Predicting the turn-around-time of pre-consultation blood tests for patients at Diabetes Centre

NUS IE 3100R - System Design Project

Presented by: HAN Chengwei, JIN Can, PANG Danyang, Somasundaram SANKAR, WANG Lei Supervisors: Associate Professor CHEW Ek Peng, Assistant Professor HUANG Boray; Industrial Liaisons: Geoffrey GUI, Matthew HAN Department of Industrial & Systems Engineering, SGH Division of Operations & Performance Management (Service Operations Unit)

Problem description:
The Specialist Outpatient Clinics (SOC) in SGH centralize blood-taking at the Clinical Laboratory. At present, there is no standardized optimal arrival time given by the SOC to patients requiring blood-taking before a same-day doctor's consultation. Most clinics brief patients to go for their blood-taking two hours before their doctor's appointment, and it is hypothesized that two hours may be too big a buffer, hence making patients wait longer than they should for their doctor's appointment. With the hope of reducing unnecessary waiting time, SGH Service Operations engaged our team to map out the workflow in the Clinical Laboratory and develop a simulation model to better predict the time for patients to report for blood-taking before their doctor's appointments. For a start, Service Operations suggested working with only the Diabetes Centre (DBC) as the DBC has a significant number of patients requiring blood-tests before their doctor's consultations.

Objectives:
1) To determine current turn-around-time for blood taking at the Clinical Laboratory; 2) To simulate effects of various scenarios in the Clinical Laboratory on turn-around-time for blood taking; 3) To determine the optimal arrival time for patients of Diabetes Centre to come for blood taking.

System Analysis:
The team observed the processes in the Clinical Laboratory and interviewed staff to map out the process for patients taking blood.

A cause and effect analysis with the Ishikawa diagram was used to identify the factors contributing to the long turn-around-time for blood taking at the Clinical Laboratory. The probable causes for long turn-around-time are:
1. Not enough phlebotomy stations; 2. Non same-day patients crowding the laboratory in the morning; 3. Patients haven't paid prior to coming to the laboratory.

As illustrated in the diagram, there are two types of patients: those who have made payment before coming to the Clinical Laboratory and those who have not. In addition, patients can also be categorized as having a "same-day" appointment with the doctor or "non same-day" appointment. At the Clinical Laboratory, there are two staff at the registration and payment counters and up to 6 phlebotomy stations are in operation for blood taking.

Time motion study and Data Analysis :

Time motion study in the Clinical Laboratory was carried out to collect data for process metrics and study the arrival pattern of patients. It was conducted between 31 October and 5 November 2011. A total of 1500 patients data was collected in the 1-week period. The team also analyzed system data to obtain the proportion of patients with same-day appointments and the time taken for processing of the blood samples. The latter is defined as the time samples are received by the laboratory to the time test results are uploaded on the system.
Same-day patients of the Diabetes Centre Registration Waiting for (sec) payment Paid Morning U(2,10) ~ Afternoon U(2,10) ~ Non-paid Morning U(2,10) L ~ 4.5 min Afternoon U(2,10) L ~ 1.9 min Waiting for blood taking ~ E ~ 17 min ~ E ~ 2 min L ~2 min E ~ 17 min L ~2 min E ~ 2 min Payment Blood Taking L ~ 4 min L ~ 4 min L ~ 4 min L ~ 4 min Sample test waiting time L ~ 12.5 min L ~ 12.5 min L ~ 12.5 min L ~ 12.5 min Sample testing L ~ 45 min L ~ 45 min L ~ 45 min L ~ 45 min

ARENA Model :
An Arena simulation model was built to determine the optimal 75th percentile total turnaround-time of patients in the three scenarios.

U is Uniform distribution; L is Lognormal distribution; E is Exponential distribution;

Average total turn-around-time for patients of Diabetes Centre

Morning: Afternoon: Paid: 80.0 min Paid: 64.9 min Non-Paid: 86.0 min Non-Paid: 68.5 min

The average ratio of the paid and non-paid patients:

Number of Paid/Number of Non-paid = 1.6

Results of simulation of the 3 scenarios:

0 1 2 3 Scenario Current Increase the number of the phlebotomy stations from 6 to 8; All patients to prepay prior to blood taking; Shift 30% of non same-day patients in the morning to afternoon.
Scenario Easy of Total Impact implementation Score * 8 4 6 5 7 4 5 * 5 3 7 6 8 8 7 * 40 12 42 30 56 32 35

8 different combination of scenarios were simulated to determine the one with most optimal arrival time for patients of the Diabetes Centre.

From the analyses of queue length, scenario 1+3 exhibited more consistency than scenario 3 alone.

Scenario 3 has the largest impact on turnaround-time, followed by scenario 1 and 2. However, there is no significant difference between implementing all three scenarios and scenario 3 only.

0 1 2 3 1+2 1+3 2+3 1+2+3

A similar trend is observed with regards to blood taking i.e. scenarios 3 followed by 1 and 2. The combination of scenarios 1+3 has the biggest impact. There is least impact for scenario 2 as even though the same day patients no longer need to make payment before blood-taking, they are pushed immediately into the phlebotomy queue, hence there is lesser impact on the waiting time.

Together with subject matter experts, the team also applied a prioritization matrix to compare the various scenarios, using the criteria of 'Easy to implement' and 'Impact'. From the matrix, the best scenario is 1+3.

Conclusion:
1. The current two-hour arrival ahead of appointment time may seem too long. It is recommended for patients of Diabetes Centre to arrive 90.0 minutes earlier to reduce their entire time spent in SGH. 2. The team propose implementation of scenarios 1+3 to further reduce the turnaround-time for patients. The optimal time for patients to arrive upon successful implementation is 67.0 minutes.