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A new method for planning an ambulatory care facility Richardson, John Ross 1976

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A NEW METHOD FOR PLANNING AN AMBULATORY CARE FACILITY by JOHN ROSS RICHARDSON B.Sc. (Hons.), U n i v e r s i t y of V i c t o r i a , 1972 A THESIS SUBMITTED IN PARTIAL FULFILLMENT OF THE REQUIREMENTS FOR THE DEGREE OF MASTER OF SCIENCE i n THE FACULTY OF GRADUATE STUDIES Department of Health Care and Epidemiology We accept t h i s t h e s i s as conforming t o the r e q u i r e d standard THE UNIVERSITY OF BRITISH COLUMBIA May, 1976 © John Ross Richardson, 1976 In p r e s e n t i n g t h i s t h e s i s in p a r t i a l f u l f i l m e n t o f the r e q u i r e m e n t s f o r an advanced deg ree at the U n i v e r s i t y o f B r i t i s h C o l u m b i a , I a g r ee t h a t the L i b r a r y s h a l l make i t f r e e l y a v a i l a b l e f o r r e f e r e n c e and s t u d y . I f u r t h e r ag ree t h a t p e r m i s s i o n f o r e x t e n s i v e c o p y i n g o f t h i s t h e s i s f o r s c h o l a r l y pu rpo se s may be g r a n t e d by the Head o f my Department o r by h i s r e p r e s e n t a t i v e s . I t i s u n d e r s t o o d t h a t c o p y i n g o r p u b l i c a t i o n o f t h i s t h e s i s f o r f i n a n c i a l g a i n s h a l l not be a l l o w e d w i t h o u t my w r i t t e n p e r m i s s i o n . Department o f Health Pare £ Epidemiology The U n i v e r s i t y o f B r i t i s h Co l umb i a 2075 Wesbrook Place Vancouver, Canada V6T 1W5 Date May, 1976 i i ABSTRACT The ambulatory care f a c i l i t y i s a new phenomenon i n the B r i t i s h Columbia h e a l t h care d e l i v e r y system. Therefore, not only i s i t s planner faced w i t h the u n c e r t a i n t y of p r e d i c t i n g f u t u r e need, but a l s o the p e r p l e x i t y of not having the very b a s i s f o r h i s p r e d i c t i o n s : past u t i l i z a t i o n data from e x i s t i n g f a c i l i t i e s . Moreover, there i s . n o r e a l agreement on what s e r v i c e s should be provided i n an ambulatory care f a c i l i t y . This t h e s i s attempts to at l e a s t p a r t i a l l y a l l a y these u n c e r t a i n t i e s by s e t t i n g down a format f o r planning an ambulatory care f a c i l i t y i n and f o r the community of D e l t a , B. C. The planning method was d i v i d e d i n t o four p a r t s : ambulatory care d e f i n i t i o n , data assemblage, data p r o j e c t i o n and f a c i l i t y s i m u l a t i o n . D e l t a p r a c t i t i o n e r s and s e v e r a l h e a l t h care consultants co-operated i n the production of an exhaustive l i s t of medical, s u r g i c a l and d e n t a l procedures d e f i n i n g ambulatory care. In accordance with t h i s l i s t , data was assembled regarding the number of ambulatory procedures r e g u l a r l y performed f o r D e l t a r e s i d e n t s , by D e l t a p r a c t i t i o n e r s . Medical and s u r g i c a l data was taken from P r o v i n c i a l Department of Health computer data f i l e s ; while d e n t a l data was gathered by q u e s t i o n n a i r e . The data t r e n d f o r each procedure was then p r o j e c t e d t o the Target Years 1978 and 1982. F o l l o w i n g these i n i t i a l s t e p s , a General Purpose Si m u l a t i o n System (G.P.S.S.) a n a l y s i s was performed on the data gathered. Other i n f o r m a t i o n r e q u i r e d f o r the s i m u l a t i o n was gathered through questionnaires t o D e l t a p r a c t i t i o n e r s and p r i v a t e conferences with h e a l t h care c o n s u l t a n t s . The r e s u l t s from the s i m u l a t i o n were expressed i n "work areas" ( i . e . examination rooms, st r e t c h e r - b e d s , etc.) r e q u i r e d i n the major departments or s e r v i c e areas. The s i m u l a t i o n a n a l y s i s could only be completed f o r the S u r g i c a l Day Care Services area, because the data from P r o v i n c i a l computer data f i l e s , r e l e v a n t t o other departments or s e r v i c e areas, was found t o be i n s u f f i c i e n t . The main problem encountered was an imprecise i d e n t i f i c a t i o n of p a t i e n t s ' geographic o r i g i n ; which i n some instances made i t impossible to i d e n t i f y procedures performed f o r D e l t a r e s i d e n t s . D e t a i l e d suggestions f o r improving the method are presented i n the D i s c u s s i o n . However, one should at l e a s t do the f o l l o w i n g : endeavour to use more than two years of data t o p r o j e c t the trend i n the P r o v i n c i a l computer data f i l e s ; and e x p l a i n the questionnaires c i r c u l a t e d to p r a c t i t i o n e r s by g i v i n g i n d i v i d u a l person-to-person i n s t r u c t i o n s , r a t h e r than group v e r b a l and i n d i v i d u a l w r i t t e n i n s t r u c t i o n s . Supervisor i v TABLE OF CONTENTS ABSTRACT i ; L LIST OF TABLES v ACKNOWLEDGMENTS v i Chapter I. INTRODUCTION 1 • I I . PLANNING METHOD TRENDS IN SOME SELECTED COUNTRIES 3 I I I . PLANNING METHOD TRENDS IN BRITISH COLUMBIA 9 IV. PLANNING AMBULATORY CARE FACILITIES IN BRITISH COLUMBIA.. 13 V. METHODOLOGY 1 6 VI. RESULTS 2 5 V I I . DISCUSSION 2 8 V I I I . SUMMARY AND CONCLUSIONS 3 4 BIBLIOGRAPHY 3 6 Appendix A. AMBULATORY MEDICAL AND SURGICAL PROCEDURES' 3 9 B. QUESTIONNAIRE TO DELTA PHYSICIANS ' 4 8 C. QUESTIONNAIRE TO DELTA DENTAL SURGEONS 5 5 D. SURGICAL DAY CARE SERVICES SIMULATION PROGRAM (G.P.S.S.) FOR THE TARGET YEAR, 1982 59 V LIST OF TABLES TABLE I. Number of Emergent and Non-Emergent Procedural Occurrences Forecast for 1978 and 1982 by Service Area 2 6 II. Waiting Times and Utilization in the Surgical Day Care Services Work Areas 27 v i ACKNOWLEDGMENTS During the course of my r e s e a r c h , the Delta p h y s i c i a n s , Delta d e n t i s t s and the a d m i n i s t r a t i v e and n u r s i n g s t a f f s from Burnaby, Richmond and Surrey H o s p i t a l s provided much needed data and i n f o r m a t i o n . However, without the counsel of: Dr. D. 0-. Anderson and h i s s t a f f i n the D i v i s i o n of Health Manpower, Research and Development, Fa c u l t y of Medicine, U.B.C.; Dr. L. Kanee, Pres i d e n t of the Delta Medical S o c i e t y ; Dr. R. B. K e r r , s p e c i a l medical consultant appointed by the Greater Vancouver Regional H o s p i t a l D i s t r i c t Board Advisory Committee; and Mr. G. L. Hastings, Research Co-ordinator f o r the Greater Vancouver Regional H o s p i t a l D i s t r i c t , the f u r t h e r accumulation of e s s e n t i a l data and i t s u l t i m a t e a n a l y s i s would have been impossible. S p e c i a l notes of g r a t i t u d e must be extended t o the D e l t a Centennial H o s p i t a l S o c i e t y Board members and the Delta H o s p i t a l A d m i n i s t r a t o r , Mr. J . J . M i l l e r f o r a l l o w i n g me to p a r t i c i p a t e i n the planning of the Delta Ambulatory Care F a c i l i t y . To the t y p i s t s of t h i s manuscript, Mrs. S. E. Fleming and Mrs. M. R. Richardson, my s i n c e r e a p p r e c i a t i o n f o r a s u p e r l a t i v e t r a n s c r i p t i o n . 1 CHAPTER I INTRODUCTION The problem approached i n the f o l l o w i n g was p r a c t i c a l : f i n d i n g a v i a b l e means of planning an Ambulatory Care F a c i l i t y f o r the De l t a Centennial H o s p i t a l S o c i e t y i n D e l t a , B. C. The method devised i s new. But, i n order to a l s o be a t r u l y p r a c t i c a l a d d i t i o n t o the planning t o o l s c u r r e n t l y a v a i l a b l e f o r h e a l t h care f a c i l i t y planning i n B. C., i t was designed to use an e x i s t i n g computerized data base and to be implementable by any aut h o r i z e d h o s p i t a l planning committee w i t h i n B. C. The problem reduced i n i t i a l l y t o the p e r p l e x i n g task of d e f i n i n g what e x a c t l y i s meant by "ambulatory care" or an "ambulatory care f a c i l i t y " . Attempts at d e f i n i t i o n s have been made i n the past (Jacobs, 1973; Anderson, 1974; Tenney, White and Williamson, 1974), but f o r the purposes of t h i s t r e a t i s e , these q u i t e s u b j e c t i v e d e f i n i t i o n s were forsaken f o r a d e f i n i t i o n comprised only of a l i s t of procedures l i k e l y to be performed i n the ambulatory care f a c i l i t y being planned. This l i s t i s probably not g e n e r a l l y a p p l i c a b l e to a l l ambulatory care s i t u a t i o n s , because i t was composed by Delta p h y s i c i a n s , w i t h the a s s i s t a n c e of a Greater Vancouver Regional H o s p i t a l D i s t r i c t Board (G.V.R.H.D.B.) s p e c i a l medical c o n s u l t a n t ( K e r r , 1975). However, i t does c l e a r l y d e l i n e a t e the procedures t h a t w i l l probably be performed, from day to day, i n the ambulatory care f a c i l i t y being planned f o r D e l t a . The next task was the establishment of p o t e n t i a l workloads i n 2 the f a c i l i t y . This end was accomplished by a s c e r t a i n i n g the number of times each procedure on the procedure l i s t above was performed i n past years and p r o j e c t i n g these numbers to f u t u r e Target Years. The p r o j e c t e d data was i n t u r n subjected t o a s i m u l a t i o n procedure which p r e d i c t e d the numbers and types of rooms and or c u b i c l e s t h a t would be r e q u i r e d i n the various s e r v i c e areas w i t h i n the f a c i l i t y . The main q u a l i t y i n a l l t h i s methodological development i s i t s emphasis on planning a f a c i l i t y t o s u i t the observable morbidity i n a s p e c i f i c community. In so many past f a c i l i t y planning ventures, mainly h o s p i t a l developments, the planning technique has been o v e r - s i m p l i f i e d . Beds or other s e r v i c e elements have been a l l o t t e d on the b a s i s of f i x e d quotas or per c a p i t a r a t e s ; determined through the accumulated experiences i n comparable h o s p i t a l s (Anderson, 1971). These comparative f i g u r e s may i n d i c a t e the s e r v i c e s r e q u i r e d f o r the community's populace, but then again they very w e l l may not. As Engels (1967) p o i n t s out the h e a l t h care planner has been l e f t with an unfortunate dilemma; "Every-body agrees on the l i m i t e d value of such "bed quotas" or "bed r a t e s " , but on the other hand no h o s p i t a l planner can omit to use them". The method suggested here i s by no means h e l d up as the u l t i m a t e s o l u t i o n t o the problems faced by the h e a l t h care f a c i l i t y planner. There are c h a r a c t e r i s t i c flaws i n i t t h a t w i l l be discussed i n the f o l l o w i n g chapters. However, as a s t y l e of p l a n n i n g , i t i s probably worth pursuing, e s p e c i a l l y i n the planning of ambulatory care f a c i l i t i e s ; developments that w i l l probably be more community-specific than the t y p i c a l general or community h o s p i t a l . 3 CHAPTER I I PLANNING METHOD TRENDS IN SOME SELECTED COUNTRIES The d i s c u s s i o n t h a t f o l l o w s below i s an enumeration of the he a l t h care f a c i l i t y p lanning methods used i n England and Wales, Sweden and the United Sta t e s . The choice of example c o u n t r i e s was unf o r t u n a t e l y l i m i t e d by the a v a i l a b l e l i t e r a t u r e and correspondence. However, the examples given do cover a range from a f u l l - f l e d g e d master planning method, i n the case of Sweden, to what might be described as a "non-planning" method i n the case of England and Wales. United States As i n d i c a t e d by Anderson (1971), h e a l t h care f a c i l i t y p lanning i n the western world r e a l l y began with the invoking of the H o s p i t a l Survey and Construction A c t — H i l l - B u r t o n Program (U.S. P u b l i c Law 79-725) i n 1946. At the o u t s e t , i n order t o q u a l i f y f o r matching g r a n t s , each s t a t e had t o e s t a b l i s h the l o c a t i o n and the bed need r e l e v a n t to each of i t s h o s p i t a l s . The bed need was e s t a b l i s h e d using the s o - c a l l e d H i l l - B u r t o n Formula, which i s s t i l l i n use: 4 E x i s t i n g Beds X Occupancy Rate"1- ^ + 10 beds" = Current Bed Need Occupancy Factor Excessive numbers of beds were noted i n urban as opposed to r u r a l areas. Therefore, by an ad hoc standard of 4.5 general h o s p i t a l beds per 1000 p o p u l a t i o n , r u r a l areas were provided with more beds (Anderson, 1971). This measure d i d not completely e q u a l i z e the bed per p o p u l a t i o n r a t i o , because l a r g e amounts of c a p i t a l were s t i l l a v a i l a b l e i n the more wealthy urban areas of the country through p r i v a t e p h i l a n t h r o p y . ( H i l l e b o e and Barkhuus, 1971) More recent l e g i s l a t i v e e f f o r t s , the Heart-Cancer-Stroke and. Kidney Disease Programs (Regional Medical Program), implemented i n 1965 and the Comprehensive Health Planning Programs, s t a r t e d i n 1966 have i n t e n s i f i e d h e a l t h care f a c i l i t y planning e f f o r t s . The former o f f e r e d the d i r e c t i n c e n t i v e of monies, i f the h o s p i t a l s concerned developed the medical programs s t i p u l a t e d by the Regional Medical Programs d i r e c t o r a t e . The l a t t e r e s t a b l i s h e d s t a t e planning agencies which funded p r o j e c t s approved by the l o c a l and non-governmental h o s p i t a l - p l a n n i n g c o u n c i l s . "'"The Occupancy Rate i s simply the average d a i l y census. 2 The Occupancy Factor i s a constant r e f l e c t i n g the f a c t t h a t h o s p i t a l s should operate at l e s s than 100 percent occupancy. This f a c t o r was o r i g i n a l l y .80, but was changed t o .85 i n 1972. 3 The ten beds added t o the l e f t s i de of the equation have the e f f e c t of reducing the occupancy f a c t o r on a s l i d i n g s c a l e t o b e n e f i t s m a l l h o s p i t a l s o perating at lower occupancy l e v e l s . Current bed needs were p r o j e c t e d f o r f i v e years by a p p l y i n g the r a t e of p o p u l a t i o n growth or d e c l i n e ( o p t i o n a l l y a g e - s p e c i f i c ) i n the area concerned (Rowan, 1975). 5 These agencies for the most part establish bed needs in accordance with the Hill-Burton Formula mentioned above. Also, experimental attempts at establishing broad-based data inventories have been funded (Derry et a l , 1968; Petrich and House, 1973). O f f i c i a l sources have indicated that the planning methods used in the U.S. w i l l shift away from the Hill-Burton Formula method (Rowan, 1975). The methodological trend has not yet emerged. However, the most recent legislation dealing with health services planning, the Health Planning and Resources Development Act of 1974 (U.S. Public Law 93-641), establishes a structure of federal, state and area health planning bodies that w i l l develop and implement new technical materials including methodology, policies and standards appropriate for use in health planning. Sweden In Sweden, the National Board of Health, along with the local government''', decided in 1954 to regionalize the planning of a l l personal health services for the 20-year span from 1955 through 1975. More recently, several regional planning agencies have updated those regional plans using similar or newer methods (Navarro, 1970). But, the overall strategy has been the formation of a national master plan. The master plan contained several concurrent planning a c t i v i t i e s : the selection of regional centres; the definition of optimal organization for medical f a c i l i t i e s within each region; the definition of the minimum demographic size of the regions for teaching; the planning for regional ambulatory care f a c i l i t i e s (Navarro, 1970). "'"A three tiered administration comprised of the region or province, the county and the commune. 6 There were t o be e i g h t r e g i o n a l c e n t e r s , but s e l e c t i o n of l o c a t i o n s was l i m i t e d by one of the main c o n s t r a i n t s i n the mandate set before the governmental commission i n charge of the master p l a n ; that'maximum advantage should be taken of e x i s t i n g f a c i l i t i e s (Navarro, 1970). There were f i v e c i t i e s already c o n t a i n i n g s i x teaching h o s p i t a l s s u i t a b l e as r e g i o n a l h o s p i t a l centers. Therefore, the problem was reduced t o s e l e c t i n g the two remaining centers. P o p u l a t i o n d e n s i t y maps, compiled f o r the p e r i o d 1955-75 using occupation and employment t r e n d data, t r a c e d the p o t e n t i a l socioeconomic and demographic development. By 1 2 superimposing these on i s o c h r o n i c and isodapan maps compiled f o r 11 a l t e r n a t i v e r e g i o n a l center c h o i c e s , i t was p o s s i b l e to choose the remaining two centers (Navarro, 1970). Both the o p t i o n a l o r g a n i z a t i o n of medical f a c i l i t i e s and the minimum demographic s i z e o f r e g i o n f o r teaching purposes were defined u s i n g a n a t i o n a l "expert's o p i n i o n " survey amongst a l l teaching h o s p i t a l department heads. To define the optimal o r g a n i z a t i o n of medical f a c i l i t i e s , they s p e c i f i e d the o r g a n i z a t i o n a l l e v e l - ( r e g i o n a l or community h o s p i t a l ) at which t h e i r s p e c i a l t y should occur, and the o p t i o n a l number of beds and p h y s i c i a n s t h a t ' s h o u l d be provided. To approximate the demographic s i z e o f the r e g i o n , f o r teaching purposes, department head estimates of the number of beds r e q u i r e d f o r a f u l l - t i m e ~*"A map presenting isochrones or l i n e s connecting p o i n t s of equal t r a v e l l i n g time from a c e n t r a l p o i n t . 2 A map w i t h isodapans or l i n e s j o i n i n g p o i n t s where t r a v e l l i n g cost from a c e n t r a l p o i n t are approximately' equal. 7 s e r v i c e were co-ordinated w i t h estimates of the r a t i o of beds to p o p u l a t i o n (Navarro, 1970). 1 The f u t u r e r e g i o n a l requirement f o r ambulatory care f a c i l i t i e s i n Goteburg (a r e g i o n a l d i v i s i o n ) was determined through an a n a l y s i s of u t i l i z a t i o n based on a r a t i o c a l l e d the "Consumption U n i t " : Mean annual number of p h y s i c i a n . v i s i t s 9 f o r e i g h t d i f f e r e n t age groups and three d i f f e r e n t f a c i l i t y types ( s o l o p r a c t i c e , group p r a c t i c e and Consumption h o s p i t a l O.P.D.s) Unit Mean annual number of p h y s i c i a n s f o r a l l age groups. The Consumption U n i t was c a l c u l a t e d from data a v a i l a b l e f o r the years 1955-1965. The t r e n d was then p r o j e c t e d t o y i e l d Consumer Unit estimates f o r the years 1966-1980. These estimates were transformed i n t o the "Consumption Volume Index" by m u l t i p l i c a t i o n w i t h the corresponding p r o j e c t e d p o p u l a t i o n f i g u r e f o r Goteburg. By comparing the Consumption•Volume Index f o r the current year and X F o r example, i f the head of p l a s t i c surgery decided t h a t 60 beds c o n s t i t u t e s the number of beds r e q u i r e d f o r a f u l l - t i m e s e r v i c e and the d e s i r e d r a t i o of p l a s t i c surgery beds t o p o p u l a t i o n i s 5.5 per 100,000 persons, then the minimum s i z e of the r e g i o n needed to support the department i s approximately 1 m i l l i o n persons [(60 x 100,000) ^ 5.5 ] Age was an important v a r i a b l e m the e s t i m a t i o n of f u t u r e u t i l i z a t i o n , because of the p o l a r i z e d age s t r u c t u r e i n the Swedish p o p u l a t i o n . 8 f u t u r e y e a r s , i t was p o s s i b l e to estimate the r e q u i r e d increment i n each type of ambulatory f a c i l i t y . ( i . e . a f o r e c a s t f i v e percent increase i n the Consumption Volume Index f o r 0..P.D.s would i n d i c a t e a corresponding increased need f o r f a c i l i t i e s ) . Separate estimates of the p o t e n t i a l changes i n the a v a i l a b i l i t y and p r o d u c t i v i t y of various ambulatory care resources i n f l u e n c e d the acceptance of the r e q u i r e d increments c a l c u l a t e d as above (Navarro, 1970). England and Wales U n t i l l a t e 1974-, h e a l t h care f a c i l i t y planning had not r e a l l y appeared i n England and Wales. At l e a s t not i n the same sense as i n the United States and Sweden. Before 1974, planning d e c i s i o n s were made i n an a r b i t r a r y and somewhat haphazard way by the s o c i a l e l i t e s (by popular e l e c t i o n , t r a i n i n g or c l a s s o r i g i n ) ; and the p o l i c i e s t r i c k l e d down to the lower echelons of the N a t i o n a l Health Service (N.H.S.) s t r u c t u r e , which had no f i s c a l r e s p o n s i b i l i t y (Anderson, 1971). There were no r e g i o n a l planning bodies. With the more recent developments surrounding the r e o r g a n i z a t i o n of the N.H.S., a r e g i o n a l l y - b a s e d planning system does appear to be emerging (Moss, 1975). Planning methods per se, have s t i l l not been • devulged, but there i s a c l e a r p o l i c y to delegate the r e s p o n s i b i l i t y f o r planning t o r e g i o n a l and lower l e v e l s of government i . e . : the Regional Health A u t h o r i t i e s , Area Health A u t h o r i t i e s and D i s t r i c t Health A u t h o r i t i e s . Plan r e v i s i o n s w i l l be made an n u a l l y , w i t h D i s t r i c t s . a n d Areas planning three years ahead and Regions planning 10 years ahead (Moss, 1975). 9 CHAPTER I I I PLANNING METHOD TRENDS IN BRITISH COLUMBIA In B r i t i s h Columbia there are three t i e r s i n the h o s p i t a l planning and a d m i n i s t r a t i v e h i e r a r c h y : the i n d i v i d u a l h o s p i t a l s ; the Regional H o s p i t a l D i s t r i c t Boards, composed mainly of r e p r e s e n t a t i v e s appointed by the Lieutenant Governor i n Co u n c i l or t r u s t e e s of each m u n i c i p a l i t y w i t h i n the r e g i o n ; and B r i t i s h Columbia H o s p i t a l Programs (B.C.H.P.), the bureau w i t h i n the Health M i n i s t r y r e s p o n s i b l e f o r h o s p i t a l planning and a d m i n i s t r a t i o n . Of these i n s t i t u t i o n s , the H o s p i t a l s and the Regional H o s p i t a l D i s t r i c t Boards do most of the h e a l t h care f a c i l i t y planning. The Regional H o s p i t a l D i s t r i c t Boards planning e f f o r t s p r i m a r i l y i n v o l v e r e g i o n a l survey r e p o r t s t o e s t a b l i s h f u t u r e s e r v i c e needs at the r e h a b i l i t a t i v e , c hronic or acute l e v e l s of c a r e \ while h o s p i t a l s e f f o r t s center on e s t a b l i s h i n g the f a c i l i t y requirements f o r fut u r e changes to t h e i r own p h y s i c a l p l a n t . (O'Toole, 1974; Brawn, 1975). I t i s beyond the scope of t h i s study t o examine a l l the planning methods used by the B.C. Regional H o s p i t a l D i s t r i c t Boards and the B.C. H o s p i t a l s . However, i t i s appropriate t o examine the general method that has been used by the H o s p i t a l s (O'Toole, 1974; Brawn, 1975; Richardson, 1975) "'"Example r e p o r t s compiled f o r the Greater Vancouver Regional H o s p i t a l D i s t r i c t Board Advisory Committee are the Emergency Medical Services Report, 1970 and the Day Care F a c i l i t i e s Study, 1973. 10 and t o a more l i m i t e d extent by the Regional H o s p i t a l D i s t r i c t s (Emergency Medical Services Report, 1970; Purdy, 1972) f o r s p e c i f y i n g the f a c i l i t y requirements i n proposed h o s p i t a l developments. The f i r s t step i n t h i s g e n e r a l i z e d example i s t o gather h i s t o r i c a l data r e l a t i n g the number of s e r v i c e u n i t s ( p a t i e n t days, examinations, v i s i t s , e tc.) per year f o r the f a c i l i t y area(s) (emergency department, r a d i o l o g i c a l s u i t e , n u r s i n g u n i t ) being planned. The second step i s to determine the data trend e x h i b i t e d by the h i s t o r i c a l data, when extended t o a f u t u r e p o i n t i n time, w i t h appropriate a t t e n t i o n t o the p o s s i b l e i n f l u e n c e s of corresponding p o p u l a t i o n , demographic and h e a l t h care d e l i v e r y trends. In some cases t h i s step i s s h o r t -c i r c u i t e d , as w i t h the planning of r a d i o l o g i c a l s e r v i c e s , where a r e g u l a t o r y body (the R a d i o l o g i c a l Advisory C o u n c i l t o the B.C. Government i n t h i s case) has deemed a f i x e d r a t i o of examinations per p o p u l a t i o n per year (e.g. 400/1000/year) as an appropriate i n d i c a t o r of workload. The workload i n d i c a t o r may be adopted from previous r e p o r t s or based on accepted norms suggested by B.C.H.P. c o n s u l t a n t s ; i n s t e a d of being e s t a b l i s h e d through a separate examination of the r e l a t e d experience at the time of the planning study. To i l l u s t r a t e the g e n e r a l i z e d example, one might consider the planning technique used to s p e c i f y beds f o r a medical n u r s i n g u n i t enlargement. The h i s t o r i c a l r e c o r d of p a t i e n t days/year are p r o j e c t e d t o a f u t u r e year; adjustments are made to account f o r changing p o p u l a t i o n trends, the development of a competing f a c i l i t y or other extraneous f a c t o r s . Then the r e s u l t i n g workload i s d i v i d e d by the i n d i c a t o r of 11 workload per s e r v i c e area, i n t h i s case the occupancy r a t e (probably 85%), to i n d i c a t e the beds r e q u i r e d i . e . : P r o j e c t e d p a t i e n t days per medical Beds r e q u i r e d = n u r s i n g u n i t enlargement  .85 x 365 days One s i g n i f i c a n t departure from the g e n e r a l i z e d planning method was the.study of ambulatory f a c i l i t y requirements f o r the B r i t i s h Columbia Medical Centre (B.C.M.C.) (Anderson, 1974). This study used s e v e r a l methods to derive p a t i e n t and p r o f e s s i o n a l s t a f f volume p r o j e c t i o n s , but emphasized an "experts' o p i n i o n p o l l " method-somewhat s i m i l a r to t h a t used i n Sweden (Chapter I I ) t o a s c e r t a i n the best d i s t r i b u t i o n of medical and s u r g i c a l s p e c i a l t i e s amongst the h o s p i t a l s w i t h i n the r e g i o n . A questionnaire was c i r c u l a t e d t o the chairmen f o r a number of c l i n i c a l s p e c i a l t y task committees; asking t h a t they comment on s e v e r a l s e r v i c e parameters t h a t would de p i c t t h e i r proposed s p e c i a l t y c l i n i c s (e.g. expected average d a i l y p a t i e n t l o a d , per 5-day week; maximum.patient load per day or per 3-hour time b l o c k ; geographic f u l l - t i m e (G.F.T.) and f u l l - t i m e (F.T.) p r o f e s s i o n a l s t a f f r e q u i r e d f o r the c l i n i c concerned; d e s i r a b i l i t y of s h a r i n g f a c i l i t i e s w i t h other c l i n i c s ) two years a f t e r the ambulatory care f a c i l i t y was opened. Fol l o w i n g a subsequent i n f o r m a l meeting of chairmen t o di s c u s s a p r e l i m i n a r y r e p o r t r e l a t i n g t h e i r estimates, a summary o f the s e r v i c e parameters f o r each s p e c i a l t y c l i n i c was produced. For some of the proposed s p e c i a l t y c l i n i c s i n s u f f i c i e n t ' in f o r m a t i o n was provided f o r the e s t i m a t i o n of a l l the s e r v i c e parameters. In these cases, 12 the parameters were estimated using other methods based on p r o f e s s i o n a l judgment f a c t o r s and a l t e r n a t e data sources e.g.: i n the absence of a questionnaire estimate o f the G.F.T. and F.T. p r o f e s s i o n a l s t a f f , a judgment was made based on the expected medical school enrolment f o r 1979; i n the absence of a que s t i o n n a i r e estimate of the p a t i e n t workload, an approximation was made by c a l c u l a t i n g the average workload per p h y s i c i a n w i t h i n the Greater Vancouver Regional H o s p i t a l D i s t r i c t and m u l t i p l y i n g by the estimate of G.F.T. and F.T. s t a f f . 13 CHAPTER IV PLANNING AMBULATORY CARE FACILITIES IN BRITISH COLUMBIA An ambulatory care f a c i l i t y i s r u d i m e n t a r i l y d i f f e r e n t from a h o s p i t a l . I t contains no beds, i n the t r a d i t i o n a l i n p a t i e n t sense and processes p a t i e n t s t h a t , on the average, r e q u i r e l e s s complicated examinations or treatment. I t i s t h e r e f o r e r a t h e r i n a p p r o p r i a t e to adopt a planning method f o r ambulatory care f a c i l i t y planning t h a t i s s p e c i f i c a l l y t a i l o r e d t o the planning of h o s p i t a l f a c i l i t i e s . The prime question i s one of adaptation; can a method l i k e the g e n e r a l i z e d h o s p i t a l planning method, discussed i n the previous s e c t i o n and widely used i n B.C. f o r h o s p i t a l f a c i l i t y p l a n n i n g , be used f o r ambulatory care f a c i l i t y planning? The answer must c l e a r l y be n e g a t i v e , because t h i s method i s c r i t i c a l l y dependant on the assumption t h a t the workload c a p a b i l i t y per year (or other u n i t of time) i s known f o r every s e r v i c e u n i t ( h o s p i t a l bed, examination room, x-ray room, e t c . ) w i t h i n the f a c i l i t y being planned. There j u s t are no ambulatory care f a c i l i t i e s i n B.C. suburban communities than can y i e l d t h i s type of e x p e r i e n t i a l data. Even i f t h i s data were a v a i l a b l e , i t probably would be community-s p e c i f i c , i . e . h i g h l y dependant on the indigenous types and numbers of ambulatory cases. There are a l t e r n a t i v e planning methods. • In the summary of planning method trends i n other c o u n t r i e s (Chapter I ) , i t was noted t h a t 14 i n Sweden, ambulatory care f a c i l i t i e s were planned by: c o l l e c t i n g h i s t o r i c a l data from s o l o p r a c t i c e s , group p r a c t i c e s and h o s p i t a l out-p a t i e n t departments; p r o j e c t i n g the data t r e n d s ; and making p r o v i s i o n f o r p r o p ortionate reductions or. enlargements t o each of the three f a c i l i t y types. I f i t was not f o r the inadequacies i n the data a v a i l a b l e from h o s p i t a l s and p r i v a t e p r a c t i t i o n e r s i n B.C., t h i s general approach would be v i a b l e . At present, the data a v a i l a b l e from p r i v a t e p r a c t i t i o n e r s are not disaggregated according to the geographic o r i g i n of the p a t i e n t 1 . Therefore, i t i s impossible to assemble data r e f l e c t i n g the need i n a geographic area. A l s o , there i s no general agreement from h o s p i t a l experts on what should be i n c l u d e d under the r u b r i c "ambulatory care procedures". Thus, i t i s o f t e n impossible t o d i s t i n g u i s h ambulatory from i n p a t i e n t procedures. The method suggested below (Chapter V) i s a f u r t h e r . a l t e r n a t i v e . I t makes allowances f o r the data inadequacies (as discussed I n Chapter V I I ) and attempts to a l l e v i a t e the incongruence between.the g e n e r a l i z e d h o s p i t a l planning method and the t a s k . o f planning an ambulatory care f a c i l i t y , by completely i g n o r i n g e s t a b l i s h e d i n d i c a t o r s of the workload c a p a b i l i t y f o r s e r v i c e u n i t s . I t takes r e a d i l y a v a i l a b l e data f o r Medical Service Commission (M.S.C.) and B r i t i s h Columbia Hospital'Programs (B.C.H.P.) tapes; determines the workload or the number of ambulatory procedures t h a t w i l l be done i n the f a c i l i t y being planned; and f i n a l l y produces an i n d i c a t i o n "'"Because of the payment mechanism f o r c e r t a i n employed groups, the p a t i e n t ' s f i l e does not always l i s t h i s home address. 15 of the number of work areas and/or s t a f f t h a t w i l l be r e q u i r e d t o meet the need i n a s p e c i f i e d f u t u r e y e a r ( s ) . One f u r t h e r a t t r i b u t e of the method i s the d e t a i l t h a t can be i n c o r p o r a t e d i n t o the planning a n a l y s i s . I f , f o r i n s t a n c e , there was some controversy over whether a cystoscopy room should be i n c l u d e d i n a proposed s u r g i c a l s u i t e , one could program a sub-analysis o r - r e - a n a l y s i s or the p r o j e c t e d work flow s i m u l a t i o n f o r the s u r g i c a l s u i t e , but j u s t f o r cystoscopy procedures. From t h i s sub-analysis or r e - a n a l y s i s , i t would be q u i t e c l e a r how o f t e n a proposed cystoscopy room would be used and thus whether i t was warranted. 16 CHAPTER V METHODOLOGY Data The data used was two computer records stored at the U n i v e r s i t y of B r i t i s h Columbia i n the D i v i s i o n of Health S e r v i c e s , Research and Development,'Office o f the Co-ordinator (the Medical Services Commission (M.S.C.) p r o f i l e tape and B.C. H o s p i t a l Programs (B.C.H.P.) t a p e s 1 ) , s u b j e c t i v e input from s e l e c t e d h e a l t h care consultants and ques t i o n n a i r e i n f o r m a t i o n provided by d e n t i s t s and ph y s i c i a n s p r a c t i c i n g i n the. Delta area. S p e c i f i c notes about these data sources are given below: (1) The M.S.C. tape was a record of i n d i v i d u a l p h y s i c i a n p r o f i l e s which i t e m i z e d and ca t e g o r i z e d the type and number of procedures performed by each p h y s i c i a n i n B.C.; (2) The B.C. H o s p i t a l Programs tapes i n d i c a t e d the p h y s i c i a n and school d i s t r i c t f o r each se p a r a t i o n from an acute or extended care h o s p i t a l ; (3) The s u b j e c t i v e input from s e l e c t e d h e a l t h care consultants was mainly a s s i s t a n c e w i t h the comp i l a t i o n of a l i s t o f ambulatory medical and s u r g i c a l procedures (Appendix A) and the r e l a t e d Release o f t h i s data was approved by W. J . L y l e , Deputy M i n i s t e r , H o s p i t a l and Medical Programs, p e r s o n a l ' l e t t e r ; and G. Stewart, Chairman, M.S.C, personal l e t t e r . 17 p h y s i c i a n times and nu r s i n g times a s s o c i a t e d w i t h each procedure; (4) By completing q u e s t i o n n a i r e s , (Appendix B) the p h y s i c i a n s i n the Del t a area r a t i f i e d the l i s t of ambulatory medical and s u r g i c a l procedures suggested by the medical consultants and provided an estimate of the percentage of time these would be performed on an emergent, as opposed t o a non-emergent b a s i s ) . (5) The questionnaires (Appendix C) completed by the d e n t i s t s i n the Delta area r a t i f i e d a suggested l i s t of d e n t a l day care pro-cedures ; l i s t e d the numbers of procedures r o u t i n e l y performed or r e f e r r e d to an o r a l surgeon; and e s t a b l i s h e d the performance time r e q u i r e d f o r each procedure. Procedure A p r o v i s i o n a l l i s t of ambulatory medical and s u r g i c a l procedures (Appendix A) was compiled by Dr. R. B. Kerr (1975) and Dr. Louis Kanee (1975) us i n g the B.C. College of P h y s i c i a n s and Surgeons fee schedule (1973) as a g u i d e l i n e . This l i s t was presented along with i n s t r u c t i o n s f o r i t s r a t i f i c a t i o n t o the members of the Delta Medical S o c i e t y ; who were i n d i c a t e d as probably the prime users of the proposed Ambulatory Care F a c i l i t y . B a s i c a l l y , each p h y s i c i a n was asked t o s t a t e whether or not he agreed'that the proposed l i s t of ambulatory medical and s u r g i c a l procedures was a complete l i s t i n g o f the types of medical and s u r g i c a l procedures that would probably be performed at the proposed Ambulatory Care F a c i l i t y . The o p t i o n was l e f t f o r him t o make a d d i t i o n s t o the l i s t . 18 When a s a t i s f a c t o r y l i s t had been d e r i v e d , he was asked t o estimate the percentage of time t h a t each procedure would be performed i n the proposed f a c i l i t y on e i t h e r (1) an emergent or (2) a non-emergent b a s i s . After- the l i s t of medical and s u r g i c a l procedures had been r a t i f i e d by De l t a p h y s i c i a n s , the B.C.H.P. se p a r a t i o n tapes were examined f o r the calendar years 1971 and 1973. F o l l o w i n g one i t e r a t i o n of the tape, f o r each year, a percentage f i g u r e was assigned t o each p h y s i c i a n who had rel e a s e d a Delta r e s i d e n t from hospital-, thus i n d i c a t i n g the percentage of D e l t a r e s i d e n t versus other M u n i c i p a l i t y r e s i d e n t h o s p i t a l separations i n t h a t p h y s i c i a n ' s p r a c t i c e . The p h y s i c i a n ' i d e n t i f i c a t i o n - n u m b e r on the B.C.H.P. se p a r a t i o n tapes was then cross-matched/with p h y s i c i a n i d e n t i f i c a t i o n numbers on the M.S.C. tapes f o r each of the two years examined. Those numbers on the B.C.H.P. tapes that d i d not match with any p h y s i c i a n number on the M.S.C. tapes were a l l examined. B.C.H.P. p h y s i c i a n i d e n t i f i c a t i o n numbers unknown t o the M.S.C. ( i . e . t h a t d i d not match with- a M.S.C. i d e n t i f i c a t i o n number from any B.C. Regional D i s t r i c t ) were ignored because they-were b e l i e v e d to belong to h o s p i t a l i n t e r n or r e s i d e n t s t a f f 1 . B.C.H.P. p h y s i c i a n i d e n t i f i c a t i o n numbers that d i d match with a M.S.C-. i d e n t i f i c a t i o n number f o r a p h y s i c i a n i n a Regional D i s t r i c t other than the G.V.R.D. were a l s o not used. These p a t i e n t s were probably non-resident admissions i n other areas as a r e s u l t o f t r a v e l or a c c i d e n t s , and thus would not be r e l e v a n t t o the planning of D e l t a h e a l t h care f a c i l i t i e s . The l i s t of M.S.C. p h y s i c i a n i d e n t i f i c a t i o n numbers that remained was subsequently used t o withdraw p h y s i c i a n p r o f i l e s (a q u a n t i t a t i v e l i s t i n g "'"There were only 4- cases i n v o l v i n g 23 separa t i o n s . 19 of procedures performed by any one p h y s i c i a n ) f o r each G.V.R.D. p h y s i c i a n who t r e a t e d D elta r e s i d e n t s . Each procedural item on the p r o f i l e s was m u l t i p l i e d by the separation percentage, f o r the r e l e v a n t p h y s i c i a n , from the B.C.H.P. separation tape, to y i e l d an estimate of the percentage of time t h a t procedural item was performed f o r a D e l t a r e s i d e n t . The p r o f i l e s were theni;compiled across p h y s i c i a n s , by the ambulatory medical and s u r g i c a l procedure items mentioned above. Each procedure i n the compiled p h y s i c i a n p r o f i l e s f o r 1971-2 and 1973-4 was subsequently p r o j e c t e d t o the Target Years 1978 and 1982, using a simple computer program. A l i n e a r t r e n d curve was assumed f o r the p r o j e c t i o n of each procedure. The formula used f o r the p r o j e c t i o n s f o l l o w s below: where: J=78,82 X=occurrences of a procedure. (Wertz, 1975) The data generated were the t o t a l number of times t h a t each procedure would l i k e l y occur i n the Target Years 1978 and 1982. These numerical estimates i n c l u d e d both emergent and non-emergent occurrences. To separate the emergent occurrences of each procedure, each t o t a l d e rived above was m u l t i p l i e d by the percentage estimate deemed by Delta p h y s i c i a n s to represent the percentage of time t h a t the procedure i n v o l v e d would be performed on an emergent b a s i s . By s u b t r a c t i n g the 20 d e r i v e d number of emergent occurrences from the t o t a l occurrences f o r each procedure, the number of non-emergent occurrences was a l s o d e r i v e d . The d e n t a l day care procedures l i s t e d on the questionnaire c i r c u l a t e d to Delta d e n t i s t s were added t o the l i s t of ambulatory medical and s u r g i c a l procedures. The responses regarding the estimated number of each procedure that would be performed, per month, were m u l t i p l i e d by twelve; p r o j e c t e d to 1978 and 1982, i n accordance w i t h the expected po p u l a t i o n t r e n d (Lambert, 1975j\ and d i v i d e d i n t o emergent and non-emergent occurrences, as i n d i c a t e d f o r each procedure. This data was then added to the body of data f o r ambulatory medical and s u r g i c a l procedures discussed above. Because the Delta Ambulatory Care F a c i l i t y w i l l not o f f e r s e r v i c e s , except during the day s h i f t (0800-1700 h o u r s ) , i t was necessary to assume t h a t a percentage of the emergent occurrences foreseen f o r 1978 and 1982 would a c t u a l l y be performed by other h e a l t h care i n s t i t u t i o n s . The percentage assumed was 50% of the emergent occurrences. The estimated emergent and non-emergent occurrences, f o r a l l procedures and i n both Target Years, were then subjected t o a General Purposes Simulation System (G.P.S.S.) ( S c h r i b e r , 1974) a n a l y s i s . The d e t a i l s o f how the G.P.S.S. a n a l y s i s was implemented can be determined from the steps i n the computer a n a l y s i s performed by Hastings (1976) (See Appendix D). However, t o a s s i s t those not versed i n G.P.S.S., the l o g i c steps behind t h i s a p p l i c a t i o n are expressed below. Before the s i m u l a t i o n could be performed the ambulatory d e n t a l , medical and s u r g i c a l procedures, presented i n Appendices A and C, had t o be "'"The l i n e a r p r o j e c t i o n f o r medical and s u r g i c a l s e r v i c e s was assumed to i n c l u d e p o p u l a t i o n growth. 21 regrouped. Three groupings were d e r i v e d , with the a i d of medical c o n s u l t a n t s ( K e r r , 1975 and Kanee, 1975): 1. Emergency Procedures, i n c l u d i n g a l l medical and minor s u r g i c a l procedures that would normally be performed i n an Emergency Services Area or Department; 2. Medical Day Care Procedures, i n c l u d i n g a l l non-emergent medical procedures t h a t would normally be performed i n a Medical Day Care Services Area; 3. S u r g i c a l Day Care Procedures, i n c l u d i n g a l l d e n t a l and s u r g i c a l procedures t h a t would normally be performed i n a S u r g i c a l Day Care Services Area ( s u r g i c a l s u i t e ) . Thus, the r e s u l t i n g l i s t s of procedures described the type of procedural a c t i v i t i e s l i k e l y to be performed i n three f a c i l i t y areas. The f i r s t step i n the s i m u l a t i o n procedure was t o randomly a s s i g n the occurrences of each procedure t o the days i n the Target Year, 1978 and 1982. The s t r u c t u r e of the computer s i m u l a t i o n language (G.P.S.S.) made i t necessary t o assign the occurrences using two methods. The s i m u l a t i o n language normally simulates s t o c h a s t i c occurrences by randomly va r y i n g the time between occurrences ( i . e . i n t e r - a r r i v a l t i m e ) . This method i s most e f f e c t i v e when the occurrences, w i t h i n a time span, are r e l a t i v e l y l a r ge i n number. In the s i m u l a t i o n performed, the number of procedural occurrences per year v a r i e d from only one to s e v e r a l hundred. The i n t e r - a r r i v a l time method would not give v a l i d simulated r e s u l t s when a p p l i e d t o ambulatory procedures w i t h only a few occurrences per year. 22 The assignment method used f o r high volume procedures randomly v a r i e s the i n t e r - a r r i v a l time using an exponential d i s t r i b u t i o n . A value from the exponential d i s t r i b u t i o n i s obtained by using a random number. This value i s then m u l t i p l i e d by the average i n t e r - a r r i v a l time (the average having been derived w i t h the d i v i s i o n of the annual number of working days by the f o r e c a s t annual number of occurrences). This randomized i n t e r - a r r i v a l time i s then added to the time of the previous occurrence g i v i n g the s p e c i f i c hour of the next s e q u e n t i a l occurrence. The assignment of low volume procedural occurrences was accomplished by randomly designating a week of a r r i v a l and s o r t i n g the occurrences i n ascending order of a r r i v a l week; f i r s t week t o 52nd week. The occurrences of each week were then randomly assigned an hour of a r r i v a l and, f i n a l l y , s o r t e d i n ascending order of a r r i v a l hour. The second step i n v o l v e d a s s i g n i n g to each occurrence of each procedure, the values f o r ten d e s c r i p t i v e parameters: 1. The code number f o r the procedure. . 2. The number of 15-minute time blocks r e q u i r e d t o perform each procedure. 3. The average time r e q u i r e d t o perform each procedure, as i n d i c a t e d by the questionnaire c i r c u l a t e d t o Delta p r a c t i t i o n e r s and co n s u l t a n t s . 4. One standard d e v i a t i o n of the average time recorded as parameter 3. 5. The week ( i n e i t h e r 1978 or 1982) to which the p a r t i c u l a r occurrence has been assigned. 23 6. The hour i n the week ( i n e i t h e r 1978 or 1982) to which the p a r t i c u l a r occurrence has been assigned. 7. The code number of the p a r t i c u l a r f a c i l i t y s e r v i c e area(s) (O.R., examination room, etc.) to be used. 8. The time each procedure j o i n e d the queues i n the s i m u l a t i o n . 9. The numeric name of the memory l o c a t i o n that h e l d records of the cumulative u t i l i z a t i o n f o r the O.R. s e l e c t e d . 10. The r e a l time r e q u i r e d t o perform each occurrence. In the t h i r d s t e p , a l l the procedural occurrences f o r both Target Years were stacked according t o two p r i o r i t i e s : 1. In what week they would occur (Parameter 5) and 2. In what hour of the week they would occur (Parameter 6). Choosing the f a c i l i t y work area (O.R., examination room, etc.) where each procedural occurrence would happen was the f o u r t h step i n the s i m u l a t i o n . For each day of the two Target Years, s t a r t i n g at the f i r s t day, procedural occurrences were assigned t o the f a c i l i t y work area with the lowest cumulative booking time f o r th a t day. I f other procedural occurrences, with e a r l i e r occurrence times (Parameter 6 ) , had already taken a l l the time a v a i l a b l e on the day i n q u e s t i o n , the procedural occurrence was given p r i o r i t y on the next day. ' I f the procedural occurrence was emergent, i t pre-empted a l l non-emergent procedural occurrences t h a t were w a i t i n g at the time the emergent procedural occurrence.was scheduled t o happen (Parameter 8). 24 Once the procedural occurrences had a l l been stacked i n order of occurrence and assigned t o a f a c i l i t y work area, each was given a r e a l procedure time i . e . , the time r e q u i r e d to perform the procedure, given a c e r t a i n l e v e l of u n c e r t a i n t y '(Parameter 10). The time was a l l o t t e d based on the average time r e q u i r e d (Parameter 3) +_ a randomly assigned percentage o f two standard d e v i a t i o n s from the'mean (Parameter 4). In a d d i t i o n , s u r g i c a l procedural occurrences, r e q u i r i n g an ana e s t h e t i c were a l l o t t e d times r e p r e s e n t i n g the time spent i n the Post-Anaesthetic Recovery Room and/or the S u r g i c a l Day Care Holding Area (an area where s u r g i c a l p a t i e n t s recuperate before going home). These va l u e s , r e s p e c t i v e l y , were: a mean of 35 minutes - t a randomly assigned percentage of two standard d e v i a t i o n s (3 min.) and a mean of 210 minutes + a randomly assigned percentage of 2 standard d e v i a t i o n s (15 m i n . ) 1 . At the end of every day simulated i n the Target Years, a . t a b u l a t i o n was made of the average w a i t i n g time experienced by each procedural occurrence and the percentage u t i l i z a t i o n of r e l e v a n t ' f a c i l i t y work areas. By v a r y i n g the s i z e of the f a c i l i t y work areas, (e.g. the number of O.R.s, P.A.R.R. beds or holding'room beds), through i t e r a t i o n s of the s i m u l a t i o n , i t was p o s s i b l e to approach'optimal average w a i t i n g time estimates and optimal f a c i l i t y work area u t i l i z a t i o n estimates - provided by the Delta H o s p i t a l A d m i n i s t r a t i o n . "'"Both these values were adjudged-by a medical c o n s u l t a n t . 25 CHAPTER VI RESULTS The r e s u l t s discussed below are grouped i n t o three s e c t i o n s : Questionnaires, P r o j e c t i o n of Data, and S i m u l a t i o n ; i n correspondence with the approximate d i v i s i o n s i n the method (Chapter V). Questionnaires Questionnaire to Delta P h y s i c i a n s . Of the 20 questionnaires c i r c u l a t e d , 13 were returned and of these only 8 were s u f f i c i e n t l y complete to be used. Because of t h i s s m a l l usable r e t u r n and considerable v a r i a t i o n i n the percentage estimates expressed f o r some procedures, a mode was used as the p o i n t o f c e n t r a l tendency, f o r a l l percentage estimates, f o r a l l procedures l i s t e d i n Appendix A 1. Questionnaire t o Dental Surgeons. Eleven of the 28 questionnaires d i s t r i b u t e d were returned. A l l were usable. The mean estimates of the procedure time r e q u i r e d and the number of procedures l i k e t o be per-formed per year were recorded f o r a l l procedures l i s t e d i n Appendix C 1. P r o j e c t i o n of Data Dental, Medical and S u r g i c a l Procedures. The t o t a l number of emergent and non-emergent procedures f o r e c a s t f o r s t h e Target Years 1978 "'"The numerical questionnaire r e s u l t s are not reproduced here, because of t h e i r length and d e t a i l ; but they are a v a i l a b l e from-the author. 26 and 1982 are reported below, by Ambulatory Care F a c i l i t y Service area. T h i r t e e n of the procedures l i s t e d i n Appendix A were not pr o j e c t e d . TABLE I NUMBER OF EMERGENT AND NON-EMERGENT PROCEDURAL OCCURRENCES FORECAST FOR 1978 AND 1982 BY SERVICE AREA Ambulatory Care F a c i l i t y Service Area Medical Day Care Services Emergency Services S u r g i c a l Day Care Services ( i n c l u d i n g Dental Se r v i c e s ) 1 Target Year 1978 IS 82 Emergent Non-Emergent Emergent Non-Emergent 4106 ' 1348 837 4182 5524 2024 1042 5602 T o t a l 5454 5019 7548 6644 27 Simulation The G.P.S.S. a n a l y s i s o f Ambulatory Care F a c i l i t y s e r v i c e areas was only performed f o r one s e r v i c e area, S u r g i c a l Day Care S e r v i c e s 1 . The r e s u l t s are l i s t e d below f o r a s e r v i c e area w i t h three operating rooms; 2 t h i s was the optimal s i t u a t i o n . • TABLE I I WAITING TIMES AND UTILIZATION IN THE SURGICAL DAY CARE SERVICES WORK AREAS Work Area Size Average Waiting Time (min./occur-rence ) U t i l i z a t i o n (per-cent of time/day) 1978 3 1982 1978 3 1982 Operating Room 3 (rooms) 37 ' _ 65 P.A.R.R. 5 (beds) 0 33 Holding Room 19 (beds) 0 38 See Discussion - P r o j e c t i o n of Data Attempts were a l s o made t o simulate the s e r v i c e area w i t h 2 and 4 o.R.s A c t u a l s i m u l a t i o n was c a r r i e d out f o r 1982 o n l y , see D i s c u s s i o n . 28 CHAPTER VII DISCUSSION The Disc u s s i o n i s d i v i d e d i n t o three s e c t i o n s corresponding t o those i n the Results chapter; Questionnaires, P r o j e c t i o n of Data and Simulation. Questionnaires Both questionnaires were i n v o l v e d and r e p e t i t i v e and the questionnaire to Delta p h y s i c i a n s was quite long (10 pages; see Appendix A). To at l e a s t p a r t i a l l y r e l i e v e the p u n i t i v e e f f e c t of performing an i n v o l v e d and r e p e t i t i v e t a s k , an i n t e r v i e w e r should have d e l i v e r e d the q u e s t i o n n a i r e s , given a c l e a r explanation of the task s t r e s s i n g i t s importance and a s s i s t e d the respondent with a few sample e n t r i e s . A complete lack of funds f o r t e c h n i c a l a s s i s t a n c e precluded t h i s course of events and n e c e s s i t a t e d r e s o r t i n g to a mailed q u e s t i o n n a i r e . In any subsequent planning attempts using t h i s method, the need f o r i n t e r v i e w i n g a s s i s t a n c e could be reduced by t a k i n g a simple random sample o f the p r a c t i t i o n e r p o p u l a t i o n . The length of the questionnaire to Delta p h y s i c i a n s c o u l d have been reduced by randomly c i r c u l a t i n g p a r ts of the o r i g i n a l q u e s t i o n n a i r e t o the p h y s i c i a n s concerned. Medical and S u r g i c a l Questionnaire. From the c o l l e c t i o n of q u e s t i o n n a i r e 29 r e s u l t s to the time when the s i m u l a t i o n of the proposed f a c i l i t y was undertaken, a number of procedures, o r i g i n a l l y defined as ambulatory care procedures, were deleted. These d e l e t i o n s were made by the medical c o n s u l t a n t s , because they were e i t h e r no longer considered appropriate f o r the d e f i n i t i o n o f ambulatory care or not r e q u i r e d t o define the s e r v i c e s areas forseen f o r the De l t a Ambulatory Care F a c i l i t y . These procedures do not appear i n Appendix A 1. Data P r o j e c t i o n Some of the medical and s u r g i c a l procedures l i s t e d i n Appendix A, could not be p r o j e c t e d to the Target Years, because there was e i t h e r i n s u f f i c i e n t data a v a i l a b l e or a negative number of procedures i n d i c a t e d f o r both o f the Target Years. When there was a negative p r o j e c t i o n , the pr o j e c t e d values were assumed t o be zero. A f t e r the data p r o j e c t i o n s had been performed, i t was decided by the Delta H o s p i t a l a d m i n i s t r a t i o n t h a t there was i n s u f f i c i e n t need demonstrated to warrant the separation of the Medical Day Care Services from Emergency S e r v i c e s , and the Dental Day Care Services from the S u r g i c a l Day Care S e r v i c e s . Therefore, these four s e r v i c e s , o r i g i n a l l y considered to need t h e i r own dedicated space and s t a f f , were combined under two t i t l e s : Emergency Services and S u r g i c a l Day Care S e r v i c e s . In a d d i t i o n , i t was decided t h a t minor s u r g i c a l procedures would be performed i n the Emergency Services area. Thus, three procedures ^A l i s t of the deleted procedures i s a v a i l a b l e from the author. 30 o r i g i n a l l y l i s t e d under S u r g i c a l Day Care Services i n Appendix A (procedures #7021, 7034 6 7035) were reassigned t o Emergency S e r v i c e s . The Audiology Services and R e s p i r a t o r y Function T e s t i n g Services were de l e t e d a l t o g e t h e r . The Delta H o s p i t a l a d m i n i s t r a t i o n , i n c o n s u l t a t i o n with i t s medical a d v i s o r s , deemed th a t a u d i o l o g i c a l s e r v i c e s would be more a p p r o p r i a t e l y provided at a secondary or t e r t i a r y care i n s t i t u t i o n . The R e s p i r a t o r y Function T e s t i n g Services were absorbed by the P h y s i c a l , Occupational and Other R e h a b i l i t a t i o n S e r v i c e s . The workload f o r these s e r v i c e s was c a l c u l a t e d u s i n g a method d i f f e r e n t from the one discussed h e r e i n . The method used f o r p r o j e c t i n g the number of medical and s u r g i c a l procedures that would be done i n the Target Years was h i g h l y dependant on the inherent q u a l i t i e s of the data sources. U n f o r t u n a t e l y , the primary data source, the M.S.C. p h y s i c i a n p r o f i l e computer f i l e , was not as good as i t might have been. While each occurrence of a procedure was recorded i n i t under a p h y s i c i a n ' s b i l l i n g number, there was no corresponding record of when the procedure was performed or the geographic o r i g i n of the p a t i e n t i n v o l v e d . As a r e s u l t , estimations of both seasonal f l u c t u a t i o n s i n the performance of a procedure(s) and how many procedures were performed i n a p r e s c r i b e d catchment area, per u n i t time, were d i f f i c u l t to c a l c u l a t e . S e a s o n a l i t y was ignored i n the study,'on the advice of my t h e s i s a d v i s o r s . However, i t was necessary to determine how many procedures would be per-formed i n the D e l t a catchment area, to which the Ambulatory Care F a c i l i t y would l i m i t i t s s e r v i c e . The p r o j e c t i o n method chosen, presumed t h a t the r a t e at which ph y s i c i a n s discharged Delta p a t i e n t s from h o s p i t a l would be p r o p o r t i o n a l 31 to the percentage of Delta p a t i e n t s i n t h e i r caseload . Assuming t h i s p o s t u l a t e was t r u e , i t was p o s s i b l e t o simply m u l t i p l y " t h e occurrences of each procedure i n each G.V.R.D. ph y s i c i a n ' s caseload by the ra t e at which he discharged Delta p a t i e n t s and a r r i v e at the number o f occurrences p e r t i n e n t t o Delta p a t i e n t s . U n f o r t u n a t e l y , when the data p r o j e c t e d to the Target Years was examined,"it was discovered t h a t the f o r e c a s t f o r those procedures aggregated as Emergency Services was consider a b l y lower than.the present u t i l i z a t i o n r a t e s at e x i s t i n g comparable i n s t i t u t i o n s . 1 This apparent under-estimation of emergency procedures was a t t r i b u t e d t o the sep a r a t i o n percentage f i g u r e assigned t o each G.V.R.D. p h y s i c i a n (pp. 18-19). As explai n e d i n Chapter V, t h i s s e paration percentage reduced the f o r e c a s t number of occurrences f o r the G.V.R.D. t o j u s t the number of occurrences f o r e c a s t f o r De l t a . In order f o r t h i s r e d u c t i o n t o produce a v a l i d f o r e c a s t , the s e p a r a t i o n percentage had t o be an accurate i n d i c a t o r of percentage of time t h a t G.V.R.D. ph y s i c i a n s performed emergency procedures f o r De l t a r e s i d e n t s . I t i s qu i t e p o s s i b l e t h a t the sep a r a t i o n percentage under-estimated the number of emergency procedures performed f o r De l t a r e s i d e n t s , because c e r t a i n G.V.R.D. p h y s i c i a n s performed more procedures than the separation percentages i n d i c a t e d . "'"Incidence r a t e s of h o s p i t a l discharges i n the G.V.R.H.D., by each I.CD.A.-8 c l a s s , were comparable f o r 1971 and 1973 as were the t o t a l number.of cases per age group (B.C. Health S e r v i c e s , 1971 S 1973). There-f o r e , the percentage o f discharges taken i n those two ye a r s , by G.V.R.H.D. p h y s i c i a n s , f o r D e l t a r e s i d e n t s , was probably not biased by abnormally high occurrences of cases i n c e r t a i n L CD.A.-8 c l a s s e s or s p e c i f i c age groups. 32 As one might surmise from the above discussion,, the low number of emergency procedures f o r e c a s t precluded'the s i m u l a t i o n of the Emergency Services area. Simulation As explained i n the preceding p o r t i o n s of t h i s chapter, i t has been necessary t o combine Ambulatory•Care F a c i l i t y Services t h a t had o r i g i n a l l y been envisaged as e x i s t i n g by themselves and exclude the Emergency Services from the s i m u l a t i o n . As a r e s u l t , only the S u r g i c a l Day Care Services was l e f t t o undergo s i m u l a t i o n . The S u r g i c a l Day Care Services area contained three work areas: the operating room, the pos t - a n a e s t h e t i c recovery room (P.A.R.R.) and the ho l d i n g room. Of these, the operating'room was considered the primary generator of a c t i v i t y . The l a t t e r two areas were used f o r p a t i e n t preparation"and/or recovery. The o r i g i n a l i n t e n t i o n had been t o simulate the De l t a Ambulatory Care F a c i l i t y f o r both 1978 and 1982 (the years t h a t bracket the proposed l i f e s p a n o f the f a c i l i t y ) . These s i m u l a t i o n s would have f a c i l i t a t e d the es t i m a t i o n of the r e q u i r e d s t a f f i n g and f a c i l i t y s i z e f o r e i t h e r Target Year. Funds were not a v a i l a b l e f o r the s i m u l a t i o n of both years. Nevertheless, the procedure i n v o l v e d and the u l t i m a t e s i z e of the De l t a f a c i l i t y , as p r e s e n t l y planned, were demonstrated by a s i m u l a t i o n f o r the Target Year, 1982. A s i m u l a t i o n performed assuming .3 operating rooms, 5 P.A.R.R. beds and 19 h o l d i n g beds was found to minimize t h e . w a i t i n g time per occurrence and maximize the u t i l i z a t i o n of the f a c i l i t y . The average w a i t i n g time f o r the primary work areas, (O.R.s) was 37 minutes per occurrence w i t h no w a i t i n g time f o r the P.A.R.R. or ho l d i n g room areas. 33 Adding another primary work area (O.R.) would have obviously reduced the average w a i t i n g time f o r these areas below the optimal estimate r e q u i r e d by the D e l t a H o s p i t a l A d m i n i s t r a t i o n 1 . However, i t would have a l s o decreased the u t i l i z a t i o n percentage f o r various work areas below the l e v e l s expressed i n Table I I . These were the l e v e l s t h a t were approximately 2 acceptable t o the Delta H o s p i t a l A d m i n i s t r a t i o n . Therefore, the f a c i l i t y work•area s i z e s expressed i n Table I I were considered optimal f o r S u r g i c a l Day' Care Services i n the Delta f a c i l i t y . The s t a f f i n g f o r 1982 was determined by the D e l t a H o s p i t a l A d m i n i s t r a t i o n , using e s t a b l i s h e d B.C.H.P. s t a f f i n g quotas, per each work area ( i . e . operating room, P.A.R.R. £ h o l d i n g room) and the proposed hours of operation.- The s t a f f i n g f o r 1978, the proposed opening year, was determined by an unknown means completely independent of t h i s planning study. ^Optimal w a i t i n g time was 30 minutes 2 F i f t y percent was the minimal u t i l i z a t i o n percentage. 34 CHAPTER V I I I SUMMARY AND CONCLUSIONS A new method was proposed f o r the planning of an ambulatory care f a c i l i t y . This method used p h y s i c i a n b i l l i n g data, h o s p i t a l discharge data, questionnaire data, consultant inputs and s i m u l a t i o n technique t o i n d i c a t e the "work areas" (examination room, s t r e t c h e r - b e d s , etc.) f o r a proposed f a c i l i t y . A f t e r an i n i t i a l a p p l i c a t i o n . o f the method i n the planning of the Delta Ambulatory Care F a c i l i t y (Stage 1 of the Acute Care F a c i l i t y i n D e l t a , B . C . ) , . i t was concluded t h a t : 1. The Medical Services Commission data base should be improved. Since the date of performance i s recorded f o r each procedure f o r each p a t i e n t , seasonal v a r i a t i o n s t u d i e s could be performed on p a t i e n t p r o f i l e s . A l s o , i f the geographic o r i g i n of the p a t i e n t was recorded f o r each procedure, then the d e f i n i t i o n of the morbidity i n the area concerned could be more a c c u r a t e l y determined. 2. In the p r o j e c t i o n of the M.S.C. data, the c r i t e r i o n of more than two data p o i n t s should be used. The p r o j e c t i o n used was based on data from only two years. I f data was a v a i l a b l e f o r more year s , a more accurate p r o j e c t i o n would be p o s s i b l e . 3. The ques t i o n n a i r e c i r c u l a t e d t o p h y s i c i a n s , asking .them to r a t i f y the proposed l i s t of procedures and make estimates i n 35 regard to those procedures, should be explained and c o l l e c t e d by an i n t e r v i e w e r . The questionnaire was n e c e s s a r i l y d i f f i c u l t t o complete. An i n d i v i d u a l e x p l a n a t i o n and a f a c e - t o - f a c e commitment f o r the r e t u r n of'the document would improve the response r a t e . 4. The time estimates f o r the performance'of i n d i v i d u a l medical and s u r g i c a l procedures were based on c o n s u l t a n t s ' o p i n i o n s . A p r o s p e c t i v e study of the time r e q u i r e d f o r each•procedure should be conducted t o v a l i d a t e the consultant estimates. 5. The new method could best be v a l i d a t e d by r e p l i c a t i n g the study f o r a whole area. I f one p r o j e c t e d the ambulatory care f a c i l i t y requirements f o r the whole G.V.R.H.D. or a l t e r n a t i v e l y f o r a remote community, then one would minimize the e f f e c t of p h y s i c i a n and/or p a t i e n t i n f l o w and outflow. For a community l i k e D e l t a , B.C., where p h y s i c i a n s have m u l t i p l e h o s p i t a l appointments and Delta p a t i e n t s have the freedom to choose non-Delta p h y s i c i a n s , i t i s impossible to l i m i t the use of a new D e l t a f a c i l i t y t o Delta r e s i d e n t s and to ensure t h a t D e l t a p a t i e n t s do not go elsewhere. Therefore, the v a l i d a t i o n f o r any p r e d i c t i o n of D e l t a or a s i m i l a r community's f a c i l i t y requirements would be d i f f i c u l t i f not impossible. 6. Once the Delta f a c i l i t y i s e s t a b l i s h e d , f u r t h e r study may be made of the i n t e r r e l a t i o n of s t a f f , p a t i e n t s and f a c i l i t i e s i n a manner s i m i l a r to t h a t d e t a i l e d by Reuter (1974) or Rockhart (1974). 36 BIBLIOGRAPHY LITERATURE CITED Anderson, D.O. F i n a l Report on Ambulatory F a c i l i t y • R e q u i r e m e n t s -Shaughnessy S i t e . Vancouver, B.C.: B r i t i s h Columbia Medical Centre, (1974). Anderson, O.W. " S t y l e s of Planning Health S e r v i c e s : the United S t a t e s , Sweden, and England." I n t e r n a t i o n a l J o u r n a l of Health Services 1: 106-20, 1971. Brawn, G. F u n c t i o n a l Program f o r the Richmond General H o s p i t a l . Richmond, B.C.: Richmond General H o s p i t a l , (1975). 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C.: Greater Vancouver Regional H o s p i t a l D i s t r i c t , 1970. Engels, Arthur. "Areawide H o s p i t a l Planning...Swedish Experience." Canadian H o s p i t a l 44: 71-4, 1967. H i l l e b o e , H.E. and Barkhuus, A. "Health Planning i n the United S t a t e s : Some C a t a g o r i c a l and General Approaches." I n t e r n a t i o n a l J o u r n a l of  Health Services 1: 134-147, 1971. H o s p i t a l Survey and C o n s t r u c t i o n Act - H i l l - B u r t o n Program. U.S. P u b l i c Law 79-725, T i t l e VI o f P u b l i c Health Service Act. August, 1946. 37 Jacobs, Arthur R. et a l . "Case C l a s s i f i c a t i o n of Ambulatory Care Demand." American J o u r n a l of P u b l i c Health 63: 721-25, 1973. N a t i o n a l Health Planning and Resources Development Act of 1974. U.S. P u b l i c L..: Law 93-641, T i t l e XV of P u b l i c Health S e r v i c e . A c t . January, 1975. Navarro, Vicente. "Methodology on Regional Planning of Personal Health S e r v i c e s : A Case Study: Sweden." Medical Care 8: 386-394, 1970. 0'Toole, L l o y d . F u n c t i o n a l Program f o r the Coquitlam and D i s t r i c t H o s p i t a l . Coquitlam, B.C.: Coquitlam and D i s t r i c t H o s p i t a l , (1974). P e t r i c h , Frank A. and House, Marlyn A. "Improved Data Generation Need f o r Ambulatory Plann i n g / " H o s p i t a l Progress: 84-86, 1973. Purdy, H.L. Data S i g n i f i c a n t t o Acute Care.in D e l t a , B.C. Vancouver, B.C.: Greater Vancouver Regional H o s p i t a l D i s t r i c t , (1972). Report of the Day Care F a c i l i t i e s Study Group ,±o the Advisory Committee of the Greater Vancouver Regional H o s p i t a l D i s t r i c t Board. By J.R. F a r i s h and Ian Manning, Co-Chairmen. Vancouver, B.C.: Greater Vancouver Regional H o s p i t a l D i s t r i c t , 1973. Reuter, Louis F. "Programming Ambulatory Care F a c i l i t i e s and Manpower." Medical Care 12: 173-185, 1974. Richardson, J . Ross. D e l t a H o s p i t a l Diagnostic and Treatment F a c i l i t y  F u n c t i o n a l Program'.- D e l t a , B.C. : D e l t a H o s p i t a l , (1976). Rockhart, John F. and Herzog, E r i c L. "A P r e d i c t i v e Model f o r Ambulatory P a t i e n t Service T i m e . M e d i c a l Care 12: 512 - 519, 1974. S c h r i b e r , Thomas L. Simulation Using G.P.S.S. New-York:- John Wiley and Sons, 1974. Tenney, J.B. ; White, K.L.; and Williamson, J.W. N a t i o n a l Ambulatory Medical  Care Survey: Background and Methodology.- R o c k v i l l e , Md.r.U.S. Dept. of H e a l t h , Education and Welfare, (1974). DHEW P u b l i c a t i o n No. (HRA) 74-1335. PERSONAL COMMUNICATIONS Hastings, G.L. Research Co-ordinator, Greater Vancouver Regional H o s p i t a l D i s t r i c t , Vancouver, B.C. C o n s u l t a t i o n , 1975-6. Kanee, L. P r e s i d e n t , D e l t a Medical S o c i e t y , D e l t a , B.C. C o n s u l t a t i o n , 1975. 38 K e r r y R.B. S p e c i a l Medical Consultant, Advisory Committee of the Greater Vancouver Regional H o s p i t a l D i s t r i c t Board, Vancouver, B. C. C o n s u l t a t i o n , 1975. Lambert, P a u l . H o s p i t a l Planner, Greater Vancouver Regional H o s p i t a l D i s t r i c t , Vancouver, B. C. L e t t e r , November 1975. Moss, Raymond. Reader i n A r c h i t e c t u r e , D i r e c t o r of M.A.R.U., Department of Environmental Design, The P o l y t e c h n i c o f North London, London. L e t t e r , January 1975. Rowan, John D. C h i e f , Program Planning and Evaluation.Branch, D i v i s i o n of F a c i l i t i e s U t i l i z a t i o n , P u b l i c Health S e r v i c e , Department of Health Education, and W e l f a r e , . R o c k v i l l e , Md..Letter,. February 1975. Wertz,. Margaret.' Computer Su p e r v i s o r ' A n a l y s t , D i v i s i o n . o f Health Services Research and Development, U n i v e r s i t y ' o f B r i t i s h Columbia, Vancouver, B.C. C o n s u l t a t i o n , 1975. 39 APPENDIX A AMBULATORY MEDICAL AND SURGICAL PROCEDURES" Procedure MEDICAL DAY CARE SERVICES Number Intramuscular i n j e c t i o n 0010 Intravenous i n j e c t i o n 0011 I n t r a - a r t e r i a l medication 0013 I n t r a - a r t i c u l a r medications by i n j e c t i o n - h i p 0014 - a l l other j o i n t s 0015 Blood t r a n s f u s i o n s administered i n h o s p i t a l 0021 Manipulation therapy without anesthesia 0045 Electrocardiogram and i n t e r p r e t a t i o n - o f f i c e 0316 Master's 2-step electrocardiogram and i n t e r p r e t a t i o n 0321 Cardi o v e r s i o n 032 5 Master's 2-step electrocardiogram and i n t e r p r e t a t i o n 0531 I n t e r p r e t a t i o n of electrocardiogram f o r c h i l d r e n under 2 years - t e c h n i c a l fee 0534 Bronchoscopy 0700 D i r e c t laryngoscopy 0701 Sigmoidoscopy 0714 xBetween the times when t h i s procedures l i s t was c i r c u l a t e d to D e l t a p h y s i c i a n s , as a que s t i o n n a i r e and the f i n a l data a n a l y s i s , a number o f procedures, o r i g i n a l l y l i s t e d , were dropped. The reasons f o r these d e l e t i o n s are discussed i n the Results Chapter, under "Questionnaire" and " P r o j e c t i o n o f Data". 2 B.C.M.A. fee schedule, 1973. 40 Sigmoidoscopy w i t h biopsy 0715 Lumbar puncture 0750 D i l a t i o n of oesophagus 2416 D i l a t i o n of oesophagus-repeat one month 2417 I n s e r t i o n i n t r a u t e r i n e c o n t r a c e p t i v e device 4540 Routine p e l v i c examination i n c l u d i n g Papanicolau smear 4560 EMERGENCY SERVICES Stomach lavage and gavage 0040 Bedside and r e s u s c i t a t i v e s e r v i c e s - f i r s t hour 0081 - subsequent hours 0082 Night v i s i t - l o c a t e d at or c a l l e d t o emergency- department while i n h o s p i t a l (night hours) 0105 Emergency v i s i t f o r a c u t e l y i l l p a t i e n t r e q u i r i n g emergency admission t o h o s p i t a l , i n c l u d i n g h o s p i t a l v i s i t same day 0111 Emergency v i s i t - 8:00 a.m. - 6:00 p.m. 0112 Tracheostomy 2407 Biopsy of s k i n or mucosa 7021 A d d i t i o n a l l e s i o n removed at the same s i t t i n g 7034 E x c i s i o n of benign tumor of s k i n or subcutaneous t i s s u e or s m a l l scar 7035 Fractures Finger phalanx - r e q u i r i n g r e d u c t i o n 5201 Metacarpal - r e q u i r i n g r e d u c t i o n 5203 41 Base of 1st metacarpal (Bennet's) 5205 Scaphoid ( i n t r a - a r t i c u l a r ) 5207 Radius and ul n a at w r i s t , r e q u i r i n g r e d u c t i o n 5209 Greenstick - r e q u i r i n g r e d u c t i o n 5210 Radius or ulna s h a f t , c l o s e d r e d u c t i o n 5211 Radius and ulna s h a f t , complete displacement r e q u i r i n g c l o s e d r e d u c t i o n 5212 Head of r a d i u s - c l o s e d r e d u c t i o n 5213 Olecranon - closed r e d u c t i o n 5215 Olecranon and humeral epicondyles 5216 C l a v i c l e - c h i l d 5222 C l a v i c l e - a d u l t 5224 Other than d i s t a l phalanges - open r e d u c t i o n and w i r i n g - f i r s t 5227 - each a d d i t i o n a l - e x t r a 5228 F i b u l a - malleolus c l o s e d r e d u c t i o n 5270 F i b u l a - s h a f t or mal l e o l u s - not r e q u i r i n g r e d u c t i o n 5271 T a r s a l bones - c l o s e d r e d u c t i o n 5274 M e t a t a r s a l bone - c l o s e d r e d u c t i o n 5275 M e t a t a r s a l bone - two or more 5276 Shoulder - c l o s e d i n i t i a l r e d u c t i o n 5304 Elbow - c l o s e d r e d u c t i o n 5307 Toe - c l o s e d r e d u c t i o n 5318 P l a s t e r c a s t s - non-fracture cases and f r a c t u r e s not reduced Finger or toe 5580 42 Short arm 5581 Long arm 5583 Shoulder s p i c a 5584 Ankle ( f o o t t o midleg) 5585 Knee (f o o t to t h i g h ) 5586 Walking c a s t 5587 Body - shoulder t o hips 5590 Body - i n c l u d i n g head (Minerva) 5591 P e t r i e abduction cast 5592 Burns L o c a l care - dressings 6078 L o c a l care - s u r g i c a l debridement-for each 5% of body surface 6079 Lo c a l care - subsequent debridements "- f o r each 5%, of body surface 6080 General care - f i r s t hour 6083 Minor l a c e r a t i o n or f o r e i g n body not r e q u i r i n g anesthesia 7029 Minor l a c e r a t i o n or f o r e i g n body r e q u i r i n g l o c a l a nesthesia 7030 SURGICAL DAY CARE SERVICES (and other procedures r e q u i r i n g anaesthesia) Dermatological biopsy 0215 Cystoscopy t o include d i l a t i o n and panendoscopy 0704 Cystoscopy w i t h c a t h e t e r i z a t i o n of u r e t e r s (with kidney f u n c t i o n t e s t and i n j e c t i o n of s o l u t i o n f o r pyelogram to i n c l u d e d i l a t i o n and panendoscopy) 0705 Gastroscopy i n c l u d i n g oesophagoscopy 0707 Gastroscopy 0708 43 Oesophagoscopy 0709 G a s t r i c biopsy 0711 Panendoscopy 0712 Arthroscopy - examination under general anesthesia 0713 Duodenal biopsy 0731 L i v e r biopsy 074-0 Lymphnode biopsy 0745 P a r i e t a l p l e u r a l , i n c l u d i n g t h o r a c e n t e s i s 0749 J o i n t a s p i r a t i o n - h i p 0756 J o i n t a s p i r a t i o n - other j o i n t s 0757 Paracentesis - t h o r a c i c 0759 Paracentesis - abdominal 0760 Cyst or bursa a s p i r a t i o n 0761 P e l v i c examination under anesthesia 0770 R e t i n a l examination under anesthesia 0771 Naso-pharyngeal examination under anesthesia 0772 D S C 0780 Cervix punch biopsy 0784 Endometrial biopsy 0785 Biopsy o f penis 0795 Cystometrogram 0796 Removal of f o r e i g n body from ear - r e q u i r i n g general a n e s t h e t i c 2201 Paracentesis o f the ear drum 2210 Removal of a u r a l polyp 2220 Removal of f o r e i g n body from nose-complicated w i t h anesthesia 2301 44 C a u t e r i z a t i o n o f septum - e l e c t r i c 2303 A n t r a l lavage - u n i l a t e r a l 2324 A n t r a l lavage - b i l a t e r a l 2325 I n c i s i o n of p e r i t o n s i l l a r abscess 24-00 T o n s i l s and adenoids - c h i l d 2401 T o n s i l s and adenoids - a d u l t 2402 Tonsillectomy under l o c a l anesthesia 2403 Curettage f o r a b o r t i o n ( i n c l u d i n g p o s t o p e r a t i v e care) 4110 T.A. - l e s s than 12 weeks g e s t a t i o n 4111 Venereal warts, cautery or e x c i s i o n 4305 E x c i s i o n of venereal warts under general anesthesia i n h o s p i t a l 4306 Biopsy of v u l v a 4315 Removal of v a g i n a l i n c l u s i o n c y s t 4404 Removal of other v a g i n a l c y s t 4405 D i l a t i o n of c e r v i x and curettage ( t h e r a p e u t i c , except f o r abo r t i o n ) 4500 Removal of c e r v i c a l polyp w i t h d i l a t i o n and curettage 4506 Biopsy of c e r v i x under general anesthesia 4508 Biopsy w i t h d i l a t i o n and curettage - t o t a l 4510 D i l a t i o n and curettage w i t h cone biopsy of c e r v i x f o r abnormal cystology under general anesthesia 4536 Amputation <- transmetacarpal 5425 Amputation - f i n g e r any j o i n t or phalanx 5426 Removal of Kuntshner n a i l 5607 Removal of Smith-Peterson n a i l 5608 45 E x c i s i o n benign tumor of s k i n or subcutaneous t i s s u e or s m a l l s c a r , face 6069 Wounds,- avulsed and complicated L i p s and e y e l i d s 6075 Nose and ear • 6076 Complicated l a c e r a t i o n s of the s c a l p , cheek and neck 6077 Biopsy of f a c i a l area 7022 E x c i s i o n biopsy of lymph glands f o r malignancy, under general anesthesia 7023 Scalene gland biopsy 7024 Temporal a r t e r i a l biopsy 7025 Opening s u p e r f i c i a l abscess, i n c l u d i n g f u r u n c l e 7026 Deep abscess, i n c l u d i n g carbuncle, r e q u i r i n g general anesthesia 7027 Minor l a c e r a t i o n or f o r e i g n body r e q u i r i n g general anesthesia 7031 Extensive l a c e r a t i o n or f o r e i g n body r e q u i r i n g general anesthesia 7032 L o c a l i z e d carcinoma of the s k i n , proven h i s t o p a t h o l o g i c a l l y 7036 Removal of medium-sized tumor or scar where general anesthesia or r e g i o n a l block i s necessary 7037 A s p i r a t i o n s - Bursa 7039 - J o i n t 7040 - Abdomen and chest 7041 Paronychia 7044 A n t e r i o r c l o s e d space abscess 7045 Web space abscess 7046 46 Midpalmar, thenar and d o r s a l subaponeurotic -space abscess 7049 Removal of n a i l - simple operation 7050 Wedge e x c i s i o n of one n a i l 7051 Removal of n a i l - w i t h d e s t r u c t i o n of n a i l bed 7052 Removal of n a i l - w i t h shortening of phalanx 7053 Bursa, S y n o v i a l Cysts and Ganglia E x c i s i o n of p r e p a t e l l a r , olecranon'or 'trochanteric 7054 Ganglia - of w r i s t 7055 Ganglia - of tendon sheath or -joint 7056 Ganglia - compound 7057 Acute t e n o s y n o v i t i s - f i n g e r 7079 I n j e c t i o n of v a r i c o s e veins 7200 F i s t u l a - i n - a n o - submucous 7675 I n c i s i o n and drainage of s u p e r f i c i a l p e r i a n a l abscess 7678 I s c h i o - r e c t a l abscess 7679 Enu c l e a t i o n of e x t e r n a l thrombotic haemorrhoid 7684 Anal polyp 7686 Anal f i s s u r e - e x c i s i o n under l o c a l anesthesia 7687 Anal d i l a t i o n under general a n e s t h e t i c 7689 Tongue t i e 7735 Cystoscopy w i t h f u l g u r a t i o n 8200 S t r i c t u r e of u r e t h r a - d i l a t i o n i n h o s p i t a l , i s o l a t e d procedure with anesthesia 8265 Ci r c u m c i s i o n - c h i l d 8303 Cir c u m c i s i o n - a d u l t 8304 47 Vasectomy - b i l a t e r a l 8345 AUDIOLOGY SERVICES Audiogram - pure tone (AC and BC) 2520 Audiogram - speech (SRT, TB, MCL) 2521 Audiogram - SISI 2522 Audiogram - tone decay 2523 Audiogram - Bekesy 2524 Impedence t e s t 2525 Cold C a l o r i c s t e s t 2526 Play audiometry 2533 Free f i e l d audiometry 2534 RESPIRATORY FUNCTION' TESTING SERVICE Screening r e s p i r a t o r y f u n c t i o n t e s t - t e c h n i c a l fee (without b r o n c h o d i l a t o r ) 0790 48 APPENDIX B QUESTIONNAIRE TO DELTA PHYSICIANS (Sample Only) STRICTLY CONFIDENTIAL ( f o r your i n f o r m a t i o n only) March 10, 1975 Members Del t a Medical Society D e l t a , B. C. Gentlemen: Over the past s i x months the Delta Centennial H o s p i t a l Society has prepared and submitted a f u n c t i o n a l program f o r an Extended Care H o s p i t a l , which i s now i n the process of being transformed i n t o a r c h i t e c t u r a l drawings. While t h i s f i r s t phase of the p r e s e n t l y a n t i c i p a t e d three-phase h o s p i t a l development f o r De l t a i s proceeding towards the b u i l d i n g stages, the De l t a Centennial H o s p i t a l Board Medical Services Committee has i n i t i a t e d the second planning stage, the f u n c t i o n a l program f o r a Dia g n o s t i c and Treatment F a c i l i t y - e s s e n t i a l l y a 150-bed h o s p i t a l with a l l the s e r v i c e f a c i l i t i e s necessary f o r a 150-bed h o s p i t a l i n c l u d i n g emergency care f a c i l i t i e s , but  without the beds. The view i s toward r a p i d l y expanding with the a d d i t i o n o f a 150-bed tower b u i l d i n g . However, the planning process f o r the Diagnostic and Treatment F a c i l i t y i s t r o u b l e d by one major problem - no precedent. D i a g n o s t i c and Treatment F a c i l i t i e s or Ambulatory Care F a c i l i t i e s are prevalent i n other parts of the world, but there i s no precursor i n B.C. The f r o n t i e r aspect 49 of t h i s development r e q u i r e s a r a t h e r hard nosed, o b j e c t i v e planning approach i f i t i s to produce a s u c c e s s f u l argument before the G.V.R.D. and B.C.H.I.S. approving committees'. Dr. L. Kanee, Dr. R. B. Kerr ( r e c e n t l y r e t i r e d Chief of Medicine at V.G.H. and U.B.C.), and I have been attempting t o e s t a b l i s h the most o b j e c t i v e planning approach we could conceive, given the l i m i t e d data sources. I t s t a r t s w i t h an o p e r a t i o n a l d e f i n i t i o n of ambulatory care, created by p a r t i a l l i n g out the procedures i n the B.C.M.A. fee schedule, (appendix I) that could be performed on an ambulatory b a s i s . With t h i s cut and d r i e d , l i n e by l i n e d e f i n i t i o n of what a c t u a l l y w i l l be done i n a hy p o t h e t i c a l ' D i a g n o s t i c and Treatment F a c i l i t y , i t w i l l be possible, to make r e l i a b l e p r e d i c t i o n s of p a t i e n t l o a d ; which d i c t a t e planning data l i k e f l o o r s p a c e and numbers and kinds of s t a f f or equipment r e q u i r e d . Conceptually, p r e d i c t i n g the workload f o r the Diag n o s t i c and Treatment F a c i l i t y r e q u i r e s t a k i n g the o p e r a t i o n a l d e f i n i t i o n of ambulatory care (the l i s t of procedures i n Appendix I) and e x p l o r i n g f i v e years of past M.S.C. b i l l i n g records e s t a b l i s h e d per G.V.R.D. p h y s i c i a n (those who t r e a t Delta p a t i e n t s ) and pres e n t i n g volume or workload estimates f o r t h i s group, f o r each of the l i s t e d procedures. Once t h i s i s done and r a t i f i e d by age and sex v a r i a t i o n i n the p o p u l a t i o n base (where the f i g u r e s are a v a i l a b l e ) , one could proceed t o say, w i t h some a u t h o r i t y , what f a c i l i t i e s or s t a f f w i l l be necessary. The computational work i n d i c a t e d i s q u i t e f e a s i b l e and w i l l be handled i n a manner th a t preserves the c o n f i d e n t i a l i t y of the i n d i v i d u a l p h y s i c i a n ' s p r a c t i c e record. But, t o make sure we are sampling the data 50 th a t w i l l p r e d i c t f u t u r e medical needs i n D e l t a , we request t h a t you as a Medical S o c i e t y member help i n reviewing the l i s t o f procedures t h a t form the o p e r a t i o n a l d e f i n i t i o n of ambulatory care and the b a s i s of the a n a l y s i s . ' In t h i s r egard, would you please: (1) Read through the l i s t o f procedures provided, making any a d d i t i o n s or d e l e t i o n s you f e e l would produce a b e t t e r d e f i n i t i o n of ambulatory care. (2) I n d i c a t e , i n your experience, the percentage of time each procedure l i s t e d would be considered: 1. a d i a g n o s t i c and treatment procedure (a procedure t h a t would be performed i n the proposed d i a g n o s t i c and treatment f a c i l i t y ) . 2. a h o s p i t a l procedure (a procedure t h a t would r e q u i r e an i n -p a t i e n t stay and be performed i n e x i s t i n g acute h o s p i t a l f a c i l i t i e s ) . 3. a t r u e emergency procedure (a procedure performed i n an emergency department). 4. an o f f i c e procedure (a procedure performed i n a p h y s i c i a n ' s o f f i c e ) . Place your percentage estimates i n the three r e s p e c t i v e columns ( l a b e l l e d D i a g n o s t i c and Treatment Procedure (% t i m e ) , H o s p i t a l Procedure (%time) and Emergency Procedure (% time) on pages 1-10 of Appendix I.) Yours s i n c e r e l y , Ross Richardson APPENDIX I AMBULATORY CARE PROCEDURES Procedure GENERAL SERVICES Intramuscular i n j e c t i o n Intravenous i n j e c t i o n Venepuncture and dispatch of specimen to Laboratory (with no other charge) I n t r a - a r t e r i a l medication I n t r a - a r t i c u l a r medications by i n j e c t i o n h i p - a l l other j o i n t s Blood t r a n s f u s i o n s administered i n h o s p i t a l Stomach lavage and gavage Manipulation therapy without anesthesia Bedside and r e s u s c i t a t i v e s e r v i c e s - f i r s t hour - subsequent hours Diagnostic O f f i c e 6 Treatment Procedure Procedure (% Time) (% Time) H o s p i t a l Emergency Procedure Procedure (% Time) (% Time) 75% 25% 98% cn 25% 25% 100% 95% 75% 75% 75% DIAGNOSTIC SERVICES Bronchoscopy D i r e c t laryngoscopy Cystoscopy t o in c l u d e d i l a t a t i o n and panendoscopy Cystoscopy w i t h c a t h e t e r i z a t i o n o f ur e t e r s (with kidney f u n c t i o n t e s t and i n j e c t i o n o f s o l u t i o n f o r pyelogram t o in c l u d e d i l a t a t i o n and panendoscopy) Gastroscopy i n c l u d i n g oesophagoscopy Gastroscopy Oesophagoscopy Panendoscopy Arthroscopy - examination under general anesthesia Procedure Number 0700 0701 0704 0705 0707 0708 0709 0712 0713 Diagnostic O f f i c e 6 Treatment Procedure Procedure (% Time) (% Time) 100% 100% 100% 100% 100% 100% 100% 100% H o s p i t a l Emergency Procedure Procedure (% Time) (% Time) 100% DIAGNOSTIC SERVICES Cont'd Procedure Number O f f i c e Procedure (% Time) Diagnostic £ Treatment Procedure (% Time) H o s p i t a l Procedure (% Time) .Emergency Procedure (% Time) Sigmoidoscopy 0714 25% Continued This q u e s t i o n n a i r e was continued t o include a l l of the procedures l i s t e d i n Appendix A; although there the procedures were d i f f e r e n t l y grouped. 55 APPENDIX C QUESTIONNAIRE TO DELTA DENTAL SURGEONS Based on the present p r a c t i c e a t a l o c a l r e f e r r a l h o s p i t a l , a l i s t of d e n t a l procedures f o r the Delta D i a g n o s t i c and Treatment F a c i l i t y has been compiled. Would you make any changes to the l i s t you f e e l are appropriate and i n the columns t o the r i g h t of the l i s t i n d i c a t e the f o l l o w i n g i n f o r m a t i o n : Column 1 - Given the d i a g n o s t i c and treatment f a c i l i t i e s o u t l i n e d " , would you perform t h i s procedure y o u r s e l f ? (Write "yes" or "no" i n the box a f t e r the procedure name.) Column 2 - Given the d i a g n o s t i c and treatment f a c i l i t i e s o u t l i n e d " , would you do the procedures i n an o f f i c e , d i a g n o s t i c and treatment f a c i l i t y or r e g u l a r acute h o s p i t a l s i t u a t i o n ? (Write " o f f i c e " , "D. £ T.F." or " h o s p i t a l " i n the box a f t e r the procedure name.) Column 3 - Would you normally r e f e r t h i s procedure t o an o r a l surgeon? Column 4 - How many procedures o f each type l i s t e d would you do or r e f e r t o the Diagnostic and Treatment F a c i l i t y i n one month? (Write your numerical estimate i n the box a f t e r the procedure name.) Column 5 - Would you estimate the average amount of d e n t a l surgeon's 56 pr o r a l surgeon's time t h a t would be spent doing each procedure i n the Diagnostic and Treatment F a c i l i t y . (Write your time estimate (min.) i n the box a f t e r the procedure name.) " An o u t l i n e of the s e r v i c e s and f a c i l i t i e s t o be i n c l u d e d i n the proposed D. £ T.F. was given i n an accompanying l e t t e r . 57 DENTAL AND ORAL SURGERY-Performed on an ambulatory b a s i s Per-formed By you? 1. M u l t i p l e e x t r a c t i o n of te e t h 2. Alveolectomy 3. Cysts ( i n some cases) 4. Fractures of mandible, m a x i l l a or malar r e d u c t i o n and i m m o b i l i z a t i o n 5. Resection of mandible, m a x i l l a or c o r r e c t i o n developmental, n e o p l a s t i c or traumatic deformity 6. I & D of s u b p e r i o s t e a l abscess 7. C e r v i c o f a c i a l abscess 8. S a u c e r i z a t i o n and/or sequestrectomy f o r o s t e i t i s or o s t e o m y e l i t i s of the jaws 9. Antrostomy - f o r removal o f tooth and/or root Refer-red t o Where O r a l Per- Surg-formed? eon? How Length Many of Pro-per cedure Month? (min.) 58 10. Antrostomy - c l o s u r e of o r o - a n t r a l f i s t u l a Per-formed By You? Where Per-formed? Refer-red t o O r a l Surg-eon? •How Many Per Month? Length of Pro-cedure (min.) Any a d d i t i o n a l procedures should be l i s t e d below and documented i n the manner above B. I f you wish, please l i s t the type of equipment you would l i k e to see i n the proposed Diagnostic and Treatment F a c i l i t y f o r t r e a t i n g d e n t a l p a t i e n t s . 59 APPENDIX D SURGICAL DAY CARE SERVICES SIMULATION PROGRAM (G.P.S.S.) FOR THE TARGET YEAR, 1982 SIMULATION OF DELTA AMBULATORY CARE FACILITY 1982 $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ FUNCTION DEFINITION CARDS $$$$$$$$$$$$$$$$$$$$$$$$$$$$ XPDIS FUNCTION RN1,C24 0 , 0 / . l , .104/.2,.222/.3,.355/.4,.509/.5,.69/.6, ,915/. 7,1.2/.75,1.38 • 8*1.6/. 84*1.83/. 88 ,2.12/.9 ,2.3/.92,2.52/.94,2.81/.95,2.99/.96,3.2 .97, 3.5/.9 8, 3 .9/. 99, 4. 6/. 995, 5. 3/. 998, 60 2/. 9991 7/o 9998,8 SNORM FUNCTION RM »C25 0,-5/.00003,-4/.00135,-3/.00621,-2. 5/. 02275 ,-2 ,066 81,-l05/e11507,-1.2/.15866,-1/.21186,-.8/.27425,-.6 .34458,-.4/.42074,-.2/.5,0/.57926,.2/o65542,,4 .72575,06/.78814,.8/.84134,1/.8 8493*1.2/.93319,1.5 .97725,2/.99379,2.5/.99865,3/.99997,4/1,5 ASGN WEEK HOUR REV1 REV 2 TIME1 TIME 2 TIME3 UTIL1 UTIL2 UTI L3 UTIL4 UTIL5 if * $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ VARIABLE DEFINITION CARDS $$$$$$$$$$.$$$$$$$$$$$$$$$$$$ VARIABLE VARIABLE VARIABLE VARIABLE VARIABLE FVARIABLE FVARIABLE FVARIABLE FVARIABLE FVARIABLE FVARIABLE FVARIABLE FVARIABLE P7+3 1+RN1*52/1C00 1+RN2*4Q/1000 53-P5 95-P6 P4*FN$SN0RM+P3/2 3*FN$SNQRM+35 15*FN$SN0RM+210 XH4/480*100 XH5/480*100 XH6/480+100 XH$PAR/2600*100 XHSHQLD/13775*100 NAME OF MEMORY FOR O.R. UTILIZATION ASSIGN THE WEEK OF ARRIVAL. ASSIGN THE HOUR OF ARRIVAL. ASSIGN PRIORITY ACCORDING TO THE WK ASSIGN PRIORITY ACCORDING TO THE HR PROCEDURE TIME ACTUAL. PAR TIME ACTUAL. HOLDING AREA TIME ACTUAL. * UTILIZATION OF O.R.# ONE. % UTILIZATION OF O . R . # TWO. % UTILIZATION OF O.R.# THREE. % UTILIZATION OF THE PAR. % UTILIZATION OF THE HOLDING AREA. *$$$$$$$$$.$$$$$$$$$$$$$$$$$$ LOGIC SWITCH INITIALIZATION $$$$$$$$$$$$$$$$$$$$$$$$$$$$ INITIAL LS$HOUR/LS$WEEK/LS$NITE * PAR HOLD * $$$$$$$$$$$$$$$$ STORAGE CAPACITIES $$$$$$$$$$$$$$$$$$$$$$$$$.$$$ STORAGE 5 PAR HAS FIVE BEDS. STORAGE 19 HOLDING AREA HAS 19 BEDS $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ TABLE DEFINITIONS $$$$$$$$$$$$$$$$$$$$$$$$$$$$ 0RQ1 TABLE 0RQ2 TABLE 0RQ3 TABLE MP8,0,15,21 MP8,300,60,20 MP8,1440,1440,5 WAIT FOR 0»R o , WAIT FOR O 0 R 0 , WAIT FOR O . R . , 0 MIN TO 5 HRS. 5 HRS TO 24 HRS. 1 DAY TO 5 DAYS, 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 32 33 34 35 36 37 38 39 40 41 42 43 44 45 46 47 48 49 50 51 52 53 54 55 56 57 58 59 60 61 62 63 64 65 66 67 68 69 70 71 72 60 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 PARQ HO'LDQ 0PRM1 0PRM2 0PRM3 PAR HOLD TOTAL CODE * ONE TABLE TABLE TABLE TABLE TABLE TABLE TABLE TABLE TABLE MP8,0,5,12 MP8»0,5,12 VSUTILl.Of5»20 V$UTIL2,0,5,20 V$UTIL3,0,5,20 V$UTIL4,0,5,20 V$UTIL5,0,5,20 XH$TOTAL,1,1,40 PI ,1 ,1 ,100 WAIT FOR THE PARo WAIT FOR THE HOLDING AREA. % UTILIZATION OF 0©R©# ONEo % UTILIZATION OF O.RJ TW0o % UTILIZATION OF 0©R©# THREE© UTILIZATION OF THE PAR© UTILIZATION OF THE HOLDING AREA. NUMBER OF CASES PER DAY TABLEo NO. OF CASES BY PROCEDURE CODE© BEGIN WEEK SEGMENT© 7200,,!,,127,0 CREATE WEEK TIMER, WEEK+,1,H UPDATE CURRENT WEEK SIGN© HQUR,0,H RESER HOUR TO 0. WEEK OPEN GATE=WEEK• LEAVE THE MODEL© GENERATE SAVEVALUE SAVEVALUE LOGICS TERMINATE DATA CARDS $ $ It sje s£ $ $ * PROCEDURE CODES ARE GROUPEO BY PROCEDURE TIME© THIS IS AN EXAMPLE OF THE GENERATE SYSTEM FOR PROCEDURE GROUPS WITH FEWER THAN 100 PATIENTS / YEAR IN 1982© GENERATE ASSIGN TRANSFER GENERATE ASSIGN ASSIGN ASSIGN ASSIGN ASSIGN TRANSFER , ,,12,,10,F 1,8 , ONE ,,,01,,10,F 1,8 10,1 2,30 3 ,37 4,1 ,ENTER CREATE 12 PATIENTS© IDENTIFY THEM AS PROCEDURE CODE # 8© CREATE 1 PATIENT. SIGNIFY EMERGENCY PROCEDURE © OoR© BOOKING TIME IN MINUTES© AVG PROCEDURE TIME X 2 FOR ROUNDING© ONE STANDARD DEVIATION FROM AVG PROCEDURE TIME. PROCEED TO THE DCTF© THIS IS AN EXAMPLE OF THE GENERATE SYSTEM FOR PROCEDURE GROUPS WITH 100 OR MORE PATIENTS/YEAR IN 1982. THE ©A© PARAMETER = AN INTERARRIVAL TIME IN MINUTES 52 WEEKS X 5 DAYS X 1440 MINUTES / CASES PER YEAR© GENERATE ELEVN ASSIGN ASSIGN ASSIGN ASSIGN TRANSFER 0484,FN$XPDIS,,,,,F 1,30 2 ,30 3,4 7 4,1 ,PRIOR * THE REMAINING DATA USED IN THE SIMULATION IS IDENTICAL IN FORMAT TO THE ABOVE EXAMPLES, AND IS NOT INCLUDED IN THIS PRINTOUT© 73 74 75 76 77 78 79 80 81 82 83 84 85 86 87 88 89 90 91 92 93 94 95 96 97 98 99 100 101 102 103 104 105 106 107 108 109 110 111 112 113 114 115 116 117 118 119 120 121 122 123 124 125 126 12 7 128 129 130 131 132 61 564 565 566 567 568 569 570 571 572 573 574 575 576 577 578 579 580 581 582 583 584 585 586 587 588 589 590 (*> 591 592 593 594 595 596 597 598 599 600 601 602 603 604 605 606 PRIOR ASSIGN ASSIGN PRIORITY GATE LS TRANSFER 5,XH$WEEK 6 ,XH$HGUR V$REV2 NITE ,EMERG WEEK = CURRENT WEEK, HOUR = CURRENT HOURo GIVE A PRIORITY ASSOCIATED WITH THE HOUR. IF ARRIVE DURING NITE, WAIT TILL MORNING, * * # $ $ $ $ # * * $ 3fs * * * * * * * * * # * * * * * * # OPERATING ROOM / PAR / HOLDING AREA SEQUENCE ENTER ASSIGN PRIORITY ADVANCE n GATE LS TRANSFER LINK 1 LINK TEST2 TEST G LOGICR GATE LS TRANSFER UNLINK ASSIGN PRIORITY ADVANCE FWD1 GATE LS TRANSFER LINK2 LINK TEST3 TEST G LOGICR GATE LS TRANSFER FWD2 UNLINK EMERG TEST E PRIORITY FWD3 ADVANCE QUEUE MARK 8ACK3 SELECT MIN ASSIGN ADV FWD5 TEST L SAVEVALUE SAVEVALUE TEST G SAVEVALUE GATE LS TRANSFER SAVEVALUE SAVEVALUE 5 ,V$WEEK V$REV1 1 WEEK,LINK1 ,TEST2 POOL1,FIFO DETERMINE WEEK OF ARRIVAL• GIVE PRIORITY ASSOCIATED WITH WEEK, ALLOW CASES TO SORT 8Y PRIORITY. GATE FOR THIS WEEK© IF NOT THIS WEEK, WAIT IN POOLlo P5,XH$WEEK,FWD1 DOES THE PATIENT ARRIVE THIS WEEK? WEEK IF NOT, CLOSE GATE=WEEK0 WEEK WAIT BEHIND THE GATE. ,TEST2 RETEST PATIENTS WEEK OF APRIVALo POOL!,TEST2,1 BRING ANOTHER PATIENT IN © 6,V$H0UR DETERMINE THE HOUR OF ARRIVAL© VIREV2 GIVE PRIORITY ASSOCCIATED WITH THE HOUR© i ALLOW CASES TO SORT BY PRIORITY© H0UR,LINK2 GATE FOR CURRENT OPERATING HOUR© ,TEST3 P00L2,FIF0 IF MOT THIS HOUR, WAIT IN P00L2© P6,XH$HQUR,FWC2 DOES THIS PATIENT ARRIVE THIS HOUR? HOUR IF NOT, CLOSE GATE=HOUR© HOUR WAIT BEHIND THE GATE. ,TEST3 RETEST PATIENTS HOUR OF ARRIVAL© P00L2,TEST3,1 BRING ANOTHER PATIENT IN. P10,1,FWD3 IS THIS AN EMERGENCY PROCEDURE? 126 1 WAIT TO ORDER EMERGENCY PRIORITIES© OPRM JOIN THE WAITING LINE FOR THE OR© 8 NOTE THE TIME OF QUEUE ENTRY© 7,1,3,,XH SELECT THE OR WITH THE MINIMUM BOOKING. 9,V$A5GN CREATE OR UTILIZATION XH NAME© XH*7,480,ADV IF ORS ARE BOOKED FOR THE DAY, WAIT TILL TOMORRO ADD,XH*7,H CREATE TEST HOLD© ADD+,P2,H ADD BOOKING TIME© XH$ADD,485,FWD5 IF PROC TAKES OR BEYOND 1600, WAIT© ADD,0,H CLEAR TEST HOLD© WAIT WAIT UNTIL MORNING. ,BACK3 P7+,P2,H ADD THE O.R© TIME TO THE 0«R© SCHEDULE© ADD,0,H CLEAR TEST HOLD. 853 854 855 856 857 858 859 860 861 862 863 864 865 866 867 868 869 870 871 872 873 874 875 876 877 878 879 880 881 882 883 884 885 886 887 888 889 . 890 891 892 893 894 895 896 897 898 899 900 901 902 903 904 905 906 907 908 909 910 911 912 62 607 608 609 610 611 612 613 614 615 616 617 618 619 620 621 622 623 624 625 626 627 628 62 9 630 631 632 633 634 635 636 637 638 639 640 641 642 643 644 645 646 647 648 649 650 651 3jK TAB1 ASGN SEIZE DEPART TABULATE TABULATE TABULATE ASSIGN SAVEVALUE ADVANCE RELEASE QUEUE MARK ENTER DEPART TABULATE ASSIGN SAVEVALUE ADVANCE LEAVE QUEUE MARK ENTER DEPART TABULATE ASSIGN SAVEVALUE ADVANCE LEAVE TABULATE SAVEVALUE TERMINATE P7 OPRM 0RQ1 0RQ2 OR 03 10,V$TIM£1 P9+.P1CH P10 P7 PAR 8 PAR PAR PARC 10,V$TIME2 PAR+,P10,H P10, PAR HOLD 8 HOLD HOLD HOLDQ 10»V$TIME3 H0LD+,P10,H P10 HOLD CODE TOTAL+,1,H ENTER THE OPERATING ROOMc LEAVE THE O.R. QUEUEo TABULATE THE WAITING TIME FOR O.R. TABULATE THE WAITING TIME FOR 0,R» PUT OR PROCEDURE TIME IN P10. ADD PROC TIME TO OR UTILIZATION SUM, DAY SURGERY PERFORMEOo LEAVE THE O.R. JOIN WAITING LINE FOR THE PAR. ENTER THE PAR. LEAVE THE PAR QUEUE. RECOVER IN THE PAR. LEAVE THE PAR. JOIN WAITING LINE FOR HOLDING AREA* ENTER THE HOLDING AREA. LEAVE THE HOLDING AREA QUEUE. REST IN THE HOLDING AREA. LEAVE THE HOLDING AREA. TABULATE PATIENT BY PROCEDURE CODEo ADD TO TODAYS PATIENT COUNT. LEAVE THE D£TF. * * $ * 3fC * * £ # * if * * £ * * * * # * * * * * * * $ * BEGIN DAY SEQUENCE. **************************** GENERATE 1440,,2., ,0 CREATE DAY TIMER. SAVEVALUE H0UR+,1,H UPDATE CURRENT HOUR SIGN, LOGICS HOUR OPEN GATE=HQUR. TERMINATE LEAVE THE MODEL. *********&************ ****** END HOUR SEGMENT. ****#*is#^* GENERATE GATE LS SAVEVALUE SAVE VALUE SAVEVALUE SPLIT SPL IT ASSIGN SAVEVALUE TEST L SAV EVALUE 6 C » »61» » »1 N ITE,TERM1 HCUR+,1,H PAST+ ,60,H SPLIT,1,H 1 , ASGN 1,ASGN 1 ,XH$SPLIT SPLIT+,1,H CREATE HOUR TIMER. IS CURRENT TIME IN OFFICE HOURS? UPDATE CURRENT HOUR. UPDATE THE ELAPSED TIME BY 60 MINUTES. SPLIT lNDICATER=lo CREATE O.R.#2 XACT. CREATE O.R. #2 XACT. Pl= O.R.#. IDENTIFY THE NEXT TRANSACTION. XH*1,XH$PAST,TEST1 P1,XH$PAST,H IF NOT, IS THE O.R, BOOKED PAST THIS HOUR? UPDATE T HE SCHEDULE. 914 915 916 917 918 919 920 921 922 923 924 925 926 927 928 929 930 931 932 933 934 935 9 3 6 937 938 939 940 941 942 943 944 945 946 947 948 949 950 9 51 952 953 954 955 956 957 958 959 96 0 961 962 963 964 965 966 967 968 969 970 971 972 c < i N t i n < ) r ~ o o ^ O f H ( M r n > ^ i n < ) r ~ c o o > o ^ c j r ^ > t i r \ v o r - o o cr> o-* cr> o> cr> (X1 <?> o> cr> o > c r c ^ c > a > o ^ o > < y > o ^ o ^ c ^ ^ ^ c ^ Q > c r > c r * P O O O O O O O O O O H H H H ^ H H H r f H M N N M N N o > o o o o o o o o o o o o o o o o o o o o o o o o o o O > < o UJ 3 o X II UJ m cc • 3 r-t O a . x •H-•* » O *8' H~ * Z * UJ *• x « o # # ;>- * <t * a * * 0 a 0 oc U- oo U J UJ 0 2- o 00 >-4—4 >—i < < h~ z o a oo _j oo UJ CC o > 0 X 3 < X h-o U J a o 0 X X o H O o z o o OC >- UJ UL z tu U, X «t X 00 0 O H O O • Ui o z U J U J 3 a: _ l a cc 00 U J 00 H Z o o t—« UJ UJ X <J 4—4 3 (— CO 00 H- QC O H-•» < x < 3 Z UL UJ O OC a i - o o o Z Z Z Z o X I o < o o a _ J oo U_ o O O CD i—i 4—4-41—4 A t-4 u_ X M | Z Ul Z J — V~ Z 1— o O >- o z z UJ 1— cc. 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«^» v» •«« v» •w «» V* g oo Q OC *f> <t *» o •w « _ J Q *ft z •w o « o OC < o \~ z 00 U J * * # * * ( N j r n ^ - t n so r - co o> o H M m - t i n v O s o o o > O H M f r i ' t t f t < O N co o> o —• cm cry m i n i u m m m i n i n 0 0 0 0 ^ ) 1 0 - o ^ - - o - o r ~ r v » r - - r - r " - i v - f s - f s - f ^ r * . c o c o c o c o R E L A T I V E C L O C K 374401 A B S O L U T E C L O C K 374401 65 B L O C K C O U N T S B L O C K C U R R E N T T O T A L B L O C K C U R R E N T T O T A L S L O C K C U R R E N T T O T A L B L O C K C U R R E N T T O T A L B L O C K C U R R E N T T O T A L 1 0 52 11 0 1 21 0 749 31 0 30 41 0 1 2 0 52 12 0 139 22 0 8 32 0 8 42 0 1 3 0 52 13 0 139 23 0 8 33 0 8 43 0 24 4 0 5 2 14 0 139 24 0 8 34 0 8 44 0 24 5 0 52 15 0 139 25 0 1 35 0 8 45 0 24 6 c 12 16 0 749 26 0 1 36 0 34 46 0 12 7 0 12 17 0 749 27 0 1 37 0 34 47 0 12 8 0 12 18 0 749 28 0 1 38 0 34 48 0 12 9 0 1 19 0 749 29 0 30 39 0 1 49 0 12 10 0 1 20 0 749 30 0 30 40 0 1 50 0 6 B L O C K C U R R E N T T O T A L B L O C K C U R R E N T T O T A L B L O C K C U R R E N T T O T A L B L O C K ' C U R R E N T T O T A L B L O C K C U R R E N T T O T A L 51 0 6 61 0 3 71 0 15 81 0 2 91 0 1 5 2 0 6 62 0 3 72 0 15 82 0 2 92 0 1 53 0 2 63 0 3 73 0 15 83 0 2 93 0 1 54 0 2 64 0 2 74 0 15 84 0 2 94 0 1 55 0 2 J 65 0 2 75 0 15 85 0 2 95 0 1 56 0 2 66 0 2 76 0 15 86 0 2 96 0 1 57 0 25 67 0 54 77 0 2 87 0 2 97 0 1 58 0 25 68 0 54 78 0 2 88 0 5 98 0 10 59 0 2 5 69 0 54 79 0 2 89 0 5 99 0 10 60 0 3 70 0 15 80 0 2 90 0 .5 100 0 10 B L O C K C U R R E N T T O T A L B L O C K C U R R E N T T O T A L B L O C K C U R R E N T T O T A L B L O C K C U R R E N T T O T A L B L O C K C U R R E N T T O T A L 101 0 1 111 0 3 121 0 79 131 0 7 141 0 1 102 0 1 112 0 25 122 0 323 132 0 21 142 0 1 103 0 1 113 0 25 123 0 323 133 0 21 143 0 11 104 0 1 114 0 25 124 0 323 134 0 21 144 0 11 105 0 68 115 0 10 125 0 323 135 0 2.1 145 0 11 106 0 68 116 0 10 126 0 14 136 0 31 146 0 2 107 0 68 117 0 10 127 0 14 137 0 31 147 0 2 108 0 68 118 0 10 128 0 14 138 0 31 148 0 2 109 0 3 119 0 79 129 0 7 139 0 i 149 0 2 110 0 3 120 0 79 130 0 7 140 0 1 150 0 21 B L O C K C U R R E N T T O T A L B L O C K C U R R E N T T O T A L B L O C K C U R R E N T T O T A L B L O C K C U R R E N T T O T A L B L O C K C U R R E N T T O T A L 151 0 21 161 0 7 171 0 20 181 0 1 191 0 1 152 0 21 162 0 7 172 0 20 182 0 1 192 0 1 153 0 3 163 0 7 173 0 20 18 3 0 1 193 0 1 154 0 3 164 0 25 174 0 1 184 0 1 194 0 1 155 0 3 165 0 25 175 0 1 185 0 3 195 0 19 156 0 3 166 0 25 176 0 1 186 0 3 196 0 19 157 0 25 167 0 1 177 0 I 187 0 3 197 0 19 158 0 25 168 0 1 178 0 69 188 0 27 198 0 38 159 0 25 169 0 1 179 0 69 189 0 27 199 0 3 8 160 0 7 170 0 1 180 0 69 190 0 27 200 0 38 B L O C K C U R R E N T T O T A L B L O C K C U R R E N T T O T A L B L O C K C U R R E N T T O T A L S L O C K C U R R E N T T O T A L B L O C K C U R R E N T T O T A L 201 0 38 211 0 69 221 0 9 231 0 4 241 0 2 202 0 7 212 0 69 222 0 9 232 0 4 242 0 4 203 0 7 213 0 69 • 223 0 9 233 0 4 243 0 4 204 0 7 214 0 11 224 0 4 234 0 4 244 0 4 205 0 9 215 0 11 225 0 4 23 5 0 20 245 0 4 206 0 9 216 0 11 226 0 4 236 0 20 246 0 52 207 0 9 217 0 3 227 0 4 23 7 0 20 247 0 5 2 208 0 8 218 0 3 228 0 8 238 0 20 248 0 52 209 0 8 219 0 3 229 0 8 23 9 0 2 249 0 6 210 0 8 220 0 3 230 0 8 240 0 2 250 0 6 BLOCK CURRENT TOTAL BLOCK CURRENT TOTAL BLOCK CURRENT TOTAL BLOCK CURRENT TOTAL BLOCK CURRENT TOTAL 251 0 6 261 0 1 271 0 3 281 0 17 291 0 29 252 0 6 262 0 1 272 0 3 282 0 17 292 0 29 2 53 0 7 263 0 2 273 0 3 28 3 0 17 293 0 29 254 C 7 264 0 2 274 0 17 284 0 10 294 0 36 255 0 7 265 0 2 275 0 17 285 0 10 295 0 36 256 0 2 266 0 2 276 0 17 286 0 10 296 0 36 257 0 2 267 0 18 277 0 6 287 0 10 297 0 5 258 0 2 268 0 18 278 0 6 288 0 1 298 0 5 259 0 2 269 0 18 279 0 6 289 0 1 299 0 5 260 0 1 2 70 0 3 280 0 6 290 0 1 300 0 2 0 BLOCK CURRENT TOTAL BLOCK CURRENT TOTAL BLOCK CURRENT TOTAL BLOCK CURRENT TOTAL BLOCK CURRENT TOTAL 301 0 20 311 0 5 321 0 3 331 0 7 341 0 7 302 0 20 312 0 709 322 0 3 332 0 7 342 0 7 303 0 4 313 0 709 323 0 40 333 0 1 343 0 7 304 0 4 314 0 709 324 0 40 334 0 1 344 0 2 305 0 4 315 0 709 325 0 40 335 0 1 345 0 2 306 0 4 316 0 11 326 0 54 336 0 1 346 0 2 307 0 4 317 0 11 327 0 54 33 7 0 31 347 0 20 . 308 0 4 318 0 11 328 0 54 338 0 31 348 0 20 309 0 4 319 0 3 329 0 54 339 0 31 349 0 20 310 0 5 320 0 3 330 0 7 340 0 7 350 0 10 BLOCK CURRENT TOTAL • BLOCK CURRENT TOTAL BLOCK CURRENT TOTAL BLOCK CURRENT TOTAL BLOCK CURRENT TOTAL 351 0 10 361 0 5 371 0 6 381 0 3 391 0 46 352 0 10 36 2 0 5 372 b 6 38 2 0 6 392 0 7 353 0 10 363 0 5 373 0 6 383 0 6 393 0 7 354 0 2 364 0 3 374 0 6 384 0 6 394 0 7 355 0 2 365 0 3 375 0 11 385 0 1 395 0 7 356 0 2 3 66 0 3 376 0 11 386 0 1 396 0 35 357 c 1 367 0 89 377 0 11 387 0 1 397 0 3 5 358 0 1 368 0 89 378 0 3 388 0 1 398 0 35 359 0 1 369 0 89 379 0 3 389 0 46 399 0 6 360 0 1 370 0 89 380 0 3 390 0 46 400 0 6 BLOCK CURRENT TOTAL BLOCK CURRENT TOTAL BLOCK CURRENT TOTAL BLOCK CURRENT TOTAL BLOCK CURRENT TOTAL 401 0 6 411 0 56 421 0 1 431 0 43 441 0 3 402 0 6 412 0 56 422 0 1 432 0 43 442 0 2 6 403 0 8 413 0 56 423 0 1 433 0 43 443 0 26 404 0 8 414 0 202 424 0 1 434 0 43 444 0 26 40 5 0 8 415 0 202 425 0 72 435 0 205 445 0 2 6 406 0 8 416 0 202 426 0 72 436 0 205 446 0 95 407 0 17 417 0 202 427 0 72 437 0 205 44 7 0 95 408 0 17 418 0 3 428 0 86 438 0 205 448 0 95 409 0 17 419 0 3 429 0 86 439 0 3 449 0 124 410 0 17 420 0 3 430 0 86 440 0 3 450 0 12 4 BLOCK CURRENT TOTAL BLOCK CURRENT TOTAL BLOCK CURRENT TOTAL BLOCK CURRENT TOTAL BLOCK CURRENT TOTAL 451 0 124 461 0 2 471 0 2 481 0 15 491 0 84 452 0 124 462 0 2 472 0 2 482 0 15 492 0 84 453 0 1 463 0 4 473 0 2 483 0 15 493 0 84 454 0 1 464 0 4 474 0 1 4 84 0 56 494 0 16 455 0 1 465 0 4 475 0 1 485 0 56 495 0 16 456 0 1 466 0 4 476 0 1 486 0 56 496 0 16 457 0 1 467 0 1 477 0 3 487 0 28 497 0 16 458 0 1 468 0 1 478 0 3 488 0 28 498 0 16 459 0 1 469 0 1 479 0 3 489 0 28 499 0 16 67 460 0 2 470 0 2 480 0 15 490 0 84 500 0 16 BLOCK CURRENT TOTAL BLOCK CURRENT TOTAL BLOCK CURRENT TOTAL BLOCK CURRENT TOTAL BLOCK CURRENT TOTAL 501 0 12 511 0 484 521 0 428 531 0 207 541 0 741 502 0 12 512 0 484 522 0 428 532 0 1192 542 0 741 503 0 12 513 0 484 523 0 99 533 0 1468 543 -* 0 741 504 0 12 514 0 112 524 0 99 534 0 1468 544 0 741 505 0 12 515 0 112 525 0 99 5 35 0 1468 545 0 741 5 06 0 12 516 0 112 526 0 207 536 0 1468 546 0 741 507 0 12 517 0 329 527 0 207 53 7 0 1468 547 0 191 508 0 372 518 0 329 528 0 2 07 538 0 276 548 0 191 509 0 3 72 519 0 428 529 0 207 539 0 276 549 0 191 510 0 484 520 0 42 8 530 0 207 540 0 276 550 0 191 8L0CK CURRENT TOTAL BLOCK CURRENT TOTAL BLOCK CURRENT TOTAL BLOCK CURRENT TOTAL BLCCK CURRENT TOTAL 551 0 191 561 0 173 571 0 1993 581 0 1993 591 0 6614 552 0 191 562 0 173 572 0 1993 582 0 1993 592 0 1012 553 0' 193 563 0 173 573 0 3 7 583 0 1993 593 0 6614 554 0 193 564 0 4634 574 0 1956 584 0 53 594 0 6614 555 0 193 565 0 4634 575 0 2044 585 0 1940 595 0 6614 556 G 193 566 13 4634 5 76 0 51 586 0 4245 596 0 6846 557 0 193 567 0 4621 5 77 0 51 587 0 2252 597 0 6846 55 8 0 193 568 0 4621 578 0 51 588 0 2252 598 0 6846 559 0 173 569 0 1993 579 0 1993 589 0 2252 599 0 6822 560 0 173 570 0 1993 580 0 1993 590 0 1993 600 0 6822 BLOCK CURRENT TOTAL BLOCK CURRENT TOTAL BLOCK CURRENT TOTAL BLOCK CURRENT TOTAL BLOCK CURRENT TOTAL 601 0 6822 611 0 6614 621 0 6614 631 0 6614 641 0 6239 602 0 208 612 0 6614 622 0 6614 632 0 6614 642 0 6239 603 0 232 613 0 6614 623 0 6614 633 0 6614 643 0 1820 604 0 232 614 0 6614 624 0 6614 634 0 6614 644 0 1820 605 0 6614 615 0 6614 625 0 6614 635 0 6614 645 0 1820 606 0 6614 616 0 6614 626 0 6614 636 0 6614 - 646 0 3640 607 0 6614 617 0 6614 627 0 6614 637 0 260 647 0 3640 608 0 6614 618 0 6614 628 0 6614 638 0 260 648 0 5460 609 0 6614 619 0 6614 629 0 6614 639 0 260 649 0 54 6 C 610 0 6614 620 0 6614 630 0 6614 640 0 260 650 0 5460 BLOCK CURRENT TOTAL BLOCK CURRENT TOTAL BLOCK CURRENT TOTAL BLOCK CURRENT TOTAL BLOCK CURRENT TOTAL 651 0 1292 661 0 260 671 0 260 681 0 259 652 0 546C 662 0 260 672 0 260 682 0 1 653 0 8059 663 0 260 673 0 260 683 0' 1 654 0 182 0 664 0 260 674 0 260 655 0 1820 665 0 260 675 0 260 656 0 260 666 0 260 676 0 260 657 0 260 667 0 260 677 0 260 658 0 260 668 0 260 678 1 260 659 0 260 669 0 260 679 0 259 660 0 260 670 0 260 680 0 259 ****$*:£****3>]c:4: $$#*** **************** ***** * * * FACILITIES * * * ^^*4e#^^*4e^#<t^**^#^^***^^^***%^********* -AVERAGE UTILIZATION DURING-FACILITY 1 2 3 NUM BER ENTRIES 2 3 3 6 2 2 1 5 2 0 6 3 AVERAGE TIME/TRAN 3 7 . 4 2 1 3 6 e 5 4 3 3 6 o 5 0 2 TOTAL TIME o 2 3 3 o 2 1 6 . 2 0 1 AVAIL, TIME UNAVAIL, TIME CURRENT STATUS PERCENT AVAILABILITY 1 0 0 c 0 lOGoO 1 0 0 . 0 TRANSACTION NUMBER SEIZING PREEMPTING STORAGE CAPACITY AVERAGE ENTRIES CONTENTS PAR 5 .610 6614 HOLD 19 3.700 6614 * STORAGES * $ sic -AVERAGE UTILIZATION DURING-AVERAGE TOTAL AVAIL. UNAVAIL. CURRENT PERCENT CURRENT MAXIMUM TIME/UNIT TIME TIME TIME STATUS AVAILABILITY CONTENTS CONTENTS 34.504 .121 100.0 5 209.474 .194 100.0 19 * QUEUES * QUEUE OPRM PAR HOLD $AVERAGE MAXIMUM CONTENTS 28 1 2 TIME/TRANS = AVERAGE CONTENTS 1.711 . 000 .001 AVERAGE TOTAL ENTRIES 6614 6614 6614 TIME/TRANS ZERO ENTRIES 2003 66 03 656 8 EXCLUDING ZERO PERCENT ZEROS 30.2 99. 8 99.3 ENTRIES AVERAGE TIME/TRANS 96.861 .003 .057 $AVERAGE TIME/TRANS 138.938 2.090 8.239 TABLE NUMBER CURRENT CONTENTS * * * TABLES * * ^ **************************************** TABLE 0RQ1 ENTRIES 1 IN TABLE MEAN ARGUMENT STANDARD DEVIATION SUM OF ARGUMENTS 6614 96o861 200.812 640644.000 NON-UPPER OBSERVED PER CENT CUMULATIVE CUMULATIVE MULTIPLE DEVIATION L IMIT FREQUENCY ' OF TOTAL PERCENTAGE REMAINDER OF MEAN FROM MEAN 0 2003 30.28 30.2 69.7 -.000 -.482 15 381 5.76 36.0 63.9 .154 -.407 30 588 8.89 44 o 9 55.0 .309 -.332 45 571 8.63 53.5 46.4 .464 -.258 60 369 5.57 59. 1 40.8 .619 -*183 75 325 4.91 64.0 3 5, 9 .774 -.108 90 335 5m 06 69. 1 30.8 .929 -.034 105 295 4.46 73.5 26.4 1.084 .040 120 3 05 4.61 78.1 21.8 1. 238 , 115 13 5 218 3.29 81.4 18.5 1.393 .189 150 194 2.93 84.4 15. 5 1. 548 .264 165 178 2.69 87.1 12.8 1.703 .339 180 127 1.92 89.0 10.9 1.858 • 414 195 104 1.57 90.6 9.3 2.013 .488 210 86 1.30 91.9 8.0 2.168 . 563 225 76 1.14 93. 0 6.9 2.322 .638 240 48 .72 93.7 6.2 2.477 . 712 255 47 .71 94.4 5.5 2.632 .787 270 26 .39 94.8 5.1 2. 787 . 862 285 33 .49 95.3 4.6 2.942 . 936 OVERFLOW 305 4.61 100.0 .0 RAGE VALUE OF OVERFLOW 896,77 TABLE 0RQ2 72 ENTRIES IN TABLE MEAN ARGUMENT STANDARO DEVIATION SUM OF ARGUMENTS 6614 96o861 200o812 640644o000 NON-WEIGHTED UPPER OBSERVED PER CENT CUMULATIVE CUMULATIVE MULTIPLE DEVIATION LIMIT FREQUENCY OF TOTAL PERCENTAGE REMAINDER OF MEAN FROM MEAN 300 6333 95. 7.5 95o7 4o2 3.097 l o O l l 360 47 .71 96.4 3.5 3. 716 1.310 420 2 o03 96o4 3o5 4.336 1. 609 480 0 .00 960 4 3.5 4.955 1.907 540 0 .00 96.4 3.5 5. 574 2. 206 600 0 .00 96.4 3o5 6 0194 2o505 660 0 .00 96.4 3.5 6. 813 2.804 720 0 .00 96.4 3o5 7.433 3. 103 780 0 „00 96.4 3o5 8o052 3o401 8 40 0 .00 96.4 3.5 8.672 3.700 900 0 o 00 96.4 3o5 9.291 3.999 960 0 oOO 96<,4 3.5 9.911 4.298 1020 97 1.46 97.9 2.0 10.530 4. 597 1080 57 o 86 98.8 l o l llo!49 4o895 1140 35 .52 99.3 .6 11.769 5.194 1200 20 .30 99.6 .3 12.388 5.493 1260 7 olO 99o7 o2 1.3.008 5.792 1320 10 .15 99.9 .0 13.627 6.090 1380 2 .03 99.9 oO 14.247 6o 389 OVERFLOW 4 o06 lOOoO oO AVERAGE VALUE OF OVERFLOW 1410.00 TABLE 0RQ3 ENTRIES IN TABLE 6614 MEAN ARGUMENT 96„861 UPPER OBSERVED PER CENT LIMIT FREQUENCY OF TOTAL 1440 6614 100.00 REMAINING FREQUENCIES ARE ALL ZERO STANDARD DEVIATION 20Oo 812 SUM OF ARGUMENTS 640644.000 NON-WEIGHTED CUMULATIVE CUMULATIVE PERCENTAGE REMAINDER 100.0 .0 MULTIPLE DEVIATION OF MEAN FROM MEAN 14.866 6.688 TABLE PARQ ENTRIES IN TABLE 6614 MEAN ARGUMENT .003 UPPER OBSERVED PER CENT LIMIT FREQUENCY OF TOTAL 0 6603 99.83 5 10 .15 10 1 .01 REMAINING FREQUENCIES ARE ALL ZERO STANDARD DEVIATION • 103 SUM OF ARGUMENTS 23.000 NON-WEIGHTED CUMULATIVE CUMULATIVE MULTIPLE DEVIATION PERCENTAGE REMAINDER OF MEAN FROM MEAN 99.8 .1 -.000 -.033 99.9 .0 437.825 48.268 100.0 .0 875.652 96.570 TABLE HOLDQ ENTRIES IN TABLE 6614 UPPER LIMIT 0 5 10 15 20 25 30 MEAN ARGUMENT »057 OBSERVED FREQUENCY 6568 23 9 5 6 2 1 PER CENT OF TOTAL 99.30 o34 .13 .07 .09 .03 .01 STANDARD DEVIATION .895 CUMULATIVE PERCENTAGE 99 o 3 99 06 99.7 99.8 99. 9 99.9 100.0 CUMULATIVE REMAINDER .6 .3 .2 ol • 0 .0 oO SUM OF ARGUMENTS 379.000 MULTIPLE OF MEAN -.000 87.255 174. 5 11 261.767 349.023 436. 279 523.535 NON-WEIGHTED DEVI AT ION FROM MEAN -o063 5.517 11.099 16.681 22.263 27. 845 33o427 REMAINING FREQUENCIES ARE ALL ZERO TABLE 0PRM1 ENTRIES IN TABLE MEAN ARGUMENT 260 69.542 UPPER OBSERVED PER CENT L IMIT FREQUENCY OF TOTAL 0 0 .00 5 0 .00 10 0 .00 15 0 .00 20 0 .00 25 0 .00 30 0 .00 35 1 .38 40 0 .00 45 2 .76 50 6 2.30 55 12 4.61 60 17 6.53 65 48 18.46 70 40 15.38 75 50 19. 23 80 62 23.84 85 18 6.92 90 4 1.53 REMAINING FREQUENCIES ARE ALL ZERO 76 STANDARD DEVIATION SUM OF ARGUMENTS 9.250 18081.000 NON-WEIGHTED CUMULATIVE CUMULATIVE MULTIPLE DEVIATION PERCENTAGE REMAINDER OF MEAN FROM MEAN .0 100.0 -.000 -7.518 .0 100.0 .071 -6. 977 .0 100.0 .143 -6.437 .0 100.0 .215 -5.896 .0 100.0 .287 -5. 355 oO 100, 0 .359 -4.815 .0 100.0 . 431 -4. 274 .3 99.6 .503 -3.734 .3 99,6 .575 -3.193 1.1 98.8 .647 -2. 653 3.4 96.5 .718 -2.112 8.0 91.9 . 790 -1.572 14.6 85.3 . 862 -1.031 33.0 66.9 .934 -.491 48.4 51.5 1.006 • 049 67.6 32.3 1.078 .590 91.5 8.4 1. 150 1.130 98.4 1.5 1.222 1.671 100.0 .0 1.294 2.211 TABLE QPRM2 ENTRIES IN TABLE MEAN ARGUMENT STANDARD DEVIATION SUM OF ARGUMENTS 260 64.346 12.281 16730o000 NON-WEIGHTED UPPER OBSERVED PER CENT CUMULATIVE CUMULATIVE MULTIPLE DEVIATION LIMIT FREQUENCY OF TOTAL PERCENTAGE REMAINDER OF MEAN FROM MEAN 0 0 oOO oO 100. 0 -.000 -5.239 5 0 oOO .0 100.0 .077 -4. 832 10 0 o 00 .0 100.0 .155 -4.425 15 0 .00 .0 100.0 .233 -4.018 20 0 .00 .0 100.0 .310 -3. 610 25 0 .00 o 0 100.0 .388 -3o203 30 2 .76 .7 99.2 .466 -2.796 35 1 .38 l o l 98.8 .543 -2.389 40 3 1.15 2.3 97.6 .621 -1.982 45 14 5.38 7.6 92.3 .699 -1.575 50 21 8. 07 15.7 84.2 o777 -1.168 55 25 9.61 25.3 74.6 .854 -.761 60 2 5 9.61 34.9 65.0 .932 -.353 65 36 13.84 48o 8 51.1 loOlO .053 70 41 15.76 64.6 3 5.3 1.087 .460 75 36 13. 84 78.4 21.5 1.165 . 867 80 40 15.38 93. 8 601 1.243 1.274 85 14 5.38 99.2 .7 1. 320 1. 681 90 2 o 76 100.0 .0 1.398 2.088 REMAINING FREQUENCIES ARE ALL ZERO TABLE 0PRM3 ENTRIES IN TABLE MEAN ARGUMENT STANDARD DEVIATION SUM OF ARGUMENTS 260 59. 846 15.539 15560.000 NON-WEIGHTED UPPER OBSERVED PER CENT CUMULATIVE CUMULATIVE MULTIPLE DEVIATION LIMIT FREQUENCY OF TOTAL PERCENTAGE REMAINDER OF MEAN FROM MEAN 0 0 • 0.0 oO lOOoO -.000 -3.851 5 0 .00 .0 100.0 . 083 • -3. 529 10 1 .38 .3 99.6 .167 -3.207 15 0 .00 .3 99.6 .250 -2.886 20 1 .38 .7 99.2 .334 -2.564 25 2 . 76 1.5 98.4 .417 -2o242 30 8 3.07 4.6 95. 3 .5 01 -1.920 35 4 1.53 6.1 93.8 o 584 -1.598 40 12 4.61 10.7 89.2 .668 -1.277 45 19 7.30 18.0 31.9 .751 -.955 50 34 13. 07 31.1 68.8 .835 -. 633 55 19 7.30 38.4 61.5 .919 -.311 60 31 11.92 50.3 49.6 1. 002 . C09 65 22 8. 46 58.8 41.1 I0O86 .331 70 26 9.99 68.8 31. 1 1. 169 .653 75 26 9.99 78.8 21.1 1.253 . 975 80 40 15.38 94.2 5.7 1.336 1.296 85 12 4.61 98.8 1.1 1.420 1.618 90 3 1. 15 100.0 .0 1.503 1.940 REMAINING FREQUENCIES ARE ALL ZERO TABLE PAR 1 TABLE MEAN ARGUMENT STANDARD DEVIATION SUM OF ARGUMENTS 260 33.223 5.73 8 8638.000 NON-1 UPPER OBSERVED PER CENT CUMULATIVE CUMULATIVE MULTIPLE DEVIATION LIMIT FREQUENCY OF TOTAL PERCENTAGE REMAINDER OF MEAN FROM MEAN 0 0 . 00 .0 100.0 -.000 -5.789 5 0 .00 .0 100. 0 .150 -4.918 10 0 .00 .0 100.0 .300 -4.047 15 1 .38 .3 99.6 .451 -3.175 20 4 1.53 1.9 98.0 .601 -2.304 25 20 7.69 9.6 90.3 .752 -1.433 30 65 25.00 34.6 65.3 .902 -.561 35 69 26.53 61.1 38.8 1.053 . 309 40 75 28. 84 89.9 10.0 1.203 1.181 45 26 9.99 100.0 .0 1.354 2.052 REMAINING FREQUENCIES ARE ALL ZERO TABLE HOLD TABLE MEAN ARGUMENT 260 38.211 UPPER OBSERVED PER CENT LIMIT FREQUENCY OF TOTAL 0 0 .00 5 0 .00 10 0 .00 15 0 .00 20 3 1.15 25 4 1.53 30 26 9.99 35 64 24.61 40 54 20.76 45 72 27.69 50 37 14.23 REMAINING FREQUENCIES ARE ALL ZERO STANDARD DEVIATION SUM OF ARGUMENTS 6.523 9935.000 NON-CUMULATIVE CU MULATIVE MULTIPLE DEVIATION PERCENTAGE REMAINDER OF MEAN FROM MEAN .0 100.0 -.000 -5.857 .0 100.0 .130 -5.091 .0 100.0 . 261 -4.324 .0 100.0 . 392 -3. 558 1.1 98.8 o 523 -2.791 2.6 97.3 . 654 -2.025 12.6 87.3 .785 -1.258 37.3 62.6 .915 -.492 58.0 41. 9 1.046 . 274 85.7 14.2 1.177 1.040 100.0 .0 1.308 1.807 TABLE TOTAL ENTRIES IN TABLE MEAN ARGUMENT STANDARD DEVIATION SUM OF ARGUMENTS 260 25.438 4.234 6614.000 NGN-WEIGHTED UPPER OBSERVED PER CENT CUMULATIVE CUMULATIVE MULTIPLE DEVIATION LIMIT FREQU ENCY OF TOTAL PERCENTAGE REMAINDER OF MEAN FROM MEAN 1 0 .00 .0 100.G . 039 -5. 771 2 0 .00 .0 100.0 .078 -5. 53 5 3 0 .00 oO 100.0 .117 -5.299 4 0 .00 .0 100.0 . 157 -5. 062 5 0 o 00 .0 100.0 .196 -4.826 6 0 .00 .0 100.0 .235 -4.590 7 0 .00 .0 100.0 .275 -4.3 54 8 0 .00 oO 100.0 .314 -4.118 9 0 .00 .0 100.0 .353 -3.88 2 10 0 .00 .0 100.0 .393 -3.645 11 0 .00 .0 100.0 .432 -3.409 12 2 .76 .7 99.2 .471 -3. 173 13 1 o 38 1.1 98.8 .511 -2.937 14 0 .00 1. 1 98.8 .55 0 -2.701 15 1 .38 1.5 98.4 o 589 -2.465 16 1 e38 1.9 98.0 .628 -2.229 17 3 1.15 3.0 96. 9 .668 -1.992 18 6 2.30 5.3 94.6 .707 -1.756 19 8 3.07 8. 4 91. 5 .746 -1.520 20 11 4.23 12.6 87.3 . 786 -1. 284 21 11 4.23 16. 9 83.0 .825 -1.048 22 16 6.15 23.0 76.9 . 864 -.812 23 32 12.30 35.3 64.6 .904 -o 575 24 19 7.30 42o 6 57.3 .943 -.339 25 20 7.69 50.3 49. 6 .982 -. 103 26 16 6.15 56.5 43.4 1.022 .132 27 16 6.15 62. 6 37.3 1.061 .368 28 20 7.69 70.3 29.6 1. 100 « 604 29 25 9.61 79.9 20.0 1.140 o841 30 23 8.84 88.8 11.1 1. 179 1 . 077 31 15 5.76 94.6 5.3 1.218 1. 313 32 10 3.84 9 8o4 1.5 1.257 1.549 33 4 1.53 100.0 .0 1.297 1.785 REMAINING FREQUENCIES ARE ALL ZERO TABLE CODE 82 TABLE MEAN ARGUMENT STANDARD DEVIATION SUM OF ARGUMENTS 6614 58«247 24.062 385250.000 NON-UPPER OBSERVED PER CENT CUMULATIVE CUMULATIVE MULTIPLE DEVIATION LIMIT FREQUENCY OF TOTAL PERCENTAGE . REMAINDER OF MEAN FROM MEAN 1 32 .48 .4 99.5 .017 -2.379 2 13 .19 .6 99.3 .034 -2.33 7 3 24 . 36 1.0 98.9 ,051 -2.296 4 0 .00 1.0 98.9 .068 -2.254 5 32 .48 1.5 98.4 ,085 -2.212 6 26 .39 1.9 98. 0 .103 -2.171 7 28 .42 2.3 97.6 .120 -2.129 8 13 .19 2.5 97.4 .137 -2,088 9 2 .03 2.5 97.4 .154 -2.046 10 69 1.04 3.6 96.3 .171 -2.005 11 21 .31 3.9 96.0 .188 -1.963 12 70 1.05 4.9 95.0 ,206 -1.921 13 3 . 04 5.0 94.9 ,223 -1,880 14 28 .42 5.4 94. 5 .240 -1.838 15 57 .86 6.3 93.6 .257 -1,797 16 0 .00 6. 3 93.6 .274 -1,755 17 9 .13 6.4 93.5 .291 -1.714 18 38 .57 7.0 92.9 .309 -1.672 19 17 .25 7.2 92.7 .326 -1.631 20 8 .12 7.4 92.5 . 343 -1. 589 21 4 o 06 7.4 92.5 .360 -1.547 22 7 .10 7.5 92.4 .3 77 -1.506 23 0 .00 7.5 92.4 .394 -1,464 24 21 .31 7.8 92.1 .412 -1.423 25 372 5.62 13.5 86.4 .429 -1. 381 26 35 .52 14.0 85.9 .446 -1.340 27 6 .09 14. 1 85. 8 ,463 -1.298 28 1 .01 14.1 85.8 .480 -1. 257 29 11 . 16 14.3 85.6 ,497 -1,215 30 816 12.33 26.6 73.3 .515 -1.173 31 3 .04 26.7 73.2 .532 - I . 132 32 9 .13 26. 8 73,1 .549 -1,090 33 8 .12 26.9 73.0 .566 -1. 049 34 69 1.04 28.0 71.9 .583 -1.007 35 2 .03 28.0 71.9 .600 -.966 36 14 .21 28.2 71.7 .618 -. 924 37 13 . 19 28.4 71.5 .635 -.883 38 12 .18 28.6 71.3 ,652 -.841 39 132 1.99 30.6 69.3 ,669 -.799 40 6 .09 30. 7 69.2 .686 -.758 41 3 .04 30.7 69. 2 .7 03 -.716 42 4 .06 30.8 69.1 .721 -.675 43 0 .00 30. 8 69.1 .738 -.633 44 14 .21 31.0 68,9 .755 -. 592 45 38 . 57 31.5 68.4 .772 -.550 46 2 • 03 31.6 68.3 .789 -.508 47 36 .54 32.1 67.8 .806 -.467 48 30 .45 32.6 67.3 ,824 -.425 49 6 .09 32.7 67. 2 .841 -.384 50 29 .43 33.1 66,8 .858 -.342 51 58 .87 34.0 65.9 .875 -,301 52 105 1.58 35.6 64.3 .892 -, 259 53 9 . 13 35.7 64.2 .909 -.218 54 8 .12 35. 8 64.1 .927 -.176 55 3 o 04 35.9 64.0 .944 -.134 56 35 »52 36.4 63.5 .961 -.093 57 246 3.71 40.1 59.8 .978 -. 051 58 21 . 31 40.4 59.5 .995 -.010 59 14 .21 40.7 59.2 1.012 .031 60 7 .10 40.8 59. 1 1.030 .072 61 53 o80 41.6 58.3 1.047 .114 62 41 .61 42.2 57. 7 1.064 .155 63 4 .06 42.2 57.7 1.081 . 197 64 0 .00 42. 2 57.7 1.098 .239 65 3 .04 42.3 57.6 1. 115 . 280 66 8 .12 42.4 57.5 1.133 .322 67 23 .34 42.8 57o 1 1.150 .363 68 27 .40 43.2 56.7 1. 167 .405 69 1 .01 43.2 56.7 1.184 .446 70 333 5.03 48.2 51. 7 1. 201 .488 71 0 . 00 48.2 51.7 1.218 , . 529 72 29 .43 48.6 51.3 1.236 .571 73 36 .54 49.2 50.7 1.2 53 .613 74 1465 22. 14 71.3 28.6 1.270 .654 75 754 11.40 82.7 17. 2 1.287 .696 76 5 .07 82.8 17.1 1.304 .737 77 24 .36 83.2 16. 7 1.321 o779 78 4 .06 8 3.2 16.7 1.339 . 820 79 5 .07 83.3 16.6 1.356 . 862 80 0 .00 83.3 16.6 1.373 .903 81 286 4.32 87.6 12.3 1.390 . 945 82 193 2. 91 90.6 9.3 lo407 .987 83 72 1.08 91.6 8.3 1.424 1.028 84 16 .24 91.9 8.0 1.442 1.070 85 12 .18 92.1 7.8 1.459 l o l l l 86 252 3.81 95.9 4. 0 1.476 1.153 87 84 1.27 97.2 2.7 1.493 1.194 88 129 1.95 99. 1 .8 1.510 1.236 89 56 .84 100.0 .0 1. 5 27 1. 278 REMAINING FREQUENCIES ARE ALL ZERO 

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