Simulation Design To The Encounter Bottleneck Moment 

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The universal rule of Process

Three universal rules apply to all systems (Sánchez 2018). The bottleneck law, Little’s law, and the law of differences/variation all have an impact on operations.
• Bottleneck law: It means, Bottleneck can be present in all processes. It takes a huge amount of time, which limits the activity. The bottleneck can be identified by the presence of a queue in front of activity and free space immediately following it.
• Little’s law: It states that the throughput time is proportional to the loop/cycle time compounded by the number of units in the operation. When a unit completed its process it is considered as a cycle time and the unit under the process is refers to the unit within the process.
• Law of differences/variation: Variations can exist in systems, and although it is difficult to avoid them, they may be planned and regulated, which is beneficial for companies. With an increase in resource efficiency, the throughput increases as the variance increases.
According to Hartmann (1996), when an organization focuses on the value-adding process that serves the consumer, it is referred to as productive and successful. Furthermore, non-value-added processes and throughput time can be limited and minimized.

Flow in Healthcare process

In healthcare, the process will start and stop when the patient is admitted and discharged from the hospital. In addition to the flow of patients, the information flow is also included in the healthcare process. The time between the start and endpoint of the process is called the Length of Stay (LoS). LoS varies depending on the patient’s condition and care, and sometimes within the same disease. As previously said, rather than relying on a particular framework, the knowledge and patient flow system must be seen as a whole. For example, if the emphasis of patient flow is solely on the emergency room, without regard for bed availability, a queue forms among the patients (Halsted 2008). When queueing is present, patients tend to receive low quality care if they are put in less suitable wards, according to Halsted (2008). According to Batun (2013), historically hospitals have relied on resource efficiency, but today’s hospitals must pay greater attention to the unit’s flow efficiency. Unit improvisation in the organization were not encouraged by the Nyman (2007), rather imposes the view towards the whole flow structure. Working between the units, the improvisation can be reduce but it is harder to break down the barriers in the hospital (Croxton 2001; Meijboom et al. 2011). A coherent knowledge flow across the whole organization is crucial in an organization that lacks priorities and where units frequently function individually (Davis 1993).
The three stages of the healthcare system are the admission phase, the in-patient period, and the discharge process. Not all stages of a patient flow are completed in a single ward, and an effective infrastructure is needed to keep these processes running smoothly (Bahall 2018). To avoid the delays in the patient process, the bed management among the wards are most important.
When flow of patients within the hospital is tracked over time, one can able to change the flow internally as well as externally (Walley et al. 2006). External change may refer to an object that would be delivered to the patient, while internal change refers to the patient’s time in the hospital (Halsted 2008). Compared to the patient flow many changes are interlinked with the effective flow e.g. schedule of a surgeon (Allder et al. 2010). To improve the flow of the patients, the two groups of changes i.e. the external and internal changes can be connected (Halsted 2008). The improvements can be possibly implemented within and outside of the hospitals. The process including preparation and planning are implemented when the patient discharge is called discharge process. E.g. in an operation/ surgical ward, the discharge forecast can be done by 85% of accuracy. Early forecast helps to improve the flow of patients within the ward (Bahall 2018; Halsted 2008). For certain medical procedures, the early forecast for discharge time can be predicted, which helps in prior planning (Liker 2004).

Occupancy rate

Occupancy refers to the level at which the utilization of the resource is planned. The occupancy rate is regularly measured in the hospital. In consideration of the patient flow and the cost, the planning is made by the ward manager (Halsted 2008). The target set for the occupancy rate is 80 to 85 %, which is measured at midnight of the day. When the targets reaches to 85 percent, problem is raised which leads to the decrease in the quality of care. According to Brandt and Palmgren (2015), to build a levelled flow, overcapacity is required.

Separating Flow

Separating flows is a normal occurrence in an industrial setting, and it can be seen as a requirement for achieving a quick and levelled flow (Liker 2004). The productivity can be increase, by eliminating the non- value added processes (Dolan 2003). As mention above, the flow is maintained based on the different activities in the industry and the value that are created among the customers (Liker 2004). One major contrast between a business versus a healthcare such as a hospital is that in a hospital, the patient consumes the service at the same time that it is delivered (Adan 2002). According to Dolan (2003), the focused factory defines why the industries are not yielding the same productivity. When the flow is monitored separately of the same output, it gets less complex and most successful in productivity. Similarly, the patients in the hospitals can be monitored based on the specific requirement and flow can be organized based of the treatment they required. Furthermore, the workers flow may be segregated in order to execute their tasks with the same target in mind. This approach aims to coordinate the movement of patients inside the wards and reduces errors (Jacobsson 2010). According to Hyer et al. (2009), when a healthcare switched to a more focus-based approach, the LoS strengthened. Separate flows often allow for diverse techniques to be used to prevent overcapacity (Olsson and Aronsson 2012).

Production and Capacity Planning

Production and capacity planning (PCP) aids in the systematic determination and management of patient traffic (Batun 2013). When a resource is first put to use, it must be carefully prepared and tracked (Mattsson and Jonsson 2013). According to Batun (2013), PCP assists in the organization of resources that are currently required, allowing for the provision of high-quality services to patients. In the Swedish healthcare system PCP is not usual to be seen and importance is provided to predicting potential demand for treatment to address potential challenges. To reduce wastes and unit improvisation in a patient flow, healthcare must be more constructive. Examining current demand will help to properly align staffing schedules (Brandt and Palmgren 2015).

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Standardization

Standardization is another way to enhance the process’s efficiency. Standardization in an activity must be always monitored, questioned, and regularised because it is not always perfect. Once the standardization is created, the variation will get reduces as the staffs follow the routines as per the standards (Jacobsson 2010). Standardization helps the manager to create a clam and organized routine environment and not as a control method (Seddon 2010).
Standardization also helps to eliminate the number of erroneous procedures and increases the improvisation in the routine (Spear 2005). By installing standardization, the routine among the staffs will improve as it is easy to follow the repeated tasks. Once the entire work is organised, it act as a platform to reach the newer position. According to Liker and Meier (2006), Procedures and improvements are more likely to be overlooked by design, and operations will return to the processes that are considered to be not standardized.

Visualization

Visualization method helps to visualise the process of certain activity in the form of picture. The visualization is commonly used in the industries in order to understand the process path (Monden 1983). There are distinctions between manufacturing and services, such as the hospital procedure, where the service is utilized immediately when required, making it more difficult to assess the service’s outcome. Though the final result are harder to visualize, the process can help to improve the system (Jacobsson 2010). In a hospital scenario, the process can be visualized in the form of a map and can be discussed about the number of patients in wards and availability of beds. By this managers can understand where the problem occurs and can solve the issue with the help of visualization (Jacobsson 2010).

Lean Philosophy

According to lean, all work is done with the client in mind, and work is graded as either a value add or a waste. The main focus of the lean is to eliminate the waste which is considered as a non- value added process (Liker 2004). According to Womack and Jones (2010), Lean is structured based on the five principles:
1. Defining the value.
2. Value flow mapping.
3. Flow creation.
4. Based on the customers demand establish the pull.
5. Steps taken for continuous improvement.
According to Liker (2004), certain practices in the Lean are called waste, such as high production and waiting time. In a healthcare system, the waste can be categorized as activities that are not- value added to the patients and staffs (Jackson 1996).
Healthcare has adopted the lean in the early 2000s. As previously said, one of the most significant discrepancies between lean in business and lean in healthcare is when the value is generated. Treatment procedures, unlike industrial processes, are often dynamic because the patient’s situation changes with the progress of the operation (Adan 2002). The emphasis on flow rather than resources is a key difference between hospitals that use lean and those that don’t (Cote 1999). Owing to the high variation in the inflow, it is impossible to provide fast throughput times while still providing a high resource usage (Jacobsson 2010).
Despite the fact that many good lean applications in healthcare have been introduced, there is still opposition to it, even though many people think it belongs to the industry (Stefl 2008). The techniques and principles used in the industry as lean methods can also be followed by the healthcare systems but not the exact solution (Adan 2002). Implementing lean in healthcare may also be a failing mechanism if the individuals concerned are not paying attention during the inspection, which becomes crucial. Lean techniques should be used in low variation processes which helps to remove the trouble with an increase in efficiency (Tennant 2000).

Situational Awareness

In a complex system, the decision must be made with a clear understanding of the situation and it is referred to situational awareness (Endsley 1995). The one’s situational awareness must be based on the information that is understood, and decisions are made based on the objective and goal of the system, which is based on the current scenario and future aspects. Situation sensitivity refers to a high level of understanding of a system’s inputs and outputs. According to (Endsley 1995), many choices must be made in a short period in complex settings, and tasks are based on a continuous check within the system. The framework of situational awareness through communication for cooperation is addressed by (Mackay 2013). As a result of not realizing that other teams don’t have or need such information, it’s normal to fail to share it.

Table of contents :

1 Introduction 
1.1 Context
1.2 Problem Context
1.3 Purpose and Research Questions
1.4 Delimitations
1.5 Report Outline
2 Background 
2.1 Flow and Process
2.2 Flow in Healthcare Process
2.3 Occupancy Rate
2.4 Separation Flow
2.5 Production and Capacity Planning
2.6 Standardization
2.7 Visualization
2.8 Lean Philosophy
2.9 Situational Awareness
2.10 Simulation
2.10.1 Pros and Cons of Simulation
3 Methods 
3.1 Research Method
3.2 Research Action
3.3 Data Collection
3.3.1 Literature Study
3.3.2 Observations
3.3.3 Interviews
3.3.4 Short Conversations
3.3.5 Quantitative Data Collection
3.4 Data Analysis
3.5 Ethical Aspects
3.6 Reliability
3.7 Validity
3.8 Generalization
3.9 Reflection of the Research
4 Empirical Data and Findings 
4.1 Operations of Skaraborg Hospital
4.2 Radiology Department
4.2.1 Human Resource in the Radiology Department
4.2.2 Measurement and Continuous Improvement
4.3 Patient Flow Data
4.3.1 Patient Flow at Radiology Department
4.3.1.1 Planned Patients
4.3.1.2 Acute Patients
5 Analysis 
5.1 Analysis Of Current Practice And Identified Problem
5.2 Simulation Design To The Encounter Bottleneck Moment
5.2.1 Reception and Waiting Room
5.2.2 Operator Pool
5.2.3 Front End Hierarchical Blocks: Lab
6 Results and Discussion 
6.1 Introduction
6.2 Planning in Patient Flow
6.3 Separation in Patient Flow
6.4 Standardization and Visualization
6.5 Continuous Improvement
6.6 Production and Capacity Planning
6.7 Patient Flow
6.8 Future Work
7 Conclusion

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