1. Reallocating Resources to Focused Factories: A Case Study in Chemotherapy Peter Vanberkel, PhD Candidate University of Twente Netherlands Cancer institute – Antoni van Leeuwenhoek Hospital

2. Outline About Focused Factories Case Study Decision Support Tool

3. Focused Factories History US Factory in the 1960 Focused Factory focus, simplicity and repetition breeds competence. – Skinner 1973 We produce everything! We produce Nothing Well We produce fewer things! We produce them all Well

4. 2006 Manufacture And Assembly

5. Pomegranate Phone: Ultimate Do EVERYTHING phone (www. PomegranatePhone.com) iPhone: Does less but does Everything Well

6. General Hospitals Health Care Focused Factories Specialized Hospitals Specialized Clinics

7. Focused Factories within Hospitals Poly Clinics Radiology OR Chemotherapy Radiotherapy

8. Patient Type Focused Factories? Breast Cancer Skin Cancer Colon Cancer Lung Cancer Prostate Cancer

9. Focus on Service? Or Patient? Or Mix? Breast Cancer Skin Cancer Colon Cancer Lung Cancer Prostate Cancer OR Radiology

10. Research Question General: How can we quantify the impact of decentralizing a centralized service? Chemotherapy Case Study: Design a decentralized service (Breast Cancer and Non Breast Cancer) that maintains the performance of the existing centralized department

11. Presentation Focus… Chemotherapy (Existing) Breast Cancer Chemotherapy Non Breast Cancer Chemotherapy Economies of Scale? or Economies of Focus?

12. About Chemotherapy Dept. Appt. Request Pnt. Arrives Pnt. in Wait Room Pnt. in Bed for Treatment Pnt. Leaves Appointment: Clinic Runs Smoothly when beds are Utilized at 90% Nurses can manage Waiting Room time is reasonable Currently 30 beds Access Time: < 5% of patients Should wait more than 1 days F/U New

13. About Chemotherapy Dept. Appt. Request Pnt. in Wait Room Pnt. in Bed for Treatment Pnt. Leaves F/U New Black Box Service Rate: (Patients / day) Depends on: Appointment Length Number of Beds Arrival Rate: (Patients / day) Poisson(70.2) Pnt. Arr Output / Performance: Access Time Bed Utilization

14. Service Rate P1P2P3P4 Expo (1/λ) Capacity Distribution in Patients / day: Poisson(λ) Expo (1/λ) Capacity Distribution in Patients / day: Int[Poisson(λ)/2] Appt. Length = 90 minsAppt. Length = 60

15. Model Output / Performance Lq n = (Lq n-1 + Arrivals n – Served n ) + Wait Time Distribution Utilization = Beds Used / Total Beds

16. Scenario Existing Chemotherapy BC Chemotherapy No Efficiency Improvement Expected Due to Focus Model Inputs Service Rate: 2.7 Pnts/day Arrival Rate: 72.1 Pnts/day Beds: 30 Model Outputs Bed Utilization: 90% Access time >1 day: <5% Service Rate: 2.5 Pnts/day NBC Chemotherapy Service Rate: 2.8 Pnts/day Bed Utilization: 90% Access time >1 day: <5% Bed Utilization: 90% Access time >1 day: <5% Beds: ? Arrival Rate: 29.6 Pnts/day Arrival Rate: 42.6 Pnts/day

17. Breast Cancer Chemo BedsBed Util % of Patients with Access Time > 1 1796.2%27.9% 1891.1%9.1% 1986.8%3.8% Targets Met

18. Non Breast Cancer Chemo BedsBed Util % of Patients with Access Time > 1 1196.6%34.9% 1288.7%9.1% 1381.5%2.5% Targets Met

19. Results Existing Chemotherapy BC Chemotherapy Beds: 30 NBC Chemotherapy Beds: 19 Beds: 13 Equal Performance Centralized Service Decentralized Service

20. Case Study Conclusion A decentralized Chemotherapy Service requires a total of 32 beds to ensure the same performance as the existing 30 bed centralized Service

21. General Considerations for FF 1.Proportional Sizes of the decentralized groups 2.Variability in Appointment Length 3.Efficiency Improvement Due to Focus 4.Different Performance expectations for different patients

22. Advantages of Methodology Uses Data that is commonly available from outpatient Scheduling Systems Applicable in other Focused Factory Decisions Can determine the min Economies of Focus Applicable in other outpatient environments Can be easily adapted to answering a variety of questions related to different treatment plans for a certain segment of the patient population

23. Other Applications Impact of Different Drugs with faster infusion times Impact of Less Frequent Return Appts Impact of Different Working hours Impact of Growing Demands Impact of Dedicated Lab service

24. Give Drug A Orally

25. Decision Support Tool

26. Future Research Determine the combined advantages of multiple departments decentralized to a Focused Factory.

27. Discussion & Questions?