulation Commission Bureau of Internal Revenue PhilHealth accreditation

Service Processes Characteristics of Service Personnel Personnel Nurses Junior Medical Interns OB Residents Characteristics Efficiency in record retrieval Clerical skills Efficiency in taking vital signs   Good conversational skills Clinical history-taking Clinical history-taking and physical examination Diagnostic skills Clinical decision-making

Process Analysis of Px Flow in OB-OPD Operation Time = Setup Time + Run Time ( 10 = 3 + 7) Patients start queuing from 5:30 onward outside. They first enlist themselves in the encoder section of the OPD and are given a “green card”, with which they are entitled to enlist to the specific specialty (e.g., OB-OPD). The OIC (e.g., Ma’am Angie) takes the blood pressure and other vital signs of the patients. They then wait for a THIRD time until their names are called by the Clinical Clerk (a.k.a. Junior Intern). THE OPERATION TIME OF THE OPD, HOWEVER, IS FROM 7:00-9:00 (SETUP TIME) and 9:00-4:00 (RUN TIME), and a second SETUP TIME from 4:00-5:00 for the Daily Census. Throughput Time = average of 1 hour. Cycle Time for History Taking = average of 30 minutes. Cycle Time for Physical Examination = average of 5 minutes. Value-added Time = 7.5 hours The time in which useful work is actually done, which is 9:00-12:30 and 1:00-4:00 in QMMC, Velocity = TT/VAT = 0.13 Throughput Rate= 1/Cycle Time = 1.71 Efficiency = Actual output/Standard output = 1 The OB residents see at least 15 patients per hour, compared to OB doctors, who can finish seeing roughly the same number of patients per hour. Patient enters OB-OPD/OB-ER with “green card / passport” Patient’s History is obtained by a Clerk / Junior Intern Patient proceeds to queue for the Physical Examination to be conducted by the OB Resident. Patient herself is examined. Patient is presenting with conditions that might endanger fetus. Send to OB-ER for further evaluation and monitoring Sent home. N Y Patient still has very high blood pressure after 30 minutes or has a cervix opened more than four cm. Admit to LR.

Process Analysis of Px Flow in OB-OPD Recommendations: Increase the number of OB residents to cope with the (extremely) large volume of patients. Increase the number of Nurse OICs. There are same periods where there are virtually no patients, only to find out that the Nurse OIC taking their BPs serve as the “bottleneck”. 3. Increase work area to accommodate more beds for the physical examination. 4. Train the encoder to separate the true Emergency Cases (refer them immediately to OB-ER) from those who are just seeking check-up. Patient enters OB-OPD/OB-ER with “green card / passport” Patient’s History is obtained by a Clerk / Junior Intern Patient proceeds to queue for the Physical Examination to be conducted by the OB Resident. Patient herself is examined. Patient is presenting with conditions that might endanger fetus. Send to OB-ER for further evaluation and monitoring Sent home. N Y Patient still has very high blood pressure after 30 minutes or has a cervix opened more than four cm. Admit to LR.