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# Paediatric Orthopaedic Clinic

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40% of patients are new in the clinic and they go through every step of the process. The remaining 60% of the patients are follow up patients. Of this 60%, 85% of them necessitate an X-Ray, while the remaining 15% do not. They go directly to the doctor or senior resident student. Given this, we can calculate the average time per patient in the clinic.

Average Time = 129 x 0.4 + [0.85×119 + 0.15x(25+3+33)] x 0.6

= 129 x0.4 + 110.3×0.6 = 117.78 minutes

The total time that a patient spend in clinic (a usual patient, without specification if he/she is new or a follow-up), is 117.8 minutes.

Having the throughput and the flow time, we can calculate the inventory of patients in the clinic. You can find the inventory for every step in the table above. Adding these numbers together, we can calculate the number of patients that are in clinic in a given time.

Number of patients in clinic = 4 + 5 + 7.73 + 9.86 + 0.4 + 0.6 + 5 + 6.6

39.19 on average 39 patients are in clinic

The average number of client that ate in clinic in a given time is 39. This make sense because on average the clinic is open for a half day (4 hours) and they see approximately 80 patients per half day. If we have an average time spent in the clinic of 117 minutes and average number of patients in the clinic at a given time of 39, then you are turning over your inventory (patients) twice a day.

3-How much is variability affecting capacity at the clinic? How can variability be controlled?

a) In the Front Desk Process; the variability of a patient being a new patient or a follow-up patient effects the capacity slightly. Each patient essential follows the same process excepts for the time that it takes for the nurse to determine if a follow-up patients needs to be sent for new x-rays but for new patients they automatically go regardless. This actually ends up affecting the Radiology capacity. The fact that 85 percent of the follow-up patients were sent for new x-rays and 15 percent did not, really affects the Radiology capacity.

Furthermore, the variability of the different type of x-ray for each person (which results in time taken to re adjust the machine for the next person with a different type of x-ray) and the variability of a person that needing an emergency x-ray ( which in turnÂ makes the regular new/follow-up patients wait) also affect the capacity for the Radiology process. The Hand off & Direct Patients process doesnâ€™t have any variabilityâ€™s; the process is same for every type of patient. The variability in the Exam process, that affects the capacity, is the variety of patients that may need to alterations or cast removals would have to be seen by the cast technician which would keep the capacity lower for this process.

b) Variability canâ€™t be controlled in the way that the clinic is setup right now; there is no way for us to influence/predict the treatment for every new patient or for every follow-up patient. In this clinic case the only way to control variability is to segregate your inputs (patients) to follow their on independent processes. For example, the variability that a new or follow up patients is coming in to the clinic could be controlled if segregated. If all new patients were scheduled only for a particular part of the day and follow-ups scheduled for the other half or rest of the day; then this would help in knowing that they are only going to get a particular type of patient in a particular time of the day.

4-What is the bottleneck in the process? What are the capacity constraints at the clinic?

Steps | Availability (min) | Activity time (min) | Capacity p/work day | Front Desk + Hand-off1 | 1305 | 23 + 4 | 48.33 |
Radiology Department | 2400 | 46 | 52.17 |
Direct patients/filling/exam Rm. Prep | 255 | 4 | 63.75 |
Examination Room | 765 | 19.3 | 39.63 |

1- Since Hand-off is done by the same nurses we are adding their activity time for hand-off to the activity time of front desk were they are working.

The bottleneck is in the Examination Room.

Capacity Constraints:

Front Desk Capacity: 4(New patients) + 5(Follow up patients) = 9 patients

Radiology: 7.73(New patients) + 9.86(Follow up patients) = 18 patients (rounded up)

Hand off & Direct Patients: 0.4(New patients) + 0.6(Follow up patients) = 1 patient

Exam Room: 5(New patients) + 6.6(Follow up patients) = 12 patients (rounded up)

5- What is the economic cost of wait times ?

Average London worker salary = \$44,000 annually or \$21.15/hr New Patient Wait Time Cost= \$21.15 x 1.31= \$27.78
Follow-up Patient Wait Time Cost= \$21.15 x 1.27= \$26.93

Since the clear bottleneck is in the exam room, a focus to reduce wait times in the exam room could be handled with allowing both of the residents to exam patients in parallel, which would increase staff available time by 255 mins. To keep the resident learning experience, the surgeon could only call in the resident for exams that he or she feels necessary.

In addition, the second bottle neck area is considered the radiology area with 35 mins wait time. Purchasing the new x-ray machine will reduce this wait time by 25% to 26.25 mins. This 8.75 min reduction will directly reduce the total wait time.

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