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A computer simulation of the admissions and scheduling system at St. Paul’s hospital Chase, Mark Gordon 1977

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A COMPOTES  SIMULATION  OF THE ADMISSIONS AND SCHEDULING AT ST. PAUL'S  SYSTEM  HOSPITAL  by MARK GORDON CHASE B.Sc.,Mount A l l i s o n U n i v e r s i t y , 1 9 7 5  A THESIS SUBMITTED IN PABTIAL FULFILLMENT OF THE REQUIREMENTS FOR THE DEGREE OF MASTER OF SCIENCE in THE FACULTY OF GRADUATE STUDIES I n s t i t u t e o f A p p l i e d M a t h e m a t i c s and S t a t i s t i c s  We a c c e p t t h i s t h e s i s a s c o n f o r m i n g to t h e r e q u i r e d standard  THE UNIVERSITY OF BRITISH COLUMBIA September,1977  <£) Mark Gordon C h a s e , 1977  In p r e s e n t i n g t h i s  thesis  an advanced degree at the L i b r a r y I  further  for  freely  of  the  requirements  B r i t i s h Columbia, I agree  available  for  t h a t p e r m i s s i o n for e x t e n s i v e copying o f  this  representatives. thesis for  It  financial  this  of  gain s h a l l  J^t^La^L'.y  thesis  not be allowed without my  & £ t U ^ j £ j £  The U n i v e r s i t y o f B r i t i s h Columbia 2075 Wesbrook P l a c e V a n c o u v e r , Canada V6T 1W5  Date  Z3.  that  or  i s understood that copying or p u b l i c a t i o n  w r i t ten pe rm i ss i on .  Department  for  r e f e r e n c e and study.  s c h o l a r l y purposes may be granted by the Head of my Department  by h i s of  fulfilment  the U n i v e r s i t y of  s h a l l make it  agree  in p a r t i a l  /P77  <2a*^£<S  iii  ABSTRACT  IE Paul's  this  work, t h e a d m i s s i o n s and s c h e d u l i n g  H o s p i t a l was examined  by means o f m o d e l l i n g  system and  at St.  computer  simulation. The  Hospital i s  occupancy patients of  and  a  an  acute-care  policy  of  facility  admitting  who r e q u i r e h o s p i t a l i z a t i o n .  providing  disrupting  space  scheduled  After  for  these  investigation  computer  simulation  operating  rooms, and bed  a one-day  a l l of  very  t h e emergency  I t now f a c e s t h e  patients  high  without  problem  seriously  admissions. of  the l i t e r a t u r e ,  model t h e H o s p i t a l ' s a d m i s s i o n s  service".,  with  to  and s c h e d u l i n g  i t was d e c i d e d system  to  and  use  investigate  i t s behaviour.  Patients,  areas  classified  "hospital  A GPSS s i m u l a t i o n  were  by  model which u s e s e m p i r i c a l d a t a and  t i m e u n i t was d e v e l o p e d .  The model was  verified  and  validated. Several  e x p e r i m e n t s were  methods t o r e g u l a t e to  alleviate  hypothetical were o n l y  performed  occupancy  surgical arrival  i n the various  slate  conclusion,  several  contrasts  practice  as revealed  two  by  under  existing  These  or  experiments  f o r which t h e model may be u s e d . of t h i s  points  between  different  h o s p i t a l a r e a s , and  f o r patients.  Suggestions f o r extensions In  suggest  disruptions,  patterns  a sample o f t h o s e  to  are  formal  the  data;  project are included. made:  hospital second,  first, policy i t  there  are  and a c t u a l  appears  that  simulation  can  be  useful in a hospital  context.  V  TABLE OF CONTENTS Abstract Table of Contents L i s t of Tables L i s t of Figures acknowledgement Abbreviations 1.  2.  i i i v viii ix x i i xiv  INTRODUCTION  1  1.1 1.2  1 1  What Was t h e P r o b l e m ? Chapter Outlines  PROJECT BACKGROUND INFORMATION  4  2.1 2.2 2.3 2.4  4 5 6 6  Conception Initiation Initial Familiarization P r a c t i c a l A p p l i c a t i o n s of the Model  3.  LITERATURE REVIEW  4.  INTERPRETATION AND 4.1  5.  THE 5.1  5.2  METHODOLOGY  Basic Methodological 4.1.1 4.1.2 4.1.3 4.1.4 4.1.5  4.2  8  Decisions  M a t h e m a t i c a l Method Language Time U n i t L e v e l of Aggregation E x t e n t o f t h e Model  Distinctive HOSPITAL AND  Features THE  of t h i s Project  MODEL  27 27 27 29 30 31 32 33 35  D e f i n i t i o n o f Subsystems  35  5.1.1 5.1.2 5.1.3  36 42 45  Hospital Services Hospital Units Bed G r o u p s  Admitting 5.2.1 5.2.2 5.2.3 5.2.4  Considerations  Bed Usage S e q u e n c e o f C l a i m s on B e d s "No Bed" S i t u a t i o n s P a t i e n t Admission Diagnostic Categories  47 47 48 50 51  vi  5.2.5 5.2.6 5.2.7 5.3  Surgical 5.3.1 5.3.2 5.3.3 5.3.4 5.3.5 5.3.6 5.3.7 5.3.8 5.3.9 5.3.10 5.3. 11  6.  7.,  Scheduling Considerations  O p e r a t i n g Rooms Use o f I n f o r m a t i o n on t h e a d m i t t i n g Forms Pre-Operative Stay Block Booking Service Characteristics L i m i t a t i o n s on S c h e d u l i n g Considerations of a u x i l i a r y Staff I n - H o s p i t a l Demands Handling of Emergencies T i m i n g of S l a t e C o n s t r u c t i o n General  53 54 55 55 56 56 58 58 59 60 62 63 64 65 65  MaJOB FLOW PATTERNS  67  6.1 6.2 6.3  67 68 71  P u r p o s e and Form Overview F l o w c h a r t D e t a i l Flowcharts  THE DATA AND INFORMATION 7.1  7.2 7.3 8.  C o n t r o l o f M e d i c a l Beds S u r g i c a l Non-Operative admissions General  USE  87  D e s c r i p t i o n of Data-Sets  87  7.1.1 7.1.2 7.1.3 7.1.4  87 88 91 91  Waiting L i s t s Operations Length of Stay Emergency A d m i s s i o n s  The S p e c i f i c a t i o n Comments  o f Data  and I n f o r m a t i o n  92 100  THE MODEL IMPLEMENTATION  102  8.1 8.2  General Features The Program Segments  102 106  8.2.1 8.2.2 8.2.3 8.2.4 8.2.5 8.2.6 8.2.7 8.2.8 8.2.9 8.2.10  106 107 108 112 112 114 115 117 117 117  H o u s e k e e p i n g Segments Patient Generation S u r g i c a l Request Handling M e d i c a l Reguest H a n d l i n g S u r g i c a l admissions Medical Admissions Emergency A d m i s s i o n s In-Hospital Transfers Discharges O p e r a t i n g Room Data  vii  9.  10.  11.  EVALUATION OF THE SIMULATION MODEL  119  9.1 9.2 9.3  119 129 133  EXPERIMENTS  146  10.1 10.2 10.3 10.4 10.5 10.6  146 148 149 153 156 157  FOR FOTURE CONSIDERATION  Data Model M o d i f i c a t i o n Experiments  161 161 163 164  and E x p a n s i o n  DISCUSSION 12.1 12.2  List  Admission Strategy Bed A l l o c a t i o n C o m b i n i n g Bed A r e a s Bequests f o r S p e c i f i c Surgery Dates C l a s s i f i c a t i o n of Patients Number o f P a t i e n t s  PROPOSALS 11.1 11.2 11.3  12.  Form o f t h e R e s u l t s Verification Validation  167  System L a p s e s R e v e a l e d by Data Value of Simulation i n a H o s p i t a l - A P e r s o n a l View  Context  o f References  167 169  172  Appendices 1.1 1.2 1.3 1.4  E a r l y S p e c i f i c a t i o n s f o r t h e Model The B a s i c I n f o r m a t i o n Flow The P r o p o s a l t o S t . P a u l ' s H o s p i t a l " Q u e s t i o n s " t o Ask o f t h e Model  178 180 181 184  2.1 2.2 2.3 2.4 2.5 2.6  A d m i t t i n g O f f i c e R e p o r t 1976 Patient Diagnostic Categories Patient Arrival Distributions P a t i e n t Sex and Age Groups P a t i e n t Length o f Stay Length o f Surgery  185 187 189 191 193 199  3  Program  202  Listing  viii  LIST OF I. II. III. IV.. V.  Nursing Daily  Units  Slate  Hospital Beds by  (June  TABLES  1976)  37  Subdivisions  38  Services  39  Sex  46  Operating  Rooms  57  Bed  Guidelines  61  I n - H o s p i t a l Demands f o r S u r g e r y  61  VIII.  Data  Collection  89  IX.  Data  and  X.  User  Chains  VI. VII.  XI. XII. XIII. XIV. XV. XVI.  Limit  Groups  I n f o r m a t i o n Used  93 122  Storages  123  Queues  123  Output T a b l e s  125  Model O u t p u t T a b l e s L i s t  126  Halfword  128  Matrices  T y p i c a l C r o s s - s e c t i o n o f W a i t i n g Times  168  XVII.  Orthopedic  Patients  188  XVIII.  Orthopedic  Arrivals  190  XIX.  Sex  of Orthopedics  191  XX.  Orthopedic  Male Age  XXI.  Orthopedic  Female Age  XXII.  PAS  LOS  Groups  192  Groups  192  Tabulation  194  XXIII.  Empirical  LOS  : Age  35-54 o r t h o p e d i c s  195  XXIV.  Processed  LOS  : Age  35-54 O r t h o p e d i c s  197  XXV. XXVI.  Orthopedic Length  Length  of Surgery  of Surgery : Age  15-34  199 Orthopedics  201  ix  L I S T OF 6.1  Admission  FIGUSES  and OB S c h e d u l i n g I n f o r m a t i o n  Flowchart  CI)  69  6.2  Admission  Requests Flowchart  (IIA)  6.3  S u r g i c a l S e r v i c e s and O p e r a t i n g  72  Rooms F l o w c h a r t  <IIIA)  75  6.4  Medical Service Flowchart  6.5  Emergency  6.6  In-Hospital Variations  8.1  Flowchart  f o r D a i l y Time S t r e a m  8.2  Flowchart  for First  8.3  Flowchart  for Placing  Unit Flowchart  (IVA)  79  (VA)  81  Flowchart  (VIA)  84 105  Desired Surgery  Date  109  Schedulable Surgical Patients  on t h e S l a t e  110  8.4  Flowchart  f o r Admitting Surgical  Patients  8.5  Flowchart  f o r Emergency A d m i s s i o n s  9.1  M e d i c a l "Immediate" P a t i e n t s ( p e r 3 months)  113 116 as a  F u n c t i o n o f Time 9.2  Medical Schedulable  140 Patient  Requests  (per 3  months)  as a F u n c t i o n o f T i m e 9.3  M e d i c a l Area  Discharges  140 (per 3 months)  as a Function  o f Time 9.4  141  A v e r a g e M e d i c a l Queue L e n g t h  ( o v e r 3 months)  as a  F u n c t i o n o f Time 9.5  M e d i c a l P a t i e n t s P l a c e d O f f - S e r v i c e (per 3  141 months)  as a F u n c t i o n o f Time 9.6  Surgical  "No  Bed" C a n c e l l a t i o n s (per 3 months)  Function  o f Time  142 as a 142  X  9.7  Medical Function  9.8  Medical as  9.9  "Immediate" P a t i e n t s o f Time  143  Schedulable  a Function  Medical  ( p e r 4 weeks) a s a  Area  P a t i e n t Heguests  (per 4 seeks)  o f Time Discharges  143 (per 4 weeks) as a  Function  o f Time 9.10  Average M e d i c a l Function  9.11  144  Medical  10.1  10.2  10.3  10.4  10.5  10.6  Medical  4 weeks)  : O r i g i n a l x ; Experiment  : Original  as a o  150  ( p e r 4 weeks) a s a  x ; Experiment  o  150  Bed" C a n c e l l a t i o n s ( p e r 4 weeks) a s a  o f Time  : Original  o f Time  : Original  x ; Experiment  o f Time  o f Time  : Original  : Original  : Original  P a t i e n t s Placed  152  4 weeks) a s a  x ; Experiment  x ; Experiment  S u r g i c a l Procedures  o f Time  (over  o  o  152  o  154  ( p e r 4 weeks) a s a  A v e r a g e S u r g i c a l Queue L e n g t h Function  10.8  (over  Bed" C a n c e l l a t i o n s  o f Time  Orthopedic Function  10.7  Queue L e n g t h  EENT S u r g i c a l P r o c e d u r e s Function  ( p e r 4 weeks) as a 145  A v e r a g e Use o f " O v e r f l o w " Beds Function  (per 4 weeks) 145  Bed" C a n c e l l a t i o n s  o f Time  S u r g i c a l "No Function  Off-Service  o f Time  S u r g i c a l "No Function  as a  o f Time  Average M e d i c a l Function  4 weeks)  144  Patients Placed  S u r g i c a l "No Function  (over  o f Time  as a F u n c t i o n 9.12  Queue L e n g t h  ( p e r 4 weeks) a s a  x ; Experiment (over  o  4 weeks) a s a  x ; Experiment o  Off-Service  154  (per 4 weeks)  155  xi  as a F u n c t i o n 10.9  10.10  10.11  o f Time  Surgical  "No  Function  o f Time  : Original  Bed" C a n c e l l a t i o n s : Original  o f Time  Surgical  "No  Function  o f Time  : Original  (over  : original  The B a s i c  Flowchart  A 2.1  Admitting  Office  A 2.2  Logarithmic  1976  Probability  Plot  158  as a 158  4 weeks) a s a  x ; Experiment  o  x ; Experiment  160 as a  o  of information  Report  o  o  Bed" C a n c e l l a t i o n s {per 4 weeks)  A 1.1  Orthopedics  (per 4 weeks)  x ; Experiment  A v e r a g e Use o f " O v e r f l o w " Beds Function  x ; Experiment  160 180 186  o f LOS  f o r Age  35-54 196  xii  ACKNOWLEDGEMENT  I  wish  L a s z l o and  to  express  Dean  undertaking.  H.  Dr.  my  appreciation  Oyeno  t o Drs.  f o r providing  Laszlo  guidance  d i r e c t e d the approach,  and  presentation  of the project.  in  the  d i r e c t i o n o f t h e p r o j e c t . Dr.  general  particularly Additional  the  advice  t h e s i s came from Applied the  computer  Dr.  R.,  very  grateful  there, I  of the  development,  Uyeno  supervised  simulation  aspects.  Services, me w i t h  the  i n this  Institute  and Dr., J .  H.  of  Milsum o f  Brian  H.  Greater  Vancouver  Regional  me t o t h e S t .  who would be o f  D.  MacDonald,  H o s p i t a l , Dr. E.  C.  f o r accepting  access  C u r t i s , Head o f t h e  Paul's  assistance  interest i n the project.  D i r e c t o r , and Mr.  providing  this  to participating  of  i n introducing  t o Dr.  of S t . Paul's  Medical  Mr.  and t o t h e p e r s o n n e l  am i n d e b t e d  Administrative for  Unit  and f o r h i s c o n t i n u i n g  Director the  to  f o r h i sefforts  H o s p i t a l system  Restrepo  A.  Systems.  Management E n g i n e e r i n g Hospitals  A.  and S t a t i s t i c s ,  D i v i s i o n o f Health am  and  in  on t h e p r o j e c t and on i t s p r e s e n t a t i o n  Mathematics  I  In a d d i t i o n  modelling  Charles  E.  G.  the Q.  Emery,  Van T i l b e r g ,  the  Director  our p r o j e c t  to the personnel  Executive  of  p r o p o s a l and  and r e c o r d s  which  would be o f a s s i s t a n c e . A s p e c i a l word o f t h a n k s g o e s t o t h e the  hospital,  resources  to  who answer  generously my  many  provided guestions:  following of  their  Miss  people time  Molly  at and  Smith,  xiii  Supervisor  (Admitting  Administrative Booking Unit);  Other assistance I the  (OR);  Miss G a b r i e l l e  Miss P a t r i c i a  Sister Cornner,  Unit  draft  Finally, share i n t h i s  I  Librarian.  and  a t the  part  o f my  complete.  provided a d d i t i o n a l  university.  g r a t i t u d e t o Miss Faye T a y l o r f o r t y p i n g  Health  wish  Surgical  K n i g h t , C h i e f M e d i c a l Record  of the t h e s i s of  Strain,  Bruce,  (Emergency  o n t o t h e computer. Systems  a s s i s t a n c e i n t h e p r o d u c t i o n o f the  was  K.  Sandi  Manager  at t h e h o s p i t a l  Division  thesis  Miss  p e o p l e , t o o numerous t o m e n t i o n ,  must e x p r e s s my  first  the  Supervisor  Clerk; and  Department);  to  thank  life  that  also  The  provided  staff  of  technical  thesis. Karen  f o r b e i n g so w i l l i n g  s h e became my  to  w i f e b e f o r e the  xiv  ABBREVIATIONS  CPHA  Commission  on P r o f e s s i o n a l  BO  Direct  EENT  Eye, E a r , Nose, a n d T h r o a t  El  Elective  ENT  E a r , Nose, and T h r o a t  FIFO  F i r s t I n , F i r s t Out  GPSS  General Purpose  H-ICDA  International  and H o s p i t a l  Activities  Urgent  Appended  Simulation  System  Classification  of Diseases -  (Hospital Version)  ICN  Intensive  Care  Nursery  ICU  Intensive  Care  Unit  LOS  Length o f Stay  OR  O p e r a t i n g Room  PAR  P o s t - A n a e s t h e t i c Recovery  PAS  Professional  SU  Semi-Urgent  U  Urgent  Activity  Room  Study  ( o f CPHA)  1  CHAPTEfi 1  1.1  INTRODUCTION  What Was  St.  Paul's  acute-care 93%  on  admits  although  they these  beds, they who  near  has  a high occupancy  There  a l l  must  is  a  shortage  emergency  often  be  patients placed  p a t i e n t s are t r a n s f e r r e d  have  the c a n c e l l a t i o n s  been  placed  This t h e s i s d i s c u s s e s a study  the  system  system  was  at St.  for  alleviate  hypothetical  1.2  arrival  Chapter  Chapter providing it  surgical  Medical / of  beds,  who  of  surgical but  the  need t o e n t e r -  out  o f the  beds.  "off-service"  of s c h e d u l a b l e p a t i e n t s On  t h e o t h e r hand,  St.  i t needs.  A c o m p u t e r model  experimentation  with  various hospital  disruptions,  patterns f o r  under  and of  different areas,  existing  and or  patients.  Outlines  2 d i s c u s s e s the  d e t a i l s of the  demonstrates  practical  slate  average  of the p a t i e n t a d m i s s i o n s  methods t o r e g u l a t e o c c u p a n c y i n t h e to  (an  "off-service"  Paul's Hospital.  designed  C o l u m b i a i s an  in  there.  more o p e r a t i n g rooms t h a n  scheduling  level  c a p a c i t y i n most o f t h e  o f t e n cause  should  Paul's  with  weekdays).  hospital  Unless  but  Problem?  H o s p i t a l i n Vancouver, B r i t i s h  hospital  overall,  areas  the  that  r a t h e r than  background  p u r p o s e and the  the  project.  motivation f o r the  undertaking  theoretical.  of  was  intended  By  project, to  be  2  Chapter 3 i s pertinent chapter  to  the  describes  hospital  of  the  development  of  this  existing  Hospital  literature  which  was  project.  Most o f  the  mathematical  with  a  models  particular  of  emphasis  various  on  computer  models. ,  Chapter  4  discusses  problem  investigate  i t .  presented,  which  overview  facilities,  simulation  are  an  and  the  the  interpretation  methodology  Basic methodological  together  differentiate  with  this  an  the  which  St.  was  Paul's  used  to  d e c i s i o n s which were made  explanation  project  of  from  of  those  those  features  described  in  the  literature. 5  Chapter and  processes  development admission  of  6  Paul's  collection  model.  Particular  scheduling  presents  the  which were used and  analyses  model.  brief  summary o f t h e C h a p t e r 9 i s an  the form of  the  of the  verification  Chapter  information  10  model.  data  concepts  and  of the  patterns  the  to  the  in  the  information  aspects  the  implementation  of  pointed  of  from  both  are explained,  of the  out.  and  there i s a  model. s i m u l a t i o n model.,  model i s e x p l a i n e d .  validation  describes  are  and  a c t u a l computer  e v a l u a t i o n of the  output  r e l e v a n t to  flowcharts.  i n the  details  facilities  processes.  major  of these  Noteworthy  of t h o s e  a t t e n t i o n i s paid  7 i s a d i s c u s s i o n of the data  Chapter 8 d e s c r i b e s the the  explanation  H o s p i t a l which a r e  means of a s e t o f  Chapter St.  the  in-depth  Paul's  surgical  Chapter by  an  i n St.  and  hospital,  is  of the  several  model a r e  experiments  Then,  First, details  provided. which  were  3  performed  with  selection of  the  the  model,  and  o f t h e s e e x p e r i m e n t s was range  of  situations  analyzes  their  results.  The  intended t o demonstrate  which  the  model may  be  part  used  to  investigate. Chapter  11  suggests  s e v e r a l i d e a s t o update, extend,  experiment  w i t h t h e model i n t h e  model  be  of  may  newer  improved  data  and  and  future.  In  particular,  made more p r a c t i c a l l y  renewed  discussions  u s e f u l by  with  St.  and the  means Paul's  administration. Chapter made: f i r s t ,  12 i s a  concluding  the data r e v e a l  a few  discussion.  actual  my  simulation  point  hospital context.  i t appears that  points  lapses i n the h o s p i t a l  between f o r m a l h o s p i t a l p o l i c y and vantage  Two  are  system  p r a c t i c e ; second, from can be  useful i n a  4  CHAPTER 2  PROJECT BACKGROUND INFORMATION  T h i s chapter b r i e f l y Paul*s  simulation  the basic rather  2. 1  project.  motivation  than  describes the early  history  o f the S t .  T h i s background demonstrates  behind  this  undertaking  was  that  practical  theoretical.  Conception  The  idea  of  applying  the  techniques  computer s i m u l a t i o n t o p r o b l e m s o f S t . from  discussions  between  Mr.  Hospitals) Division  and  of Health  objectives  and  f l o w diagram The  Charles Laszlo  was a l s o  requirements  main  guides  for  surgical  slate  was  Experiments  controlling order  of  the  Regional  Mr., C u r t i s l i s t e d a model.  arose  of the several  A general  produced.  objective  the h o s p i t a l .  in  Vancouver  o f t h e s e s u g g e s t i o n s was m a i n t a i n e d  through  patients  (Head  (Associate Director  o f such  model, and t h e r e f o r e t h e y  The  m o d e l l i n g and  Hospital  Curtis  Greater  Systems a t UBC).  data  spirit  the a c t u a l 1.1.  Dr.  Paul's  Brian  Management E n g i n e e r i n g U n i t o f t h e  of  to  the  included  model  with  admission  regulate  disruptions.  to  are  i n building in  patient  Appendix  flow  i n and  t h e model would s e r v e a s rate  occupancy  and p l a c e m e n t and  to  of  alleviate  5  2.2  Initiation  After further  the  for  technical  about  ability  familiar  with  development Applied  initial  d i s c u s s i o n s , the  a  year  was  the  because  not  project  manpower  available.  project  and  was with  I n Hay  decided  not  to  pursued suitable  1976,  I  became  undertake  w i t h i n the framework o f a M a s t e r ' s  its  T h e s i s program i n  Mathematics.  The  first  admitting Office,  was  p h y s i c i a n s {and the  areas.  task  Operating  A revised  to  clarify  the  Emergency  Room  (OR)  v e r s i o n of the  f l o w d i a g r a m , which c o n n e c t s  the  interaction  Unit),  Booking  original  the  Office, general  these e n t i t i e s ,  appears  between  Admitting and  the  bed  information i n Appendix  1.2. The  second  task  was  the working r e l a t i o n s h i p proposal the  was  submitted  hospital  to e s t a b l i s h with  St.  t o Dr.  terms of r e f e r e n c e  Paul's Hospital.  Van  1.3),  (Appendix  the  Tilberg,  Medical  suggesting  Therefore a D i r e c t o r of  investigation  problems of a l l o c a t i o n  and  utilization  and  and  s c h e d u l i n g of s u r g i c a l  patients.  of  the  followed  Medical  actual  personnel,  development  o f o p e r a t i n g rooms,  project  closely  of  of beds, The this  proposal. Ready  support,  forthcoming  from  permission  to  access  t o key  sprinkled  with  some  several administrative levels. proceed  personnel  with and  the  data.  project,  and  skepticism, We  were  was given  were a s s u r e d  of  6  2.3  Initial Familiarization  The  rough d r a f t o f a w o r k i n g  Paul's  {Brian  statistics booking  (Gallager  Paul's.  There  case abstracts providing  1973), and  points was  for also  length-of-stay  Admitting  Department,  2.4  and  From  certain  system  either  in  policy outside to  bed  ( S c r o g g s 1970) the  file was  of  t o prove  increase  St.  patient valuable  personnel  in  and b o o k i n g , t h e Emergency  Model  various For  variations  to modifications due  may  arise  in hospital to  changes  T h u s , t h e model i s e x p e c t e d "questions"  which  might  be  altered  to  example:  o f beds  the throughput of  to  e v e n t s i n t h e h o s p i t a l as  These  h o s p i t a l environment.  the a l l o c a t i o n  served at  drawn f r o m  o r s t r u c t u r e , o r i n an u n e x p e c t e d f a s h i o n  - Can  system  OB and  o f view, t h e model i s i n t e n d e d  vary.  by s u c h s i t u a t i o n s .  on  allocation  to knowledgeable  simulation  to  done  St.  information.  a c o n t r o l l e d manner due  the  at  Records L i b r a r y .  point  parameters  produce responses  imposed  (LOS)  which  a p p l i c a t i o n s of the  realistic  on  understanding  7.1.3),  admitting  studies  on t r a n s f e r s  supervision  the Medical  the p r a c t i c a l a  and  1974),  introduced  O f f i c e , OB  Practical  produce  1976)  on  a l a r g e data  (see S e c t i o n  F u r t h e r m o r e , I was the  May  {Lee and w e s t e r h e i m  as the s t a r t i n g  in  Curtis,  paper  to  services  be  patients?  - I f t h e number o f p a t i e n t s i n c r e a s e s ,  what happens  to  the  7  waiting  list?  -  What happens i f some o f t h e OR's  -  What i m p a c t  are closed?  would an i n c r e a s e d number o f p a t i e n t s have on  t h e volume o f s u r g e r i e s p e r room  and  number  of  "No  Bed"  occurrences? -  What happens i f emergency a d m i s s i o n s  v a r y i n number?  -  What happens i f i n - p a t i e n t  vary i n  A more d e t a i l e d  list  transfers  o f q u e s t i o n s may  be f o u n d  number?  i n A p p e n d i x 1.4..  8  CHAPTER 3  LITERATURE REVIEW  Extensive application example,  literature  exists  their  D i a g n o s i s and  book,  QEerations  Prognosis, David  bibliographic citations.  and  seven  Research Shuman  to  of  this  without  aspects  al.  "stochastic  of these:  in  is  be  citations. processes"  complete, The  are  chapters  on  Anyone  wishing  to  particular  thesis  is likely  to  search find  they  discharge,  is  Operations edited  by  reviews  which,  over  1000  "simulation"  pertinent  to  beyond the range  each of  500  particular  include  particularly  project.  of  (19 75)  I t i n c l u d e s a set o f l i t e r a t u r e to  done,  "admission,  A£££oach,  For  i n c l u d e over  A more r e c e n t s t u d y  A Critical  the  Hospitals;  studies  facilities"  project.  intending  bibliographic  One  Research  the  of  in hospitals.  Ruth S t i m s o n  review  inpatient  In H e a l t h C a r e : et  and  To  categories.  utilization  relevance  all  of o p e r a t i o n s r e s e a r c h techniques  in  identify  on  these  and this  of  books  this quite  helpful. Two also  other  articles  be  mentioned.  analysis  of h o s p i t a l  include  a useful  of eleven pertinent a p p e a r on which in  of  of a g e n e r a l or r e f e r e n c e nature Milsum  et  (1973)  management a d m i s s i o n  tabular display  t h e major  to their  al  modelling  discussion.  of the and The  hospitals.  163  papers  a  holistic  The  authors  characteristic  features  systems.  simulation  developments  most r e c e n t b i b l i o g r a p h y t o  " p a t i e n t s c h e d u l i n g " i s t h a t by  lists  present  should  r e l e v a n t to the  Kohler  et  al  problem o f w a i t i n g  (1977) lines  9  This  review  are s p e c i f i c a l l y The  first  second  relatively  data  and  provides  needs".  includes  The  stochastic  queuing  processes.  of  their  early  third  this  theory  Various  which  thesis.  analyses.  The  discussions  on  group  is  devoted of  hospital  models, a h o s p i t a l - b a s e d models,  computer  and  to  models  study  employing  models a r e a l s o r e v i e w e d  in  detail. Balintfy  (196 0)  p u b l i s h e d one  the s t o c h a s t i c d i s t r i b u t i o n s discharges.  He  argued  the d i s t r i b u t i o n Poisson  of d a i l y  process,  is  should  be  Finally, daily  lognormal,  analyzed  admission  the  distribution  noted  that  considered  the  the  negative  distribution  binomial  of  h i s observed  LOS  data.  distribution  he d e s c r i b e d t h e  a  for  possibility  of  system.  numbers  f o r LOS.  and  e m p i r i c a l grounds t h a t  which c o u l d be  negative  transfers by  and  short-stay  day-of-the-week  " f i t " to e m p i r i c a l data  distribution  t h e number o f beds  and  a c a s u a l t y ward were a n a l y z e d  t h a t a good  Poisson  reasoned  From t h e s e ,  to  They  They f o u n d  He  changes i n the  (1963).  arrivals,  d i s c u s s i o n s on  to h o s p i t a l admissions  which compares w e l l with  discharges.  Admissions  related  first  more a c c u r a t e l y d e s c r i b e d by  he s u g g e s t e d  predicting  of the  on t h e o r e t i c a l  binomial d i s t r i b u t i o n .  a  development  hospital  articles  bed  model. Young's  some  on  g r o u p s of a r t i c l e s  s o p h i s t i c a t e d models o f v a r i o u s a s p e c t s  It  Markov  is  of  "forecasting  limited, to those  relevant to the  group  group  care.  is  for  daily  A Poisson  occupied.  arrivals  distribution  was and then  by  Pike et a l  patients and  by  month.  obtained a  and  with  geometric  resulted  for  10  McCorkle in-patient various  (1966) d i d an  LOS  in  various  Medical  and  surgical  according Lew  to treatment  by  which  relate  m i g h t seem u n i m p o r t a n t found t h a t  effect  on  LOS,  that  had  had  little  Dunn The  or  statistical  a small  admission and  (1967) r e p o r t e d  as  analysis  OE  an  average  on  discharges,  an  t h a t the  had  of  certain  and  LOS,  For  example,  a  of  and  significant  category  type  admission  were  graphs of t h e  efficient  occupancy  and  Drosness  census to optimize  hospital,  but  census data  LOS  care.  diagnostic  p a t i e n t was,  procedures)  situations,,  fitting  subdivided  of  a  accommodation  scheduling  as  and  what  procedure.  the  admission  which h o s p i t a l s e r v i c e s  required.  The  computerized  number o f b e d s a v a i l a b l e o v e r  a  period.  In  daily  of the  produced  two-year  the  effect.  (urgency)  (such  g r o u p s were  to a patient's health  effect,  Besides  significance  to admissions,  the  of  private physician.,  procedure accounted f o r such things  type  they  hospital  a truncated i s one  effective  of who  it  infrequent et  al  is  d e s i r a b l e t o have  overload  or  (1967) c o n s i d e r e d  capacity.  Their  Poisson  fitting  the  work was  use  on  Bed" of  a  the  small daily  distribution  to  distribution.  the  main  can  p r e d i c t LOS  admission  a normal  high  "No  suggested that f o r a large h o s p i t a l the  would c h a n g e from  Administrators more  specialties,  the day-of-the-week of admission  patient very  graphical presentation  h o s p i t a l departments.  a staff  (1966) t e s t e d t h e  variables  he  extensive  variables  scheduling  affecting  fairly job.  occupancy.  a c c u r a t e l y can In  1968,  do  a  David  11  Gustafson  did  estimating  patient  physicians, posterior  odds  estimated  small LOS,  The l a s t  were  analysis,  study direct  Bayes*  a patient  given  training  and  known,  suggesting  prediction  methods were b e t t e r .  facilities  could  with  three  and the  symptomatic  likelihoods  supposing  method  of  t h a t the  required  Gustafson  Training  substantially  on  some  explained  and  on-line  reduce the physician  involved. Also  in  prediction initial caused  1968,  of  LOS  Bithell  discharges.  estimates  by  and  Devlin  They the  presented  discussed physician,  by r e v i s i o n o f t h e s e e s t i m a t e s  patient's  the  a s t u d y on  accuracy  of  and t h e improvement  periodically  during  the  stay.  LOS i n a m e n t a l h o s p i t a l was t h e s u b j e c t in  direct  would be d i s c h a r g e d  took t i m e f o r t h e p h y s i c i a n .  why t h e s u b j e c t i v e computer  This  the  In i t , the physician  "independent" c h a r a c t e r i s t i c features,  LOS was a l r e a d y  by  average,  demographic  He d i d so by  methods o f  estimates  Theorem  method was t h e b e s t .  day,  on f i v e  historical  and  the p r o b a b i l i t y that  characteristics.  time  These  estimation,  certain  these  comparative  regression  variations.  a  a  1973.  He  found  used s e p a r a t e means  o f Hanson's  model  t h e LOS d i s t r i b u t i o n t o be l o g n o r m a l , and and  variances  associated  with  different  diagnoses. Forecasting three that with  o f b e d needs i s t h e s o l e  e a r l y papers. concern a  within  t o p i c of the f o l l o w i n g  Most o f t h e s u b s e g u e n t their  90% a c c u r a t e  scope.  papers a l s o  I n 1963, J o h n s o n  p r e d i c t i v e method b a s e d  was  on a r e a  include pleased  population  12  and a  historical much  patterns.  more  B e e n h a k k e r and  powerful  method  for  (1964)  predicting  bed  needs  factors!  I n a s t u d y o f t h e demand f o r h o s p i t a l b e d s i n v a r i o u s  hospital  beds  affects  suggested that result, yield  demand  i s effected  operation. of  a  deserves  calculations  been  v i a p a t i e n t LOS.  As a  taken  Optimization  from  of  the  a bed  is  its  concerned The  negative  work o f  at  a  was  respect  overfill,  and  used  model  develop  census,  queue  In  Shonick  waiting-time improved specific w a i t and variation  distributions.,  t h e model number  by  incorporating  o f beds above which  only emergencies wich  permitted  number o f " n o n - a p p r o v e d " In  their  London H o s p i t a l  would  book  queue s i z e .  1973 a  be a d m i t t e d ,  emergency  Shonick  and  would be  overflow  by  and  Jackson  point  and  for  a  made t o  adding  t o an  to  (1970)  length,  cut-off  electives  rate.  distribution.  with  occupancy, to  models  Poisson  percentage this  His  exponential  complement  Shonick,  applicable  planning.  arrivals  aspects  primarily  generally  area-wide  emergency and e l e c t i v e  was  t h e o r y models t o  for different  hospital.  for  to  It  of  requirements.  particular  oriented  117  has  of queuing  This thesis  mention  on  the supply  them.  have been many m o d e l s d e v e l o p e d  analysis  considered  for  the a b i l i t y  u s e f u l e s t i m a t e s o f bed  however,  LOS  the  doubted  a hospital's  the  (1964) d i s c o v e r e d t h a t  the adjustment  Newell  There of  Newell  analysis  in  classifications,  of England,  regression  developed  seventeen  regions  by  Brooks  a  unlimited  beds.  Computing  (1972), Barber  and  Q E e r a t i o n a l Research  and A b b o t t  include  a  at  The  chapter  on  13  operational  research  "admission-discharge the  hospital  alleviate  worked  concluded waiting  was  list  Young analysis  to  elective  and  presented  a  to  process  emergent  - which  arrivals.  The  variable. control  may  is  overflow  and  arrivals  which  on  but  the  i n t o keep t h e  above  that  Abbott,  t o apply  arrivals  (at  a  admissions  strain  be  the  occupancy.  hospital  cut-off  point  In  at a no  of  to  the  given  and  1966  parallel input  service one  rate),  the  i n an L - p h a s e or  of  he  streams,  Poisson  input  Erlang  Poisson as  rate  a gamma  an  adaptive  rate of  scheduled  analysis  In t h e a  study  mathematical  1965  model and  methods  constituted  open  distributed  a rate-control first,  The  on  1972)  deterministic to  examined  stabilization  parallel  to  group  acceptance  formal  with  probabilities.  model, s c h e d u l e d  brought  two  Standard  turnaway  depended  of  streams.  taken  the  set.  level  model  represent  In  was  measure o f t h e  and  an  within  The  m o d i f i c a t i o n s , and  occupancy  (scheduled)  Young compared  admissions  of  patient  and  LOS  model.  group  occupancy.  the  the f i r s t  t o emergency  elective  is  t o d e f i n e a model and  high  Barber  theory  (beds)  corresponding  one  i s the only o v e r a l l c o n t r o l  problem  queuing  facilities  to  reduction of  probably  the  which  number o f a v o i d a b l e t r a n s f e r s .  (Page 40,  was  t o 1969  that the best  admissions  administration".  1966  s e v e r a l system  the  t h a t "the  of  A multi-disciplinary  related  They f o u n d  system  other  from  implemented  the r e s u l t s . the  study".  problems  actually  studies  yielded  feedback  control  deterministic  stream  Scheduled certain scheduled  admissions  occupancy admissions  were level, were  14  allowed. and  Again,  death  time)  unsatisfactory Bithell  (1969  a  as  based  bed-state,  the  using  models  to  found  In Markov  decision  that  general  Poisson  ones,  i f the  queuing theory computer  and  i f Young's and  difficult  and  often  situation  studied. - citing  of  on  The  elective  the  current  the  emergency variability  the  advantages  tailored  the  "adaptive  variance  was  For  the  and  refined a linear  Young's program.  processes  are  c o n t r o l r u l e s are  since only (He  occupancy  he d i s c u s s e d  occupancy  analysis collapses.  simulation,  that for  found  two  control"  significantly,  efficiency.  further  aspect  He  equals  week-day e v e n t s .  to reduce the  Kolesar  developed  appraisal  processes,  the  paper  the  depending  paper,  (Markov)  t o improved  1970,  of  variance  second  usually  to study  d e v i a t i o n o f t h e LOS.  plus a factor the  are  processes  first  variance  occupancy  In  probabilities.  times  analysis.  continuous  particular  contributing  fruitful  a  discrete-time  model was  out  on  variance  discharge.  standard  His in  the  "birth  exponentially-distributed  u s e d Markov  aid  for  reality.,  had.  to  admissions,  admissions  admissions  of  inter-arrival  b)  Young  p r o p o r t i o n a l to the  of  S  statistics  deterministic  of  and  equations  steady-state  r e p r e s e n t a t i o n s of  situation  pertinent  yielded  Young's a s s u m p t i o n  (service  same  queuing theory  processes"  Unfortunately, LOS  standard  he  Kolesar  considered  specifically admitted  F e t t e r and  model, He  first  replaced  a  pointed by  more  made more c o m p l e x , steered them  simulation  was He  clear  to  applicable  Thompson's work.)  with  of  be  very  to  the  potentially preferred  a  15  Harrovian and  model f o r i t s f l e x i b i l i t y i n t h e use  decision  rules.  efficiently. posed such for  problems as:  i. ,  each  constraint,  even  simultaneously  recovery,  stay  the  table  found  semi-Markov  rules  problem,  be  he  scheduled  with  an  overflow  utilization minor  constraints?  variations  as an  necessary  to  Results could  be  administrative aid.  a l s o been a p p l i e d t o  other  a p p l i e d Markovian a n a l y s i s four  phases  that  recovery  to account  are  p a t i e n t s who  while  those  who  to  coronary  states  f o r the  memory-less).  related  time  From  have  i n each his  r e c o v e r have a die  each  LOS  lognormal  a  negative  one.  should  LOS  with  processes  (1972) d e c i d e d  "phases"  should  for several services.  three  distribution,  Kao  programming  occupancy  identifying  Markov  he  "good"  to:  the  (1968)  into  exponential  to  overflow  a n a l y s i s has  patient  analysis  i n order  schedule  Thomas  (since  linear  obtain  many p a t i e n t s  mentioned  fields.  subdivided  can  distributions  and  in a decision  Markovian  How  a  average  minimize  Kolesar  state  day  maximize  ii.  method  Incorporating  admission  listed  That  of  be  t h a t Thomas's  refined.  distribution  He  i n the  p r o c e s s model.  model  with  its  added a h o l d i n g t i m e  four states,  H i s model even  yielding  a  awkward  according transient  p r e d i c t e d the  census  mix. In within process  1973, a unit. and  Kao In  considered a 1974  paper,  the Kao  p a t i e n t ' s path used  both  o f movement  a Markov  s i m u l a t i o n t o d e c i d e w h e t h e r t o admit  renewal  a p a t i e n t to a  16  coronary  care unit  or t o t r e a t  with the objective Another  developed their  of m i n i m i z i n g  Markovian  variables,  elsewhere  with  a simple  model  a  interesting  geriatric  the  probabilities  five  and cost  for  ward.  considering  were r e c u r r e n c e t i m e ,  in  hospital,  mortality.  analysis,  dealt  transition  variables  him  output  Meredith main  costs. until  its  (1973)  states,  Some o f  death,  the  and  with output  expected  stay. The which  remainder  are  designed Office  of t h i s  simulations  review  for  simulations  for  SIMSCRI.PT and The  which  is the  in  clinic.  occupancy  and  model o f an  reduce entire  bed  moved t h r o u g h  health.  They a r g u e d only  would s u f f i c e . and  necessary.  the One  on  used  that,  of the  noted,  GPSS,  usage.  a  by  Fetter  three-part  surgical  requirements.  different  that  was  In  1969,  care  hospital  zones  depending  found  history output  and that  of  of t h i s  zones GPSS  occupied, simulation  i f a  smooth  in  which  the  of  zones  analysis admission  simulation was  a  the  on h i s s t a t e  f o r changinq  depends on  an  they proposed  t h e p r e s e n t zone o c c u p i e d , M a r k o v i a n i t also  and  SIMSCRIPT  pavilion  they  i f the p r o b a b i l i t y  However, s i n c e  are  Admitting  c o u l d be s c h e d u l e d , i t would  progressive  patient  depended  a  an  t o note  In the m a t e r n i t y s u i t e  p r o p o r t i o n o f the admissions  in  s t u d i e s are those  presented  models  but some which  on-line  language  of a maternity s u i t e ,  outpatient  use  roughly egual  1965  to computer  most p a r t ,  interesting  frequently cited  who  simulation  It  FORTRAN had  most  Thompson,  zone  the  f o r adaptation or d i r e c t environment.  i s devoted  a  set  was of  17  probabilities zone.  The  for  results  budget-constrained overall  bed  The  various of  the  OS  National  previously  utilization  simulation defined  parameters  programming  Statistics  hospital  discharges  i n 1966.  started  a  Health  use  s i m u l a t i o n t o examine t h e  between t h e r e s p o n s e  be  annual  and  Interview  reality  outcome  of  a  with  the  a l r e a d y spent Handyside  in  individual  process,  distribution.  i n the  and  population  discharge  Morris  whose  data  that  empirical  proposed  i n the  literature.  operated  only  effects o f use  LOS  the  The  was  of various p o l i c i e s on  as  Wolfe,  stabilization  appeared  wished  to  the  survey.  was  gamma  was  The  taken  parameter  to was  variable.  per  year  was  to  be  found  simulated a  Poisson  the  department  needed.  The  which d e f i n e d of  bed  i n 1968.  an  emergency  arrival  rate,  d i d not f i t d i s t r i b u t i o n s being  considered  authors  the  examined  sequence  of  had the days  occupancy.  A SIMSCRIPT s i m u l a t i o n o f a m u l t i p l e OR and  a  LOS  (1967)  but  i t  to  hospital.  with  when  used  p r o b a b i l i t y c o n d i t i o n a l on  d e p a r t m e n t . , They were s a t i s f i e d felt  Center  of i n t e r e s t . .  p o p u l a t i o n ' s number o f h o s p i t a l e p i s o d e s binomial  the  be  Hence, t h e  time  over  may  f o r an  Poisson  a  factors causing discrepancies  to vary  lognormal,  a  optimize  Survey  considered  negative  for  The  i n o r d e r t o improve  number o f h o s p i t a l i z a t i o n s  the  i n each  produced  h o s p i t a l - d i s c h a r g e s , and  choice of s t o c h a s t i c d i s t r i b u t i o n s  annual  to  for Health  t h e number o f  The  model d e s i g n e d  Center  estimate the  of  utilization.  computer s i m u l a t i o n of had  bed  linear  levels  system,  T h e i r h o s p i t a l had  by  Barnoon  limited  beds  18  but  excess  operating  anaesthetist placing  and  values  rooms.  nurses  on  each  They  to  cases  of these  assigned (after  an  bed  s e r v i c e s they  OR,  an  selection).  examined t h e  By  costs  of v a r i o u s a l t e r n a t i v e s . Robinson with  a  et a l  (1968) e v a l u a t e d  of  s i x v a r i a t i o n s and  total  c o s t s of  operation  turnaway)  at  consisted  of  patients  and  their  operating  level  first  two  FORTRAN.  Only  patients  the  to  and  section c o s t s and  to  to  be  or  policy  to  The  i m p l e m e n t e d by  modify t h e  It  using  was  possible arrival  date assigned  the  were a v a i l a b l e .  The  on  authors  emergency  block  beds  to  be  that  OR  operating  time  day.  Each  arrival  date  a fairly  three  of  taken  possible  in  basic  arbitrary scheduling  were:  "Filled  record into  data  earliest  rule.  last  The  p a t i e n t ' s desired admission  latest  s i n c e no  the  suggested  available  an  these optimal  for  number o f b e d s was  constraint.  produce  scheduling  account  "generated" with  i.  to  the  m e r e l y a l l o c a t e them a f i x e d  scheduling  alternatives  find  and  simulation  to s c h e d u l e  a given  was  basis,  The  generator  section  daily  overflow  levels.,  reguest a  beds,  p a t i e n t s were c o n s i d e r e d .  reasonable  p r o c e e d as b e f o r e .  define  patient  given  elective  a  booking could to  evaluation  would be  only  a  attributes,  for  empty  systems  average  s e c t i o n s were w r i t t e n i n SIMSCRIPT and  thought t h a t  and  an  of  scheduling  compared t h e  operating  phases:  their  and  terms  optimal  three  patients,  The  (in  three  page", which  scheduled first  i s analogous to using  admissions,  requested  day  by  writing a  t h a t has  an  open  a book  to  p a t i e n t ' s name entry.  19  ii.  A  exact,  method and  used  the e a r l i e s t  not  o v e r l o a d the h o s p i t a l  conditional  the  requested  A method w h i c h  value.  an  estimated  p r o j e c t e d the census.  for  iii.  had  an  estimates,  noted  that patients desiring  of a c t u a l  table  LOS  census"  revisions  The  allowed,  admission  performed  quickly  a r e a l - t i m e p a t i e n t s c h e d u l i n g system.  policies They  in relation  begin  their  that the scheduler  (1968)  studied  to u t i l i z a t i o n discussion  with  figures.  second  core of  al  estimated  for different  I t was  et  would  to i n c o r p o r a t e  given the  away.  Goldman  scheduled  e x t e n s i o n o f t h e above method, a d m i t t i n g  good  suggested  p a t i e n t was  a probability  i n t h e e s t i m a t i o n o f LOS. or  a s i f i t were  f o r which h i s a d d i t i o n  i n the s c h e d u l i n g system a l l o w e d  accuracy  LOS  census.  probabilities  I t was  day  The  p a t i e n t according to "expected  Variations of  which  method best.  were o f t e n  program c o u l d  various  levels  bed  with It  was  turned be  the  allocation  levels,  using  FORTRAN  the  following  IV.  noteworthy  comments:  " I t can be mathematically shown that the p o l i c y o f a l l o c a t i n g b e d s i n any manner l e a d s t o a degradation i n o v e r a l l utilization.. Why, then, allocate beds? The principal a d v a n t a g e o f bed allocation is the potential efficiency to be d e r i v e d from g r o u p i n g p a t i e n t s w i t h s i m i l a r h e a l t h p r o b l e m s i n t h e same p h y s i c a l a r e a , c o n v e n i e n t to t h e f a c i l i t i e s and s e r v i c e s t h e y r e q u i r e . P a t i e n t grouping a l s o allows h o s p i t a l personnel to develop specialized skills in the performance of t h e i r p a t i e n t c a r e f u n c t i o n s ; and s i n c e t h e p r a c t i c e of Medicine i s subdivided in t h e same manner, t h e p h y s i c i a n can d e c r e a s e his travel time between patients by concentrating his p a t i e n t s i n one physical area." "In some c i r c u m s t a n c e s , t h e M e d i c a l c o n d i t i o n of t h e p a t i e n t d i c t a t e s isolation in a private  20  room; and s o c i a l c u s t o m d i c t a t e s t h e s e p a r a t i o n o f p a t i e n t s by sex and p o s s i b l y by age. Patient preferences and f i n a n c i a l c o n s i d e r a t i o n s may a l s o be i n v o l v e d . , Some o b v i o u s disadvantages are associated w i t h any a l l o c a t i o n p o l i c y . . Among t h e s e a r e (1) a p o s s i b l e r e d u c t i o n i n t o t a l bed u t i l i z a t i o n ; (2) a potential increase in patients waiting for admission; (3) t r a n s f e r p r o b l e m s c r e a t e d by t h e attempt to maintain any type of patient segregation; (4) a potential increase in the number o f e m e r g e n c y p a t i e n t s p l a c e d i n temporary beds ( o v e r - c a p a c i t y beds) owing t o e x t r e m e l y h i g h utilization i n any one s e r v i c e ; and (5) a p o t e n t i a l d e c r e m e n t i n p a t i e n t c a r e when a p a t i e n t i s placed i n another s e r v i c e because of high utilization in his proper service." (Pages 119-120, Goldman e t a l , 1968)  In  view  of  beds-to-service  considerations,  p o l i c i e s and  beds—to-service "restrictive"  these  policies  (Medical,  t h r e e beds-to-rooms p o l i c i e s .  The  s e r v i c e areas.  The  three  defined various  services'  on  Intensive  allowed  some  services  being  Care)  and  some  i n the sense t h a t  the  use  allocated  demand. , The  beds  of  rooms  as  d e t e r m i n e d by  elective times,  of  overall  bed  admissions overload,  conclusions  were  and  allowed.  transfers  t h a t at high  the  policies  Together  these  w h i c h were t e s t e d a t s e v e r a l  utilization^  were  meet  and  nine  levels  according  a v e r a g e demand,  gave  policies  other  in  as many b e d s t o be i n w a r d s as p o s s i b l e . allocation  would  they  ( i i ) b e d s t o be  (iii)  bed  in  t h r e e beds-to-rooms  ( i ) a l l b e d s t o be i n p r i v a t e r o o m s , types  of beds  p o l i c i e s were d i f f e r e n t i a t e d  proportion of time the  restricted  based  Orthopedics)  r e s p e c t i v e l y were o r were n o t  the  three  (Obstetrics,  "unrestrictive"  to  considered  were  they  Emergent, Bed  were  urgent,  and  utilization,  waiting  recorded..  General  l e v e l s o f bed  utilization  (about  21  95%),  any  attempt  resulted private sort  in  to s a t i s f y  extremely  rooms would  used  in  be  the  mathematically  and  demand i n t h e  long  waiting  time,  restricted and  d e s i r a b l e under c o s t  study.  T h e i r study  w a r r a n t s a t t e n t i o n by  services  a l a r g e number  parameters  was  carefully  those  of  of the  developed  interested in  the  topic. An  evaluation  published  by  the  could  real  scheduling: first;  operating  Goldman e t a l  many p o l i c i e s of  of  be  (i) first-come,  earlier  FORTRAN  IV,  with  together  a  (possible  and  data.  The  total  time  The  lowest  diagram  authors to  (ii) levels  of  were  three and  unused  daily  daily  expediting  moved  The in  to  Data  simulation  presented  used  that  disruption  of  being  The  so  longest-cases-  time increment.  in  simulation paper,  of important of  input  capacity  examined among  other  rescheduling,  gave h i g h e s t  overtime f o r a l l l e v e l s  a  were  was  the  levels  time,  longest-cases-first policy  total  used  were i n c o r p o r a t e d .  schedule)  overtime,  was  was  policies for  useful tabular discription  utilization,  waits.  time)  a five-minute  a flow  output  capable  occupancy h o s p i t a l .  a s s u m p t i o n s and with  cases  Two  policy  without  three  first-served;  starting  from a 380-bed, 63%  things  q u i c k l y and  ( i i i ) shortest-cases-first.  somewhat  scheduling  Simulation  They c o n s i d e r e d  (that i s , percentage of  and  (1969).  examined  system.  room  and  utilization  of e x p e d i t i n g  and  capacity. The Thomas  ORSA B u l l e t i n in  considered  1970,  abstracted  which  elective,  may  urgent  a  be and  paper of  given  interest. emergent  by  Shao  Their patients,  and model and  22  recognized  dependence  of  the  d a y - o f - t h e - w e e k , so t h e s y s t e m process.  The  strategies  (including priority  times.  model  A simulation  Using  two  items.  They l o o k e d  Connors he  for  environment.  at  a seven-day  eventual  It  patient's  characteristics  used  considered  constraints  requirements  with  possible  a simulation  the  f o r scheduling  and  random  the  in  figure  appropriate  by  the  using  service  program  Commission  (CPHA)-supplied  was on mean  processes date The  order of  merit,  which  Admitting  Office  patients  was  calculated  from  Professional standard  or hospital empirical  Additional  of  arrivals  and  minimize based  and  accommodation chose  from  a composite on  patient  For each p a t i e n t ,  Hospital  deviations.  data.  operating  LOS  estimates  only  assigned  a gamma d e n s i t y  and  quite  a r i s i n g f r o m the  The p a t i e n t  made f o r a l t e r n a t i v e s s u c h a s p h y s i c i a n capability)  PL/1  algorithm  to  was a n a l y s e d .  and  care.  on t h e h o s p i t a l ' s  i n c o n v e n i e n c e and h o s p i t a l i n e f f i c i e n c y . the  no-delay  reguirements.  admission  combinations  a  model i n  use i n a r e a l - t i m e  were b a s e d  Feasible  called  under  week, and p r o g r e s s i v e  c o m b i n a t i o n s were h e n c e i d e n t i f i e d .  function,  waiting  200 k i n d s o f s e r v i c e  deterministic constraints  probabilistic  these  Markov  schemes) on non-emergent  variations  involved.,  among  special  the  e f f e c t s of d i f f e r e n t admission  they  The a l g o r i t h m  occupancy.  as a  on  produced a d i f f e r e n t s o r t o f s i m u l a t i o n i n  (1970) p r e s e n t e d  intended  distribution  was p e r f o r m e d .  wards,  system, s c h e d u l i n g ,  was t r e a t e d  considered  Hearn and B i s h o p 1970.  arrival  function Activities  Provision  was  (with  update  Each admission  request  23  had  t o be a c c o m p a n i e d  admission, coald  and t h e t y p e  lowest  the  patient  o f accommodation  i t  offered  listed  calculations,  written,  day c o u l d  program  performed  and a w a i t e d  a l s o be e n t e r e d .  incorporate  OR  NO  units  ADMIT  /  and a l a r g e  then be ADMIT  Once a day  appropriate  updating  A p a t i e n t MOVE c o u l d  d i d n o t , when  the  article  This scheduling  surgical  ADMIT  PRIORITY  be r e s e r v e d .  scheduling.  causing  f o r the  Under t h e NO  the  another reguest.  The a l g o r i t h m  was made i n d e p e n d e n t l y , a  The a l g o r i t h m  d a y s which m i g h t  Under  admission  the  admissions t o  of  transfers  would  was  decision be  done  PRIORITY ADMIT mode s e g u e n c e . , S p e c i a l number  for  Under t h e ADMIT mode, i t  ( i f suitably small).  to the p a t i e n t f o r c h o i c e .  selected,  desired.  up t o t e n f e a s i b l e  mode, any a r b i t r a r y  p r e f e r r e d days  i n the admissions l o g at the date  f i g u r e of merit  option,  by  of patients*  be r u n i n any o f s e v e r a l modes.  entered  was  by a l i s t  complicate  care and  reduce the e f f e c t i v e n e s s of the algorithm. ft paper by B l e w e t t and  an  operating  a p p e a r e d i n 1972. statistical categorized Models alone, one  A d m i s s i o n s were t a k e n and  were  f o r homogeneity o f  f o r ENT a l o n e ,  lengths  was t a b u l a t e d . models.  of  empirical  P a t i e n t s were  surgery  and  stay.  i n FORTRAN, f o r O p t h a l m o l o g y  comparison  sharing  facilities  with  o f t h e models a n d t h e r e a l  T h r e e e x p e r i m e n t s were p e r f o r m e d  One e x p e r i m e n t ,  wards  consultants  to f o l l o w an  uncontrollable.  and f o r t h e two  A validity  use of  by ENT and O p t h a l m o l o g y  were d e v e l o p e d , and w r i t t e n  validated checked  theatre  pattern  another.  system  et a l d e s c r i b i n g the j o i n t  with  with the  the Opthalmology  t h e c o n s e q u e n c e s o f a new minor o p e r a t i n g  theatre  model, on bed  24  use. the  The  second  effects  operating combined  experiment,  of a change  (actually  timetable. rather  beds would  The  considered  of  by  third  without  this  study  units.  simulation  to  consider  the  operating-room  and  bed i n c r e a s e would  mean i n t e r m s  patient flow s t r a t e g i e s ,  each  surgical  facilities  under  determine  suite  of  s t r a t e g i e s compared  random i n p u t  ii.  preemptive  iii.  longest  iv.  of  temporary  throughput.  conclusions  An were  papers  they  used  number  a  of  and  on  the  a manual beds  T h e y examined  i n t h e OS  work  on  what t h e  procedures,  r e c o v e r y rooms.  GPSS  appeared  GPSS s i m u l a t i o n , with " r e a l  and  extension  -  in  1976. .  of f i v e  world"  of  Empirical and  LOS  data  It  possible  foundations.  r e c o v e r y s u i t e were t h e  surgery  to surgery  priority  were  physical used  distributions.  (existing  to The  policy) ;  f o r recovery-room  surgery f i r s t  non-recovery  longest  of  were:  i.  within  with  increased  i n 1974  consideration.  length  of  usage.  sophisticated via  a  concluded that  appeared.  comparison,  Again,  the  its  1972  of the  t h e a u t h o r s , and  most a  effect  recovery-room  manual s i m u l a t i o n  involved  in  t h e use  a series In  o f t i m e and c a p a c i t y  joined  Their  that  Kwak have p r o d u c e d surgical  this  experiment  is  of  Kuzdrall  consideration)  decreasing o v e r a l l  simulation  i n terms  model, examined  management w i t h f a v o u r a b l e r e s u l t s .  S c h m i t z and  and  under  than s e p a r a t e d s p e c i a l t i e s ,  be r e d u c e d  unusual claim  w i t h t h e cmbined  users;  w i t h i n recovery-room  users,  then  patients;  surgery  first  f o r recovery patients,  others  25  random; v.  longest  others Surgical  surgery  needing  suites  the  were  first  within  major p r o c e d u r e s ,  recovery  room, t h e n t h e  treated  together  as  rest.. a single  r a t h e r than i n d i v i d u a l l y ,  to minimize ambiguity.  that  be  utilization  w o r k i n g day using  a  i n the  new  increasing  i t s surgical  the  The load  strategy  requirements of  improved  recovery-room  strategy.  implementing  beyond  could  such  range  of  could  be  the  found  length  seriously  minimize  study  to  the  was  to  (up  of  h o s p i t a l under c o n s i d e r a t i o n and  reduced  was  by  increase.  the  that  It  facility  21%)  anyway,  (iv) an  and  then  the  However, appeared  considered additional  another  and  was  option  eventually  chosen. In  the  Computer  appears concerning states  that  implemented  a  new  to a l i g n The  considerable  amount o f  and  No  system  Aiding  (first  patients  of A p r i l  Surgery  probably  be be  further details  of the  years)  in  a  entry  or  to  system are  It  is  now  26  system  corrected expanded  an  Schedule".  personnel  scheduling  time, can  1977  t e s t e d f o r two  and  computerized  will  information.  newsletter  a "Computer  hospital.  staff,  Hedieine  OR  saves changed  retrieve published  a by  some at  present. The  preceding  departments not  been i n c l u d e d  provide the  and  a fair  review  i s by  scheduling at a l l .  in this  means exhaustive.,.  of n u r s i n g  staff,  Nevertheless,  overview of the  work p r e s e n t e d  no  literature  thesis.  the  Outpatient  f o r example, reviewed  have  articles  which i s a p p l i c a b l e t o  26  It  may  be o f i n t e r e s t  dates of the a r t i c l e s from and  Health 4 from  p r e s e n t e d h e r e . . Of t h e 45 c i t e d ,  Services  Management  remainder,  with  t o p o i n t o u t t h e s o u r c e s and r a n g e o f  R e s e a r c h , 6 more from Science.  12  12  were  Operations Research  Twenty o t h e r s o u r c e s y i e l d e d t h e  articles  from  Medical  areas,  7  from  Management S c i e n c e , O p e r a t i o n s R e s e a r c h , o r  Statistics,  from  1970, 1972 a n d 1973  Computing  contributed from  5 articles  1960 t h r o u g h  1973. from  each,  p l u s 6 from  1965, 7 f r o m  1966  to  hospital-based incentive  1973, i n c l u d i n g deal and  of applied outside  to publish.  (1975),  future  contributions  to  from  were  articles  significant.  7  appeared  1968 t o 1970.  groups  a r e more l a r g e - s c a l e boundary  4  1969, and 6 s i n c e  who  i f , as suggested  the l i t e r a t u r e  more i n f r e g u e n t , b u t more  the  There  work i s b e i n g c o n d u c t e d  consultation  p r o b l e m s o f s u b s y s t e m s and t h e i r new  one-third  Furthermore  studies  196 8.  1966-67, 4 f r o m  In a g g r e g a t e , o v e r t w o - t h i r d s o f  present, a great  al  or Engineering references.,  and  at  by b o t h  have  little  by Shuman e t  - i n c l u d i n g the  interactions  -  then  c a n be e x p e c t e d t o become  27  CHAPTER 4  The  INTERPRETATION  literature  review  that several d i f f e r e n t model  problems  stochastic, Within of  each  ways.  proceeds  to  a p p r o a c h e s have been  ours.  theoretic,  demonstrates  These  approaches  used t o include  M a r k o v i a n and s i m u l a t i o n methods.  o f t h e s e , t h e model may be c o n s i d e r e d i n a v a r i e t y This  decisions  of t h e preceding chapter  mathematical  similar  queuing  AND METHODOLOGY  made  chapter  presents  f o r the  St.  the  Paul's  basic  methodological  Hospital  t o d i s c u s s them i n t h e c o n t e x t  of  project,  the  analyses  and just  reviewed.  4. 1  Basic Methodological  4. 1. 1  Mathematical  The by  Method  generalized stochastic  Shonick  since,  Decisions  (1970) and S h o n i c k  as t h e y  rather  results  of  Paul's  Hospital  the  characteristics.,  Queuing unacceptable  approach,  and Jackson  (1973)  as  undertaken  was  rejected  s t a t e d , i t i s o r i e n t e d towards area-wide  f o r a community  applicable,  analysis  than  present in If  for a  work a r e i n t e n d e d Vancouver  the  as  with  hospital.  The  t o be o f use t o S t . i t s  particular  model t u r n s o u t t o be more g e n e r a l l y  t h a t i s an a d d i t i o n a l theory  specific  planning  used  by  benefit. Young  since i t i shighly unlikely  (1965,1966) that a r r i v a l  i s  also  rate  and  28  LOS  distributions  can  justifiably  processes.  (See K o l e s a r ,  al,  Furthermore, the  1976.)  which  requires  flexibility admission  OS  and  1970;  Blewett  to  has  be  and  process  planned  various  - i s r a t h e r complex,  represented e t a l , 19 72;  scheduling  slates  which  be  ahead  et  Paul's  with  of  amenable  Poisson  Schmitz  at St.  deqrees  not  by  some  urgency to  a  -  for  gueuing  model. Markovian convenience flexible.,  a n a l y s i s seems more p r o m i s i n g .  of  a  E m p i r i c a l data  interesting  problem  analysis. patient  can  solution  be  used.  could  we  We  be a c c o u n t e d  have  are not  states  -  posed  is  and our  occupying  as  a bed  (iv) discharged,  i n a Markovian  possible  to  demonstrate  scheduling  and  the  as  output.  the  of  impact  of c e r t a i n  waiting l i n e .  It vital  Office,  admission, proper  One  bed,  intent  scheduling  probably  of and  clear  of f l e x i b l e  interaction  with  Even i f  I t i s not  sort  would  (1972)  consecutive  a  remain.  an  Markovian  awaiting  other  quite  However,  hospital.  ( i i i ) occupying  model.  Admitting  bed  not  be  between  OS  i t s important  "No  Bed"  model  very  (  S i m u l a t i o n , on complex  <i)  s c h e d u l i n g , o r any  scheduling  variable  say,  the  Kao  for  number  p r o b l e m s would s t i l l  v a r i a t i o n s on  t o i n c l u d e OR  suitable a  the  (1970) added  for realistically.  in  off-service,  being  program.  in a progressive care  p r o j e c t i s to d i s c o v e r the  bed-complement how  Kolesar  not  interested  p a t i e n t s t a t e s were d e f i n e d a s , (ii)  while s t i l l  idea i n incorporating a linear  showed t h a t LOS the  c l o s e d form  It maintains  situations.  the other Its  hand, can  use  be  used  to  i n t r a n s p o r t a t i o n , economic  and  29  energy to  models i s q u i t e f a m i l i a r .  health care  and  Stimson  to  model  has  1972, the  Furthermore,  been d e m o n s t r a t e d  admissions  application  t o some e x t e n t  o r Shuman e t a l 1975).  patient  its  and  (see  Simulation  can  Stimson be  s c h e d u l i n g system  used  at St.  Paul's Hospital.  ft.1.2  Language  Having among  a  number  languages were  decided  a higher  would  of  order language  was  statistical  project  to  processing  seemed,  suggested was  to  be  cumbersome.  be  built  Of  the  time-stream  are  language  and  processing  with  diverse  operations.  the  of three  the  model in  the  "lines"  T h e r e i s no  main-line simulation  mentioned,  best c a p a b i l i t i e s .  SIMULA  was  However, when  this  i t seemed t h a t UBC  was  going  a good  language  for  large  models.  event-oriented s t r u c t u r e are convenient,  constructs  to  language.  SIMSCRIPT seems t o be Its  one  considered, of t h a t  and  Since  in.  that  best.  have  stop i t s support  possibilities  were u s e d t h e  List  disadvantage  admission  then,  being  The  simulation  SIMULA).  l a n g u a g e , i f FORTRAN  awaiting  l a n g u a g e s would  on  choose  q u i c k l y e l i m i n a t e d from c o n s i d e r a t i o n .  expected  patients  must  (FORTRAN) o r a g e n e r a l l y a v a i l a b l e  i s weak - a d e f i n i t e  It  .Reitman's a r t i c l e  (GPSS, SIMSCRIPT o r  a specialized  be  language  o f languages.  language  FORTRAN i s not  c o m p u t e r s i m u l a t i o n , one  (1967) g i v e s some u s e f u l p o i n t e r s .  simulation  it  t o use  for  data.  However,  there  as are  30  disadvantages. processor become  The  will  amount o f  make a v a i l a b l e i s  inefficient  Consultation  and  compared  GPSS  to  computer memory t h a t  and  reguire  support i t  uncertain,  at  tends  and  skill  UBC  is  to  be  cons.  On  the  SIMSCSIPT  large  models  in  programming.  limited.  Furthermore,  e x p e n s i v e , and  has  poorer  diagnostics. GPSS a l s o has  p r o s and  s t r u c t u r e s u g g e s t s what i s internal by  the  line  working  of  code,  to  internally  tables  be  -  although  support  they  do  Such  the  each  desirable. discrete  (This  language language  processor  be  very  GPSS  point tends  each  which  updates,  last  somewhat  demands,  gives  regular  the  with  Statistics  UBC  of  alleviated  output  block  to  are and  large  "major" and  guick  did  prove  be  fairly  i s well-known. led  to  the  choice  of  GPSS as  the  project.  Unit  Depending of  bugs.  language f o r t h i s  Time  be  the  much  GPSS m o d e l s c a n  expensive.  considerations  simulation  4.1.3  The  and  may  usual  consultation,  system  worthwhile.)  However,  model.  c o v e r a l l the  get  good  to  efficient,  the  added c o n v e n i e n t l y .  with  attention  This  level,  for i n c o r p o r a t i n g documentation explain  maintained may  happening.  i s disguised.  GPSS p r o v i s i o n  a surface  on  day's (The rather  the  level  activites, simulation than  of  detail  different  involved time  l a n g u a g e s which we  continuous  i n the  simulation  intervals considered  t i m e stream.)  may use  be a  Goldman e t a l  31  (1969) u s e d study,  on  the other  processes the  a five-minute  turnovers time  In  c h o s e n was  on  t h i s can  be  4.1.4  Level of  how  simulated  i s mainly  there  per  day.  day  Although  (eg.  Our  minute  of i n t e r e s t  day.  for  Similarly, As  bed  result,  the  a number o f e v e n t s  must  discharges  by a s s i g n i n g " p r i o r i t y  and  admissions),  levels".  Aggregation  must d e c i d e  completely  t h e OR  study.  to c o n s i d e r the  a day-to-day b a s i s .  one  happen i n s e g u e n c e e a c h  One  fact,  f o r t h e i r OB  intended  p a t i e n t s scheduled  are normally  unit  interval  hand, i s n o t  o f t h e OR.  number o f  time  which h o s p i t a l  to d i f f e r e n t i a t e  facilities  to represent  patients according to t h e i r  and care  needs. The  problem  facilities involving A set  up  should  involved  adequate and  specialty  system  consultation group  groups  be  with  these  groups.  collection.  possible.  based on " h o s p i t a l a p p r o p r i a t e OR,  beds.  These  questions  However, i t would  into  Furthermore,  service" bed  5.1.1).  a c c o r d i n g t o H-ICDA  a group of experienced codes  and  f o r c o n s i d e r i n g most  (see a l s o S e c t i o n  of p a t i e n t types may  OR's  scheduling.  t o match p a t i e n t s t o t h e  procedures  data  be  classification  subdivision  patient  posed  p a t i e n t flow  physician  to  as  area,  be and  A further  diagnoses  and  require extensive  hospital  administrators  a manageable number o f such  can  s u b d i v i s i o n would  homogeneous complicate  32  4.1.5  Extent  Should much s t a f f be  and  every should  answered It  o f t h e Model  h o s p i t a l u n i t be i n c l u d e d be shown?  i n general  i s quickly  These a r e other  evident  that  / s u r g i c a l function  Section  5.1.1).  t h e Day C a r e ,  This  of St.  are  operations, inclusion It  involved  patients  at  conditions,  (see  also  that the e s s e n t i a l flow.  Only  of this rate  need t o be  units  (as t h r o u g h  considered  an  staff  does  for  do  more  from  t h e model.  of a n a e s t h e t i s t s for this  determine  noted  i t  was  The one-day the  identified  as  the  number  of  normal  labour  in  Section  5.3.7,  to  explaining emergencies.  decided time  the  unit  to exclude and  the  h o s p i t a l would e n s u r e t h a t t h e  was a p p r o p r i a t e  decision.  under  particularly  hesitation  that  not  contribute  operations,  bit  assumption  is  employ  merely s u g g e s t s t h a t the  hospital, As  will  t o handle the p a t i e n t s  are  This not  established  of handling a  the h o s p i t a l  nurses  i n t h e model.  but v i c e v e r s a .  anaesthetists realistic  control  of the b a s i c  Hospital  patient  t o assume t h a t  considerations  With  account  the  As a r e s u l t ,  entities  efficiency  of  complement i s n e c e s s a r y  s i z e of the nursing  number  in  be s a f e  who a r r i v e t h e r e .  nursing  may  i n t h e model.  nursing  separate  Paul's  b e d s , and bed t r a n s f e r s )  should  whatever  which  P s y c h i a t r i c , Renal  independently  h i g h - l i g h t s the f a c t  matter of i n t e r e s t i s t h e r a t e which  questions  How  terms a t the o u t s e t .  Nursery u n i t s operate e f f e c t i v e l y  Medical  i n t h e model?  to the service  pattern,  33  4.2  Distinctive  St.  Paul's  scheduling, hospital the The  of this  Project  d e s i r e d a model o f i t s p a t i e n t  and  the l i t e r a t u r e  modelling.  existing  Features  contained  admissions  s e v e r a l approaches t o  Would i t h a v e been p o s s i b l e t o a d o p t  models t o t h e p r o b l e m  a t hand?  i t from  other  related  one o f  The answer i s no.  f o l l o w i n g s e c t i o n d i s c u s s e s f e a t u r e s of t h i s  differentiate  and  work  project  published  which i n the  literature. Probably several  t h e most o u t s t a n d i n g  "characteristic"  simultaneously  (presently  implemented). in  the  placed  Paul's  that  about  admissions  off-service. Medical  As  a  patients  EENT, and O r t h o p e d i c s a r e  that  75%  that  of  admissions, schedulable handled  cases  according  categories.  the schedulable  are  of  model  stream.)  many  must  toSt.  immediate admitted  transfer  enough  t o m i n i m i z e "No  5.2.3). basically  two  groups  (SU)  and  The  elective  models d i f f e r e n t i a t e d  However, i n  of  and a r e c a t e g o r i z e d and  (0), semi-urgent  few o t h e r  main  (see S e c t i o n 5.2.4).  form a w a i t i n g l i s t ,  (Very  when i t i s  them must be  s e r v i c e areas  and i m m e d i a t e  t o urgent  may be  Medical admissions  30%  out of s u r g i c a l  schedulable  emergency a d m i s s i o n s  T h e r e a r e so  the  modelled  when b e d s a r e n o t a v a i l a b l e  the  about  result,  there  are  T h i s becomes s i g n i f i c a n t  c a n c e l l a t i o n s (see S e c t i o n Secondly,  (El)  Medicine,  a r e on an i m m e d i a t e b a s i s .  Medical  Bed"  services  s e r v i c e areas,  i n a l t e r n a t e areas.  considered  hospital  I t i s recognized  appropriate  f e a t u r e o f o u r model i s t h a t  contrast  to  most  within other  34  m o d e l s , our of All  being  model d o e s not  a b l e to handle  emergency  all  patients  immediate admissions  allow  emergencies"  are  account  admitted, f o r 45$  of  the  Medical  ones.  Still,  of  9 3 % f o r the  whole  hospital,  described  by  our  Thirdly, methods waiting  list  patient  is  limits,  and  against with  "probability "occupancy".  the  result  of a l l a d m i s s i o n s  occupancy i s very and  higher  and  h i g h - an for  that 75%  average  the  services  different  admission  model.  the  for  a t r a d e - o f f of t h e  hospital  the  modelled  different  i s admitted first  services.  when a bed  scheduled  i s then  admitted  observes  for on  the  A Medical  is  p a t i e n t on  available.  surgery,  A  subject to  a p p r o p r i a t e day  the  surgical certain  i f a bed  is  available. Fourthly, parametric patient  we  found  that  while  in  distributions  have  often  been  a r r i v a l s and  provide  an  empirical  adequate  data  Finally,  and  considered closing  at  such  parametric  "fit".  Thus,  to describe these this  terms o f occupancy, patients,  LOS,  study  waiting St.  under-used  Paul's operating  p l a c e m e n t o f p a t i e n t s , and  various  to  describe  used  distributions did  not  f o r added r e a l i s m , we  to i n d i c a t e  availability times)  past  use  processes.,  i s designed  bed  the  might  Hospital. rooms,  v a r y i n g bed  for be  what e f f e c t  scheduled had  Such  by  restricting numbers or  surgical  changes  changes  (in  being  include  "alternate"  allocation.  35  CHAPTER 5  THE  This St.  chapter  The  hospital's  assumptions  to  patient  will  be  T h e s e two,  supplemented  to  5. 1  determine  not  hospital.  are  not  There this  exist fairly  different records, specialty,  by  well. groups,  or  to or  have developed  of  the  processes  subdivisions will  be  the  discussed topics  of  considerations.  in-hospital transfer through  depending  principal  scheduling  receive  f o r our  and  LOS  data,  hospital.  groups i n  the  word  depending an  on OR  h o s p i t a l area.  at  differences  to consider  called  "service"  treatment  most  formulation  classifications The  identical  purposes  i t i s preferable  describe a  the  Subsystems  and  natural  developing  decision  two  surgical  Nevertheless,  homogeneous p a t i e n t  the  a l l patients  important  of  preference  by  p a t i e n t flow  D e f i n i t i o n of  Obviously the  and  in  processes i n  described.  and  followed  admitting  and  and  considerations  locational  classification  This  examined  detailed  are  f u n c t i o n a l and  interest,  serve  were and  flow  MODEL  those f a c i l i t i e s  structure  patient  Hospital  first.  which  physical  pertaining  THE  discusses  Paul's H o s p i t a l  modeli  on  HOSPITAL AND  of  relatively the  model.  " s e r v i c e s " which  may  define  whether i t i s used designation,  do  slightly  in hospital  a  physician  From t h e s e c l a s s i f i c a t i o n s ,  a functional classification  to  be  used  in  I  the  36  model. units  We  note  that  t h e r e a r e some s p e c i a l - p u r p o s e  defined according  patient's  "service".  t o t h e care they Within  a hospital  c h a r a c t e r i z e beds f u r t h e r as b e i n g ward, and a s b e i n g  offer rather  designated  area,  hospital than  the  i t i s possible to  private,semi-private, or i n a  f o r a male or f o r a f e m a l e ,  or f o r  e i t h e r one.  5.1.1  Hospital Services  When an a d m i s s i o n things  must  request  be d e t e r m i n e d ;  arrives  at  i f a p p l i c a b l e , i n which 08 h i s s u r g e r y  The  daily  stations slate  (Table I ) .  are  operating schedule  into  or  eleven  groups  of  and p l a c e a p a r t i c u l a r  scheme i s "hospital Library.  most  useful.  service" (The  analysis.) can  The OR B o o k i n g O f f i c e  theatres  By  obtain functional  visual  sections theatres  is  an  are  the o r i g i n a l  p a t i e n t groups  two  be l o c a t e d  be p e r f o r m e d . i t s 2 1 nursing file  and d a i l y  corresponding to {Table  item  a b s t r a c t s kept  abstracts  regrouping  into  patient, a single  There  on c a s e  coded  should  d i v i d e s the h o s p i t a l  subdivided  hospital,  where t h e p a t i e n t s h o u l d  and,  census sheet  the  II).  To  classification  referred  by t h e M e d i c a l  submitted  to  codes f o r t h i s  which we w i l l  to  as  Records  CPHA  for  item,  we  call  services  One  service,  (Table III) . One p r e c a u t i o n a r y General  Surgery,  note  should  be added h e r e . ,  d i v i d e s i t s p h y s i c i a n s , bed a r e a s ,  and OR  a c c o r d i n g t o s u b d i v i s i o n s "A", "B", and "C", w h i c h a r e to  within  the  hospital  as  "services".  The  usage  referred  model d o e s n o t  37  TABLE I NURSING UNITS  Hard  1JUNE 1976.1  Beds P r i v Semi Ward  Use  6  South  Maternity  6  South  Nursery  19  2  Bassinets  31  10 35  5 North  Gynecology  ICN  Nursery  5  South  Gen'l  4  North  EENT  4  North  Orthopedics  21  12  35 41  8 14  Surgery A  Rated Capaci  14  3  18  23  44  3  14  18  35  10  16  26  4 East  Orthopedics  1  2  41  44  4  South  Urology  7  14  22  43  3  North  Medicine  4  16  12  32  3  Neuro  Neurology & Neurosurgery  3  4  16  23  3 East  Gen'l Surgery B  1  6  24  31  3 Main  Gen'1 S u r g e r y C  8  24  32  3  Activation  16  16  South  40  20  20  8  4  8  20  1  10  4  15  8  14  17  39  2 South B Medicine ( a l l closed teaching)  28  28  C2A  Psychiatry  10  10  C2B  Psychiatry  30  30  Medicine 2 North (20 semi - c l o s e d t e a c h i n g ) 2 East  ICU  2 West  Cardiac  Unit  2 South A Medicine (18 s e m i - c l o s e d t e a c h i n g )  TABLE  II  DAILY SLATE SUBDIVISIONS  Gynecology  Room 1  Room 2  G e n e r a l S u r g e r y " s e r v i c e " A, B, o r C {depending on day o r need)  Urology Day  ( i n c l . Cystoscopy)  Care  Room 7, a n d p e r h a p s  EE NT Open H e a r t  Rooms 3 and 4, and p e r h a p s  Rooms 8 a n d 9 Rooms 10 and 11 and V a s c u l a r  5  5  ENT M / H / F O p t h a l m o l o g y T / Th  Room 12  Room 14  General  Orthopedics  Room 16  Room 17  General  Room 18  Neurosurgery P l a s t i c Surgery  Room 19  S p e c i a l X-rays {Pneumoencephalogram and C a r o t i d Angiogram)  Surgery  "service"  A, B, o r C  Surgery  "service"  B or C  M / W / Th am / F pm T / Th pm / F am  39  TABLE HOSPITAL  O r i g i n a l CPHA Divisions  III SERVICES  New F u n c t i o n a l Divisions  Comme n t s  10  Medicine  14  Communicable  18  Dermatology  32  Neurology  Not  Examined  38  Psychiatry  Not  Examined  40  General  48  Medicine  Surgery  Opthalmology  50  ENT  54  Dental  58  Orthopedics  Same  62  Orology  Same  56  Neurosurgery  EENT  } }  60  I n c l u d e s Open H e a r t and Vascular cases  Same  Plastic  Surgery }  70  Gynecology  11  Renal  75 76  Abortion Obstetric undelivered  77  Neurosurgery and Plastic  Surgery  Same Not  Examined  Not  Examined  Not  Examined  Obstetric delivered  Not  Examined  80  Newborn  Not  Examined  89  Stillborn  Not  Examined  40  observe these s u b d i v i s i o n s The  reasons  functional  services  "Medicine'*, overall heart  have  as  combinations y i e l d i n g  follows.  Patients  and "Dermatology" identified  by  does  from  not) a r e  General  advantageous, share  a  Furthermore, individual  I t would  common  bed  area  Neurosurgery  OR and s o m e t i m e s , s i n c e  Plastic  Open  in  the  CPHA  be i n c o n v e n i e n t , b u t The  EENT  and a common s p o t on t h e  although t h e o r e t i c a l l y and d i f f e r e n t  by  room) and v a s c u l a r  differentiated  Surgery.  new  a l l use t h e same  t o s e p a r a t e them i n t h e f u t u r e .  OR's  some i n t e r m i n g l i n g .  not  identified  "Medicine".  (which h a s a s e p a r a t e o p e r a t i n g  (which  subgroups slate.  are  bed a r e a , s o a r e a l l  services perhaps  the p a r t i c u l a r  "Communicable",  surgery  surgery  for  per se.  Opthalmology  days, i n p r a c t i c e  and P l a s t i c  Surgery does  Surgery  and ENT there i s  share  an  n o t have i t s own, a  bed a r e a . , Some following  services  Neurosurgery". admission  could  c o n s i d e r e d i n t h e model, f o r t h e  form  (which i s o f t e n  and  largely  and P l a s t i c  almost  Neurology  area  be  termed  and N e u r o s u r g e r y  (colour entirely  coded  surgery s e r v i c e  do i n d e e d  as f o r  share  the  t y p e s ) , a bed Neurosurgery),  I n any c a s e , t h e N e u r o s u r g e r y  was not i m p l e m e n t e d  of considering  "investigative  for distinct  categorized  t h e same p h y s i c i a n s .  and t h u s t h e p r o b l e m not  not  reasons.  Neurology  same  were  how  in  the  model,  t o i n c l u d e Neurology  was  faced. Psychiatry,  effectively  which  is  housed  independent., There  i s no  in  a separate building, i s  bed  overlap  with  other  41  areas.  If  one  hospital  bed,  Since the  of the  he  is reclassified  the  ordinary  variability  maternity  p a t i e n t s r e q u i r e s surgery  of  the  admissions  informs  the  separate  are  bed  in,  an  births,  OR  Caesarian OR  on  ward what  may  be  Maternity  an  in  The  usage,  and  bleeding  was  for  tendency  original For  data  As  o f young  yield  groups  of  to  a history  i s due  LOS  may  be  patients  p l a c e m e n t , LOS,  s p e c i a l care patterns.  was  (who  As  a  were  was  consequence,  to  no  compensate  included  in  the  i t  would  have  of diagnoses  which t e n d  to  are  homogeneous  in  of  (and  other  S u c h an  operative  exogenous  stays.  groups  length  to the  s e r v i c e , but  adjusted  patient classification  who  sent  that this effect  safely..  data  of  slot.  t o have a P e d i a t r i c  examine  patients  H-ICDA d i a g n o s i s and  occasionally a  p o s s i b l e t o have  felt  t o have s h o r t  a more e x t e n s i v e  necessary  and  a result,  sample)  been  hospital  excluded  H o s p i t a l used  does.  the  t o be  it  week  the Gynecology  need t o i n c l u d e n u r s e r i e s e i t h e r .  longer  each  model as a r a n d o m l y - o c c u r r i n g but  room  come  there  St.Paul's  case  d e l i v e r y room i s  cases  I t would be  women,  to  small  no  and  I f a p a t i e n t with  sufficiently was  The  There i s very  booked i n a d v a n c e t h r o u g h  accommodate  pregnant  differently.  rooms.  emergency b a s i s .  OR  labour  not  p r e d i c t a b l e c a r r y i n g time,  s e r v i c e i n the  on  will  to expect.  Gynecology.  but  process  p r o s p e c t i v e mothers,  sections, ligations,  on  demand  with  of  different  recounted.  handled  the o p e r a t i n g  interchange  difficult  an  maternity  from  admission  outset  keeps a p r e - n a t a l r e c o r d  and  or a  demands) o f  attempt,  g r o u p s , was  on  the  considered.  terms  surgery, basis  of  However,  42  this  was s o o n  time  seen  i t would  formulating  t o be i n f e a s i b l e  have  such  familiarization  demanded  a  from  service"  and  of  capable of  the  amount  of  service  In reality,  based  i t  is  may be a d m i t t e d  physicians,  may  transfer  during h i s stay.  on t h e  not  a p a t i e n t s h o u l d be c l a s s i f i e d  emergency p a t i e n t and  i s generally  a d m i s s i o n " , we c o n s i d e r e d i t t o be  a good b a s i s f o r a s u b d i v i s i o n .  another  amount  i t would have demanded o f t h e m o d e l l e r .  "primary d i a g n o s i s e x p l a i n i n g  which  the  professionals  classification,  S i n c e t h e CpHA " h o s p i t a l  clear  i n terms of  t o the care of  from  always  under.  two  ftn  different  one a r e a o f t h e h o s p i t a l t o  Such ambiguity  was n o t t h o u g h t  to  be  freguent or serious.  5.1.2  Hospital  There which  Units  are several  special  units  within  St.  a r e d e f i n e d i n terms o f t h e c a r e they  terms o f a p a t i e n t ' s " s e r v i c e " The  fienal  now  operates  each  o f which  unit's  another be  w h i c h used  may be used  he w i l l  would  admission  be r e - c l a s s i f i e d A patient  classified he  to define  be  rather  than i n  a  day.  General  in  Urology. due  If  and c o u n t e d  under  category,  one  beds,  of  the  t o t h e main h o s p i t a l  being prepared  i n t h e M e d i c a l LOS d a t a  service  I t has o n l y seven  three times a  requires  offer  Hospital  classification.  an o u t p a t i e n t b a s i s .  service.  removal, present  on  patients  overnight,  would  Unit,  Paul's  to  admitted  fora dialysis  Surgery. Some  as  area  For  a  to  setup kidney  m i n o r f l a w s may be  unclear  classification  43  prior  to  and  during  the  Renal  Unit's  reclassification  as  outpatient. As  noted  on  T a b l e I I , one  for  Day. C a r e s u r g e r y ,  is  also  handled  w i t h t h e main  on  Of  a Day  course,  scheduling surgery  or s o beds.  or  OR  and  use.  room)  is  OR  Booking  on  i s to  use  a particular  day,  i n the  who  Office  model.  The  even  may  but  As  need Day  this  overlap the  with  is  PAR Renal  reclassifed. t o worry  Care  level  Care surgery  used  service  does n o t  used.,  both  Day  This  Not  Care p a t i e n t s t a y i n g o v e r n i g h t  a surgeon  time  ten  o p e r a t i n g rooms a r e  an o u t p a t i e n t b a s i s ,  Recovery  the  not observed  with  h o s p i t a l ' s bed  (Post-Anaesthetic patients,  along  o r two  about  and  other  of d e t a i l  process  was  was  not  in  the  included. The  most complex u n i t  i s the I n t e n s i v e Care Unit Z C o r o n a r j Care Unit  hospital  set-up  (referred  to only as  receives  patients  receive  ventilation  may  who  ICU) ,  have had  patients and  failure  arrive  surgical transfer the  the  which  has  myocardial  twenty  beds.  It  i n f a r c t i o n s and  will  "conservative" non-surgical treatment.  respiratory  renal  i n terms of i t s i n t e r a c t i o n s  vigorous  assisted  physiotherapy.  or u n c o n s c i o u s n e s s  due  to  v i a the  Emergency  Unit.  disaster  requiring  intensive  t o t h e ICU.  Emergency  Unit, thorax,  the  24  after  or  mechanical  Patients  with  poison or drug  Any  Medical care  the  next  h e a r t , and  largest  may  number  major v a s c u l a r  hours of m o n i t o r i n g  i n t h e PAR),  acute  overdose  failure  Many o f t h e p a t i e n t s i n t h e ICU  (Neurosurgical, ICU  requiring  I t also receives  or  result  in a  come  from  from cases and  the  PAR  go  to  the  rest  44  from t h e  ward c a t a s t r o p h e s  usually  return  before for  being a  intended  to  an  number  as an  entirely  the  whole  appropriate  discharged.  large  in  As of  area a f t e r  a result,  the  in-hospital  Medical  hospital.  unit,  Patients  stabilizing  ICU  and  is  responsible  transfers.  Originally  t h e ICU  does  handle  some  surgical patients.  D e  d  A nearby  unit  which works c l o s e l y  cardiac  surgery,  h e a r t p a t i e n t s and "aggressively"  unit.  spend  are  cardiac  admitted  surgery  they  before  r e t u r n i n g t o the c a r d i a c u n i t  some o v e r l a p and but  basically  24  hours i n the  interaction the  ICU  is  T h i s i s the area  in-hospital  treated  with  unit  2-3  until  i n t h e use  cardiac  arrests  and  who  outside will  surgery. days i n  and  be  After the  discharge.  o f ICU  i s the  fifteen  t o which  before  PAB  the  ICU  There i s  c a r d i a c beds,  open h e a r t s u r g e r y  bed  area. The has  activation  about f i f t e e n being  Medicine,  General  patients  are sent  their  treated  the  discussed  their  originate  and  Orthopedic  home or f o r c a r e ,  patient  in as  separate  use,  classification  section,  number o f beds " p o o l e d "  month.  about e q u a l l y from  the  areas.  the  Most  l e s s than  5%  used  not  from  they  these  f o r the  was  would r e c e i v e c a r e  u n i t s i n the  beds  with  per  It  of  returning  area.  p a t i e n t s who  this  rehabilitation.  30-35 p a t i e n t s  here  Surgery,  enough t o i d e n t i f y  by  processes  previous hospital  Since  inclusion  i s used t o s t a r t  beds and  Patients  to  area  were  model. areas  not  specific  i n the  considered  areas for  However, i f i n d i c a t e d were added t o t h e  appropriate  services.  total  45  5.1.3  Bed  As  Groups  Table  I indicates, a patient  h o s p i t a l s e r v i c e s can accommodation. require is  Isolation  p r i v a t e rooms.  usually  desiring  a  If  elective  patient  are  only  males  and  large  patient  sex.  transfer  cost.  is  that type  However,  i s seldom r e f u s e d  i t becomes  available,  may  and  type  of  f a c t o r i n LOS., i s intended  a s some which may  much j u g g l i n g  i s done among  h o m o g e n e i t y by s e x .  admission  an  be c a l l e d  As Lew (1966) c a l c u l a t e d ,  f o r females, as w e l l  wards t o m a i n t a i n  patients  when a v a c a n c y  i n T a b l e I V , some accommodation  some  ward  however,  Of t h e  wait u n t i l  accommodation  i s not a s i g n i f i c a n t  used by e i t h e r and  and  d i d not s p e c i f y  As i s i n d i c a t e d for  admitted  private  who  or  d i f f e r e n c e i n accommodation  o f p r e f e r e n c e and c o s t .  i t at the e x t r a  accommodation  semi-private  a c c o m m o d a t i o n , some w i l l  others  appears.  private,  t o most  r e q u e s t s such a s t h o s e f o r i n f e c t i o n  The  matter  non-ward  available,  offered  request  d e s i r i n g admission  ( f o r very  be  small  In p r a c t i c e , a  long  anyway)  due  movements  in  to h i s o r her sex. It the  i s very  hospital.  billing the  difficult No  record  purposes).  ward  the there  hospital  done a t S t .  show  bed b o a r d ,  where  any  large  the  (except  perhaps f o r  patient  file,  a particular patient records  of t h e  number o f p a t i e n t s .  been a few s m a l l  Paul's.  of patient  of l o c a t i o n  t o keep p r e c i s e  for  have o n l y  i s kept  The main  records  would be d i f f i c u l t  t o keep t r a c k  studies  of  i s , but i t  path  through  As a  patient  and  result,  transfers  46  TABLE  IV  BEDS BY  Service  SEX  M  Gynecology  F  M or F  20  21  6  12  17  Orthopedics  40  30  Urology  29  7  7  6  6  11  33  38  36  EENT  Neurology 6 Neurosurgery General  Surgery  Cardiac  Unit  4  11  47  As model  a result we  of  considered  each p a t i e n t used  Admitting  hospital.  booking  forms  (once t h e  been d e t e r m i n e d ) placed  areas  the  areas, also  an  by  this  admitting  are  by  the  Usage  primary  beds  i s the  available. i n mid  to  reserved  be  there. For  observed.  special  and  who  waiting  in  TV  p a t i e n t s and  15%  of  hence o f  admission  beds, but  patients  the  surgical  teaching for  most  and  informed  it  is  and  surgery  the  the 93%,  this  p a t i e n t s are  of  board.  25%  number and  i s not  of  of  i s even  beds are  sometimes  About  bed  are  Paul»s H o s p i t a l .  is  about  must  rooms o r a l c o v e s .  are  Transfers  factor i n St.  averages  patients  u n i t s or  T h e o r e t i c a l l y about eighteen  result,  temporarily  surgical  g o e s where.  files  of  and  care  f o r emergency p a t i e n t s , b u t a  which  placement  forms  c o n t r o l the  scheduling  Occupancy  week,  As  the  for  Emergency  office,  critical  c o n s t r a i n t on  higher  sex.  booking  date of surgery  c l e r k decides  5.2.1  space  accommodation o r  responsible  Medical  office.  I t maintains  The  is  filed  discharges.  Bed  the  have a " p o o l " o f beds f r o m  r e s i d e n t p h y s i c i a n may  co-ordinated  Bed  to  Office  i n the  also  g r o u p beds by  above,  Considerations  patients  has  mentioned  one.  Admitting  The  considerations  d e v e l o p e d d i d not  E a c h s e r v i c e was  5.2  the  meant  strictly  be  placed  the  Medical  initially  admitted  48  to  the  proper  wrong  area.  Q u i t e a few a r e n e v e r  transferred  to the  area.  I n t h e n u r s i n g u n i t s d e s c r i b e d i n T a b l e I , i t i s known t h a t many o f t h e b e d s may be used  f o r other  services.  Gynecology  ten  usually  beds,  non-Gynecology beds,  patients.  f o r which  General among in  about  Surgery.  the Most  Though  to  ten  off-service  of the General  by  no  probable  an  I t i s the  The f a c t  that  admissions  a r e emergent o r d i r e c t  magnitude  of  cannot  expect  the  problem.  the a v a i l a b l e  the  urgent these  beds.  l i s t , the  Admitting  arrivals  45% o f t o t a l  When  from are  Orthopedic  p a t i e n t s a r e seldom  emergency  about  with  misplacements  or guantitative  a r e s u g g e s t i o n s from Elective  41  p a t i e n t s may be p l a c e d  means  t h e wrong a r e a .  shuffling.  Orthopedic  ENT p a t i e n t s may go t o  variations.  filled  patients are often  Surgery  exhaustive  the  t r u e f o r t h e 43 U r o l o g y  beds..  preceding statements of  The same h o l d s  t h e A, B, a n d C a r e a s .  Neurosurgery  are  Of  Office admitted  who  reguire  and 7 5 % o f M e d i c a l  (DU)  underlines  the  p a t i e n t s a r r i v e , one  beds t o be where one would  like  them  to be.  5.2.2  Seguence o f C l a i m s  Since  i t  i s clear  offer  the right  beds  must be f o l l o w e d .  is  faced with  reguire  or  bed, then  on Beds  that  t h e Admitting O f f i c e cannot  some p a t t e r n When new s t a f f  a number o f i n - h o s p i t a l desire  in  transfer  handling  a r r i v e s each  patients  who  always  claims  on  morning, i t may  either  and a number o f e l e c t i v e p a t i e n t s  49  desiring Office  schedules  Office  has  been  to  admit  to  be  stamped on  office  tries  a s u r g i c a l case  Office  booking  i t , t o be  not  then  is  in  the  filed  and  this  the  of  there. Failure  situation,  major c o n c e r n Medical  of  beds.  Office  An uses  as f o l l o w s . Late overnight admissions  placed  i n the  a Medical 5.2.5)  shifts  area  who  of  had  c a r e . . For PAR  t o be be  if  (for  been  up  found  appropriate made  to  placed  is  proper  hours  arranged to  any  24  need  surgery  area.,  After  other  patients  After  the day's emergencies,  i f  ICU  its  should  these, who  there  are  previous  be  intensive  patients  transferred  i n the  had  any  wrong  some  beds  who  to  should  t o be  after  of  monitoring)  attempt  are  be  facilities,  " e x t e n s i o n beds"  an  moves, and  Next,  should  demand f o r  Medical  p a t i e n t s who  a l l these  The  of p o s t - o p e r a t i v e  elsewhere.  M e d i c a l emergency  area.  five  moved.  rooms on  requiring  i n the  be  explained i n Section  areas..  period o f high  must  t o be p l a c e d i n  r e s i d e n t s h o u l d be  longer a  ( t o be  unit  had  i n a l c o v e s or TV  to  no  to  surgical  move  particularly surgical  the  those p a t i e n t s s t i l l  p l a c e m e n t s h o u l d be have  of  moved  i t  emergency  A l s o , p a t i e n t s who  will  patients  particularly  to the  " c l o s e d t e a c h i n g bed"  should  emptied  the  hospital.  a g a i n s t the  patients  for  date  Bed"  a p p r o x i m a t e s e q u e n t i a l p a t t e r n which t h e A d m i t t i n g is  Admitting  process.  Thus the of  Booking  arranged  i s a "No  use  OR  sends the with  to d i s r u p t  section.  the  form  when s c h e d u l e d  d i s c u s s e d i n the next Admitting  indicated,  p a t i e n t s f o r surgery,  admission  Admitting  the  As  a copy o f t h e a d m i s s i o n  desired The  admission.  put  an be  area, in  a  allowance left  then  50  schedulable admissions  5.2.3  "No  The and,  Bed"  OR  may  the  Office  schedules  each  necessary  admission  date  pre-operative stay s p e c i f i e d copy of the admission in  advance.  Office  t o as a "No The  find  Bed"  OR  by  booking  I f when t h e  cannot  considered,  Situations  Booking  indicating  be  a bed  the  Booking  Office  They  upcoming s l a t e .  upsets from  hospital.. a  Office the  patient i n , i t  well  Admitting  is  must i n f o r m t h e s u r g e o n ,  this  who  job,  (usually  to  referred  and  it is  vacant  try  spot  of t h e  had  to arrange  for  of t h i s  a  on  the  change.  sort  another.  badly  a t one  It  f o r time  babysitter.,  reflects  to  attempted  undesirable situation.  inadvertent,  favour  the  informed  perhaps  difficulty  physician  i s an  probably  and  although  Repeated  weeks  p a t i e n t must be  reasons,  her  inconvenience,  date a r r i v e s ,  must t r y t o f i l l  patient,  h i s or  cause  The  obvious the  the  situation.  week l a t e r ) .  For  to  p h y s i c i a n , sends a  to the Admitting  admission  r e s c h e d u l e h i s p a t i e n t w i t h i n two one  according  the admitting  form  to put  patient f o r surgery  off Such  on  the  hospital  will  A l s o , i t d i s r u p t s the  slate. Nevertheless, of  my d a t a i s from  were  free  cases  per  of  "No 1974  "No  month, w i t h  cancellations  Bed"  occur  when, i n 250  Beds". up t o in  s i t u a t i o n s happen q u i t e o f t e n . operating  T h e r e was twenty  on  an  days,  average a  single  a l l surgical services.  of  Most  only  160  "No  Bed"  39 day.  There has  These been  51  some improvement s i n c e  1974  but i t i s s t i l l  concern t o  5.2.4  Patient  All were  five  Admission  patient  considered.  indicated is  a real  by  submitted  elective,  admission of  physician  are  Each hospital of  a  of  the  policy.  directive  or  given". urgent into  the  i f  two  physicians that  threaten In  life  result  DU  May  booking  and form  and  direct  are which and  urgent  i s b r o a d l y d e f i n e d by a r e from 1973.  i f hospital  hospital  patient  treatment  but  "a  emergency illness  treatment 24  may  i s not  hours.  which  I  may  An  develop  suffer  serious  i s d e l a y e d f o r more t h a n a  A semi-urgent  s h o u l d not be  admission,  An  within  o f moderate s e v e r i t y the  Appendix  severe pain, chronic  s h o u l d be a d m i t t e d  admission  o v e r two  delay  need  months.  should  not  be  Elective  not  directly  t o be an  emergency  health".  practice a patient  c a s e i f he further  or  month),  on d i a g n o s i s )  schedulable  follow  in  "death,  may  i s "one  weeks, b u t  patients desire  except  to  maximum o f f o u r t e e n d a y s " . within  per  immediate-attention.  a s t a t e o f emergency o r  deterioration  are  emergency  e x c e r p t s which  Such p a t i e n t s condition  c a t e g o r i e s {based  The  permanent d i s a b i l i t y  31  They a r e u r g e n t , s e m i - u r § e n t  categories  c o n d i t i o n i s so s e v e r e  was  administration.  on t h e a d m i s s i o n  also  c a t e g o r i e s , which r e q u i r e  average  these  f o r the p a t i e n t . There  1976  Diagnostic Categories  Three  the  {the  i s admitted  classification  i s only c l a s s i f i e d  v i a t h e emergency d e p a r t m e n t . used,  called  "direct  There i s a  urgent",  which  52  probably  includes  emergent and the  some  some a s u r g e n t .  physician  admitted  Office  immediately  patient  goes d i r e c t l y  hospital.  -  form  could  see  to the  If  there  the  i f  that  He  no  room  may  room. and  in  fill  the p a t i e n t  he  the patient  t o t h e emergency  When beds a r e f u l l , that  he s e n d s  terms i t  a  his patient  "backdoor  emergency  and  Onfortunately, particularly device  is the  the out  for  the  scheduled  priority  In  classification, may  influence  description categories Section  practice,  or  by  differs  12.1.)  by  to  immediately an  admission submit i t o r he  strongly  unit,  may  classified  the  enough  hospital  in  results  any  as  an  records.  waiting i n such  staff  gueue,  tactics  (a  itself). theoretically  a l l  amount o f  physician  priority.  the h o s p i t a l ,  among p h y s i c i a n s .  a l l  semi-urgents,  there i s a f a i r  communication  his patient's given  often  than  The  J  feels  is  of  admissions,  first,  adherence.  It  movement  perpetuates  p a t i e n t s are handled electives.  the p h y s i c i a n  differentiated  Medicine,  the  unit.  admission."  slow  decides  i s admitted  i s u r g e n t and  t o t h e emergency  not  which c l e a r l y  Of  but  when  I f so,  w i t h some added e m p h a s i s - t o t h e a d m i t t i n g O f f i c e ,  send  as  c o n t a c t s the admitting  admitting Office is  f o r whom,  o r elsewhere,  t h e r e i s any  physician  indicating  be c l a s s i f i e d  These are p a t i e n t s  very g u i c k l y .  to  foreseeable future, booking  who  s e e s them a t h i s o f f i c e  t h e y s h o u l d be  the  patients  may  urgent  then  the  judgment i n  change  the  with the a d m i t t i n g  clerks  Furthermore, t h e use  despite  of these  the  diagnostic  (See a l s o t h e comments  in  53  5.2.5  Control  St.  Medical  Paul's i s a  Admitting beds t o  of  Office  For  beds o v e r which t h e In  nursing  teaching  alcoves. next  Admitting  the  and  late  are  twenty  a  B,  all that  emergency  his  of  the  the  patients  not  will  the  semi-closed  teaching  I f these are  reguired  f o r m s and  picks  " i n t e r e s t i n g " ones.  not  should  out  O f f i c e may  beds.  to enter  In  those  chosen  t r a n s f e r the  inform  the  ICU  or  resident  one  Paul's  looks  over  residents of  the  filed  Active  staff  to  admit  their  the  few  ways f o r  Medical  bed  easily  an  i s to  bed.  guidelines i f more t h a n  fact,  a St.  for  them,  make a r r a n g e m e n t s w i t h t h e  chosen f o r a t e a c h i n g  suggest t h a t are  Admitting  beds i n 2 S o u t h A  regularly  Hospital  filling  probably inform  resident  be  Admitting  the  teaching  patient  almost  out  use  elective  has  transferred  b e d s , and  to teaching  "closed  before  responsible  patients  some  displeasure.  more i n 2 N o r t h .  members a l s o  are  the  the  admission  the  assigning  are  resident  there  are  charge  beds  emergency p a t i e n t s ,  The  in  there  night,  patients  in  eighteen  f o r the  result,  control.  e v e n i n g or a t  resident  O f f i c e of  There  has  means  However, i f t h e s e  day,  As  i n s t r u c t i o n a l purposes,  This  place  hospital.  have c o m p l e t e f r e e d o m  u n i t 2 South  beds". ,  may  not  resident  complete c o n t r o l . , In Office  teaching  does  patients.  Beds  20% by  given  the  of  patients  the  the  high  resident,  wrong o n e s o u t .  Still,  demand f o r beds in  the  teaching Admitting  residents  beds Office  claim  that  54  there  a r e s o m e t i m e s 25% o r 50% " n o n - t e a c h i n g "  patients i n their  beds. Due  to  teaching  the  beds,  non-teaching  complexity  the  variation  patients,  model.  5.2.6  Surgical  Not  area  admit  surgery  a  patient  LOS  beds have n o t beds a r e used  lab  between  been  on  who  gets  teaching  and  differentiated  in  identically.  who  on.  are  for investigation The b o o k i n g  scheduled  to enter a  Sometimes a p h y s i c i a n before  forms  p a t i e n t s go t o t h e A d m i t t i n g  and  data  Admissions  patients  bed a r e o p e r a t e d  Booking O f f i c e ) . X-ray  the  i s advisable.  surgery  of  Non-Operative  a l l of  surgical to  A l l Medical  gathering  and t h e l a c k o f a c o n s i s t a n t p a t t e r n i n  u s i n g t h e beds, t e a c h i n g the  of  deciding  wants whether  f o r pre-investigative  Office  {rather than  t h e OH  Such p a t i e n t s a r e a d m i t t e d  on weekdays,  since  facilities  are  only available  on an emergency  b a s i s on t h e weekend. Since are  i t i s not clear  { i t appears t h a t there  later  operated  a r e few) n o r how many  these  are  these p a t i e n t s .  patients  (many from with  Orthopedic  "bed r e s t "  Urology  noted  t h a t a number o f o t h e r  t h e Emergency U n i t )  Patients  and  be  be  there  demands anyway), t h e model d i d n o t d i f f e r e n t i a t e also  would  of  type  i n in-hospital  should  (these  many p a t i e n t s o f t h i s  included  It  on  how  bleeding  ulcers  or  a r e never traumas  surgical  operated that  stabilize  patients, patients f o r Neurosurgical  p a t i e n t s who p a s s t h e i r  stones  a r e of t h i s  on.  tests  type.  55  5.2-7  -General  St.  Paul's  admission  has a l a r g e r e f e r r a l  is  preference  may  handled be g i v e n  physician requests  submit.  to  A limit  not  Admitting  of f i v e  office  c a n c e l l e d a second There  is  Consultant, Non-Active and  Research.  For  admission  things  being  admissions  by  Active,  staff and  category  hence  active  staff  is  seldom  t h e p a s t two y e a r s , Booking  The  admission  date  Staff  By-Laws". "other  factor  (most staff  Considerations  St.  office.  patient  Scientific  As a r e s u l t ,  Paul's  Hospital  Admission  is  scheduled  i s indicated  has  booking  patients (non-investigative) are sent  physician. necessary  Scheduling  Courtesy,  and  a  anyway).  Surgical  surgical  Dental,  Visiting  i s only considered  5.3  OR  that  patients.  Associate,  Fellows,  was n o t i n c l u d e d i n t h e model.  separate  i n order  c a t e g o r i e s : Honorary,  These a r e d e s c r i b e d i n " M e d i c a l  are  physician  due t o "No Bed".  Clinical  equal"  the  day.  his highest-priority  Active,  priority,  Often  o f forms which a  category  For  patients.  Some  attempts t o ensure t h a t a p a t i e n t i s  time  Courtesy,  consultant.  had been recommended  a number o f s t a f f  Senior  local  admission  t o t h e number  t h e p h y s i c i a n would i d e n t i f y The  a  out-of-town  a particular  T h e r e i s no l i m i t may  through  program, f o r which p a t i e n t  for  there surgery  on one copy  of  had  a  forms  for  from  the  and  the  the  form.  56  which  is  then  admission.  taken  Although  surgery",  there  t o the Admitting it  are  is  simple  Office to  which  say  handles the  "scheduled  many f a c t o r s t o be c o n s i d e r e d .  for  These a r e  now d i s c u s s e d .  5.3.1  Operating  Rooms  T a b l e I I , with i t s d a i l y how  the  various  were a s o f J u l y switched  o p e r a t i n g rooms a r e n o r m a l l y  1976.,  rooms.  In  August,  also used  Orthopedics  There are a c t u a l l y  a r e needed and, s t a f f Table  slate subdivision,  nineteen  c l a i m , none i s r e a l l y  indicates - or r a t h e r  and  Gynecology  rooms, b u t n o t a l l  l a r g e enough.  V g i v e s a p p r o x i m a t e s i z e s o f t h e rooms, and comments  on t h e i r u s e .  5.3.2  Use o f I n f o r m a t i o n  on t h e A d m i t t i n g  There are s e v e r a l pieces o f i n f o r m a t i o n booking course, model  form  concerns does  admission  case  beds"  are  useful  not  consider  roughly  the latter)  category)  and d a t e  certain  special  equipment,  c o n s t r a i n t s was c o n s i d e r e d c r i t i c a l the  model.  Also,  the  Day  Care  surgery  i s desired.  but  (the  The t y p e o f  preferred are  overnight  admission  The f i r s t , o f  when t o t r y t o f i t t h e p a t i e n t i n .  may c a u s e i t t o u s e one o f f i v e or  on  i n scheduling.  whether I n - P a t i e n t o r  (diagnostic  determine of  which  Forms  used  to  The t y p e  PAR " e x t e n s i o n  neither  of  these  enough t o be i n c o r p o r a t e d i n  t h e p h y s i c i a n i s noted,  because each has an  57  TABLE  V  OPERATING Room 1  Size  U s u a l Use  Use  Large  Orthopedics  Formerly Gynecology Can be G e n ' l S u r g e r y o r a l m o s t a n y t h i n g - even d o u b l e s e t u p s  Medium  General  Use by G e n ' l S u r g e r y A, B, o r C d e t e r m i n e d by c a s e t y p e S day  Medium  Urology  Seldom 3 and 4 b o t h i n use Often f r e e f o r emergencies  Medium  urology (Cystoscopy)  Only f o r c y s t o s c o p y Does most o f U r o l o g y  Day C a r e (Cystoscopy)  Only f o r Cystoscopy U s u a l l y r e s e r v e d f o r Day  Medium 6  Tiny  Storage  7  Medium  Day  8  Small } } Small }  ENT  9 10 11  ROOMS  Small } 3  Surgery  Comments  Exclusively  Care  Day  cases Care  Care  Small l i g h t s I n a p i n c h , c o u l d do s o m e t h i n g e l s e - o f t h e f o u r , 10 i s b e s t Opthalmology  Small } 12  One OH p e r day, t h e n v a s c u l a r I f spare time, c a n do a n y t h i n g  Large  Open H e a r t Vascular  13  Medium  Pathology Lab  14  Large  General Surgery Vascular  15  Small  C a s t Room  16  Medium  Gynecology  Formerly  17  Small  General  Surgery  Use by G e n ' l S u r g e r y A, B, o r C d e t e r m i n e d by c a s e t y p e & day  18  Medium  Neurosurgery & P l a s t i c Surgery  Cramped, b u t p o s s i b l e f o r o t h e r  19  Large  X-ray  Special  Use b y G e n ' l S u r g e r y A, B, o r C d e t e r m i n e d by c a s e t y p e & day  Orthopedics  X-ray  eguipment  only  58  upper l i m i t  on  number o f beds he  is  not  The  date of r e c e i p t  for  pre-operative stay  if  on  the  X-rays  active staff,  Honday, s i n c e X - r a y s  5.3.3  The required only  niqht  always  before.  the  hospital a f u l l  or  tests  probably  need a b o u t  day  The on  just  OR any  services out One  so  done o v e r  two  indicates For  day  priority.  number o f  be  For  days  example,  scheduled  for  weekend.  the  pre-operative the  P a t i e n t s needing  days.  five  Heart,  patients  stay it  is  blood are u s u a l l y  those  requiring  v a s c u l a r and  o r more days b e f o r e  in  X-rays  bowel p a t i e n t s  Obese p a t i e n t s a r e  O f f i c e cannot  which f i t s  St.  the  most  surgery.  certain  major a d v a n t a g e o f t h i s  practice.  I f he  Wednesday  mornings,  "block  that  can  provision.  constraints. booked".  a patient  Most  surgical  Rooms a r e  physicians are  given  system c o n c e r n s  a surgeon's  knows t h a t he he  choose to schedule  the other  Paul's are  t h a t e a c h day  advance, with  i f he  Booking  Booking  at  The  not the  and,  of lower  reason.,  60%-70% o f  t h r e e days p r e p a r a t i o n .  Block  the  will  before surgery,  time-consuming, needing  5.3.4  with  day  Stay  for his patient.  the  be  the form.  surgery  a r e not  physician  on  are noted,  Pre-Operative  book p e r  h i s r e q u e s t may  i s stamped  a r e needed, t h e  may  may plan  expect his  to  their  operate  office  blocked  hours  turn. private  on,  say,  well i n  59  Block and  booking  also enables  expectations of the s u r g i c a l  his  operations  submit  are  likely  and, i f he c a r e s  particular  patient  day  for  which  physician's filed  enouqh  only,  forms  to  on a  a  the  particular  i s a limit  t o the  i f he h a s  not  h i s b l o c k e i g h t days i n  i s thrown open f o r u r q e n t  i s  which day  For t h a t matter,  In p a r t i c u l a r , fill  long  many f o r m s t o  predict  on.  on how  patients  of  other  requests. Surgery  blocked  are  not  block  by " s e r v i c e " c a t e g o r y  booked.  A, B, and C  n o t by p h y s i c i a n .  5.3.5  Service Characteristics  Since attempt  General  is  made  Surgery  i s  to balance  patient  f o r each a c t i v e s t a f f  Choice  is  choice  guided  Surgery  Vascular per  are usually f i l l e d The  by  service  by s u r g e o n as w e l l . surgeon  i s  of receipt  only,  some  G e n e r a l l y one  chosen  at  a  time.  o f the form, and each  e i g h t days i n advance.  There  i s  backlog.  surgery  week,  blocked  by t h e d a t e  i s p l a c e d on t h e s l a t e  General  time  probably  However, t h e r e  of the block.  and f o r i n - h o s p i t a l  Surgery  he knows how  be o p e r a t e d  N e u r o s u r g e r y and P l a s t i c General  Depending  t h a t h i s p a t i e n t be s l a t e d  request  advance, h i s b l o c k surqeons,  t o take,  he i s booked.  control  t o r e g u l a t e h i s demand  booking.  t o , he may  will  p h y s i c i a n may r e q u e s t  no  a surgeon  has t h e e q u i v a l e n t o f two d a y s o f  and i s a l w a y s booked up.  blocked  T h e open h e a r t  spots  f o r a month ahead.  N e u r o s u r g e r y and P l a s t i c S u r g e r y  slate  i s also  prepared  60  eight  days i n advance, r a t h e r  than  being  developed  as  forms  arrive. Orthopedics blocked of  the  and  surgeon,  Gynecology spots are o f t e n not  but  are f i l l e d  up a f t e r b e i n g  used  by  opened t o  the  others  service.  Urology  i s not  thrown open v e r y  o f t e n . , I t has  no  backlog.  EENT i s o f t e n booked f o u r t o s i x weeks a h e a d .  5.3.6  L i m i t a t i o n s on  The beds.  main l i m i t If  booked  up  on  patients  s c h e d u l i n g f o r s u r g e r y i s the with  t o t h e bed  in-patients.  Scheduling  a schedulable admission  limits,  there  A p p r o x i m a t e bed  is  limits  by  number  of  category  are  always  room  left  service  a p p e a r on  for Table  VI. The  recovery  {overnight required  patients).  f o r such  craniotomies, There The  are  per  used  once p e r  one  procedure  as  only  may  be  day. day. at  are  classified  The a  "extensions"  closely,  and  perineals.  f o r one  and  instrument  d i a g n o s t i c and  constraints. one  operative  and  arthroscope  image i n t e n s i f i e r  can  only  time.  Although they  distinctly  are  tumors,  mediastinoscope  constraints, so  five  h e a r t o p e r a t i o n s , pacemakers,  used The  take  beds a r e m o n i t o r e d  a l s o some e q u i p m e n t  these  them), so t h e  These  cases  consider not  can  c h e s t o p e r a t i o n s and  laparoscope  procedure  room  a r e not  be  the Booking critical  model d o e s n o t c o n s i d e r s u c h  used  Office  {and  a s t o be i d e n t i f i e d limits.,  may  be on  must  patients as  needing  TABLE BED L I H I T  VI GUIDELINES  Service  p e r day  p e r week  Gynecology Urology ENT Opthalmology Orthopedics Neurosurgery  4 5 6 6 4 2  19  Plastic General A 2 B 1 C 2  3  Surgery Surgery rooms H / H ; .1 F } room H / Tu ; 3 Th } rooms Tu / F ; 1 W }  TABLE IN-HOSPITAL Service  17 } } }  9  VII  DEMANDS FOR SURGERY Number • "  General Surgery Vascular Open H e a r t Urology Orthopedics Neurosurgery P l a s t i c Surgery Gynecology EENT  19  4 -6 2 / 1 / 1V 1 / 2 / 1 / 1 / 1 /  ~ "  / day week week day (2 days) wee k week week (2 weeks)  62  The  major  nature  of  c e r t a i n cases  done " f i r s t  thinq"  ( a t 8 am).  operations  start  in  At  room  1,  a b d o m i n a l p e r i n e a l s i n room  14.  5.3.7  Considerations  In employ and  qeneral, whatever  others)  staff  They a r e n e v e r  expressly  included  after  3:30  preceding  need t o s t a b i l i z e  last  immediately  quickly  instruments  for  the  Booking O f f i c e allows hour  Neurosurqical require The  anywhere  model, not  a fixed  one  can  18  and  will  anaesthetists, patients  entities  effect  of  in  the  auxiliary  day's s l a t e ,  from  time.  -  major  about  are  there or  are  nursinq  operation?  quarter  on  up  in  a  and  OR  In  a  and  anaesthetist housekeeper a l l busy  staff  prepare  bookinq  time,  the  a small  to forty  more f o r v a s c u l a r  minutes  OR  operations,  major o r m i n o r o p e r a t i o n s  five  by  they  h o u r between minor ones,  particular  influenced  Does t h e  Is  the  In r e a l i t y ,  operatinq  turnaround  wash  next  between  cases.  as  operations  patient?  to  How  half  the  adherence to the  (between  elsewhere?  one  noting  following operations.  the  hip"  hospital  p h y s i c i a n s and  s e v e r a l f a c t o r s - which  and  room  be  pm.  time  depends on  available  (nurses,  by  Turnaround  the  the  o f demand  availability  theatre)  that  of a u x i l a r y s t a f f  time,  "total  in  level  turnaround  any  they  Staff  assumes  However, i t i s worth on  time  craniotomies  Auxiliary  model  levels  that the  warrants. model.  this  of  that  requires that  or can  turnaround.  t i m e s c a l e anyway, o n l y  uses  63  There addition  a r e two c h a r g e to  nurses  monitoring  and  a  and e v a l u a t i n g  place extra  nurses or step i n themselves  slate  as  run  staff  timed.  They  members g e t b r e a k s .  nurses  to help with  It  aid),  i n order  t o have two n u r s e s  help  the  a l l of the nursing  p e r room  "Open h e a r t " g e t s t h r e e n u r s e s .  8:00  this  time,  there are four afternoon nurses  that after  also  extra  Up t o two " s t a g g e r n u r s e s " c a n be  from  from  to  in  may  T h e head n u r s e c a n a r r a n g e f o r  run  three  who,  l a t e c a s e s and r e l i e f .  i s preferred  nurses*  nurse  nursing s t a f f ,  make s u r e t h a t  i f cases get behind.  called  head  am  t o 3:30 pm.  3:30 t o 11:30).  (as w e l l  as one  Normally  cases  Besides the regular (one f r o m  Two n i g h t s h i f t  nurses f o r 3 t o 11 and  n u r s e s come on, so  11:30 pm, one emergency room c a n be used  as  long  as  necessary. It  i s worth n o t i n g t h a t  day's s l a t e ,  5.3.8  i s e v e r removed from t h e  the length of previous operations.  I n - H o s p i t a l Demands  One slate  whatever  no p a t i e n t  of  i s that  their  the  Plastic  complicating factors i n scheduling the  p h y s i c i a n s may s u b m i t  patients  already  major  already  in  had one o p e r a t i o n . Surgery,  p h y s i c i a n ' s next services in-patient  are  such day  added  the  to  f o r surgery  hospital.  usually  surgery., the  slate  wait  Requests as soon  happens t o r e f u s e a t i m e t h a t  for  Some o f t h e s e have  For General Surgery,  requests of  requests  Neurosurgery or f o r the proper from  the  other  as p o s s i b l e . ,  I f an  i s offered,  he g o e s  to  64  the  end  o f the  list  again.  A p p r o x i m a t e numbers o f demands f r o m a p p e a r on  Table  to  bed  \or  in time  Handling  are  placed  left  after  of  surgery  for his in-patient, If p o s s i b l e , the  scheduled  t h e same day, first-served would be  on  the  but!' c a n  request slate.  wait,  on  emergencies  always  several  room i s a l w a y s c h o s e n .  by  o u t p a t i e n t s were l i m i t e d  due  are  summoned.  i s inserted Since  the  not n e c e s s a r y  For  they  floor  requesting  i s "How  urgent  is  next  day  be d e f e r r e d t o t h e  those  which s h o u l d  are orqanized  of the  which s h o u l d there  slate.  on  Any  be  a  handled  first-come  chanqe i n  rooms The  be  handled  not  i n use.)  anaesthetist  Another  when a s t a f f e d  differentiate  promptly,  i s always a p l a c e  order  The on  I f the  largest call  model's o u t p u t  for  emergencies - which i s , i n f a c t ,  nursing slate"  t o t a l time  recorded  of the  free.  a one-day t i m e  merely i n d i c a t e s the  available  and  unit, i t i s  among emergency h a n d l i n g  The  as  (There  patient i s stable,  room becomes on  such  t o go.  option i s to "break the  model o n l y o p e r a t e s to  operating  will  some room, hence making i t l a t e . case  unclaimed  a physician-to-physician basis.  h a e m o r r h a g i n g i n t h e PAR,  staff  left  t h e main q u e s t i o n  b a s i s a t t h e end  worked out  For  are  in spots  Emergencies  When a p h y s i c i a n comes t o t h e  and  services  space.,  5.3.3  it?".  various  VII.  In-hospital requests physicians,  the  by  methods.  used e a c h  hospital  day  staff.  65  5.3.10  Timing of S l a t e  The booking added  OR  Booking  forms to  previously. to  file, The  limits,  in  she  to that  in  on  the  the s l a t e  Extra  s p a c e may  physician usually  would not  hour.  be go  kept  and  everything  i s OK.  still  cause  This w i l l  5.3.11  like  c o n t r o l OR  time  adjusts  toward a c c u r a c y time  day.  and  room  Bookings are  days away, any  have  o v e r a week. days  "No  open s p o t s  in-hospital Real urgents admitted A copy  ahead.,  Office  Cancellations,  changes.  mentioned  pm.  to  Admitting  they are  nurse  within  w i t h u r g e n t or  waiting  the  next  and  T h e n a b o u t noon t h e f i n a l day.,  other factors  affect  the are  of the s l a t e i s  are checked  usage t h e f o l l o w i n g  (those  quickly)  The  Beds"  demands.  morning,  t o make s u r e in-patients copy  i s made.  General  T h e r e a r e a few Besides  booking  f o r each  day i s e i g h t  p r e p a r e d i n t h e a f t e r n o o n two physicians  The  slates  which  estimated operating  to n o n - a c t i v e s t a f f . ,  clearly  on  considerations  Keeping  p a s t 3:30  filled  file  p h y s i c i a n ' s tendency  the  operating  may  on  usually  e s t i m a t i o n . ,•  fills  visual  As t h e s e f o r m s a r r i v e ,  has  quarter  n e v e r s c h e d u l e d t o run Once  a six-week  depending  physician  time a c c o r d i n g inaccuracy  has  inserted.  a m u l t i p l e o f one  the or  Office  are  the  Construction  physicians'  knows) , t h e i r  office  hours  which  (which  t i m e away f o r c o n f e r e n c e s  and  the  OR  scheduling.  Booking  holidays  Office  must  be  66  observed.  Some  rooms  are  occasionally  unavailable  due  to  problems.,  For  maintenance. There  are  also  example, a p a t i e n t talking  to other  surgery  consent  are  included  not  may  some u n e x p e c t e d s o u r c e s o f be  slated,  and  p a t i e n t s a r o u n d him,  form. i n the  Such t h i n g s model.  do  admitted. he not  may  Then,  refuse  happen v e r y  after  to s i g n  the  often  and  67  CHAPTER 6  6. 1  FLOP? •PATTEgjlS-  P u r p o s e and Form  The visually relevant of  MA JOE  extended  flowchart  describes interactions  t h e model t h e s e  processes  The f i n a l  the u n a v a i l a b i l i t y  form  o f data  of  the  identifies a l l  During  the development  "physical  two  unit"  describe  the  flowcharts  includes  streams a r e o f t e n In  of interest information  the  description  flow  relative  hospital,  i t  information,  unaccompanied  by  surqery,  t h e r e i s no  aqain  information the  i s vitally  patient  information probably about  arrives flows  be h e l p f u l  patient.  When  actual  important at  the  often  as a  patient  patient  to t h i s  model.  hospital,  coincide.  at  the  here  at the usually  i s slated for hand,  but  the  Of c o u r s e ,  once  physical  and  Nevertheless,  t o conceive o f the flows  the  i t  will  as i n f o r m a t i o n  patients. The  Book  a  form,  These to  request a r r i v e s  a  used  i s the patient.  F o r example, when an a d m i s s i o n as  with  identified,  patients.  arrives  by t h e  on some a s p e c t s o f t h e s y s t e m .  flowcharts,  diagrams a c t u a l l y  chapter  which had t o b e made t o d e a l  i n f o r m a t i o n f l o w and p h y s i c a l f l o w . here,  and  i n this  r e l e v a n t model f e a t u r e s and d e t e r m i n i n g  and a s s u m p t i o n s  system  framework  w i t h i n the system.  of c l a r i f y i n g  modifications  model  presented  c h a r t s c o n t r i b u t e d t o and were r e f i n e d  data requirements.  In  the  system  format  outline  of this description (Grams  1972).  tends  to follow  The c o m p l e x i t y  the  o f t h e model  System calls  68  for  an  overview flowchart  subsequent  flowcharts,  the  of  details  number  in  operations  6.2  the  and  statement  This f i r s t  as  a  graphic  index  to  s e v e r a l system f l o w c h a r t s d e p i c t i n g  subsystems.  parentheses  Overview  patient  which s e r v e s  Each  associated  g i v i n g any  flowchart with  necessary  or  it  symbol which  has tags  a an  useful explanation.  Flowchart  flowchart  information  flows  sets of the  out, model.  in  general  terms,  the  69  (1)  GENERATE AND IDENTIFY ADMISSION REQUEST  .(3)  (2)  SURGICAL SCHEDULABLE ADMITTING • AND OR BOOKING PROCESS  MEDICAL .00  ADMITTING  EMERGENCY (5)  SCHEDULABLE PROCESS  ADMITTING  IN-HOSPITAL  PROCESS  TRANSFERS AND OR DEMANDS  1 t 1 SURGICAL BED POOL AND OR FILES  T  (7)  (6)  *  (8)  MEDICAL BED POOL FILES  SPECIAL UNIT BED FILES  (9)  DISCHARGES  Fig.  6.1  A d m i s s i o n and  OR  scheduling  information  flowchart  (I)  70  Operations  Statements  1.  the  From  booking  at  patient  f o r m s from  with admitting  <I)  pool,  Medical  physicians  privileges,  or through  t h e h o s p i t a l . , See f l o w c h a r t  2.  Schedulable  3.  Schedulable  Medical  emergency  surgical  and  specialists  {or DO)  patients"  admission  patients* requests  and  served.  DO  patients  arrivals  requests  procedures.,  See  are  processed  for  pools i d e n t i f i e d  here.  6.  See f l o w c h a r t I I I A .  7.  ICO and C a r d i a c u n i t s .  8.  See f l o w c h a r t IV A .  9.  Patients  pool  (or a r e deceased).  no  reguiring  admission  are  See f l o w c h a r t V A .  I n - h o s p i t a l demands r e s u l t  between  surgical  as  S e e f l o w c h a r t IV A .  Emergency  immediately 5.,  or  arrive  I I I A.  admission. 4.,  OS b o o k i n g  f o r admission  I I A.  (non-immediate)  undergo c o o r d i n a t e d flowchart  requests  longer  i n some OS use and b e d t r a n s f e r s See f l o w c h a r t VI A .  See f l o w c h a r t VI A .  occupying  a bed r e t u r n t o t h e p a t i e n t  See f l o w c h a r t IV A .  71  6.3  Detail  The describe  Flowcharts  flowcharts  and  operations  in  the  processes  detail  statements indicated  which on  the  follow overview  chart. The  numbers  i n sguare  a r e c r o s s - r e f e r e n c e s t o any (Data  and  Information  Osed).  b r a c k e t s a t t h e end a p p r o p r i a t e data  of each  items  of  comment  Table  IX  72  (i)  REQUEST ADMISSION  Fig.  6.2  Admission requests f l o w c h a r t (IIA)  73  Operations Statements  1.  Patient  ( I I A)  " g e n e r a t i o n " i s by s e r v i c e , and  t h e number o f p h y s i c i a n s  active  i n that  i s proportional  service.  Services: Medicine General  Surgery  includes may Eye,  vascular  include  Ear,  open  Nose and  heart  Throat  (EENT)  Orthopedics Urology Gynecology Neurosurgery Plastic  } } }  Surgery  Each p a t i e n t a d m i s s i o n  t h e model c o m b i n e s  these  reguest i s assigned:  service admission  diagnostic  Elective, Direct  category:  Semi-Urgent,  Urgent,  \  Urgent,  Emergent  physician age,  sex  LOS any  requested  p e r h a p s ... f o r those  admission  transfer timing  p a t i e n t s t o be  pre-operative  date  LOS  operated  and on:  routing  to  74  length  of surgery [4,5,6,7,8,9,10,11,12, 13]  2. ,  The  immediate  categories 3.  are handled  (DD,Emergent)  and  (E1,S0,U)  separately [6]  The s c h e d u l a b l e p a t i e n t s a r e d i v i d e d  surgical  schedulable  between  services [4]  4.  To t h e s t a r t  o f emergency  unit  processing.  5.  To t h e s t a r t  of surgical  6.  To t h e s t a r t  of Medical s e r v i c e s processing.  services processing.  Medical  and  75  Fig.  6.3  Surgical services  and  operating  rooms f l o w c h a r t  (IIIA)  76  Operations Statements  1.,  In  t h e OR B o o k i n g O f f i c e ,  tentative box  ( I I I A)  location  on t h e s i x - w e e k  t o go t h e r e .  as p a t i e n t  t h e r e q u e s t forms a r e f i l e d  Requested  booked  by p h y s i c i a n  booked  by s e r v i c e  which  is  not  A, B,  block  category.  booked).  There  maximum  o f seven hours per t h e a t r e ) .  some f l e x i b i l i t y  i s left.  2. ,  emergency  spaces  left  in-hospital patients  About in  and  must  The  reguest 4.  Maternity  week  the  f o r today  5.,  here  implies  determined may appear  produced  preliminary  cause  (a  stage,  some  of  scheduled  be  filled  Postponers  be  slate  surgery,  by b a c k l o g ,  and  "No  treated  that  be known w e l l final  ahead  [Not  a definite  Bed"  an e x o g e n o u s  implemented]  copy  of  or i s i t  s u r g e r y day h a s been  may be n o t i f i e d . ,  o f time, t h i s  working  as  (on an emergency b a s i s )  - so the Admitting O f f i c e  on t h e  constraints  P a t i e n t s who a r e made t o w a i t a  may  implemented]  "Final"  f o r each  [3,24]  [Not  to  to  reguests.  service  demand  time  At t h i s  ahead  begin  schedulable?  it  are  on OR t i m e , w i t h s e p a r a t e b e d s . ,  Is  Surgery  a r e bed l i m i t s  admissions  re-booked..  l o n g t i m e may c a n c e l . , 3.,  There  slate  urgent be  generally  [5,6,12,13,14,15,16,17]  one  the  Surgery i s  file  as w e l l  o r C, and N e u r o s u r g e r y / P l a s t i c  p e r day and p e r week.  modifications.  the  ( e x c e p t f o r G e n e r a l S u r g e r y which i s  service  Surgical  or i n  s u r g e r y date i s c o n s i d e r e d ,  admission diagnostic  block  visual f i l e ,  in a  operation the  one day b e f o r e s u r g e r y and c o n t r o l s OR  Although  i s expected  slate usage.  wich  is  77  6.  I f the request  admitted. 7.  was  in-hospital,  the  patient  need  not  be  [24]  Is this  in-hospital  patient  in a special  unit  or a  surgical  area? 8.  Once  the  day  pre-operative  LOS  the admission  date.  Admitting The  10.  I f t h e r e i s no i s a "No  This  may  Bed"  has  been  determined,  the p h y s i c i a n  information  is  i s used  then  to  filed  the  specify in  the  [10 ]  9.  it  surgery  a s s i g n e d by  Office. patient  of  postpone.  [Not  Implemented]  a p p r o p r i a t e space  f o r a scheduled  admission,  situation.  11.,  The  patient enters a hospital  12.  Is the admission  bed.  [20,21,23,24]  to a regular s u r g i c a l  bed  or to a  cardiac  bed? 13.  A  record  procedures  is  per  both scheduled procedures from  room and  which  emergency  handled:  kept and  the  a  (variations  14.  slate may  Surgical  be  in  kept  bed  First-Out the  after  At  the  3:30)  one  available  may  are  -  (iii)  arranged  completion  be  room  o r d e r a t t h e end on  of a  of  the  o r a maximum o f  two  open as l o n g as n e c e s s a r y . is  They  an a n a e s t h e t i s t ;  (FIFO)  (those  i n a d v a n c e ) come  requests.  sequence  pool information  scheduled  Emergencies  f o r a day  and  of  o p e r a t i n g time f o r  ( i i ) i n the f i r s t  basis).  (especially  daily  in-hospital  with nurses  First-In,  physician^to-physician  theatres  and  number  operations.,  be p l a n n e d  ( i ) i n a s p a r e room;  slate  total  of the t o t a l  cannot  admissions  basically  scheduled  the  emergency  which i s a l r e a d y s t a f f e d in  of  updated  [11,17,23] by  admissions,  78  transfers can  and  develop  discharges.  from h e r e .  15.  From s u r g i c a l  16.  From  17.  An  operation  18.  The  19.  Open h e a r t  20.  From  bed  in-hospital from on 21.  the  VI  A6,  at  least  matches may are  one  be  OS  day  demands VI  A5  to  demands  unit  from  must be  noted.  unit.  cardiac  unit V  who  beds.  A5  surgery  patients  and  ahead.  admissions  which r e g u i r e unit  A6  in a special  admitted  emergency  special  V  in a special  surgical  of  and  requests.  admissions  a patient  patients  status  and  today.  are  to  be  from Also,  operated  A9. To  update the  operated 22.  for  which  admission  emergency  demands VI  transfers  [22,23,24]  service  surgical  in-hospital  In-hospital  status  Medical  patients  surgical  a d m i s s i o n s V A7  b e d s VI  A8.  To  A1,  bed  special  unit  patients  who  have been  V A4,  emergency  on.  From  23.  of  discharges  demands VI  IV  information A4.,  taking  and  A4, for  a surgical  in-hospital  in-hospital transfers  bed  transfers  transfers VI  A2,  to  from  and  surgical  surgery  in-hospital  VI OB  79  (ii  FORM QUEUE  WAIT A2)  'IN-HOSP^ DQJJE  N  0  YES A3)  HATCH PATIENT T$>~«vBED^  NO  DONE  NO  ^TATIEN  YES (5)  ADMIT  (6) (9)  MEDICAL BED POOL INFORMATION  t  (10)  (11)  (7)  DISCHARGE  Fig.  6.4  M e d i c a l s e r v i c e f l o w c h a r t (IVA)  80  Operations  Note:  Statements  Scheduled  {IV A)  surgical  investigative  and  non-operative  p a t i e n t s f o l l o w a s i m i l a r r o u t e , but to a s u r g i c a l 1.  A queue f o r m s ,  category and  and  ordered  length of wait.  whether o r n o t  factors.. actually order  In  physician 2.  3.  with  the  The s t a f f  of  level  clerks  stamped  also  on  them,  Pressure  factor.  transfers  be  from  in the  [6]  must  be  processed  11]  admissions.  attempt  may  mental - forms are  names.  b u t unprogrammable  diagnostic  of the physician  out-of-town  receipt  in-hospital  admitting  is  last  considering schedulable  The  admission  t h e gueue i s a l m o s t  physicians•  morning,  patient  patient  the date  i s a a real  Each  before  the  practice,  filed of  by  bed.  to f i n d  an a p p r o p r i a t e bed.  [19] 4.  The p a t i e n t may  5.  The p a t i e n t e n t e r s a h o s p i t a l bed.  6.  Medical  transfers,  bed  and  postpone.  pool  information  The p a t i e n t no l o n g e r  8. ,  From M e d i c a l  9.  From emergency M e d i c a l  10. bed 11. VI  To  area  occupies  s e r v i c e admission  is  u p d a t e d by  a hospital  admissions,  bed.  requests.  admissions  V A3 and t r a n s f e r s t o t h e  VI A3.  in-hospital  transfers  i n f o r m a t i o n f o r t r a n s f e r s VI From s u r g i c a l A9,  [23,24]  discharges..  7.  Medical  [Not Implemented]  discharges  from t h e M e d i c a l  area  VI A1 and  A2.  I I I A9 and s p e c i a l  unit  discharges  81  Fig.  6.5  Emergency U n i t f l o w c h a r t  (VA)  82  Operations Statements  1.  This  {V  A)  o v e r a l l process  i s the  Patients  included  are  patients  from t h e  physician's  in is  his opinion, safe  to  assume  that  2.  the  patient  s p e c i a l care  Unit?  [Not  3.  I s the  4.  If  closed,  to  patient  this  and  in  the  are  Intensive  bed..  These  point  The  will  Does  patient  is  [2,6]  Coronary)  provided this  the  patients  closed,  /  or  Care  in fact  8.  From emergent a d m i s s i o n  9.  To  the  10.  To  a Medical  require  emergency or  and  11.  A  Medical  any  may  cause  i s placed  probably causes a t r a n s f e r . data  for  occupy  a  in-hospital  o v e r f l o w b e d s used [18,20,21,22]  operations,  only  of another s e r v i c e ?  [4]  [23,24]  one  reguests.  (Some w i l l  patient  perhaps  or  (Perhaps a t r a n s f e r should bed.  [4]  [23]  i n a s u r g i c a l area?  a cardiac  m o d i f y OP  surgical?  patient  probably  immediately?  Is  ICU.  or  (including semi-closed,  beds)  7.  To  capacity  m o n i t o r i n g and  p r o b a b l y cause t r a n s f e r s soon.,  6.  12.  bed  or,  queue.. I t  i f needed.  {and  Medical  semi-closed,  needed  the  as  full  some " o v e r f l o w "  Is surgery  care  slow a d m i s s i o n  c l o s e enough  urgent"  either c r i t i c a l  a v a i l a b l e i n storage  classified  5.  the  the  are  "direct  Emergency U n i t ' s  require  beds  t r a n s f e r s soon. at  be  the  who  patients.  implemented],  Medical  surgical  office  need t o c i r c u m v e n t  - o l d beds are  the  o f emergency  e i t h e r e m e r g e n c i e s or a r e  sufficient Does  routing  today.,  cause  be  arranged.)  transfers.)  i n a s u r g i c a l bed,  ...which  83  13.  Surgery i s r e q u i r e d  14.  To  a surgical  15.  To  a cardiac  later,  bed. unit  bed.  so  the  slate  must be  modified.  84  (1)  IN-HOSPITAL TRANSFERS ROUTING  F i g . 6.6  I n - h o s p i t a l v a r i a t i o n s flowchart  (VIA)  85  Operations Statements  1.  (VI A)  The p r o c e s s which  follows  is  the  routing  of  in-hospital  transfers., 2.  The a d m i t t i n g  appropriate  bed,  clerk which  s h o r t a g e o f beds t h a t  a t t e m p t s t o match t h e may  be  I f matched, t h e p a t i e n t  location  t o t h e new one.  3.  a M e d i c a l bed?  special)  A patient  unit  although a  imply 5.  or  at t h i s  must be removed f r o m  ( t h e b e d might o t h e r w i s e  point  not r e q u i r i n g  surgical  be  done  h i s former  be s u r g i c a l o r  may need a s p e c i a l any o p e r a t i o n ,  bed from a s p e c i a l  unit.  or surgical  o r may  be  care  returning  T h e s e c a s e s would n o t  a need f o r s u r g e r y . Demands may come from s u r g i c a l o r c a r d i a c  already (in  the  [4]  4.  to  to  anywhere., I f t h e r e i s s u c h a  t h i s c a n n o t be done y e t , i t w i l l  later.  To  patient  had one o p e r a t i o n  o r who s u f f e r  w h i c h c a s e a bed t r a n s f e r from  investigative,  Medical,  patients  some "ward  catastrophe"  may n o t be a d d i t i o n a l l y o r ICU p a t i e n t s  who have  found  implied), to  require  surgery. 6.  F o r t o d a y o r n o t ... s e e I I I A n o t e  7.  To  a  special  unit  bed  or  a  13., [ 2 3 , 2 4 ]  surgical  area bed?  [Not  implemented] 8.  "Special  updated  units"  by a d m i s s i o n s  amount o f t r a n s f e r r i n g 9.  (ICU and c a r d i a c to the cardiac  unit,  and d i s c h a r g i n g . ,  From M e d i c a l t r a n s f e r s  unit)  bed i n f o r m a t i o n i s  and  a  considerable  [Not implemented]  IV A3 and s u r g i c a l t r a n s f e r s  I I I A9,  86  10.  From  Medical  information  bed  information  To a M e d i c a l b e d .  12.  From s u r g i c a l  unit  13.  To t o d a y ' s  data.  14.  To modify  15.  From  special  cardiac  OR the  OR  admissions unit  needing  admissions  To a s u r g i c a l  17.  From  cardiac  special  ICU  by  today's  monitoring  bed  unit  OR  requests  III  A3,  updating  of  III  A5,  run  I I I A7, emergency  and c a r e V A2,  and  emergency  to the s u r g i c a l  admissions  V A8. , bed. bed  information  match I I I A4, p a t i e n t s t o t o d a y ' s A4.  surgical  demands.  to the c a r d i a c unit  patients  16.  IV  and  slate.  slate-modifying  admissions  A3  I I I A9.  11.  scheduled  IV  OR  data  I I I A6, and  discharges  87  CHAPTER 7  The  THE DATA AND INFORMATION USE-  unavailability  definition  of data  In  this  work,  utilized:  a magnetic data tape  completed  surgical  surgical  processed,  slates,  admission  as w e l l as t h e  Appendix  2.1)  (Scroggs,  1970) .  7.1  and,  to  Description of  The will  variety  constraint  sources,  the  four  important  for this  Waiting  i n the  o f t h e depth o f  data  sources  was  of patient census data, copies of  emergency a d m i s s i o n s booking  forms  1976  Admitting  some  forms.  Medical  i n the course  o f being  report  (see  extent, a patient t r a n s f e r  study  Office  Data-Sets  gathered,  efforts.  data-sets  and  study  Defined described  their  sources,  and t o a s s i s t any  according below  to  were  their  t h e most  work.  Lists  As i t has been m e n t i o n e d , s u r g i c a l a r e r e c e i v e d by t h e OR B o o k i n g the date  of r e c e i p t .  another  copy  of  of  t h e scope of t h i s  data c o l l e c t i o n  7.1.1  a  d e s c r i p t i o n o f the data  serve to c l a r i f y  future  prime  o f t h e model and i n t h e d e t e r m i n a t i o n  the study.,  and  is a  Office  admission  booking  and, u s u a l l y ,  Once t h e p a t i e n t i s s c h e d u l e d  the  form  i s  sent  forms  stamped  with  f o r surgery,  t o the Admitting  Office.  88  Medical  f o r m s and  Admitting  Office,  admission (or  at  p r e - i n v e s t i g a t i v e surgery  least  data  period  order  presence)  and  i s t o r e c o r d and  t o the h o s p i t a l  from t h e s e  forms d a i l y .  found  Section  in  data  here  (age,  sex,  waiting times for certain The  items  forms  are  for  the  best  Unfortunately,  One  appearance forms.  way  to  it  in  that  another another  a long  not  always  available  from their  regard  the  supplement  p a r t i s the  be data other  validate  only  source  diagnostic category).  observing use  data  may  part serves to  ( p r e - o p e r a t i v e LOS,  and  over  difficulty,  part serves to  yet  is  The  observe  t o have someone c o l l e c t i n g  rates),  listed  waiting times  of these  Because o f t h i s  ( o u t p u t ) , and  data  booking  arrival  parameters  The  (A s u g g e s t i o n  are sparse.  the  observe  disappearance  staff  11.3.)  on  to  f o l l o w a l l f o r m s on f i l e  days.  convenient  data  to  records of waits!  of c o n s e c u t i v e  gathered  to gather  t o a feed, i t i s n e c e s s a r y  h o s p i t a l k e e p s no these  In  f o r m s a l s o go  the  commented  admission  on,  in  Table  VIII.  7.1.2  Operations  One Office  copy o f t h e after  use.  operations,  and  operations  have  the  interest,  length  To  slate this  presence  been  b e c a u s e p a t i e n t LOS Since  final  a stratified  and  f o r 1974 surgery  kept  copy,  added.  data of  is  the  in  slates  random sample  the was  Booking scheduled  of  a l l  emergency  from  1974  were used  were c o n v e n i e n t l y was  OH  duration of  duration  The  the  primary collected.  available. variable The  of  days of  89  TABLE  VIII  DATA COLLECTION GROUPS D a t a Group  Item  WAITING  D a t e form  Use received  Date o f a d m i s s i o n  Cancellations Postponements "No B e d s " Service Physician P r e - o p e r a t i v e LOS Age Sex Diagnostic category Date r e q u e s t e d  P o t e n t i a l use i n d a y - o f - t h e week d i s t r i b u t i o n Rate o f sc h e d u l a b l e a d m i s s i o n s W a i t i n g t i me v a l i d a t i o n P o t e n t i a l use i n d a y - o f - t h e week d i s t r i b u t i o n S e l f - e x p l a natory Schedulable p a t i e n t s per service P a t i e n t vo lume p e r p h y s i c i a n B o o k i n g pa t t e r n Service's distribution II  tt  it  ft  ti  Proportion f o r service P a t t e r n o f use P o t e n t i a l use f o r p r o p o r t i o n  T e a c h i n g bed? n n ti it Accomodation T h i s g r o u p c o u l d a l s o be u s e d t o show v a r i a t i o n s made i n t h e s l a t e and p l a c e m e n t o f p a t i e n t s a s p e r d a t e r e g i e s t e d , d i a g n o s t i c c a t e g o r y , t e a c h i n g bed, accomoda t i o n , s e x , and service. OPERATIONS  Number p e r room  Limit D i s t r i b u t i on, f o r v a l i d a t i o n Length o f s u r g e r y d i s t r i b u t i o n Service's distribution  Booker's time Age ti II Sex Surgeon Room u s e p a t t e r n Cancellations P o t e n t i a l use f o r p a t t e r n A n o t e i s now made on t h e s l a t e s o f a c t u a l " s k i n - t o s k i n " t i m e , n o t j u s t t h e b o o k e r ' s e s t i m a t e p l u s t u r n a r o und. I f the s t a r t i n g t i m e o f e a c h p r o c e d u r e was a l s o no t e d , a c t u a l t u r n a r o u n d and s u r g e r y t i m e c o u l d be c a l c u l a t e d . Also, i f t h e p h y s i c i a n ' s e s t i m a t e was added, t h e n a s t u d y o f t h e a c c u r a c y o f h i s and t h e b o o k e r ' s e s t i m a t e s c o u l d be o f v a l u e , I n s t e a d o f r e c o r d i n g a l l e m e r g e n c i e s t o g e t h e r , i t might be u s e f u l t o n o t e t h o s e which " b r o k e " t h e s l a t e (see s e c t i o n 5.3.9). I t would be u s e f u l f o r t h e d a t a - c o H e c t o r t o n o t e f e a t u r e s , i f a n y , w h i c h c a u s e some o p e r a t i o ns o f a p a r t i c u l a r s e r v i c e t o be done i n one OR and o t h e r o p e r a t i o n s t o be done i n a n o t h e r OR a l s o used f o r t h a t s e r v i c e .  90  TABLE LOS  Admission  VIII  {cont.)  date  O v e r a l l admissions rate P o t e n t i a l use i n day-of-theweek d i s t r i b u t i o n P o t e n t i a l use i n t i m e - c y c l e study Discharge date Length o f stay P o t e n t i a l use i n study o f o c c u p a n c y c o n t r o l v i a LOS Service P a t i e n t s per s e r v i c e Classification of patients Age Service's distribution Sex " " Number o f o p e r a t i o n s U s e f u l o n l y i f decoded t o i d e n t i f y OR p r o c e d u r e s A l t h o u g h n o t a v a i l a b l e on t h e t a p e u s e d , CPHA c o u l d provide i n f o r m a t i o n on t h e use o f s p e c i a l c a r e u n i t s and d i s c h a r g e s t a t u s , as w e l l as d i a g n o s e s . EMERGENCIES T i m e o f a r r i v a l Time t h a t A d m i t t i n g was i n f o r m e d Time t h a t p a t i e n t was p l a c e d Service Physician Bed r e c e i v e d To OR? Age Sex  A r r i v a l rate P r o p o r t i o n p l a c e d i n morning of day-shift P o t e n t i a l use i n s t u d y o f of delay Emergency p a t i e n t s p e r s e r v i c e P a t i e n t volume p e r p h y s i c i a n Ward / s e r v i c e p a t t e r n P o t e n t i a l use f o r p r o p o r t i o n Service's distribution " *'  91  the  y e a r were l i s t e d  on t h a t sized  day.  a c c o r d i n g t o t h e number o f p r o c e d u r e s  These s e t s of days  groups  (strata)  aligned  were d i v i d e d  by t h e  number o f d a y s t o s a m p l e was  stratum  t h e same p r o p o r t i o n o f days was  Table VIII l i s t s  7.J.3  Length  The  of  largest  abstract  for  P r o f e s s i o n a l and  prepares  a  1974  Hospital  from  the  case  commission  assembles  patient  The  Emergency  The as  well  liable For  emergency as  to disappear  the  each  ;  on  i t  For  to  magnetic  PAS  Commission  Hedical  case on  each  patient  Records  Library  diagnostic the  CPHA.  tape  and This  files,  and  o b t a i n e d c o n t a i n e d some 21,000  w h i c h we  abstract*s  tape of  (CPHA).  submits  t a p e w h i c h we  had  requested,  information deleted.  e x t r a c t e d from  with  the  Table VIII  those records.  Admissions  unit  a form  this  from  a t random.  demographic,  data  t h e i n f o r m a t i o n we  from  the  of  and  the  r e s t of the o r i g i n a l  7.1.4  and  uses.  a magnetic  Activities  records of data items  details  chosen  and  obtained  abstract  information,  i t .  was  hospital,  treatment  analyzes  determined,  The  Stay  block of data  data  discharged  the data items  i n t o roughly egual  number of p r o c e d u r e s .  desired  done  maintains a daily  on e a c h  patient  i f the p h y s i c i a n  study,  records  record  admitted.  of  admissions  (These forms a r e  wants them.)  covering  the  period  of  the  92  waiting-time period  d a t a were u s e d .  c o u l d a l s o have been  The  data  7.2  The  Most o f t h e  data  to  o f D a t a and  incorporated  empirical for  However,  some  characteristics  and  be r e p r e s e n t e d  information, of  the  model i n s u c h  numbers in  the  used  of  beds.  by  the  The  final  IX  t h e model, and found  form  priorities  model  which  various  have  been  describe  the  hospital  are i d e n t i c a l  as  over a l l s e r v i c e s ,  descriptions.  the seguence of  description  services.  of  Other  the s t r u c t u r e  events  the data  or  incorporated  f o r which the d e r i v a t i o n  model  from  the  e x p l a n a t i o n may  raw be  be  of  collected  found found  the  in  data  data i s Appendix  i n the  program  3., the  types  of data  and  i n f o r m a t i o n used  f o r which f u r t h e r d i s c u s s i o n  in may  appendix.  for a couple  o f program  were a r r a n g e d  including  the  St., Paul's, determined  i n d i c a t e s those  first.  in  o f a l l f u n c t i o n s may  lists  a l s o t o F i g u r e 8.1}.  not  the  In cases  simulation  i n the  Except  but  from  Information  simpler single  A brief  i n Appendix  Table  created  by  involved, a f u l l e r  listing,  be  of  details  model f o l l o w s .  rather 2.,  obtained  time  VIII.  functions  characteristics  could  each  a longer  used.  usage i s d e s c r i b e d on T a b l e  Specification  converted  A s a m p l e drawn from  Each  book-keeping  to cause the day,  Emergency and admission.  items,  event  f o l l o w i n g sejuence  (refer  the reguests DU  reguests  Orgeat,  f o r admission  were p r o c e s s e d  semi-urgent  and  were up  to,  elective  93  TABLE  IX  DATA AND INFORMATION Item Number 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24  Type  OSED More I n Appendix ?  Event sequencing P r o p o r t i o n of morning d a y - s h i f t emergencies P r o p o r t i o n of long-wait c a n c e l l a t i o n s Daily patient a r r i v a l s (non-schedulable and s c h e d u l a b l e ) by s e r v i c e P h y s i c i a n s per s e r v i c e / P h y s i c i a n s ' days f o r surgery Patient admission d i a g n o s t i c category P a t i e n t sex P a t i e n t age g r o u p Patient length of stay P a t i e n t p r e - o p e r a t i v e LOS Patient length of surgery P r o p o r t i o n r e q u e s t i n g an a d m i s s i o n d a t e Time u n t i l r e g u e s t e d a d m i s s i o n d a t e D a i l y bed l i m i t f o r s l a t e D a i l y o p e r a t i n g time l i m i t f o r s l a t e (420 min. * no. o f OR's) Scheduling priority features Turnaround time M e d i c a l bed l i m i t f o r m o r n i n g e m e r g e n c i e s M e d i c a l beds a l l o w e d f o r s c h e d u l a b l e patients Alternate areas L i m i t on u s e o f o f f - s e r v i c e b e d s P a t i e n t s to stay i n o f f - s e r v i c e areas P r o p o r t i o n o f p a t i e n t s r e q u e s t i n g emergency surgery P r o p o r t i o n o f p a t i e n t s with i n - h o s p i t a l operation reguests  Yes  Yes Yes Yes Yes Yes  9H  requests and  were  processed  queued up.  processed  Discharges  next.  The  A number o f emergency would  appear  claim  on b e d s .  requests  were  placed  arrangement i s  wherever  St.  obtained  placed  by  between 6 am  p a t i e n t s with The who  11  and  the t o t a l  over  waiting  The  the  on  p a t i e n t s were operation  " i n the  possible.  The  morning")  Finally,  the  o p e r a t i o n s were done. represent  particular, in the  the  the  This  bed-claim  p r o p o r t i o n of  morning of the  plus  an  arbitrary  number o f immediate  seven  next  day-shift  number o f emergency p a t i e n t s b e i n g  am  weeks,  is  50%  of  DO  patients. each  fairly  week,  of  those  a r b i t r a r y , based  on  times.  "Patient Generation  amount of d a t a . based  be h a n d l e d  which  admitted.)  not  proportion of patients c a n c e l l i n g  waited  observed  In  were  made t h e  in-hospital  ( a l l those was  day)  proportion  patients  closely  Paul's.  comparing  other  day's  to  the  the d a y - s h i f t  the  i t  the  believed  immediate p a t i e n t s t o was  from  to  scheduled  b e d s were t r a n s f e r s .  room, s c h e d u l e d  and  patients  regarding  at  still  beds f o r the  these  patients equal  generated  calculations  sequence  freed  c l a i m on  (Emergency  emergency  then  first  I f t h e r e was  next.  were  (which  d u r i n g the morning o f  admitted  remaining  i n t h a t o r d e r as f a r as b e i n g  Segment" o f t h e  model u s e s a l a r g e  Each o f s e v e r a l p a t i e n t i d e n t i f i c a t i o n  a different  function (series  of  items  is  p r o p o r t i o n s ) f o r each  service. For daily  the  arrivals  categories  was  arrival  distributions,  f o r each o f emergency smoothed  and  the  observed  (with DU)  tailored  and  p a t t e r n of schedulable  to a c c e p t a b l e r a t e s f o r  95  yearly  totals.  arrival  rate  The of  an  T h e s e d i s t r i b u t i o n s were used  f o r each type  number o f arbitrary  patients  for  sampled  from  were  "average  each  same  during  the  and  some 33 the  active  time  observed. each could  The  of  value  of  an  It  was  be  category known  proportion was  b a s e d on  Appendix The  emergency sex,  blocks  and,  Appendix  PAS  to  on  basis  number  were  in effect, for  in  busy load  Medicine,  patients  during  a level  of  have a r e a s o n a b l e  the  is  slate,  partially  an  22  load.  physicians and  a  example,  patient  at  of  partially in  i d e a of  the  effect  p_atient  diagnostic  staff.  of  patients  the  observed  patients,  35  that  l o a d " to give  t o t a l s o f emergency and  schedulable  see  decided  the  Most were q u i t e  1 to  from  considered  decreased  that,  extremity,  i n c l u d i n g these composite  or  so  Orthopedics,  other  2.3).  The  model e v e n e d t h e  the  dailj  characteristics  listed.  the  At  "average p a t i e n t  increased The  of  staff  i d e n t i f y i n g physician's  defining  In  each admitted  physicians,  in  used.  physicians.  physicians  their  the  t a k e n on  physician.  distributions,  was  Appendix  s e r v i c e was  and  t i m e o b s e r v e d - so  kept nine  (see  active"  physician  the  nine  patient  Bl,l§icians p e r  "composite" p h y s i c i a n there  of  to give  and  DU  in  each  number patients,  of  emergency  cases,  known s l a t e d  numbers  known o v e r a l l t o t a l s .  For  details,  2.2. data,  cases f o r each  together was  with observed data  used t o  sex,  the  give  the  proportion  from  proportion i n each  of  §,a§  slated patients SEoup.  and by (see  2.4).  Length of  stay, was  obtained  by  a more complex  calculation.  96  From  the  PIS d a t a , LOS was s u b d i v i d e d  seasonally-relevant  g r o u p s o f months.  was  age,  dependent  The  on  calculation  was a l m o s t there  entirely  by  age  accounted  test  of  this  acceptably these  elderly  hypothesis  straight were  line  log-normal deviated  sufficiently  2.5) showed  the  a  For  from  but  that  a  this  patterns ( i . e . the female  by s e x , t h e n  the  best  LOS  parametric  would be t h e l o g - n o r m a l . done  by  plotting  Although  for  chi-square most  groups,  log-normality  computer-tabulation  the  data.,  the  the data parametric  were used f o r  points obtained  o f PAS  an  service-age  however,  that  on  hypothesis),  supported  Empirical distributions  of i n t e r m e d i a t e  giving  some  test  A rough  points  not  the log-normal  Actually,  even  a number  that  (to support  was a v o i d e d .  LOS, i n c l u d i n g of  different,  age-sex  LOS  time-of-year.  - which b o o s t e d  paper.  hypothesis.  distribution  graphs  was  helpful.  g r o u p s , t h e g r a p h and  on  that  t h e o r e t i c a l c o n s i d e r a t i o n s and t h e  LOS  probability  plots  by  females  suggested  to represent  logarithmic  for  Furthermore,  literature  distribution  significantly  Hence age g r o u p s were a s s i g n e d  group.  existing  was  ( i n c l u d e d i n Appendix  were many more  average s t a y ) .  I t was o b s e r v e d  but n o t s i g n i f i c a n t l y  average f o r each s e x  simple  by s e x , age g r o u p , and 3  from t h e  (Appendix  2.5  c o n t a i n s a more c o m p l e t e d e s c r i p t i o n . ) Pre-o^erative  stay, was a s s i g n e d  b a s e d on t h e p h y s i c i a n s ' a d m i s s i o n The by  data  collected  age g r o u p a n d s e x .  varied  according  forms.  on l e n g t h o f s u r g e r y  Although  in  g r e a t l y by sex i n t h e f i r s t  to distributions  EENT,  was a l s o t a b u l a t e d  the  average  length  t h r e e o f t h e age g r o u p s , t h e  97  hospital could offer small  for  modelled,  Orthopedics.  age  assigning  was  taken  length  arbitrarily The  ao e x p l a n a t i o n .  and  of  used  t o be t h e surgery.  as i n p u t  proportion  of  (by d i a g n o s t i c c a t e g o r y ) When  a  t h e day each date date  date  was  of the  then,  f o r which t h e which was  date  any  the  f r e e day,  bed  limit  number o f OR's Scheduling,  priority  c o u l d be  lower-category  physician  variable was  a certain  f o r surgery  almost  in  always  booked.  on For  the  next  was  and  the  booked, was  processed  the next  the  request  booked  model  is  and  date.  entirely  h o p e f u l l y have some i d e a  of  wanted t o "bump" one  of  his  time  on  the  8.2).  and  the  indicated  was  scheduled  lim.it  by t h e  represented  no  requirement  less  requested  p a t i e n t s of the  (ii)  (based  hospital. by  than  t h a t the  e i g h t days i n advance), or  data.  d e l a y between  empirical data  selected  in  smoothed  empirical  was  ( i ) p a t i e n t s f o r whom no  to the  date  on  i t was  of weeks f r o m  used) were a s  requested  requested  The  Figure  per day  mechanism:  (no  entirely  in reality  or o f w h e t h e r he  decision  forms a t l e a s t  2.6).  p h y s i c i a n would  (see a l s o  (correspondinq  (see Appendix  services  w h i c h p r o p o r t i o n o f p a t i e n t s would  date  h i s next  The  data  based  number  whereas t h e  patients  Empirical  t h e r e was  requested.,  random,  own  was  relatively  surgical  dependent  appropriate physician  given  Onfortunately,  the  only  week f o r which t h e  request  in  was  p a t i e n t s r e q u e s t i n g a date  requested,  smoothed t o d e t e r m i n e a  Hence,  Variation  the  following  specific eight  date  days  away  p h y s i c i a n submit true  w i t h i n two  urgent  was  his cases  weeks) c o u l d bump  t h e same p h y s i c i a n , ( i i i )  bumped  98  patients  were  replaced  one  week  later  ( i v ) c a n c e l l e d p a t i e n t s were r e - s c h e d u l e d (v)  patients  could  only  of  handled  on  cases  Figures  8.4  i n c l u d e these  the  total  and  Since instead  only  of  making  the  lengths of adjacent fifteen  placement  reality,  teaching  and  are  there  capacity the  proportion  or  on  the  teaching effort  of  certain  cannot  keep i n mind t h e model, m o r n i n g of  Medical Since of  or  Furthermore, admitted. was  one  by  dependent  on  not  the  waiting short,  line  were  less  p a t i e n t s were  specifying  queue l e n g t h ,  an  upper  then d e f i n i n g t h r e e  for acceptable,  and  extra  one  for short  beds, made o f an  b e d s , and  to  up  time t o  the  a  admit the  number  of  determined. p a t i e n t s were  admitted.,  and  to  queue and  D e p e n d i n g on  long,  the  In  allowed  the  beds,  a v a i l a b l e on  model.  i t was  In  beyond  a c t u a l use  l e n g t h of  was  of  teaching  teaching  When  time  the M e d i c a l  are  the  the  5.3.7).  admissions data  on  a problem.  number o f p a t i e n t s t o a d m i t was  the  I f i t was  implemented  acceptable long,  i f  day.  interest,  turnaround  of the  beds.,  day,  service,  of  d i s t i n g u i s h e d i n the  emergencies  p a t i e n t s f o r the  beds, the  was  patient using  number o f a v a i l a b l e beds were n o t e d . available  OR  c o n t r o l some o f  effect  Medical  own  (see a l s o S e c t i o n  LOS, be  basis,  a c o r r e c t block  p a t i e n t s presented  wards.  in  urgent  their  a constant  of each category  number  scheduled  t i m e per  emergency  difference  to  "tune" the  Medical  possible),  considerations.  reasonable  Medical  beds, they  an  t i m e between o p e r a t i o n s  residents  many  of the  daily  operations,  m i n u t e s seemed  The  t o be  on  OS's  (vi) non-urgent 8.3  had  use  (if  This  lower l i m i t  functions  (one  on for  queues) s p e c i f y i n g  99  t h e number o f p a t i e n t s  t o admit  capacity".  and  The  limits  they  are  placed  arbitrary  limit  used  off-service  by  defining  cannot  in  an  is  level  be a d m i t t e d  t h e number o f beds  patients.  to  Data  suggest  because  M e d i c a l emergency  are  to  avoid  Off-service  d a t a and  proportion  of  off-service  beds.  The  ICU, 6  and  the A c t i v a t i o n  The  total  data.  number  beds  of  per  The  those  surgical "No  5 f o r O r t h o p e d i c s , and  proportion  OR  Booking  surqery.  included of  use  implemented i n  Bed"  transfers situations.  suggest to  reflects  Office,  demands on  and  the  in  the  admitted  model patients  actual  includes  a p p r o x i m a t e l y by  5 f o r General  p e r day  by  the  use  as  Surgery. was  some d a t a , s u g g e s t e d  t h e OR  the  stay i n  the  number o f emergency r e q u e s t s on t h e OR  of i ^ h p s p i t a l  were  actually  allowed  n o t be p l a c e d w i t h i n a week, t h e y were h a n d l e d These  beds  patients  beds a r e d i v i d e d  sequence o f  beds,  Medicine  be  (Overflow  hospital  for  not  area  with the  service  However, t h e a l l o t m e n t  for Medicine,  from  types  of  just  i s an  Service  patients  excessive  consultation  other  number  situation..  areas, not  For Medical patients i n  arranged  may  f o r empty beds.  are necessary  proper  There  which  model a s an o v e r f l o w a r e a .  t h e model.)  the  which  in this  beds i n many s e r v i c e  "remaining  arbitrary.  used  extra  of  a l t e r n a t e - area*  a l t e r n a t e a r e a s s o u l d be c h e c k e d "2"  each  numbers a r e  When emergency p a t i e n t s area,  at  found the  ( i f these could  as  emergencies).  having  an a p p r o p r i a t e  request  such  special  100  7.3  Comments  The  adequacy  discussed. too  or f a u l t y ?  omitted  without  of  have been  Let The  so  too  old?  Were any  lists  were  Section  rate!  any  11.1 The  taken  staff  suggests  length)  from  has  a  sample.  f e a t u r e s included or Would  other  types  The  calculated,  but  good  time the  a t about fact  a r e a and  and  sample  was  when, y i e l d s such  FIFO.  had  admissions  gave good d a t a  the e n t i r e  year  should  (except  the  Data  which  as p a t i e n t operations  However, the OH  supervisory  data  a slightly  data  criteria  of o p e r a t i o n s  LOS  of  on  somewhat s i n c e The  third  that teaching residents  on  sample.  one  197 4,  (and  hence  different  specialty effect  be q u i t e a c c u r a t e . that a  their  s o t h a t newer  were a l s o t a k e n  removal of the p e d i a t r i c  be  identified.  i n that the  some  p a t t e r n based  these data  might  groups  especially  changes.,  probably  sample  data  from from  than  a the  that  Emergency  selected  from  preferable)..  m e n t i o n e d b e f o r e , i t might be so  samples  M e d i c a l a d m i t t i n g f o r m s moved  increased  h o s p i t a l has  model  observed  be  regarding  that d i f f i c u l t y  might show s l i g h t  model s h o u l d  suggestions  diagnostic category,  were  As  the  the  important  includes  Furthermore,  analytical  admission  large  Were  disappointing  d e c i d e whom t o a d m i t t o t h e i r deny  in  helpful?  during the c o l l e c t i o n  normal  used  adequate data s u b s t a n t i a t i o n ?  sample c o l l e c t i o n . slowly  data  us c o n s i d e r t h e f o u r d a t a c o l l e c t i o n  waiting  small,  the  Were t h e d a t a  small,  data  of  t h a t the l e n g t h of time  preferable to  to a requested  modify  the  admission  date  101  is  not random.  individual It limit  This  would  physician's  would a l s o for  be p r e f e r a b l e  scheduled  which  patients  a  closer  observation  of  practice.  surgical  observance of the f i n a l of  require  t o have a l e s s r i g i d patients.  s l a t e a s i t emerges are  scheduled  and  This  would  - with which  daily  a  bed  reguire  knowledge  patients  are  in-hospital. The a study which  main u n a v a i l a b l e  information  o f t r a n s f e r s between were  corrections  number o f p a t i e n t s M e d i c i n e ) would  placed  of  which  of value  is  s e r v i c e a r e a s - w i t h a knowledge  of  off-service  would be  placement.  o f f - s e r v i c e f o r each s e r v i c e  a l s o help. ,  The  total  (not j u s t  102  CHAPTER 8  THE  This  chapter explains  programmed entire  model,  computer  At  MODEL IMPLEMENTATION-  and  briefly  program  present,  the actual concepts involved  is listed  three  8.1  General  be  "composite" slates,  i t s contents.  i n Appendix  3.  h a v e been  implemented  The  i n the  Features  features  the  program  are:  (i)  the  first.  physician,  ( i i )the implementation  ( i i i ) the d a i l y  These  of  explained  and  the  Orthopedics.  There are probably t h r e e should  summarizes  services  model: M e d i c i n e , EENT, and  in  of  the  which  idea of a surgical  sequence o f e v e n t s which the  model  observes. (i)  In order  physicians, certain  suggest the  i t was  number  particular  to r e l a t e patient considered  of  the  desirable  physicians,  physician.  In t h i s  e f f e c t on p a t i e n t  number o f p h y s i c i a n s  patterns  are  by  patients,  some v e r y be  load  and  load  on s t a f f .  Some  patients  to  physicians  request  specific  patients,  others  for  that  have a  each p a t i e n t  have a  would  be or  However, p h y s i c i a n Some p h y s i c i a n s  others  admission others  days  active  each s e r v i c e  of increasing  physicians  semi-urgent,  a few,  that  manner, i t  no means s i m i l a r . few.  t o t h e number o f  consider  easier  decreasing practice a d m i t many a l l  a l l elective. for  f o r none.  to  a l l of  their Some their  Because of t h i s  10 3  v a r i e t y , and because i n staff  only  a  increasing  or  decreasing  the  " t y p i c a l " p h y s i c i a n can be considered  was f e l t t h a t a I l c o m g o s i t e ^ p h y s i c i a n should mentioned i n S e c t i o n 7 . 2 ) .  be  easily, i t  used  i n the model have  Furthermore,  rather  than  identical  having  a  practice  specified  patterns.  patient  generated f o r each p h y s i c i a n , the language i s b e t t e r generate  patients,  the  number  of  physicians  attributable  to  the  of  i n guestion, admission  device  this f i l e  i n the program a r e matrices  The  counting  counterparts t h e scheduled each  week,  corresponding c h a i n s on which complete p a t i e n t data f o r each  operation matrix,  are f i l e d . , For the  through F r i d a y  first  row  each  surgical  service  there  of  which  gives the "dates"  of t h e present  week.  Each o f the  is a  of Monday  s i x pairs  of  a f t e r that corresponds t o a p a r t i c u l a r week i n the f u t u r e . f i r s t row of each p a i r s t o r e s the number of p a t i e n t s  admitted row  and to  diagnostic  number and t o t a l time of p a t i e n t s t o be operated on  The  DO  i n the OS Booking O f f i c e at  the h o s p i t a l i s a six-week v i s u a l s l a t e f i l e .  rows  and  Refer t o Chapter 10 f o r examples.  ( i i ) The main scheduling  and  to  f u n c t i o n s . , I t may a l s o be necessary t o a d j u s t c e r t a i n  l i m i t s on p a t i e n t flow.  of  addition  schedulable  physicians  r e - c o n s t r u c t t h e p a t i e n t a r r i v a l r a t e and category  structured  f o r the s e r v i c e i t w i l l be  necessary t o re-compute the p r o p o r t i o n patients  load  and then t o assign a p h y s i c i a n t o each.  As a r e s u l t , i f the s t a f f s i z e i s to be v a r i e d , i n changing  (already  Hence, except f o r random v a r i a t i o n s ,  a l l physicians  to  active  and  operated on f o r each day of the week.  o f each p a i r accumulates the o p e r a t i n g  time  (and  to  be  The second turnaround  104  time)  required two  by  are  the  may  have s u r g e r y The  is  on  minutes  assumed  that  a given  break.  Since  interest,  between  day  to  m i n u t e s t o be  only t o t a l  could  operatinq  p a i r of  whether a n o t h e r  follows. 3:30  pm  patient  operatinq  a h a l f hour f o r  Turnaround  patients.  time  durinq  time per  s e r v i c e per  the  i s counted  p a t i e n t s - and  no  of  However, i t i s  proceed  turnaround  These  9.1).  Each  with  used.  between  "over-lunch"  first  as  am  added  in-patients.  {refer also to Section  work  turnaround  the  the  420 is  one  w e l l as  f a c t o r s determining  s l a t e d f r o m 8:00  which g i v e s  fifteen  of  critical  p a t i e n t s as  time c a l c u l a t i o n s  theatre lunch,  these  as  lunch day  is  fallinq  t i m e i s added  for  that. For the  each  matrix  of the  there  Data-entities filed  on  between and  the  chain.,  are  levels) here.  The  was  To  a  through daily  8.1  done  patient-related requests  for  Priorities  are  patients,  urgent  set  in  service.  operated  are  i s a p o i n t e r which i n d i c a t e s which  rows  the  week.  pointer  7,  but  (effected  changes  The  "book-keeping"  the  generation  categories a are  of way  of  that,  priority repetition  first  and  events. patient  patients  processed  by  i s worthy o f  time stream.  are  reguests  This  sets.  i n chapter  such  between  on  and  day  a l l  each  to  rows  "present"  data  se&uenee o f e v e n t s  events,  for  p a t i e n t s t o be  shifting  d e p i c t s the  each  "chain"  the  avoid  of the  mentioned  Figure  things  also  there  those  weekly, c y c l i n g {iii)  is  representing  chains,  chain  s i x weeks m e n t i o n e d above, i n a d d i t i o n  of  first,  is  last  Of  the  admission  done  first.  the  schedulable  then  semi-urgent  105  BOOK-KEEPING  GENERATE  ITEMS  ADMISSION  REQUESTS  PROCESS EMERGENCIES UNTIL  WAITING  QUEUE  &D U ' S  ADMISSION  PROCESS  U/SU/EL  ONTO W A I T I N G SLATES  AND  LINE  SLATES  BEDS  DISCHARGES  TRANSFER  QUEUE  TRANSFER  QUEUE  TRANSFERS  .(SOME)  AVAILABLE  -*-  CLAIM B E D S  -f»  CLAIM B E D S  "MORNING" EMERGENCIES  &DU'S  ADMITTED  ADMIT WAITING  QUEUE  SCHEDULABLE  MEANWHILE SLATES  EMERGENCY & OR  TRANSFER  QUEUE  -«*  (SOME)  LINE  GENERATE IN-HOSPITAL  DEMANDS  REMAINING EMERGENCIES  &DU'S  ADMITTED  SLATES  OR  CALCULATIONS  BOOK-KEEPING  Fig.  8.1  Flowchart  . CLAIM B E D S  PATIENTS  FROM W A I T I N G  fordaily  time  ITEMS  stream  -is-  CLAIM BEDS  106  ones, then  the e l e c t i v e s .  Also,  processed  before  the next.  affect the to  bed o c c u p a n c y ,  hospital be p l a c e d  Scheduled the  rest  discharges  follow.  during  are  of  in  realistic  cancellations  first.  t h e n make t h e i r  i s computed.  is  completely  Transfers  proportion  the  of the emergencies f o r the  OR d a t a  request  Then, o f t h e e v e n t s  An a p p r o p r i a t e  t h e morning  admissions  day's a  beginning  each  day.  come  on beds, To  of  f o r scheduled  waiting  next.  followed  close  by  o f f , the  T h i s seguence i s i n t e n d e d  simulation  within  of emergencies  day-shift  claim  which  time,  to r e s u l t "No  p a t i e n t s , and o f f - s e r v i c e  Bed"  placement  o f emergency p a t i e n t s . ,  8.2  The P r o g r a m  The  Segments  program l i s t i n g  definitions  for  GPSS d e f i n i t i o n s .  begins  reference,  followed  The r e m a i n d e r  s e c t i o n s by comment l i n e s .  with  an  extensive  by d i f f e r e n t  of the l i s t i n g  table  of  categories of  i s divided  These s e c t i o n s a r e b r i e f l y  into  explained  below.  8.2.1  Housekeeping  The each  first  segment i n t h e program  "Saturday"  mentioned  Segments  (the  i n Section  on  t h e week j u s t  not  been p l a c e d  sixth  day  updates  the  o f each s e v e n ) .  8.1 i s moved t o a new " p r e s e n t  completed  i s erased.  on t h e s i x - w e e k  "visual  slate  file  The p o i n t e r week".  Data  P a t i e n t s whose f o r m s had file"  (due t o a s p e c i f i c  107  request As  or  lack  o f space)  h a d been f i l e d  many o f t h e s e a s i s a p p r o p r i a t e  "fifth  last  first  final  a r e now moved  onto  place.  the  two program s e g m e n t s a r e a l s o f o r  of  these  i s to control  program segment i s a t i m e r .  print-outs  8.2.2  Patient  A (Each  i s released  which  transaction.  as desired. of  some d a t a  how  moves  d a i l y and marked  through  As i n t h i s c a s e ,  the  with t h e date.  model  i s  called  transaction  - which  which  represents  a patient.) to  Then  generate  schedulable patient appropriate generating  arrival  To  each  admission  Medical  leaves  patient  patient,  diagnostic  Emergency r e g u e s t s  first  the  service,  will the  non-schedulable  reguests i n  accordance  for  that  t h e model, and  usually  be  transaction then  the  with  the  service.  the  to a  This  reguests  are  physician,  an  characteristics. ,  the  model  category,  are  and s u r g i c a l  each  distributions  transaction  t o be a s s i g n e d  a patient  for  admission  a  use o f t h e t e r m i n t h i s t h e s i s i s e n t i t y , as opposed  "splits"  many  gathering.  n o r m a l l y t o i d e n t i f y an i n t e r n a l program  called  The  Generation  transaction entity  "housekeeping".  I t keeps t r a c k  d a y s t h e program h a s r u n , and h e l p s w i t h  sent  new  week" l o c a t i o n . , Weekly d a t e c h a n q e s a r e made.  The The  i n a separate  then  requests.  assigns  a  a s e x , an age g r o u p , and a LOS.  diverted,  as  are  the  remaining  108  8.2.3  S u r g i c a l Request  For s u r g i c a l LOS  i s longer)  requests  observed  by  5.3.4). time  r e q u e s t s , p r e - o p e r a t i v e LOS  and  patient  length of surgery are  their  (Only  a date  service  block  on  which t o a t t e m p t  be  "as  soon  time  i n the f u t u r e .  are  to  the  blocked seven  f o r the days  Figure  the  proper  away  first  I t i s necessary date  the  method Section  model a t  the  i t e m t o be d e t e r m i n e d  is  surgery.  o r may to  surgeon  s i n c e the  may  requested  decide  which  of s u r q e r y . , For t h e s e ,  p o s s i b l e date  date  may  f o r some patients that  date 7.2).  {Section  of s u r g e r y  i s determined.  I t must  which i s be  over  p h y s i c i a n i s r e q u i r e d t o submit  e i g h t days i n advance.  one  be  This  with e m p i r i c a l data  othsrs, the e a r l i e s t  surgery,  attempt  Having  to schedule  a desired  the  his date  p a t i e n t , as i n  8.3.  If  the  date  i s over  a chain correspondinq  main  see  i n the  total  Then  bookinq  booking,  i s implemented  to schedule  i n accordance  requests at l e a s t  on  block  as p o s s i b l e "  have a r e q u e s t e d  determined  for  booking  sure  must be a s s i g n e d .  a c c o r d i n q to the  (e.g.  shown i n F i g u r e 8.2,  either  For  separated  (makinq  of w r i t i n g . ) As  is  Handling  six-week f i l e .  admission If  date  is  scheduled  f o r that date  the  or  bed  time  to the  file  box  Another copy of the  c h a i n to wait the  s i x weeks away, t h e r e q u e s t i s p l a c e d  f o r the  -  separate  request  appropriate  limits  be  i s added t o  an  operations already  Here t h i s  exceeded?  the  day.  w i t h i n s i x weeks, t h e are checked.  from  one  added,  would  I f t h e r e i s room,  the  109  YES  NO  f FIND NE XT DAY PHYSICIAN IS BOOKED  FIND NEXT DAY PHYSICIAN IS BOOKED  1  DETERMINE DESIRED DELAY  ADD 1 WEEK  ADD, FOR DATE TO TRY  1  NO  YES  ADD 1 WEEK  " " V* •  TRY THAT DATE  Fig.  8.2  Flowchart  for first  desired  surgery  date  F i g . 8.3 Flowchart the s l a t e  for placing  schedulable  surgical  patients  on  111  patient  i s added t h e r e .  fee f o u n d  schedule  two  i t one  weeks  week  the  from  allow  the  trying  again.  admitted  than  model  semi-urgent,  t h a t an  new  i t  admission  to  proper  a  room  as  and  and  taken  out  the  date o r i g i n a l l y  obtained  Once  is  successful  a  are  day  surgery  or  a  would before to  be  i s being  the  physician  reguested  d a t e . , The  come a s k i n g  specifically  considered  I f i t cannot possible  be  to  desire  f i t into  date  is  the  found,  first  day  weeks,  above.  file.  before t r y i n g  and  supposed  p a t i e n t i s added t o t h e  admission  obtained  date,  first,  i f a request  were bumped must be removed of  physician.  I f t h e r e a r e none w i t h i n two as  but i s  patients.,  is  the e a r l i e s t  time.  same  because  d i d not  possible.  p h y s i c i a n . , The  top-priority,  "urgent"  o r more weeks away  who  to  beyond  a week i s added  patients  model i t i s  which  date  an e l e c t i v e  time,  t o bump h i s own  t h i s r e q u e s t bumps a n o t h e r , Patients  attempt  I f t h e r e i s none w h i c h  and  long-term  request  w i t h enough s p a c e  an  the  weeks., As a r e s u l t ,  soon  of  bump  d e s i r e d day.  physician's slot,  regardless  try  p a r t o f the with  as  really  will  two  two  be  request f o r a  which i s not  patient  urgent  will  requests of  model o n l y a l l o w s him  admission  urgent  Note t h a t u r g e n t  in this  An  there  non-urgent  the  within  submitted  for  must  later.  away i s one  more i m p o r t a n t  handled  request,  i s considered  Hence,  date  as f o l l o w s . ,  For a non-urgent  It  I f t h e r e i s no room, a l a t e r  for  from  the  A week i s added  slates to  the  these r e q u e s t s ,  the  again. any  of  hence, a d m i s s i o n  date  is  marked.  112  The  r e q u e s t i s added t o t h e s l a t e and  8.2.4  M e d i c a l Heguest  A  Medical  admission.  8.2.5  Surgical  Once a day, released  from  Figure  8.4.  These  are  that  the  surgical  Bed" be  will  treated  extra  originally OR,  i t  initiate  more begins  two  on  weekend,  a  to  those  category l e v e l  t o be t r i e d  as  d a y s from  they  are  admitted,  the  available. i s reset  so  reguests.  week l a t e r .  there in  and  and  The  for  begins  with  were  demands on  For  the to  operations.  the next  or i f t h a t the  hospital  being admitted  In-hospital  must be s c h e d u l e d .  another  the  in-r h o s p i t a l  set  him).  is  f o r which they  patients  the present time,  checking  as shown i n  urgent  one  are  date i s found.  emergency  using  date  no room  high-priority  use  generated  warrants  complex,  find  In order t o represent these  for  are  that  proceeds  p r o p o r t i o n of the p a t i e n t s  decided  p a t i e n t ' s LOS  who  for  operations - besides that  demands  Emergencies  as  o n c e a new  admitted.  was  Admission  Their  the s l a t e  patients  A certain  have  admissions  patients.  category i s restored the  added t o t h e queue o f  s h o u l d be a d m i t t e d  They a r e removed from  process.  simply  Admissions  Some who  they w i l l  For  is  t h e w a i t i n g queue.  "No  file.  Handlinq  request  awaiting  to the admission  day  ( i f the  requests  are  them, c h e c k i n g day  following  would  be  Monday).  113  NO  NO BED! YES TAKE OFF SLATE SCHEDULE FOR NEXT DAY CLASSIFY AS  NO  IF  URGENT  1  YES  ENTER BED  ADD 1 WEEK  I  TRY 2 DAYS  TO ATTEMPTED  HENCE  OPERATION DATE  ARRANGE DISCHARGE  r  TIME DETERMINE  GO TRY  (AS F I G .  8.3]  PHYSICIAN THEN  WHEN RE-SCHEDULED, RESTORE CATEGORY  YES  ADD TO SLATE ADD  1  OPERATING  DAY  YES  MAKE IT AN EMERGENCY OPERATION  Fig.  8.4  Flowchart  for admitting  surgical  patients  114  Having  decided  the  d a t e , the  identified.,  One  go  until  on  looking  only is  enouqh t i m e .  found, the  still  be  patient the  will  one  is.  The  patient  i n the  Note  within  taken care  check  hospital  be  slate.  Now,  now  {Recall  already  remaining  of.  He  i s put  must  be  i s possible,  or  "possible" a bed)..  that  the  this  operation  in-hospital  weeks, i t i s c h a n g e d  the  gathered.  an  date  has  sure  h o s p i t a l , the i f  operates then  that  (or e l s e i g n o r e s  that  two  who  whether t h e  model c h e c k s t o be  i n the  scheduled  are  may  physician  request). is  scheduled  on  request  cannot  t o emergency  i n a bed  and  appropriate  LOS,  entering  he  is  will the  an  his  date  If  for  to  Once a  patient  details  According  requires  be  handling.  patient  are  statistics  scheduled  for  discharge.,  8.2.6  Medical  Each from  the  length  day,  a  when t h e  waiting  of the  space,  decision  extra  admitted. The statistics for  made  are  gathered.  Medical  D e p e n d i n g on  concerning  allowed  patients  are  According  how  if  the  many b e d s t o  the  waiting  put  i n Section in  to their  of  allow  line  is  less  are  7.2.),  beds and LOS,  the  amount  i n ; i f i t i s short,  i s discussed  patients  admit  number o f b e d s a v a i l a b l e and  Furthermore,  algorithm  admitted  discharge.  is  patients  the  to  determined.  to take.  (The  are  time comes  line,  gueue a r e  these patients long,  Admissions  appropriate  they are  filed  115  8.2.7  Emergency  Figure  8.5  d e p i c t s emergency  Note t h a t  both  identically., DO  other  arrivals  p r o c e s s i n g i s not  sequencing. discharges wait As  emergency  are  The and  with  day  DO  patients  possible.  Morning  after  regular  the o t h e r  unit,  day-shift  claim  scheduled  and  to  affect  beds  after  admissions.  The  admissions.  p a t i e n t s admitted,  a r r i v a l s c a u s e emergency These emergencies,  before  to  handled  time  (by p r o p o r t i o n s )  morning ones a r e a l l o w e d but  are  i s t r e a t e d as one  differentiated  transfers,  until  admissions. and  Since the e n t i r e  proper  rest  Admissions  and  in-hospital  however, a r e c o n s i d e r e d  a proportion of operation  these  reguests.  t o happen on  the  same  day. If  a  would  not  bed  and  permitted also).  bed  i s a v a i l a b l e i n the  e x c e e d an on  the  t o an  Any  their  that area  to stay  area. are  file.  file.  Other  day.  for  the  patient in  the  admission  is  restrictions  there  placed i n s u r g i c a l  Section  8.2.8  beds  regarding  in surgical  beds  are  number o f b e d s a r e s t i l l  free  in  the p a t i e n t s placed  to stay there.  (and  Otherwise,  must be (See  area  p a t i e n t i s put  p a t i e n t s placed  i f a specified  next  the  (except  p a t i e n t s who  A proportion of  allowed  t r a n s f e r s the  discharge  a special  transfers.)  allowed  limit)  a l t e r n a t e area  Medical  a r e a l s o p u t on  allowable  proper  The  rest  are  i n the filed  overflow to  cause  NO ARRANGE PRIORITY & BED LIMITS FOR AFTER SCHEDULED ADMISSIONS  JUL  YES  — \  •  r  ARRANGE PRIORITY & BED LIMITS FOR BEFORE SCHEDULED ADMISSIONS MEDICAL ?  GENERATE EMERGENCY & IN-HOSPITAL OPERATIONS SIMILARLY TO FIG, 8.4  YES  . YES >  PLACE IN OWN AREA DETERMINE NEXT ALTERNATE AREA  >  SCHEDULE FOR DISCHARGE  STAY IN EMERGENCY UNIT  ML.  <  ARRANGE TRANSFER NEXT MORNING  Fig.  8.5  Flowchart  f o r emergency  admissions  117  8.2.8  In-Hospital Transfers  These  happen  transferring morning".  right  p a t i e n t s get f i r s t The  s u r g i c a l areas  a r e enough beds f r e e patients. of  If  the a r e a s  patients  proper  to  not,  to  to  area, they  after  are  excessive  transferred,  taken  from t h e  on  assuring  released  are checked t o see admission  beds  "each  whether  slated  there  surgical  p a t i e n t s are t r a n s f e r r e d out  "No i f  of  that  Bed"  cancellations.  For  t h e r e are beds i n the  off-service  area  and  placed  proper i n the  s e r v i c e area.  8.2.9  Discharges  This  is  the p a t i e n t s  the  first  change a f f e c t i n g  scheduled  to  leave  appropriate records are  kept.  8.2.10  Data  Operating  Note scheduled due  to  that,  Room  as  i s the  far  violation  independent,  of t h i s  an  as  explained i n Section All be  of the operated  as  today  assumption  specific  study.)  are  discharged,  the  operated.  warrants  (Any  and  Turnaround  length of  can  time  All and  time  problem  be  covered  i s included  7.2,  d a y ' s emergency on  c e n s u s e a c h day.  o p e r a t i o n s go,  a c t u a l l e n g t h of time  by  to  claim  enough M e d i c a l  avoid  be  allow  discharges,  and  regularly  scheduled  are r e l e a s e d f o r processing.  For  patients emergency  118  operations  and  t o t a l t i m e s and  for  each  service's  p a t i e n t s are  scheduled  accumulated  and  operations,  tabulated  each  the day.  119  CHAPTER 9  IIALJJftTION  This  chapter  OF THE SIMULATION MODEL  discusses t h e "behaviour"  simulation  model.  The  simulation  program  is  explanation  of the v e r i f i c a t i o n  Verification as  the modeller Validation  provides  i s  the  explained.  i s  This  and v a l i d a t i o n  process  which  representation  by  followed  the  by  an  o f t h e model: internally  tests  that  t h e model  of r e a l i t y .  1967)  simulation  the  run  in  set of s t a t i s t i c a l  model.  If  the  GPSS  automatically  results  the format of  waiting  instance),  times,  print-out.„  The l a n g u a g e a l s o  "transaction"  (normally  specified  monitoring  for  be  arrange  voluminous,  f o r GPSS  available information. results  which  are  print  by  the  freguency  the  be i n c l u d e d  on any s p e c i f i e d As t h e  i n the  tables  monitoring  output  a  behaviour  any m a t r i c e s  will  (of  i n the  of  each  file  or a t  from  such  In a d d i t i o n , i t i s p o s s i b l e out  The f o l l o w i n g  provided  generates  i t t e n d s t o be u s e f u l o n l y f o r  purposes.  to  any  allows  a patient)  debugging o r v e r i f i c a t i o n  uses  they  l o c a t i o n i n t h e model.  may  describing  programmer  program, o r s p e c i f i e s  to  i s  given  a c h e c k t h a t t h e model b e h a v e s  the  a reasonable  "standard"  any  results  Form o f t h e R e s u l t s  A  of  of  Paul's  intends.  .{Fishman and K i v i a t ,  9.1  form  of the S t .  GPSS  any  subset  discussion without  of the t o t a l includes a l l  needing  t o be  120  specified. First  i t  cumulative total  time).  preceding allows  time  a run  To  that s e v e r a l of the  (cumulative  sums  i s l o n g , the e f f e c t  i s weighted  ones.  noted  less  and  avoid t h i s ,  less  due  items  divided o f the  to  by  most  the  time  intervals  the  recent  effect  a "RESET" between "START"  individual  are  t o be  of  blocks  generated  displayed.  waiting  averages p r i n t e d with times  particular  o r LOS  process  e l s e w h e r e may  being  be s l i g h t l y  then.  time  b i a s e d due  i n the  interval,  of the time  The  have c o m p l e t e d  the  the  by  i f any  as  averages  since the  i f p a t i e n t s are and  of  fact  divide  interval  those  to the  process  and  such  p a t i e n t s who  monitored.  Inaccuracies result  start  the " t a b l e s "  represent  p a t i e n t - d a y s spent  current  the  If  i n f o r m a t i o n on  All  all  be  averages over  time i n t e r v a l  and  should  t h a t they start  elapsed  being are  being  of p r i n t - o u t . , Schribner's text Simulation  (1974)  and  GPSS  manual  point  out  count  of  time  the since  processed  the time  the  listed  at  processed  these  at  Jsins  GPSS  biases  more  completely. The  first  counts".  Each  items  p r i n t e d i n the  functional GPSS  statement  (as  statement)  in  numbered on  assembly - t h e r e i s a count  number o f t i m e s for carefully  i t was  time  used.,  f o l l o w i n g the  are included i n t h i s Any  i s a "block".  standard  opposed  are  to  through  which i s  o f t h e c u r r e n t and counts the  are  "block  "comment"  For each " b l o c k " -  Since these  flow  output  total  u s e f u l only  model, no  examples  description.,  a "transaction" (patient)  must  be  filed  for  a  121  period  o f time before  being  used a g a i n ,  p l a c e t h e t r a n s a c t i o n on a  "user  "user  (see  chain"  counts.  SLEW1-6  patients for  information are  slated  the v a r i o u s  operations  week,  cycling  as  away.  weeks i d e n t i f y when  probably  average  Table six  and  how  and  total  validation. which  those  number  is  number w a i t i n g  the  chain  EMSGC p r o v i d e s in line  for and  experiments. i n line  and  The guite area  This  identifies  useful.  same the  critical  of  on  I t gives  (1=Medicine,  due t o  six  weeks  information current,  maximum,  (probably  as  i s useful for  patients  MALTn  for  f o r surgery,  s e t of values  Medical  similar  concerns awaiting  o f l i t t l e use) identifies  bed a r e a s ,  the  where n=3 f o r  The a v e r a g e numbers may be u s e f u l  identifies  the  2=overflow,  patients  DISCH  t o be  "storages"  details  other  total  a l l o f whom a r e on f i l e information  beyond  information  patients i n surgical  XFERC  EENT  columns  SLEEN g i v e s  f o r admission  t o be t r a n s f e r r e d back.  MALT3-U)  hospital,  the  information  EENT and n=4 f o r O r t h o p e d i c s .  of  (The number f o r t h e  8.1.)  f o r emergency s u r g e r y .  of Medical  chains  n o t be t h e f i r s t ,  identifies  A s i m i l a r and v e r y  admission. on  may  give  w e l l as t h e average time waited.  ADMMC,  one-week  the "block"  many p a t i e n t s a r e w a i t i n g f o r  Section  p a t i e n t s . , ADMSC  print-out,  X), follows  a r e scheduled.  SLOEN  the  The " c u r r e n t c o n t e n t s "  the l a r g e s t , in  In  on EENT p a t i e n t s t o be s c h e d u l e d  SL0W1-6  Orthopedic  they  explained  information  the  chain".  f o r operations.  and  present  for  i t i s most e f f i c i e n t t o  off-service  (together  with  XFERC  number o f p a t i e n t s i n t h e discharged. (bed  pools,  on t h e u t i l i z a t i o n 3=EENT,  Table of  XI) i s  each  4=0rthopedics).  bed The  TABLE * * * * * * * * * * *  X  ti  * *  * *  USER CHAINS  * ** ** *  USER  CHAIN  SIEW1 SLEW2 SLEW3 SLEW* SLEWS SLEW6 SLEEM SLOWl SLOW2 SLOW3 S10W4SLOW 5 SL0W6 SLOEN AOMSC ADMMC DISCH  EMRGC  XFERC MALT 3 MALT 4  TOTAL ENTR IE S 40 35 30 2 9  23 I1 6  36 24 20 21 16 V 5 5 2 84 124 909 34 16 61 3a  AVERAGE TIME/TRANS 4 .875 10.085 12.000 15.137' 12. 739 6.454 11.833 5.472 10.500 13.349 11.047 15.937 7.599 5.599 10.193 5.354 8. 102 .500 1.000 3.803 8.578  * ********************************  CURRENT CONTENTS 9 6 2 2 23 11 14  s I 16 15 104 24 249  17 5  AVERAGE CONTENTS 6. 964 12.607 12.857 15.678 10.464 2.535 2. 535 7.035 9. 000 9.53 5 8.285 9. 107 4.071 .999 103.392 23.714 263.035 .607 .571 8.285 11.642  MAXIMUM CONTENTS 29 29 28 27 23 1 1 5 21 18 18 18 16 1 5 3 137 34 279 6 17 21  ****************************************  TABLE  STORAGE  *  XI  AVERAGE CONTENTS 164.321 9.000 32.250 71 . 7 5 0  165 100 35 75  ENTRIES  WMEDU WM E D S WMEOE WE E N U WEENS WEENE WORPU WORPS UORPE LOSME LOSMM LOSMF LOSEE 10SEM LOSEF 10SOR LOSOM LOSOF MI N2 MIN3 MI N't E IN2 E IN4  01 N2 01 Hi •AVERAGE  AVERAGE TIME/UNIT 8.747 7.200 4 . 3 00 9.476  526 35 210 212  -AVERAGE TOTAL TIME .995 .090 .921 .956  *  UTILIZATION DURINGAVAIL. UNAVAIL. CURRENT TIME TIME STATUS  *  TABLE X I I  OUEUE  STORAGES  * » »»»*•***********<**«»*********«*****»**»  CAPACITY  1 2 3 4  *  *  QUEUES  *  AVERAGE CONTENTS l l .071 4 . 107 9.178 1.321 .678 66.357 . 392 8.964 40.428 187.250 101.857 85.392  3  2 7 1 TIME/TRANS  =  TOTAL ENTRI ES 65  ZERO ENTRIES  22 50 4 3 183 I 23 109  620 326 294 145 22.857 11.321 72 11.535 73 67.214 192 32.571 97 34.642 95 22 7.500 9.964 68 5.464 27 . 392 4 .285 3 1.107 9 . 107 3 AVERAGE TIME/TRANS  CURRENT CONTENTS 165 10 35 67  MAXIMUM CONTENTS 165 16 35 75  *  *  MAX I MUM CONTENTS IS 8 15 3 2 88 1 12 50 199 114 99 33 24 18 7B 38 43 12 18 14  PERCENT AVAILABILITY 100.0 100»0 100.0 100.0  1  EXCLUDING  PERCENT ZEROS .0 .0 .0 .0 .0 .5 .0 .0 .0 .0 .0 .0 .0 .0 .0 .0 .0 .0 .0 .0 .0 .0 .0 .0 .0 ZERO ENTRIES  AVERAGE TIME/TRANS 4.769 5.227 5.139 9 . 2 50 6.333 10.153 11.000 10.913 10.385 8.456 8.748 8.132 4.413 4 . 4 02 4.424 9.802 9.402 10.210 9.545 4.102 5.666 2.750 2.666 3.444 1.000  *  *  SAVERAGE T I M E / TRANS 4.769 5.227 5.139 9.250 6.333 10.208 11.000 10.913 10.385 8.456 8 .748 8 . 132 4.413 4.402 4.424 9.802 9.402 10.210 9.545 4.102 5.666 2.750 2.666 3.444 1.000  TABLE NUMBER 7 8 9 10 11 12 13 14 15 16  17  18  CURRENT CONTENTS 12 3 14 1 I 83 7 50 186 105 81 24 16 8 67 33 34 5 1 1 5  5  CO  124  "average  utilization  variable. with  "Average  off-service  day-to-day The "user  contents"  usage.  gueue  semi-urgent Orthopedic  Those  output and  LOS  by  gueues  area  3 - EENT b e d s ) . average  The  useful  when compared  is  useful  for  that  for  Information  Of t h e s e  each may  experimentation.  on  may  the  At a  glance,  for  urgent,  EENT  be  found  the  average  and  ,WOSPU,  (LOSME,  LOS EE,  (LOSMM, LOSMF, numbers i n  the  Also, a quantification f o r each  service  of  there  averages  in  each  area  and  (see T a b l e  XIII  be i n f o r m a t i v e .  mean and  i s identical  standard  distribution  for  waits  "Table  (eg., MIN3 means M e d i c a l s i n  "tables"  "table" be  under  Medical,  Finally,  off-service.  freguency  entry  w i t h i n each s e r v i c e  appears.  Their  to  WMEDS, HMEDE, WEENU, ...  disposition.  of a l l the  what  an  of  in giving  off-service  format  unbiased.  bed  of those  examples).  identify  most  is similar  having  patients  by sex sex,  by sex  are  for  contents"  information  (BMEDU,  suggests  difference  The  the  interesting  f o r e a c h s e r v i c e may  picture  hospital,  overall  be  is  described in a table.  elective  patients  The  queues  gives  LOSOR), as w e l l a s LOS  LOS  may  ( T a b l e XII)  more c o m p l e t e l y  Overall  ...).  time"  "Current  queue i n f o r m a t i o n  chains".  ...).  total  examination.  Number" a r e the  during  deviation figures  t a b l e s may  shows, see  the  verification,  be  list  are  of use.  To  i n Table  XIV.  validation,  or  TABLE  XIII  OUTPUT TABLES  TABLE ORPSN ENTRIES IN T A B L E 20  MEAN  OBSERVED FREQUENCY 0 1 3 1  0 I 2  3 4 5  6 FREQUENCIES  TA8LE ORPST ENTRIES 1 TABLE 20  PER CENT OF  TABLE ENTRIES  MEAN  ARGUMENT 289.500  OBSERVED FREQUENCY 0 0 120 3 180 2 240 1 300 2 360 6 420 6 F R E O U E N C I E S A R E A L L ZERO  WTUl IN T A B L E 50 UPPER LIMIT 0  TOTAL .00 4.99 14.99 4 . 99 50.00 19.99 4 . 99  10 4 1 A R E A L L ZERO  UPPER LIMIT 0 60  REMAINING  MEAN  PER  29.99  ARGUMENT 6. 03 9  OBSERVED FREQUENCY  .00 .00  TABLE ENTRIES  WTS1 IN T A B L E 11  REMAINING  TABLE ENTRIES  FREQUENCIES  7.99  28  55.99  MEAN  ARGUMENT 5. 909  OBSERVED FREQUENCY  PER CENT OF T O T A L  0 2 4  0  .00 .00  6 8 FREQUENCIES  UPPER LIMIT 0  0 3  27.27  2 6  18.18 54.54  10 FREUUENCIES  24.9 74.9  94.9 100.0  DEVIATION 115.000  CUMULATIVE PERCENTAGE  .0  .0 14.9 24.9 29.9 39.9 69.9  MEAN  ARGUMENT  OBSERVED FREQUENCY  18 21 ARE A L L ZERO  PER CENT OF T O T A L  SUM  C U M U L A T I VE REMAINDER  6.52 3 9 . 13 45.65 8.69  91.3 100.0  6.5 45.6  ARGUMENTS  72.7 54.5  .0  CUMULATIVE REMAINDER 100.0 100.0 93.4 54.3 8.6 .0  OF  SUM  OF  DEVIATION FROM MEAN -5.769 -3.859 -1.948 -.038 1.8/2  ARGUMENTS 65.000  MULTIPLE OF MEAN -.000 .338 .676 1.015 1.353  100.0 100.0  DEVIATION 1.371  CUMULATIVE PERCENTAGE .0 .0  OF  MULTIPLE OF M E A N -.000 .331 .662 .993 1.324  92.0 36.0 .0  27.2 45.4 100.0  . 00 .00  .621  .829 1.036 1.243 1.450  OEVIATION FROM MEAN -2.517 -1.995 -1.473 -.952 -.430 .091 .613 1.134  302.000  DEVIATION 1.511  .0 .0  .207 .414  SUM  DEVIATION FROM MEAN -3.06 8 -2.261 -1.453 -.646 . 161 .969 1.776  ARGUMENTS 5 7 9 0 . 000  -.000  l oo.o  100.0  ARGUMENTS 76.000  MULTIPLE OF MEAN  CUMULATIVE REMAINDER 100.0  7.9 63.9  CUMULATIVE PERCENTAGE  OF  85.0 75.0 70.0 60.0 30.0 .0  DEVIATION 1.046  .0 .0  STANDARD  6.739  SUM  100.0  100.0  CUMULATIVE PERCENTAGE  OF  MULTIPLE OF MEAN -.000 .263 .526 .789 1.052 1.315 1.578  CUMULATIVE REMAINDER 100.0  A R E A L L ZERO  2 4  6 8  4.9  STANDARD  UPPER LIMIT  WTEl IN T A B L E 46  REMAINING  35.99  18 ARE A L L ZERO  SUM  CUMULATIVE REMAINDER 100.0 95.0 80.0 75.0 25.0 5.0 .0  19.9  STANDARD  PER C E N T OF T O T A L  4  REMAINING  CENT TOTAL .00 .00 14.99 9.99 4.99 9.99 2 9 . 99  DEVIATION 1.238  CUMULATIVE PERCENTAGE .0  STANDARD  OF  2 6  STANDARD  3.799  UPPER LIMIT  REMAINING  ARGUMENT .  DEVIATION FROM MEAN -3.908 -2.585 -1.262 .060 1.383  ARGUMENTS 310.000  MULTIPLE OF MEAN -.000 .296 .593 .890 1. 1 8 7  1.483  DEVIATION FROM MEAN -4.915 -3.456 -1.997 -.539 .919 2 . 378  126  TABLE XIV MODEL OUTPUT TABLES  Name  LIST  Pu rjsose  EENSN  Number o f EENT p a t i e n t s  EENST  Total  OBPSN  Number o f O r t h o p e d i c p a t i e n t s  ORPST  Total  HTU1  Medical urgent patients*  WTS1  Medical semi-urgent  WTE1  Medical e l e c t i v e p a t i e n t s '  WTU3  EENT u r g e n t p a t i e n t s '  ITS3  EENT s e m i - u r g e n t  WTE3  EENT e l e c t i v e p a t i e n t s *  WTU4  Orthopedic urgent p a t i e n t s '  BTS4  Orthopedic semi-urgent  ITE4  Orthopedic e l e c t i v e patients'  STA1  LOS f o r M e d i c a l  STA3  LOS f o r EENT  STA4  LOS f o r O r t h o p e d i c  EMTBN  Number o f (combined)  EMTBT  Total  t i m e f o r EENT  slated  patients  each  s l a t e d each  waiting  patients'  weekday  s l a t e d each  weekday  time  waiting  waiting  waiting  weekday  s l a t e d each  time f o r O r t h o p e d i c p a t i e n t s  patients*  weekday  time  time  time  waiting  waiting  time  waiting  patients*  time  time  waiting  waiting  time  time  patients  patients patients patients  t i m e f o r (combined)  d a i l y f o r emergency s u r g e r y  patients  d a i l y f o r emergency  surgery EMGDU  Total  d a i l y number o f emergency and DU a r r i v a l s  NOBED  Total  daily cancellations  f o r "No Bed"  127  Following printed.  the  Most  tables,  of  these  However, t h e f o l l o w i n g  CftNCL =  Number who  the are  three  "halfword internal  may  be  c a n c e l l e d from  sarevalues"  and  not  too  are  helpful.  useful:  s u r g e r y due  to  a  very  long  Medical area,  since  this  wait. EhDIS  =  Number o f d i s c h a r g e s f r o m is  MEMBN =  not  identical  Number o f T h i s has  Several very follow  these.  service 0 / SO The  date  on  important  "halfword  There i s a matrix Rows 1-5  of  discharges.  DU's  the day-to-day  i n the  morning.  queue.  m a t r i c e s " , as i n T a b l e patient  correspond  El diagnostic categories.  Row  to  numbers  for  XV, each  t h e Emergent / DU  6 i s the  total  /  of  those.  date  should  c o l u m n s a r e as f o l l o w s : 1.  Patients  qenerated,  2.  Patients  admitted,  3.,  Patients requesting a particular  4.  Patients getting  5.  Patients placed  6.  P a t i e n t s returned to the  Note t h a t t h e be  patients'  e m e r g e n c i e s and  impact  implemented. /  to Medical  Medical an  the  lower  in  should  Two  date,  off-service, proper  number o f p a t i e n t s g e t t i n g the  i s entirely  a date  that  model t h a n  random and  know when he  more t y p e s  of  date,  service  a reguested  in reality,  in reality has  matrices  free are  area.  the  since i n the physician  model  the  requesting  time. printed,  but  have  not  been  TABLE  HALFWORO  HALFWORO  MATRIX  I  1863 472 333 117 321 3106  MATRIX  3  4  5  6  HALFWORO  MATRIX  ROW/COLUMN  1863 472 328 116 316 3095  0 0 0  2  3  92 24 21 26 701 864  92 24 21 28 689 854  0 0 10 27 478 515  0 0 7 20 449 476  29 6 0 0 0 35  .  4  5  2  3  4  5  0  0  0  0  46 12  80  6 65  0  96 184  147  ORPNO 1  1  333  333  115  3 4.  9 87 389 933  115 9 91 389 937  5  557 145 0 0 0 702  1  2  6  0 0 0  EENNO-  ROW/COLUMN 1 2  MATRICES  MEONO  ROW/COLUHN  HALFWORO  XV  8  76  0  0 58  129  shown  in  first  the  figures  of these  are the  as t h e i r slate  use  matrices  They a r e e x p l a i n e d i n S e c t i o n 8.1. allowable alternate areas. of  the  patient.  areas. column  That 1.  The  The  The  columns correspond  implementation  One  concern  accuracy  p r o v i d e s an  were  system  algorithm  to  to  the  of  service  alternative  column  2,  then  i s f o r overflow.  been  worked a s on  for eight identical  uses  such  way  "0"  that  "random" e l e m e n t s i s  h e n c e number and  built-in  For  used.  GPSS  generators.  i n which a p r o p o r t i o n o f the  others,  rest  another,  the  c h o i c e of a  The  generators  discretion.  i n such  t h a t the sequence of p a t i e n t s  their'  1  1.  model  programmer's a way  characteristics, runs.  however, have been a s s i g n e d generator  as those  the  intended.  i n t h e model and  generator  aligned and  one  consecutive experimental  in-hospital  ensure  s i m u l a t i o n based  procedures,  i s a t the  generated,  since  then  services.  i s a matrix  o f t h e pseudo-random number g e n e r a t o r s  certain  generator have  item  The  overnight".  performed  i n any  patients are routed the  surgical  to allowable  first,  behaved i n a c o n s i s t e n t manner and  For  internal.  Verification  Several tests  the  last  a r e a "2"  means " s t a y i n t h e emergency u n i t  9.2  f o r the  rows c o r r e s p o n d  o f column 3 i s t r i e d  In t h i s  is primarily  to  The  can  1.  determines  (This the  s e q u e n c e , o f p a t i e n t s demanding  operations  -  which  duplicated  in  length-of-surgery functions,  generator  necessarily  be  require  was  done  p r o p o r t i o n , and emerqency  and  lenqths-of-surgery.)  130  Also,  generator  operations. alter  the  1 c o n t r o l s the  As  a  construction  Several  tests  generated  " f i t " a  interval.  The  c h e c k e d , as the  proportions The  particular  sample.  0.  value  (e.g.  proportion  of  patients  -  of  check that  distribution  of  patients  in  the  surgical  tested.  tending  for  i n each  also  dates  for  model  will  the on  numbers the  to  22,000  transferring  different patients  Each get  was  diagnostic  acceptably  closer  c a t e g o r y was  and  requesting  the  "immediate" Medical  diagnostic  was  close  larger patients,  accurate  a  to  to the the  within  2%.)  The done,  random number s e e d s were c h a n g e d  to  different the  test  the  repeatability  of  the  pseudo-random number s t r e a m s .  results  for  one  four-year  and  long  processes  Figures  run  runs  9.1  (after  t o 9.6  one  each t h r e e  to  a  with p r i n t - o u t s each f o u r  show  o n e - y e a r run  (These f i g u r e s , which a r e chapter,  may  be  found  referred  at the  end  i s a c t u a l l y a c l o s e r look  during  which  the  to of  a t the  the  chapter.)  third  of  a v e r a g e and  there  were  output  variables.  The  graphic  i n model p e r f o r m a n c e  no  extreme results  variables.  Figures  times  the  number o f o f f - s e r v i c e M e d i c a l  near the  variances  several  show  year  with p r i n t - o u t s  9.12  months.  were  despite  initialization)  run  0-1  "morning d a y - s h i f t " emergencies  proportion  was  change i n the  to  flat  the  proportion  date  intended  performed  of  requested  slates.  uniformly  proportion  of  a l m o s t any  of the  were  w e l l as  categories.  the  result,  pattern  The four  of 9.7  weeks.  in  this  one-year years,  placements  was  fluctuations  in  show  Other  the  typical  runs  yielded  131  similar in  results.  Section  9.3,  demonstrate that The  assignment  for  present  purpose  the  appears results  random  that,  number  instead  generators  o f being  aligned  were  also  by s e r v i c e , t h e  was s h u f f l e d )  to test  any  c o r r e l a t i o n i n t h e s t r e a m s d e p e n d e n t on a p a r t i c u l a r T h e r e was no n o t i c e a b l e  d i f f e r e n c e i n the  range  of  variables.  To  check both  separate  test  mean r a t e s  was  t h e g e n e r a t o r and t h e f u n c t i o n done on t h e M e d i c a l  were w i t h i n  distribution For  verification  being  development o f the s l a t e . slated  each  specified In  properly  As i n t e n d e d ,  observed  These v a l u e s "patients  showed  of the  as  constant  the waiting considerably.  on  queues and numbers This  s o u r c e s o f v a r i a t i o n h a d been of  patients  value  r a t e s and  near t h e o r i g i n a l  intended  the  time).  the  g e n e r a t e d " columns o f t h e " p a t i e n t  addition,  stabilized  up  values  during  that  t h e t o t a l amount o f t i m e  (plus turnaround  by c o n s t a n t  The  freguency  demonstrated  another run, t h e d i s t r i b u t i o n s of a r r i v a l  replaced  LOS  the  a  length-of-surgery  This  day was an i n t e g r a l m u l t i p l e  per procedure  functions.  and  the  by a c o n s t a n t .  were  specified,  s p e c i f i e d by t h e f u n c t i o n .  purposes  was r e p l a c e d  t i m e and bed l i m i t s  arrival  1% o f t h o s e d e s i r e d ,  s u i t a b l y matched t h a t  distribution  In  the  of generators to functions  generator.  were  of the i n d i v i d u a l items  t h e model i s s t a b l e .  (so  of  output  but  different  reallocated  chance  A discussion  mean  LOS  values.  tables  numbers  LOS  and  matrices".  placed  off-service  was e x p e c t e d , s i n c e  t h e two main  removed.  i n t h e model depended f i r s t  on s e x , which  132  was used t o d e t e r m i n e t h e age g r o u p , determine  the  distribution year  LOS.  within  5%  patients).  simulated)  the  magnitude  this  matched t h e e m p i r i c a l  averages  Pediatric  Despite  as  of  For  the  data  sets  so  was  complication, guite  used  well,  data  are  with  short-term  one  t o remove  (empirical  of  to  the o v e r a l l  (as m o d i f i e d  of  deviations  means,  i n turn  originals  both  standard  which  about  the  averages  and same  fluctuate  considerably. The  average l e n g t h  seems t o be a b o u t  of  surgery  generated  4-7% low compared t o e m p i r i c a l  the surgery d u r a t i o n  i n t h e model i s a l s o b a s e d  which  according  are  divided  from l a r g e s a m p l e s . relatively  small.  and s i m u l a t e d proportions is  the  As a r e s u l t ,  results  might  of patients  of e m p i r i c a l  In a d d i t i o n , Medical  Depending  to sex.  i n the d i f f e r e n t simulation  are defined sample  is  observations  to the  different  values are well  idea  within  were  carried  through  o u t f o r two four-rweek  periods.  patients  number  of  "morning"  emergencies,  could  verified.  off-service  groups  groups  flow  of  could  age  age g r o u p s . .. T h i s  examinations of  number  emergencies  on  However,  averages o f the groups.  day-to-day  area  data.  validation  w e l l be a t t r i b u t e d  that  simulation,  d i f f e r e n c e s between  on t h e number o f beds l e f t  admissions  These  The l e n g t h - o f - s u r g e r y  s u p p o r t e d by t h e f a c t  t h e range  by  returning  be be  placements.  checked  the  from t h e n i g h t  from  before,  o f f - s e r v i c e beds, the  Then against  number  of  the  and t h e  scheduled  t h e r e m a i n i n g number o f the  total  number  T h e model p e r f o r m s a s i n t e n d e d . ,  of  133  9.3  Validation  This  section  model t o be  a  potentially  ultimate question In  this  discusses  i s ; How  The  s e r v i c e s are data  used  length-of-surgery samples.  These  significant  scheduled shorter  may  The  has  came are  large  from  s i n c e then.  removal of the  in  and,  both  LOS  by  for further care  changed t h e system  12.1). .  data-sets  in  several  advent  the  number  of  handling  some o f  the  length-of-surgery  s e r v i c e and  the  improved  (outside of St.  somewhat.  significant  selected  Day  and  Pediatric  The  its  and  of  reducing  cases  LOS,  and  The  and  model.  rates,  though,  The  EENT,  i n the  the  reality?  or c a r e f u l l y  1974,  impact  altered  New  Medicine,  arrival  from  particularly  Section  the  determine  an  of placement  also be  all  had  cases,  handling  to  in-patient surgical  patterns.  only  tool.  model r e p r e s e n t  p r e s e n t l y implemented  data  has  for considering  administrative  w e l l does the  c h a n g e s have o c c u r r e d  Care surgery  reasons  useful  s e c t i o n , remember t h a t  Orthopedic  have  the  latter  effect  for a l l three  Paul's)  improvement  on  LOS  of these  (see  variables  would be d e s i r a b l e . Next, Medical model  consider  area, i t  discharges are  occupancy  averaged  three-month  were  utilization  i s very  about  average  u s u a l l y not  week-day  the  in  four  occupancy  is  with  years  h i g h . . The their  still  bed  - c l o s e to  99.5%, d r o p p i n g  extremely filled  high  of the  own  areas. 100%,,  below 99%  during EENT and  a  In In  Orthopedic  patients,  n e a r c a p a c i t y due  the  f o r only period  but to  the  one when  areas typical  off-service  134  patients.  In  purpose,  the  and  model, the  excess Medical  o c c u p a n c y a v e r a g e d a b o u t 92%  95%  i n the  Orthopedic  due  to  e f f e c t o f weekends and  in  the  the  actual  services,  Medical  area.  This i s  i n the  below  just  dropped  patients  one.  partially  (In  the  significantly was  low  served  due  this  EENT a r e a  capacity  hospital, off-service patients  not  utilization  patients  to  partially  the  come  fact  from  simulation,  and  that  several  s u r g i c a l area  when o f f - s e r v i c e p l a c e m e n t  due  to  extra  discharges  or  of  fewer  emergency a r r i v a l s . ) The  high  the  Medical  to  reguire  Section  area  of  length  several  causes the  attention.  As  i f the  gueue l e n g t h fluctuates  are  emergency p a t i e n t s , f a r beyond  and  line  is  getting  make an  they can  forcing  more  extra  relax or  off-service.  effort  a bit.  less  Actually,  Since  booking forms s p e c i f i c a l l y teachinq  residents  their  beds and  well  be  t o admit.  the In  how  long  o n e s who  waiting  such  list  half  they  most  the  (see  If  Office staff  will  may  be  If  beds".  it  effected  notice  by  admission Since  c o n t r o l o v e r who  or  is  admissions  Medical  Section  increased  physicians  the  that  there.  emergency  "teaching of  stay,  of  the  extreme  more p a t i e n t s .  Medical  request  respond to  addition,  no  Admitting  t o admit  the  exert  in left  h o s p i t a l , i t i s assumed  the  about  described  t h i s queue i s  T h e s e v a r i a t i o n s may  of  list  h o s p i t a l occupancy f a c t o r s ,  i n the  long,  waiting  result  c o n t r o l of  wildly.  apparent  Medical  the  f a c t o r s i n t e r a c t to c o n t r o l the  probably short  also  10.1 demonstrates,  fluctuations  the  capacity,  careful  independent queue  number o f M e d i c a l  the fills  5.2.5), they  may  decreased  pressure  the  of  length  the  135  queue  and  act accordingly i n t h e i r  a d v i c e to p o t e n t i a l  elective  admissions. One  further  t h e queue was file  box.  direct  determined  communication  urgent "at  the  between  ever  the  desk"  through  The  collection  waiting.  might  not  the  admitting  case,  have  as  expected  admitted.  to  In  variation  in  o n l y one those  three  observed will  third  the  weeks.  t o range  probably  the  cancel  is  and  A four-week t e s t  might  outsider  and  standard  deviation  three-week 28.7  number o f  weeks,  with  long-wait  cancelled  at t h e  start  five  and  of  had  waited  the  that,  of t h e  not,  in  say fact,  t h e model y i e l d e d which  i s highly  a  that  during  hospital maybe  queue 20%  "active" 23.2  had  slight  volume o f r e q u e s t s a p p e a r e d felt  the  of these  Furthermore,  a  revealed  be a t t r i b u t a b l e t o t h e f a c t  are on  a  p a t i e n t s who  26-36, some p o r t i o n -  members. 1.5  may  average It  from  three  been a d m i t t e d !  sample  of the  an  In  have  fact,  After  none had  a  (as l o n g a s a  observation  a large  over  ...  and  form  gueue a v e r a g e d  t h e r e were s e v e n t e e n  cancelled  by  particularly  by  follows.  three-week sample, week.,  the  admitted  physician  observed  t h e r e was  never  one  be  Also, f o r  1.4. , A l a t e r  Many o f t h e s e a r e been  be  l e n g t h of the  deviation of  In each  l e n g t h of  box.  patients. to  may  p o s s i b i l i t y that the  data appear  period  small standard  patient  u n t i l the p a t i e n t i s admitted  the f i l e  empirical  The  the number o f f o r m s i n  g e n e r a t i n g a form.  o f d a y s ) , and  looking  i s i n order.  counting  cases there i s a s l i g h t  couple  36  by  note  In some c a s e s a s c h e d u l e d  r e s i d e n t without  be  explanatory  gueue  average  acceptable.  The  136  three-month averages with set  80%  of the  of averages  graphed -9.9  four years  values l y i n g  and  waiting-time matter.  was  days,  patient attempt  of  those  and  the  the  of  proqrammable  FIFO  almost  priority  Medical  to f i l e  for  Medical  a  Medical  a b o u t 6.3  patient days  cross-section  Admitting  t o the  urgent  difference  w i t h one to  day  waits,  by  the  average  schedulable clerks  three-quarters instead  t h e o n l y use to  be  the  model has  patients.  model due  w a i t s a t any  an  a  distribution)  some w i t h two,  averaqe  some w i t h  actual  since the  (which was  not  Hence,  w a i t i n q time variations.  of A  would show some p a t i e n t s  w h a t e v e r t h e c u r r e n t maximum m i q h t be The  the  basically  Postponement  with s l i q h t  instant  made  in  t o a l a c k of a c c u r a t e data.  i n t h e model has  of  determine  distinquished  admitted,  is  semi-urgent  Thus,  was  the  and  category,  patient  could  Medical  days i n t h e one-year r u n ) .  is  Office  (over  patients).  (probably reasonable) of  9.7  patients  f o r a l l three  i n c r e a s e s the v a r i a n c e of the w a i t i n q time implemented i n the  which  are  and  each-dayIs forms. , Furthermore,  alqorithm  its  year  - 9.3  very s m a l l , but  the  waiting l i s t  o f p a t i e n t s to be  queue  for  identical  Although  a  i n which  selection  one  This  9.10.)  s a m p l e was  were t e a c h i n g  entire  the c a t e g o r y  no  was  and  sample showed no  admitted  sequence  for  23.4,  number.  ( F i g u r e s 9.1  distribution  data  to give higher  ordering of  The  categories.  categories,  average  t o t h e l e n g t h o f t h e M e d i c a l gueue,  another 5.2  averages  of this chapter.  v a r i a b l e shown i n F i g u r e s 9.4 The  themselves  w i t h i n f o u r of t h i s  the four-week  a t t h e end  relate  over  t h r e e , and  (no  list  more t h a n  has  a  s o on  up  fourteen  cross-section  137  spreading one  from  "urgent The  gueue. in  teaching  Deviations  be  The  five  months  {in the  case  of  patient" noticed)!  from  seems e v e n  reality  In  1974,  to f i v e  any  given  there  no  Day  procedures  per  the  was  day  1974  surgical  particularly  number o f weeks i n  to d i f f e r e n c e s i n the  scheduled  model o b s e r v e s  b e t t e r f o r the  i n the s i m u l a t i o n ,  patients slated  f o r EENT were a l l o w e d  now).  much, a s  attributable  practice.  seems t h a t up  t o as  situation  p a t t e r n of  a d v a n c e , may  nine  day  modelling  the  1976  one  1974  data  Care surgery, for  and  and i t  Orthopedics  and  {in c o n t r a s t t o f o u r and limits  and  patient  six  arrival  rates. Because of and  8,  the  averaqes  the s c h e d u l i n g  surgical  over  four  three-quarters two-thirds sampled the  of  of  stability.  As  queue years  these  this  value  range  the  of  not  themselves values  reasonable. examination  136  the  {96  EENT, 40  simulation's  suggested  As critical area which  number  i s the may  averaqed than  5.5  queue  sample  three-month  111.4,  with  away.  About  product  The  i s well  length  one  within  despite  number o f  its  weeks  distribution,  would  require  but a  of  away  appears thorough  rules.  by t h e t i m e s t r e a m of  Orthopedics)  f o r a given  accuracy  scheduling  suggested  The  above, t h e s i m u l a t i o n ' s d i s t r i b u t i o n  " f i t " the  Greater of  less  i n Chapters 7  queue i s made up o f EENT p a t i e n t s .  of  quite  explained  i s quite stable.  number o f p a t i e n t s s l a t e d  does  mechanism  Medical  p a t i e n t s t r a n s f e r r e d to  of s e v e r a l  f l u c t u a t e {Medical  s e q u e n c e o f F i g u r e 8.1,  interacting  discharges.  variables  Medical  area  the  the wrong  each  of  returnees.  138  m o r n i n g and Only  one  data  available level per  other emergencies, value,  the  (see Appendix  of  Medical  excellent.  variable  is  guite  years  is  graphed  1455!  at the  The  number  "No  to determine,  services  has  an  average  The  Nevertheless,  values  difficult  average  for  Beds"  since  per  was  31  placed  that  i t s average  ( F i g u r e s 9.5 for  EENT the  and  month.  this  variables over  one  four  year  are  9.11).  Orthopedics  daily  as h i g h a s  per  and  model's  off-service  suggests  This varied  month, b u t  i n 1976  the  f o u r y e a r s and  only  been r e c o r d e d .  o f 39  1460  line).  i s currently  to f l u c t u a t i o n s i n the  of t h i s chapter of  waiting  that at  simulation  sensitive  The  end  a r a t e of  The  i t s level.  the  I t suggests  admissions,  is  of  y e a r ' s t o t a l f o r 1976,  2.1).  year  which d e t e r m i n e  length  total  for  is  a l l  greatly  i n 1974,  with  twenty  in  day!  one  I t i s not c l e a r  whether  t h e improvement i s random o r a r e s u l t  of greater care i n p a t i e n t  placement  p r o p o r t i o n o f "No  and  identical may  are:  115  over  the  before  causing  The slated  9.12  t h e model.  to  of the  year  (at the  which  proper  Bed"  validation  surgery. 1974  1976  117!  and  the  area  (and  data  EENT and  rate). The  off-service  beds b e f o r e b e i n g  show "No  final for  per  transfers  take o f f - s e r v i c e and  the  f o u r y e a r s o f about  level  emergencies  9.6  If  to the p r o p o r t i o n of procedures,  expect  average  transfers.  The  Beds" i s  Orthopedics model has  constraints in p a t i e n t s may  level  to  which  other areas)  effect  fill  beds  morning  are allowed  placed  elsewhere.  was  number  an  to  Figures  numbers. item  used  For O r t h o p e d i c s , suggested  4.5.  the this  The  of  averaged  distribution  patients about 4 i n for  the  139  model  was c o r r e s p o n d i n g l y  day.  Heal  data  gave  6.7,  may  well  be  differences "composite  physician"  day  any  with  Particularly days  but  As very  urgent  on  a  small  attributable  to  sample.  block  patients  or  service,  booking to  fill  in-hospital  by his  patients.  f o r which e a c h  booked and t h e o t h e r  These  of  four  has o n l y o n e , t h i s  factor. t h e s e comments on v a l i d a t i o n  long-term. available,  Since  a  particularly complete  indicate, for  t h e model  simulation  variables  behaves  over  range of v a l i d a t i o n  and t h e a c c u r a c y o f d i f f e r e n t  data  i s  the i s not  not  well  nor i s the s e n s i t i v i t y o f t h e system t o t h e i r changes, I  do  not f e e l t h a t  in  terms such To  but  i n the Orthopedic  satisfactorily,  known,  F o r EENT t h e model gave 5.7 p e r  and n o t a l l o w i n g anyone e l s e  h a s two p h y s i c i a n s  may be a  low.  a quantification  o f the p r e c i s i o n  as " a c c u r a t e t o w i t h i n  summarize,  the r e s u l t s  variables,  incuding  interacting  forces,  some suggest  ..."  obtained  which that  are  would  o f the  be m e a n i n g f u l .  f o r a l l of the the  model  result  t h e model s t r u c t u r e  of  critical several  i s good.  140 Uoo-i  2  ui 108H  VO<«4  T  3 Z TIME lyecrs) F i g . 9.1 M e d i c a l " i m m e d i a t e " p a t i e n t s ( p e r 3 months) a s a function of time  T I M E  F i g . 9.3 of time  Medical area discharges  TIME  Ivje.^v-s ) 1  ( p e r 3 months) a s a  function  ( «.«.»•*) a  F i g . 9.4 A v e r a g e M e d i c a l queue l e n g t h f u n c t i o n o f time  ( o v e r 3 months) a s a  1 4 2  T I ME  ( y e.(x^s^  F i g . 9.5 M e d i c a l p a t i e n t s p l a c e d o f f - s e r v i c e ( p e r 3 m o n t h s ) a s a function of time 80n  F i g . 9.6 S u r g i c a l "No Bed" c a n c e l l a t i o n s f u n c t i o n o f time  ( p e r 3 months) as a  143  36<H  3oo4 o  F i g . 9.7 M e d i c a l "immediate" p a t i e n t s a f u n c t i o n o f time  ( p e r 4 weeks) a s  F i g . 9.8 Medical schedulable patient requests weeks) a s a f u n c t i o n o f t i m e  (per 4  144  F i g . 9.9 Medical area discharges f u n c t i o n of time 55-,  ( p e r 4 weeks) as a  F i g . 9.10 A v e r a g e M e d i c a l queue l e n g t h as a f u n c t i o n o f t i m e  ( o v e r 4 weeks)  145  o Ui co 16^  0  12  T  T I M E U « k s ) F i g . 9.12 S u r g i c a l "No Bed" c a n c e l l a t i o n s as a f u n c t i o n o f t i m e  ( p e r 4 weeks)  146  CHAPTEB 10  EXPERIMENTS  Several verified order  experiments  model.  to  These  demonstrate  used  result  some  included The  noted  system  In a d d i t i o n  appeared d u r i n g  earlier.  Unless  o f p a t i e n t s and in  deliberately  their  altered  the e x p e r i m e n t a l r e s u l t s  conclusions,  i t  would  might  model  admission  fluctuation  sensitive  determined  altered,  be  and  one is  then,  are  identical. of  patients  are w i t h i n the range In  order  advantageous preferably  the  been of the  to  draw  any  to  run  such  clear  that  four.  Strategy  t h e model,  i t became  i n t h e l e n g t h o f t h e M e d i c a l queue i s e x t r e m e l y  "tuning",  from  period  10.6), i t h a s  t o t h e a d m i s s i o n s t r a t e g y employed.  after  one-year  the sequence  10.5  y e a r s and  In the c o u r s e o f " t u n i n g "  model  the  lengths-of-stay  (Sections  e x p e r i m e n t s f o r a t l e a s t two  the  t h e model  of  o v e r t h e same  t h e e x p e r i m e n t s f o r which  has been  that  10.1  which  in  Paul's  to t h e s e experiments,  random v a r i a t i o n s i n t h e o r i g i n a l r u n . firm  i n the S t .  t h e development  e x p e r i m e n t s were t e s t e d  However, arriving  the changes  selected  and  i n t h i s c h a p t e r because of i t s s i g n i f i c a n c e .  discussed sequence  of  scheduling  to investigate.  which  with the v a l i d a t e d  p a r t i c u l a r e x p e r i m e n t s were  H o s p i t a l a d m i s s i o n s and be  were p e r f o r m e d  the  number  of  b o t h t h e number o f beds  In  patients available  the to and  present admit i s  the  length  147  of  the  Medical  model a d m i t t e d  gueue.  were a l l o w e d  were t h r e e beds l e f t . until  four  of  eight-year 0  to  "No  beds remained  run, the Medical  150,  with  should  be n o t e d  early  model  (i)  Rather  precede eight  than  the  first,  same t o t a l was  not  arrival  would  scheduled  until  critical  a single  was n o t  particularly  portion  of  length In  p a t i e n t s entered ( i i ) Rather  test  the the  of  indicated  to fluctuate  of the w a i t i n g conclusion,  It that  there  to were  were a l l o w e d  suggests having  to  that the that  this  separate  patients,  the  patients  entering  the  t h a t t h e l e n g t h o f t h e t h e gueue to  This  distribution  100!  T h i s would have i n c r e a s e d  this  admissions  gueue.  from  allowed  The f a c t  than  an  fluctuation,  being  schedulable  Medical  sensitive  scheduled  In  differences i n  arrivals  process.  realistic  averages over  were s i x beds l e f t .  factor.  (These  placements.)  and t o e n t e r u n t i l  f o r i m m e d i a t e and  A later  area.  t o g i v e t h e most  three other  arrivals  there  gueue.  waiting-time  i n the Medical  have c o n t r i b u t e d to the  v a r i a n c e i n t h e number  to  were  47.5% o f t h e emergency a r r i v a l s  model used  returned  they  guarter-year  number o f M e d i c a l a  50% o f t h e d a y s ,  20% o f t h e emergency  processes  earlier the  which  there  off-service  were  50% o f t h e until  gueue was o b s e r v e d  several  that there  beds l e f t ,  enter  and  On  gueue  had been f o u n d  Beds"  fashion.  from t h e M e d i c a l  On t h e o t h e r  p r o p o r t i o n s and l i m i t s numbers  p r e l i m i n a r y v e r s i o n of the  p a t i e n t s i n a more random  days, admissions  allowed  An e a r l i e r  originally  should  without  variance.  have  significantly  (iii)  postponed  and  altered  the  affecting  the  gueue. the  length  of  the  Medical  gueue was a  A  148  critical  variable  Indications  are  must be c a r e f u l l y length  that  the  while  adjusting  the  number o f a d m i s s i o n s  controlled  r a t h e r than  left  from  model. t h e gueue  random,  i f  the  i s not t o be a l l o w e d t o f l u c t u a t e c o n s i d e r a b l y .  10.2  In  Bed  Allocation  the  one-year  t h a t t h e r e was Orthopedic beds. beds  observed  run  an a v e r a g e  of the f i n a l  o f about  model, i t was  seven  Medical  patients  b e d s , e i g h t i n EENT b e d s , and t h i r t e e n  As a r e s u l t ,  i t was  per s e r v i c e area.  b e d s , t h e EENT a r e a  decided to r e a l l o c a t e  The O r t h o p e d i c  five  less,  and  area  the  observed in  i n "overflow"  the  number  was g i v e n f o u r  Medical  area  of less  sixteen  more. Several this  other  alterations  reallocation.  admissions capacity"  were r e v i s e d . , which would  Medical schedulable altered  The  slightly.  were n e c e s s a r y  bed The  permit  limits number  for of  the admission  to  correspond  " m o r n i n g " emergency  units  of  the s u r g i c a l  areas,  restrictions  off-service  patients  to  be  "remaining  of c e r t a i n  p a t i e n t s was r e d e f i n e d and t h e Furthermore,  to  numbers o f  pattern  s i n c e t h e r e were l e s s  was  beds i n  were t i g h t e n e d on t h e number o f  allowed  without  necessitating a  transfer. The  response  were a l l o w e d of  the  deviation  of  the  f o r t h e system  Medical  queue  i n c r e a s e d from  s y s t e m was a s f o l l o w s . to restabilize.  decreased 4.1  to  5.8  by  The a v e r a g e  three (see  Eight  weeks length  while the standard  Figure  10.1).  The  149  number  of  "overflow"  beds  which  a v e r a g e o f 4.1.., The u t i l i z a t i o n even  down  slightly.  transferred but  Beds" i n c r e a s e d  in  required  of the smaller  number o f M e d i c a l  o f f - s e r v i c e dropped  fluctuated  Figure  The  was  from  106 t o 161 o v e r  system  became c o n s i d e r a b l y  the  random  i n f l u e n c e s on i t .  number  o f Medical  patients  surgical patients.  number  p a t i e n t s who  were  t h e same t i m e  707, o f "No  period  (see  more s e n s i t i v e t o v a r i a t i o n s With  l e s s s u r g i c a l beds, the  of  non-"overflow"  Medical  fifteen  with t h e s i x t e e n  patients extra  view o f t h e i n c r e a s e d  increase  in  "No  Beds",  dropped  although  rates  the  net  by 7, t h e a v e r a g e  by  off-service  only  4.1.  (The  d r o p p e d by more t h a n  b e d s , but t h e  t o use a d d i t i o n a l o v e r f l o w In  that  b e d s was i n c r e a s e d  o f " o v e r f l o w " b e d s i n use of  t o changes i n the  o f f - s e r v i c e and i n t h e a r r i v a l  It i s significant  number  had  was  10.2).  The  number  area  The number  "No Bed" v a r i a b l e showed much more s e n s i t i v i t y  of  EENT  1261'{in 44 weeks) t o  almost as g r e a t l y as b e f o r e . from  d r o p p e d by an  surgical  patients  beds.) total  this  bed  usage  and  the  large  a l t e r a t i o n does n o t a p p e a r t o be  advisable.  10.3  Combining  An bed  experiment  areas.  was done t o combine t h e EENT  Patients  which was g i v e n originally  Bed A r e a s  o f b o t h s e r v i c e s used  as many beds  as  the  two  been a l l o c a t e d . , Any r e l e v a n t  and  Orthopedic  a s i n g l e bed areas  limits  "pool",  together  had  were c h a n g e d t o  150 3 5-i  5<M X  (J? Lii  2?J  UJ  15-1  ^  —15—;  1  1  Fi  TIME (weeks) F i g . 10.1 A v e r a g e M e d i c a l queue l e n g t h ( o v e r 4 weeks) a s a f u n 6c0t-ii o n o f t i m e : O r i g i n a l x ; E x p e r i m e n t o  TIME  (weeks)  F i g . 10.2 S u r g i c a l "No B e d " c a n c e l l a t i o n s ( p e r 4 weeks) a s a f u n c t i o n o f time : O r i g i n a l x ; Experiment o  151  t h e sums o f t h e p r e v i o u s l i m i t s . weeks were a l l o w e d  Of  the  one-year  f o r t h e model t o r e s t a b i l i z e ,  run,  eight  and t h e l a s t  44  weeks were compared. The  results  exhibited  a  pattern  utilization weighted "No  10.3)!  of  area  was t h a t an a v e r a g e 10.4).  failed  to reduce  areas  likely  to  h i s own  find  "overflow" Of  from  be  As  t h e same a s t h e  106  of  t o 46  (see F i g u r e  p a t i e n t s who were s e n t  off-service  by 90.  The o n l y  which  adverse  reaction  beds were r e q u i r e d (see  altered  be e x p l a i n e d a s  off-service  follows.  a  result,  forced  limits  bed,  surgical e i t h e r had  he  was  were  less  "No  p a t i e n t s were a l l o w e d Medical  surgical  a bed i n t h e combined  more  t h a n he would h a v e been  there  more  In a d d i t i o n ,  The  i n bed use t h a n  p a t i e n t needed a  less Medical  This  area.  The  However, t h e number  i t i n t h e combined a r e a  and  one.  number.  may  area.„  not f i n d  was a b o u t  o f 4.1 more o v e r f l o w  I f a surgical  area.  "overflow"  original  from  had more f l e x i b i l i t y  cancellations, combined  "pool™  gueue l e n g t h  o f t h e number o f p a t i e n t s r e t u r n i n g  dropping  this  together  separately.  the  significantly  Further tests  These r e s u l t s  to  bed  by 120, as a r e s u l t  Figure  to  The s u r g i c a l  of the previous areas.  dropped  to the M e d i c a l  could  new  The number o f M e d i c a l  dropped  in  interesting. similar  the  average  Beds"  were  area  patients  Bed"  i n t o the to  the  emergency p a t i e n t s who had  to  go  to  the  area.  course,  these  considered  Goldman e t a l  results  o f f e r only the  numerical  r e g a r d i n g such  an a l t e r a t i o n .  (1968)  was  which  included  aspects  The q u o t a t i o n in  Chapter  3  152 30-i  F i g . 10.4 A v e r a g e u s e o f " o v e r f l o w " b e d s ( o v e r 4 weeks) a f u n c t i o n o f time : O r i g i n a l x ; Experiment o  as  153  explains the  why  a beds-to-service allocation  administration  particularly elsewhere,  important,  for Specific  was o b s e r v e d  from  admission  forms.  The  more o f t h e d a t e s  probably  only The  let  the  half  distribution  drop  patients  and t h i r t y  fluctuated,  but  Surgery  booking  operations the  of  EENT  areas.  that  d a t e s on  a large their  F i g u r e s 10.5 -  procedures,  s u r g i c a l gueue l e n g t h s .  number  surgical  Hhat i f t h e p h y s i c i a n s clerk?  Of c o u r s e , some  clerk  the choose  physician the  their could  date.  numbers  An had  asked f o r .  was n o t a l t e r e d . gueue d r o p p e d  patients  which  average  of  Dates  w a i t i n g time.  more EENT  be  arranged  what would happen i f p h y s i c i a n s  significantly  E l e v e n more were a d m i t t e d  were  performed  with  Orthopedic that each  year. month  was t h e same f o r O r t h o p e d i c s and  o n l y one more p e r month f o r EENT. significantly.  service  as many d a t e s as t h e y a c t u a l l y  in surgical  of  be  should c o n s i d e r a removal  occasions,  length of the surgical  numbers  can  If  to  p a t i e n t s and were t r a n s m i t t e d by  of these dates  a similar  The  beds  up t o t h e b o o k i n g  was done t o t e s t  specified  The  extra  particular  However, on some  have  experiment  variable  guestion arises:  o f t h e r e g u e s t s came from physicians.  Bed"  the data c o l l e c t e d  of the p h y s i c i a n s reguested  left  i f  "No  between b e d s o f d i f f e r e n t  Reguests  It  and  the  then t h e a d m i n i s t r a t i o n  the d i s t i n c t i o n  10.4  considers  i s advantageous.  No  other  10.7 show of  variables  the comparative  Orthopedic  changed numbers  procedures  and  154  110-  bJ ZD OUO LJ  O O  cc  Q-110  100-  T I M E (we^ks) F i g . 10.5 EENT s u r g i c a l p r o c e d u r e s ( p e r 4 weeks) as a function o f time : O r i g i n a l x ; Experiment o 100n  60-  1T  2'H3'& (weeks) F i g . 10.6 O r t h o p e d i c s u r g i c a l p r o c e d u r e s ( p e r 4 weeks) a s a function o f time : O r i g i n a l x ; Experiment o  TIME  155  F i g . 10.7 a function  A v e r a g e s u r g i c a l queue l e n g t h ( o v e r 4 weeks) as o f time : O r i g i n a l x ; Experiment o  156  The  real  patients. better  gain  As  job  seems t o  mentioned  be  i n the  earlier,  o f s e l e c t i n g days t h a n  physicians  should  be  able  to  only  i n d i c a t e a change t h a t  Hovever, i t does p o i n t selecting or  i f he  expects leave  requested  i s choosing them  i t up  10.5  to  has  St.  this  in  altered as  be  the  b o o k i n g c l e r k . .,  so  of  that  365  schedulable  i f  that  (one  not  Unit  the  f r e e , while  the  experiment  may  a  model.  physician  probably  is  fashion,  future  every patient should  handled  arrival of  would  a  that  he  better  to  arrives  at  do  Patients  Emergency  the  since  made t o i m p r o v e t h e that  a v a i l a b l e , he  p o s s i b l y be  mind,  p r o b a b l y do  does,  this  surgical  s u r g i c a l dates i n a haphazard  been s u g g e s t e d  patients could  fact  to  Paul's  model  a result, be  of  physicians  when t h e y a r e  could  the  time  h i s d a t e s f a r enough i n the  Classification  It the  his  out  As  the the  tell  model s e l e c t s days a t random.  waiting  on  be  who  there.  a schedulable  patterns  of  Medical  the  immediate  patients  per  d a y ) . , No  other  were  Some o f  the  basis.  With  patients  were  re-classified  model p a r a m e t e r s were  changed. The of  the  results  Medical  queue d i d  waiting  time  patients  placed  each  dropped  rise  inconclusive. by  was  about  slightly. ,  o f f - s e r v i c e was  four-week  stabilization  were r a t h e r  time period  the  The  The  average  4.5,  but  total  number o f  same, a l t h o u g h  stabilized  (see  Figure  the  the  length average Medical  number i n  10.8).  r e f l e c t e d i n a somewhat l o w e r v a r i a n c e  for  This the  157  surgical from  gueue.  111  reached  to  130  The  (see F i g u r e  as many a s  139  be  a random r e s p o n s e  it  i s probably I n any  "No  Bed"  concern  case,  use  result  of the  of  high  10.6  B e d s " i n one  that  the  the  model i s i n t h e  one  out more  Medical  most o b v i o u s  13.4%  by  Correspondingly, area  were  The  the  o u t an  by  an  since  handling  does not  the  need  to  to  decrease  seems t o be  p a t i e n t s , not  a  necessarily  patients i n that  c h a n g e s t o be patients.  service.  i n v e s t i g a t e d by  The  p a t i e n t s by  surgeon,  which  an  number  even  were  off-service surgical  average  the  o f about  beds  Figure  The  final  experiment  "about  10%".  (It  compared) and reduced of  the  ten i n the  allowable  gueue s t a b i l i z e d  increased s i g n i f i c a n t l y , 10.10).  the  added slating  surgeons. Orthopedic  limits  before  patient.  utilization (see  of  problem  numbers o f beds r e s e r v e d as  l e n g t h of the  increased  result  However,  physicians  on t h e o n e - y e a r r u n s  making  changed,  transferring  may  so  Patients  Orthopedic  irregularity  this  U n i t . , The  a r r i v a l r a t e of  t o be  year,  standpoint  Medical  i n c r e a s e d t h e number o f O r t h o p e d i c turned  had  fluctuations.  p r o p o r t i o n o f emergency  of  4-year run  administration  Emergency  number o f t o t a l  previous  i s disturbing.  encouraging  the  Beds", however, i n c r e a s e d  The  i t seems from t h e  Number o f  One  10.9).  the r e s u l t  with  of  "No  o f "No  to the o t h e r  problem,  their  the  not,  itself  number  seven. by  an  Orthopedic  somewhat,  and  "overflow"  area  average of about  5.5  The  area  utilization  did  158 zoo-.  160 H  h-uoUJ  * 1\ * 35 H*f TIME (weeks) F i g . 10.8 M e d i c a l p a t i e n t s p l a c e d o f f - s e r v i c e ( p e r 4 weeks) as a f u n c t i o n o f t i m e : O r i g i n a l x ; E x p e r i m e n t o 3o-i „  »  1  Yl  r  1  1  18 H Ld  cO  F i g . 10.9 a function  -T 1 jfij 1 1 ^ 1— TIME (weeks) S u r g i c a l "No B e d " c a n c e l l a t i o n s ( p e r 4 weeks) as o f time : O r i g i n a l x ; Experiment o  V4-  159  not  change  returned weeks.  appreciably.  to  the  Therefore,  The  Medical  increased,  be  considerably,  only  slightly  Figure  10.11).  about  two  extra  The number week  to  As  about  20%,  p a t i e n t s who were  procedures increased  effect.  The  by l e s s t h a n  the hospital  demand.  average  probably  does  experiment  same  reducing  the impact of the e x t r a  experiment patients and  shows  would  what  probably  on t h e number o f "No  effect  such  of  better slate  in  for  the  thereby  Nevertheless,  an i n c r e a s e i n  have on t h e demand Beds".  a  t o some e x t e n t ,  patients.  The  wait  t h e use o f t h e O r t h o p e d i c  effect  by  one day.  The i n c r e a s e o f one s u r g e o n  this  had t o  b e f o r e (see  over a l l days-of-the-week. achieves  sent  number o f "No B e d s " c h a n g e d  of Orthopedic  t h e model o f l e v e l i n g  were  by 93 i n 44  106 and v a r i e d l e s s t h a n  patients increased  who  Although t r a n s f e r l i m i t s  the t o t a l  this  mentioned b e f o r e ,  than  increased  patients  compensate f o r t h e e x t r a  surgeon f a c i l i t a t e d  Orthopedic  job  by 77.  t o 107 from  per  of  t h e number o f M e d i c a l  off-service tightened  area  number  the  Orthopedic  "overflow"  beds  160 SO-i  U-t  I  |  7^  |  1  TIME  ^  1  1  ?  i  1  (weeks)  F i g . 10.11 S u r g i c a l "No Bed" c a n c e l l a t i o n s ( p e r 4 weeks) as a f u n c t i o n o f t i m e : O r i g i n a l x ; E x p e r i m e n t o  ^  161  CHAPTER  In for  11  PHOPOSALS FOR  this chapter  development,  suggestions  are  improvement  study  data  collected  at St.  suggests  improved  and  which may  and of  use  of  assistance  detailing  certain  items not Paul's.  changes i n p o l i c y  some  be  investigated  the  model.  in  These  defining  the  possibilities.  The  studies  sort,  by  the  following  are  recorded  Regarding total  overall  emergency DU  for  updating  Office. ,  Table VIII. the  point of  t h e amount o f As  of  1977,  data the  daily.,  admissions: admissions,  to extended  number o f "No  the  project  addition,  P a u l ' s , from  concerns  being  In  comments a p p e a r on  Admitting  number o f  admissions  in this  Paul's c a l l  improvement a t S t . of t h i s  gained  methods f o r o t h e r s .  Some f u r t h e r  being c o l l e c t e d items  experience  or p r a c t i c e at St.  other data.,  of  p r e v i o u s l y a v a i l a b l e a r e now  collection  A significant  (i)  areas  Data  Certain  view  I suggest  i n t e n d e d t o be  scope of f u r t h e r  11.1  EOTORE CONSIDERATION-  care,  Beds",  admissions  (total.  M e d i c a l , and  admissions,  admissions  t o the  correct  admissions  t o t h e wrong  area,  area  surgical),  162  (ii)  By  service: scheduled urgent  admissions,  admissions,  admissions "No (iii)  By  Bed"  service  t o the c o r r e c t  cancellations  area:  transfers I  strongly  validation As  urge  {how  many, where, and  t h e use  of the  I  It  t h e queue and  would  non-teaching  noted the  recorded  the  category.  Admitting  unacceptable Booking couple  of  information appears  for  of  of  waiting  update  determining  the  surgical  a r e a , the  In  slate,  collection and  should  with  operation  sessions  should  used  every  and  file  be  every admission  box.  from slate  may  After  that,  be of  respect to done  Office.  hours".  i n the  admit.  entire  done " a f t e r  day  the  a more e x a c t s t u d y  Booking  the d a i l y be  to  o f t h i s d a t a must be  OR  be  suggest  variations  particularly  s l a t e or  would  differentiated  the  describing  improved  of the l e n g t h of  whom  enable  collection  thesis,  times.  Then a d d i t i o n s and  i n t e r f e r e n c e with  on t h e  validation  records w i l l  The  i t  i n the  p r o b a b l y n e e d t o be In t h e  Office  Office,  and  o b s e r v a t i o n o f t h e queue m i g h t  first!  Careful  development  patient  will  patients.  daily.  to refine  p a t i e n t s awaiting admission  algorithm  patients  be  times  of the d i s t r i b u t i o n  pertinent  should  several  allow better  H e d i c a l a r e a , the c a r e f u l  Teaching  data  o f t h e f o r m s on  advisable.,  some  of such  why)  model.  have i n d i c a t e d  observation  area,  To of  in  avoid the  The to form  OR  first record which  additions.  163  cancellations, done " a f t e r copies will  hours",  of the help  might  particularly  (and  somewhat s i n c e  LOS now  by  OR  1974.  data,  For  data,  If  at  the This  and  other  surgery  a more r e c e n t staff  since  sample o f suggest  of o p e r a t i o n s  t h a n by  patient  1974,  surgery  that  has  s e r v i c e s , data  i t  the  increased should  be  OR. P e d i a t r i c s , are  volume v a r i e s however, t h i s  will  particularly  if  are adequate. taken at  supplemented Instead  random d a t e s  of  by  the  the  new  sinqle,  throuqhout  the  be d e s i r a b l e . it  is  desirable of  to  teachinq  distinquish and  teaching  non-teaching  beds,  patients'  a LOS  advisable.  indicated  information Medical  Care  length)  Model M o d i f i c a t i o n and  As  look  in-hospital  m u l t i p l e OH  s a m p l e , one  comparative study  11.2  As  O f f i c e records,  raiqht  be  noted.  days i n advance.  as p r e s e n t l y c o r r e c t e d t o e x c l u d e  continuous-time  would  be  improvement.  Admitting  If  two  and  noting  the  service rather  Emergency  year  one  supervisory  hence  quite reliable.,  reguire  possible to  to c o l l e c t  Furthermore,  collected  may  a l s o be  a d d i t i o n o f Day  advisable  difficulty  in  replacements  changes.  to the  be  data.  i t should  s l a t e s prepared  "last-minute" Due  p o s t p o n e m e n t s , and  may  in  reveal  scheduled  the  Expansion  comments  a more complex  patients,  and  on  data,  additional  mechanism f o r a d m i s s i o n  f o r development o f the  of  slate.  164  In p a r t i c u l a r , for  S e c t i o n 7.3  scheduled  appropriate  surgical,  date  slates,  either  Better  numbers  limits  and  particularly  care  however, as in  or  have t o be  additional  extended  terms  patients,  i s not completely  p h y s i c i a n s may  The  a less  rigid  and  daily  the  the  concept  the  requested  of  up  the  "composite"  modified. , may  also  i f "overflow" may  to the  make  be  beds are it  additional  regarding  limited. to  should  model may  useful  found  feasible  model., C a u t i o n  t h i s c o m p l i c a t i o n i n the of  to a  limit  of  In o r d e r t o f i l l  whole  rules  data  units  random.  bed  modification  a l g o r i t h m s o t h a t t h e l e n g t h of t i m e  surgery  transfers,  suggests  introduce  be e x e r c i s e d  n o t be  warranted  i n f o r m a t i o n t h a t would  be  obtained. The  services  implemented. /  require further  it  yet  However,  Neurosurgery  in  not  two  Plastic study.  useful  "completeness  11.3  for  of  these.  surgery are  not  in  the  model  General  time.  be and  b l o c k b o o k e d , and  would  Thus, i t s h o u l d  experimentation,  may  Surgery  T h i s e x t e n s i o n w o u l d be f a i r l y  t e r m s o f computer r u n would be  included  and  expensive  o n l y be not  done i f  merely  for  sake".  Experiments  The provided  questions i n Appendix  Additional doubt add  which were m e n t i o n e d i n S e c t i o n 2.4 1.4 q i y e a number o f i d e a s f o r  discussion  with  St.  o t h e r s , p e r h a p s more  and  experiments.  P a u l ' s a d m i n i s t r a t i o n would valuable  from  the  are  no  immediately  165  practical The  point  v i e w . , Some a d d i t i o n a l s u g g e s t i o n s  s c h e d u l a b l e and  analyzed of  of  for  cyclical  incorporating  example,  it  f r o m one  non-schedulable admissions data patterns,  t h i s into  might  follow.  be  the  model c o u l d  possible  d i s t r i b u t i o n and  especially  to  weekly.  t h e n be  generate  t o sample from  that  may  The  be  effect  tested.  patients  For  e a c h week  g r o u p on  a  daily  there  supposed  basis. According to  be  after the  18  to a d m i n i s t r a t i v e  beds r e s e r v e d  the  scheduled  various  observing It a r e a s by  be  sex.  The  It unit be  to  occupancy An  to  be  test  may  arrive  located  the  e f f e c t of  already  provides  females i n the  hospital,  that  random.  the  the The  a  guideline  model by  data by  effect  in of  separating on  average  service.  that  i t  restricting  These  would  beds t o  on  number o f a r r i v a l s a t decision  by  useful  of  It  into  of  investigation  the of  from  be  usage  transfers various the  emergency  this unit  might be  the  t o i n v e s t i g a t e and or  the  possible  occupancy-regulated  findings  admissions  levels  t o admit  occupancy.  hypothesis  incorporate  would be  the  Paul's.  model  somewhat  a d m i s s i o n s and  controls  who  sex.  regulated  any  order  i n t e r e s t t o check the  c o m p l i c a t e the  i s expected  investigate  patients  T h e s e beds c o u l d  in  p r o v i d e enough o f  is fairly  It  areas  of  males and  unnecessary to according  emergency  are  limit.  might  data should  the  admissions.  service  such a  numbers o f  for  suggestions,  to  emergency  model.  b u i l d i n t o the which t e n d  service  factors  may  to  areas  which  model  maintain at  control  St. the  166  length  of the  Medical  waiting  line  would  a l s o be  instructive.  167  CHAPTER J.2  This and  DISCUSSION  chapter r e f l e c t s  modelling  Hospital. revealed formal value  patient  The  on t h e i n f o r m a t i o n  a d m i s s i o n s and s c h e d u l i n g  first  section  discusses  policy.  of simulation  The  second  i n the h o s p i t a l  at  i n studying St.  certain  by t h e d a t a which was s u r p r i s i n g , hospital  gained  when  Paul's  information  compared  with  s e c t i o n comments on t h e  setting,  from  my  vantage  point. ,  12.1  System L a p s e s R e v e a l e d  by D a t a  My  first  patient  defined  by an  Even  comment  regards  administrative  within  a  single  the categories  identify  a l l his  elective  -  identical.  The  the  most  as  slated  amazing  way.  will  is  not r e s t r i c t e d  The  s i t u a t i o n i s even  The in  h i s patient  four or five  cross-section T a b l e XVI.  to s e r v i c e s with  Notice  physician  times  particularly  has  two  i s not  particularly with  are urgent  weeks.  "tight"  and  slates.  patients.  i n one r e c e n t  sample  that  patients  urgent  A  a day  uncommon  Medical  may  as a l l  t o do w i t h  within  This  pronounced  of waiting  One  as u r g e n t and r e q u e s t  weeks away!  more  a l l physicians  procedures  surgeon  surgery  not  operational problem  as  5.2.4).  Section  another  who a r e s u p p o s e d t o be a d m i t t e d  for  categories  semi-urgent,  patients  identify  (see  service,  i n t h e same  patients  though  directive  surgical  interpret  diagnostic  was a s are  168  supposed  to  be  admitted  within  p a t i e n t s w i t h i n one month.  two  weeks  and  semi-urgent  {T = t e a c h i n g )  TABLE XVI AL CROSS-SECTION  Wait s o f a r  OF WAITING  TIMES  T 0  U  0- 2 weeks  2  0  2  2  2  4  2 weeks-1 month  2  0  0  3  1  1  1- 2 months  3  1  2- 3 months  0  0  1  o v e r 3 months  1  0  2  Perhaps  the  T SO  SO  0  classification  T El  1  0  1  4  0  1 1  method  El  should  1  be  0  re-examined  or  re-emphasized. There in  i s a further  a l l acute-care hospitals.  a simple c a l c u l a t i o n made.  i n which  Consider a service,  length  of  stay  p a t i e n t s stay The  g e n e r a l problem  other  of  93%  problem  realistic  such  about  over t h i r t y  This  as  twelve  days,  a p p r o x i m a t i o n s have  days.  with  Seven  f o r an average  urge  improved  an  by  been  average  percent of the  of  have a mean s t a y o f n i n e d a y s .  should  patients  may be h i g h l i g h t e d  Medicine,  p a t i e n t s a c c o u n t f o r 30% o f t h e bed-days information  with long-stay  fifty  Then,  used.  This  placement  of  days.  1% o f t h e sort  of  long-stay  patients. Finally,  i t  appears t h a t  O r t h o p e d i c bed a l l o c a t i o n  by s e x  169  does not 40  Orthopedic  insists 35.5  correspond beds  beds t o  31.4  Value -  My  for  A Personal  and  not  experience  hospital  learning modelling  i t  is,  t i m e and  money. ,  Having a  good  said  one,  simulation by  an  the  can  be  averaging  a concern  for  a  computer  l e t me  The  a study  anyone  task  and  add  surpassing profitable (or  without  actual with data,  project,  testing  I t r e q u i r e s a good d e a l  expectations.  by  a  i n modelling  i n terms  of  model  is  and of  now  Large-scale  context team)  in  size,  appropriate  simulation,  i n a hospital  we  Master's  of t h i s  t h a t I b e l i e v e my  preferably  run  case  of becoming f a m i l i a r  processing  its  s y s t e m s and  i s carefully  for  simulation.  s i m u l a t i o n language s u i t a b l e to the  that,  hospital  hospital  in  f r a n k l y , enormous.  far  by  a proposal  consulting  research.  individual  analyzing  prefaced  s y s t e m , programming t h e  running  -  model  Context  wished t o c a r r y out  system, g a t h e r i n g  the  beds  that  I d i d have a s t r o n g b a c k g r o u n d  experience  consider  a computer  more  The  I t i s true that i n t h i s  H o s p i t a l with  some  i n such  f o r females.  a Hospital  out.  t h a t time,  However, i f a h o s p i t a l should  In  t h i s p o i n t must be  At  information  View  Paul's  project.  Mathematics,  the  30  my  males.  project i s carried  approached St.,  it  f o r males,  of S i m u l a t i o n  r e m a r k s on  the  thesis  are  I t seems f r o m  t h a t f e m a l e s a l m o s t a l w a y s use  12.2  how  to usage.  i f performed competent  in  and  simulation.  If  data  collecton,  of  170  policy the  definition,  and  of adherence t o t h a t  better., Basically  processes  an  input  a  simulation  stream  of  model  scheduling  to  produce a throughput r a t e , w a i t i n g  and  i t  can  administrative The and  such  a  system  and  reveal  of  the  of  and  Medical  validation  in  quantitatively  admission  information,  "No  model,  i f  box"  to  valuable  be  OS's,  and  "black  resources u n i t s can to  a  researcher  as  an  Having the  be  suggested  staff  (such  as  of  the  gueue and  Finally, an  Section  the  studied  questions.  data  model  data,  i n an  he  can  that i n Section  system  (such a s  by The  will  length  patients  placed  (refer  h o s p i t a l system computer of  form  the  intricate  interaction  those  particularly  a  The  the  10.5).  i t i s p o s s i b l e to develop  the  in  computer  which a r e  them  for  investigate  unguantified  a  is  necessary  i n v e s t i g a t i o n (as  number o f M e d i c a l  9.3).  be,  relatively  to c e r t a i n lapses  a l a r g e - s c a l e model on  areas  should  large-scale  which i n v i t e  11.3).  analyze  be  particular  v a r i a b l e s which a f f e c t  of  probably  examination of the  the  of such  to the  representation  An  which may  additional  off-service).  a  developing  aspects  supervisory  sensitive  certain  one  simulation in a hospital setting i s ,  limited  alerts  12.1  implementation  line  designed  studies tailored  to other  problems  hospital  of  in itself.,  model  Sections  other  the  exercise  informative  Such  S i n g l e wards o r OB  with  The  is  role  f o r h o s p i t a l s with  easily,  this  tool.  primary  small-scale.  in  be,  as  so much  a c e r t a i n number of b e d s and  cancellation information.  good,  such  patients, using  and  Bed"  mechanisms and  definition -  reasonable to  model  a l a r g e number  the can of  171  variables,  which i t would  effectively.  From  that  a p p l i c a t i o n s f o r which to with  Chapter the  10  and  the  be  otherwise  point,  results  the  w h i c h would  impact  experimental simulation potential.  of  situations. of  a  from  Though  large-scale  is used  a  to  the not  hospital  array  of  ( f o r example, r e f e r  researcher and  estimate  vast  I f i n proper  the  experiments, follow  be  11.3).  hospital administration,  numerical  there  model may  to S e c t i o n  impossible  communication  may  explain  co-operate i n  analyzing  application inexpensive, model  has  the  a  of  such  computer valuable  172  L I S T OF  REFERENCES  1.  Anonymous. (1966) "Computer Simulation of Hospital Discharges." V i t a l and H e a l t h S t a t i s t i c s ^ National Center f o r H e a l t h S t a t i s t i c s . , PHS P u b l i c a t i o n No. 1000, S e r i e s 2, No. 13. Washington, D.C: U.S. Government P r i n t i n g O f f i c e , F e b r u a r y .  2.  Anonymous. 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(1973) "A S t a t i s t i c a l Stay i n a Mental Hospital. ; Research, 8 (Spring):37-45. 1  P r e d i c t i o n and Research, 3  Model o f Length o f Health Services  29.  flearn,  C a t h e r i n e Rhys and B i s h o p , J . M. (1970) "Computer Model Simulation Medical Care in Hospital." B r i t i s h M e d i c a l J o u r n a l , 3:396-399.  30.  Johnson,  Kenneth Admissions."  31.  Kao, Edward P.C. (1972) "A S e m i - M a r k o v i a n Model t o P r e d i c t Recovery Progress of Coronary P a t i e n t s . " Health S e r v i c e s Research, 7 (Fall):191-207.  32.  . , (1973) "A S e m i - M a r k o v i a n P o p u l a t i o n Model with Applications to H o s p i t a l Planning.',' I . E . E. E. T r a n s a c t i o n s on S y s t e m s , Man,and C y b e r n e t i c s , SMC-3 (July):327-336.  33.  (1974) " S t u d y o f P a t i e n t A d m i s s i o n P o l i c i e s f o r Specialized Care Facilities." I.E.E.E. T r a n s a c t i o n s on S y s t e m s , Man,and C y b e r n e t i c s , SMC-4 (November):50 5-512.  C. (1963) "Forecasting Hospital H o s p i t a l T o p i c s , 4 1 (November) : 50-53.  34.  Kohler,  C O . , Wagner, G. , and Wolber, U. (1977) " P a t i e n t Scheduling (Bibliography)." Methods of I n f o r m a t i o n i n M e d i c i n e , 16 ( A p r i l ) : 1 1 2 - 1 1 5 .  35.  Kolesar,  Peter. Hospital Science,  36.  K u z d r a l l , P a u l J . , Kwak, N. K., and S c h m i t z , Homer H. (1974) "The Monte-Carlo Simulation of Operating-Room and Recovery-Room Osage." Operations Research, Vol. 22, No. 2, pp. 4 34-440.  (1969-1970) "A M a r k o v i a n Admission Scheduling." S e r i e s B, 116:B-384 - B-396.  Model for Management  175  37.  Kwak,  N. K., Kuzdrall, Paul J . , and S c h m i t z , Homer H. (1976) "The GPSS S i m u l a t i o n o f S c h e d u l i n g Policies for Surgical Patients," Management S c i e n c e , 22 (May):982-989.  38.,  Lew,  39.  McCorkle, Lois P. 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Newell,  44.  Pike,  45.  Reitman, J u l i a n . (1967) "The User o f S i m u l a t i o n Languages - t h e F o r g o t t e n Man. »> P r o c . ACM, pp. 537-579.  46.  Robinson, Gordon H., Wing, Paul, and Davis, L o u i s E. (1968) "Computer S i m u l a t i o n of Hospital Patient Scheduling Systems." Health S e r v i c e s Research, 3 (Summer):130-141. ,  D. J. (1964) " P r o b l e m s i n E s t i m a t i n g t h e Demand for Hospital Beds." J. Chronic Diseases, 17:749-759. Malcolm C., P r o c t o r , D a v i d M., and W y l l i e , John M. (1963) " A n a l y s i s o f A d m i s s i o n s t o a C a s u a l t y Ward." Brit. J. Preventive and Social Medicine, 17:172-176.  47. , S c h m i t z ,  Homer H. , and Kwak, N. K. (1972) "Monte Carlo Simulation of Operating-Room and Recovery-Room Usage. O p e r a t i o n s R e s e a r c h , 20: 1171-1180. ,,  48. , S c h r i b n e r , Thomas J . (1974) S i m u l a t i o n U s i n g GPSS. New Y o r k , L o n d o n , Sydney, T o r o n t o : J o h n W i l e y & Sons.  176  49.  S c r o g g s , Mrs. D. (1970) Study o f P a t i e n t T r a n s f e r s W i t h i n St.. Paul's Hospital. V a n c o u v e r , B.C.: Management Engineering U n i t of the G r e a t e r Vancouver R e g i o n a l Hospitals, April.  50.  Shao, D., and Thomas, W. H. (1970) "A Stochastic Model for the S t u d y o f t h e W a i t i n g Time o f Nonemergency P a t i e n t s i n a H o s p i t a l Admission System." O.R.S.A. Bulletin, Vol. 18, Sup.,, 2, p. B186.  51.  Shonick, William. (1970) "A S t o c h a s t i c Model f o r Occupancy - Related Random Variables in General Acute Hospitals." An._ S t a t . , A s s o c . J . , 65:1474-1500.  52.  Shonick,  53.  Shuman, L a r r y J . , S p e a s , R. D i x o n , J r . , and Young, John P. (1975) Operations Research in Health Care. B a l t i m o r e and London: The J o h n s H o p k i n s University Press.  54^  Stimson,  D a v i d H. , and S t i m s o n , Ruth, H. (1972) O p e r a t i o n s Research i n H o s p i t a l s : D i a g n o s i s and Prognosis. C h i c a g o : H o s p i t a l R e s e a r c h and E d u c a t i o n a l T r u s t .  55.  Thomas,  Warren H. (1968) "A Model f o r P r e d i c t i n g Progress of Coronary Patients." Health R e s e a r c h , 13 ( F a l l ) : 1 8 5 - 2 1 3 .  56.  Uyeno,  Dean. (1976) A Text o f N o t e s on S i m u l a t i o n f o r Commerce 510. Unpublished notes, Faculty of Commerce, University of British Columbia, Vancouver.  57.  Young,  John P. Occupancy Hospitals,  58.  William and J a c k s o n , J . R., (1973) "An Improved S t o c h a s t i c Model f o r Occupancy Related Random Variables in General Acute Hospitals." O p e r a t i o n s R e s e a r c h , 21 ( J u l y - A u g u s t ) : 9 5 2 - 9 6 5 .  Recovery Services  (1965) "Stabilization of Inpatient Through Control of Admissions." 39 ( O c t . . 1):41-48. ,  (1966) " A d m i n i s t r a t i v e Control of Multiple Channel Queuing Systems with Parallel Input Streams." O p e r a t i o n s R e s e a r c h , 14:145-156.  APPENDICES  APPENDIX 1-(Refers t o C h a p t e r 2)  .1  Early  Specifications  f o r the  Model  MICRO-SIMULATION MODEL OF ST. PAUL'S HOSPITAL PROJECT OBJECTIVE To model the patient flow i n and through St. Paul's Hospital. SUB OBJECTIVES 1.  To b u i l d a dynamic computerized model \rfiich can be U3ed to provide guidelines for management action i n controlling hospital admissions to e f f e c t i v e l y u t i l i z e hospital resources.  2.  To determine on a daily basis how many patients to admit by specialty.  3.  To demonstrate effect on hospital occupancy of adding/subtracting physicians to the medical roster. (Surgeons, non-surgeons, anaesthetists)  If. To demonstrate the effect of changing the bed allocation i n the . hospital. 5.  To reduce the number of no-bed situations.  6.  To demonstrate effect of varying numbers of emergency admissions upon bed occupancy, O.R. schedules and the number of surgical cancellations.  B.L. Curtis July, 1975  179  - 2 -  DATA REQUIRED  FOr each admission/discharge f o r the year January 1, 1974  t o December 31 > 1974:  P a t i e n t ' s age, sex Length o f s t a y ( o r admission date and discharge date) Primary d i a g n o s i s Secondary d i a g n o s i s Type o f admission S u r g i c a l procedure(s) Attending doctor Surgeon(s) Hospital Service Type o f A n a e s t h e t i c  -  180 1.2  The  Basic  Information  Flow  PATIENTS  MEDICAL PHYSICIAN  SURGICAL SPECIALIST  INVFSTIflAT[VFS BED  ADM & SURG BOOKING FORM  CONFIRMATION  BED  BOARD FORM  BED ALLOCATION  ADMITTING OFFICE SURGICAL DATE MEDICAL / QUEUE  FILE  SURG  ^LATE  INVESTIGATIVE  ADM  TO  ADM  FORMS  OR BOOKING OFFICE  FILE  TO V E R I F Y ADM SURGICAL FILE VERIFICATION  SLATE VISUAL  it. •x <  LL<o if. U LO LJ. z La.<L<C tx. •x 1 it. c  COMPLETED  SLATE  OL  c  -4tti  HQ  SURGICAL WARDS (SPECIALTIES)  MEDICAL WARDS  F i g . A 1.1  The b a s i c  flowchart of information  181 1.3  The  Proposal to  St.  Paul's  May  17,  Hospital  1976  Dr. E.C.Q. Van Tllburg, Medical Director, St. Paul's Hospital, 1081 Burrard Street, Vancouver, B.C. Dear Dr. Van Tilburg: About a year ago Mr. Brian Curtis and myself started discussion on the problem described in the attached project description. We were restrained from actual implementation of our ideas from the lack of time and, even more importantly, the lack of a suitable collaborator who can look after the detailed work. With Mr. Mark Chase joining our program we are now i n the position to proceed with this project. Presently we are f i n a l i z i n g our plans which are outlined i n the proposal. We are anxious to i n form a l l concerned staff and to ensure good co-operation. Brian Curtis has already contacted your secretary and arranged for a meeting with you on May 26th. I am looking forward to discussing the project with you i n greater d e t a i l at that time. Yours sincerely,  End. CAL/pdw  Chas. A. Laszlo, Ph.D. Associate Director Division of Health Systems  182  A Proposal f o r t h e . APPLICATION OF SIMULATION TECHNIQUES TO ALLOCATION SCHEDULING, AND UTILIZATION PROBLEMS AT ST. PAUL'S HOSPITAL  A number o f s t u d i e s have been c a r r i e d out concerned with t h e o p e r a t i o n o f i n d i v i d u a l departments i n St. Paul's u s i n g c o n v e n t i o n a l management e n g i n e e r i n g techniques. In p a r t i c u l a r , Admitting, OR Scheduling and t h e a l l o c a t i o n o f beds were i n v e s t i g a t e d i n depth. Although these s t u d i e s provided important informat i o n i t i s now apparent that because o f t h e complexity o f the i n t e r a c t i o n o f the v a r i o u s departments i n t h e H o s p i t a l more s o p h i s t i c a t e d approaches a r e required. The range o f s e r v i c e s provided by St. Paul's has been g r e a t l y extended and a l l s e r v i c e s have been i n c r e a s i n g l y u t i l i z e d mostly without corresponding increases i n f a c i l i t i e s . As a consequence o f t h i s expansion a number o f o p e r a t i o n a l problems have emerged: (1)  Scheduling o f s u r g i c a l p a t i e n t s ;  (2)  A l l o c a t i o n and u t i l i z a t i o n o f o p e r a t i n g rooms;  (3)  A l l o c a t i o n and u t i l i z a t i o n o f beds;  (4)  A l l o c a t i o n and u t i l i z a t i o n o f medical personnel ( a n e s t h e t i s t s , p h y s i c i a n s , surgeons).  Some problems o f scheduling and resource a l l o c a t i o n s may be i n v e s t i g a t e d u s i n g m o d e l l i n g and s i m u l a t i o n methods. These methods were developed i n response t o the demand generated by complex o r g a n i z a t i o n a l problems i n p r i v a t e and p u b l i c institutions. Examples o f s u c c e s s f u l a p p l i c a t i o n o f m o d e l l i n g and s i m u l a t i o n methods e x i s t i n manufacturing, marketing, t r a n s p o r t a t i o n , banking and o t h e r areas. The a p p l i c a t i o n o f modern o p e r a t i o n a l r e s e a r c h techniques t o a d m i t t i n g and scheduling has aroused c o n s i d e r a b l e academic i n t e r e s t . In p a r t i c u l a r , t h e r e have been numerous reports i n the l i t e r a t u r e o f t h e p o s s i b l e a p p l i c a t i o n o f the experience gained i n other areas t o t h i s f i e l d . Techniques have been developed, data have been c o l l e c t e d and computing systems and programs a r e a v a i l a b l e . Thus, i t seems that the time i s now r i p e f o r t h e p r a c t i c a l u t i l i z a t i o n o f s i m u l a t i o n techniques. In view o f St. Paul's we p l a n to St. Paul's  the i n c r e a s i n g acuteness o f scheduling and u t i l i z a t i o n problems a t and the p o s s i b l e u s e f u l n e s s o f modelling and s i m u l a t i o n methods, evaluate the e f f e c t i v e n e s s and p o t e n t i a l o f t h i s approach i n t h e environment. S p e c i f i c a l l y , we w i l l ; (1)  Set up a s i m u l a t i o n model;  (2)  Incorporate r e a l and r e l e v a n t data;  (3)  Simulate the e x i s t i n g . o p e r a t i o n a l environment;  (4)  Simulate p o s s i b l e a l t e r n a t i v e s f o r managerial e v a l u a t i o n .  We aim t o i n v o l v e a l l i n t e r e s t e d people i n t h i s p r o j e c t . D e t a i l e d r e p o r t s o f our progress w i l l be. made a v a i l a b l e and feedback on any and a l l a s p e c t s o f t h i s work are welcome. May 1976  Brian Curtis, Head, Management Engineering U n i t , Greater Vancouver Regional H o s p i t a l s , Vancouver General H o s p i t a l , Vancouver, B.C. V5Z 1M9  Mark Chase,* Graduate Student i n A p p l i e d Mathematics  Chas. A. L a s z l o , * A s s o c i a t e D i r e c t o r , D i v i s i o n o f H e a l t h Syste O f f i c e o f the Coordinator o f H e a l t h Sciences John H. Milsum,* D i r e c t o r , D i v i s i o n o f Health Systems, O f f i c e o f the Coordinator o f Health Sciences * 4 t h F l o o r , IRC B u i l d i n g , U n i v e r s i t y o f B r i t i s h Columbia, Vancouver, B.C. V6T 1W5  134  "Questions"  1.4  t o Ask o f t h e Model  Questions for St. Paul's Hospital Simulation 3ed Allocation Can the allocation of beds to services be altered to increase throughput of patients? What i f numbers of patients i n a l l services increases by lie; 2%; 3% - - - 20%? Can allocation of beds be altered to cope with increase of patients? What happens to length of waiting l i s t (in quantity and time to be admitted) What i f additional physicians are added to one/each service? Can allocation of beds be altered to cope with increase i n number of physicians? What happens to length of waiting l i s t (in quantity and i n time to be admitted) -  What i f beds are not allocated by service?  Can patient throughput be increased?  O.R. Scheduling What i f O.R.'s are closed? time to be admitted?  Impact on bed occupancy; waiting l i s t length and  What i f #'s of patients increase? numbers of no bed occurrences.  Impact of volume of surgeries per room,  What i f § of surgeons i s increased? Impact on number of surgeries; number of no bed situations; length of waiting l i s t and time to be admitted. What i f beds are booked f i r s t then O.R. time? What i f O.R. time i s booked f i r s t then bed? Vary number of admissions; What happens to waiting l i s t i n numbers and i n time to be admitted? Emergency Admissions What i f emergency admissions increase/decrease by percentage points; service? Impact on O.R., impact on "no bed" situation.  by hospital  Seasonality F i r s t determine  - i f occupancy varies with season - i f diagnoses vary with season If the answer to above i s YES What i f we vary bed allocation on seasonal basis? Inpatient Transfers What i f number of inpatient transfers increases/decreases? waiting l i s t .  Impact on surgical ^  185  APPENDIX 2  {Refers t o Chapter  Note t h a t for  the  model  the s e c t i o n s are  analysis  analyzed an  2.1  performed..  in  might Not  with the d e r i v a t i o n the  form  wish t o r e p e a t or a l l  of  A complete  file  the  Admitting O f f i c e Report  of B r i t i s h  1976  data  extend  the  which  were  data has been  i s a v a i l a b l e from  Systems a t t h e U n i v e r s i t y  of  o f e x p l a n a t i o n s and  appears here; the Orthopedic s e r v i c e  example.  Health  dealing  written  i n s t r u c t i o n s f o r a n y o n e who data  7)  used  as  the D i v i s i o n o f  Columbia.  186  St..Paul's Hospital VANCOUVER  1  B.C.  REPORT FROM THE ADMITTING DEPARTMENT - JANUARY TO DECEMBER 1976 NUMBER OF ADMISSIONS  20577 (22 ADMISSIONS CANCELLED BY B.C.H.P.)  NUMBER OF DAY CARE SURGICAL ADMISSIONS  3104 (29 CANCELLED AFTER ADM - 26 ADMITTED)  NUMBER OF REGULAR AND DAY CARE ADMISSIONS  23681  NUMBER OF NEWBORNS ( INCLUDING 3 COMPANION BABES ) NUMBER OF PSYCHIATRIC ADMISSIONS  1491 807  NUMBER OF RENAL ADMISSIONS JANUARY - MAY  1509  NUMBER OF RENAL OUT PATIENTS PROCESSED JUNE TO DEC.  51  NUMBER OF EXTENDED CARE ADMISSIONS  43  NUMBER OF EXTENDED CARE DAYS  1620  NUMBER OF ADMISSIONS THROUGH THE EMERGENCY  7097 - 34.5% OF TOTAL ADMISSIONS  NUMBER OF URGENT DIRECT ADMISSIONS  2152 - 10.5% OF TOTAL ADMISSIONS  NUMBER OF MEDICAL ADMISSIONS  5774 - 28.06% OF TOTAL ADMISSIONS  MEDICAL ADMISSIONS TO MEDICAL AREAS  4368 - 75.7% OF TOTAL MEDICAL ADMISSIONS  MEDICAL ADMISSIONS TO OTHER AREAS  1406 - 24.4% OF TOTAL MEDICAL ADMISSIONS  EMERGENCY MEDICAL ADMISSIONS  3525 - 61.05% OF TOTAL MEDICAL ADMISSIONS  1  883 - 15.3% OF TOTAL MEDICAL ADMISSIONS  URGENT DIRECT MEDICAL ADMISSIONS URGENT DIRECT SURGICAL ADMISSIONS  1089  ADMISSIONS TO WRONG AREAS  3151 - SURGICAL 1745 - MEDICAL 1406  CANCELLATIONS FOR NO BED  372 - AN AVERAGE OF 31 PER MONTH  NUMBER OF TRANSFERS  8795 - AN AVERAGE OF 24  PLACEMENT OF PATIENTS IN CORRECT CLINICAL AREA  2810  PLACEMENT OF PATIENTS IN ACCOMODATION OF CHOICE  810  PATIENTS' CONDITION  2304  FOR ISOLATION  272  FOR PATIENT CARE AND MANAGEMENT  2599  NUMBER OF PATIENTS FROM OUTSIDE GREATER VANCOUVER  5029  F i g . A 2.1  Admitting Office  report  1976  PER DAY  187  2.2  Patient Diagnostic Categories  Emergency d a y s showed 611 year.  In  admissions  data  collected  patients.  This  would g i v e 6965  1976,  there  were a c t u a l l y  Hence, t h e emergency d a t a although The be  which  a bit  low.  total  number o f DU  expected  to  have t h e  was  on  a l l services for patients  7097 emergency  collected  Each  same p r o p o r t i o n of DU's  in  reliable,  service  as  a  patients.  i s guite  p a t i e n t s i s known.  32  may  i t does o f  emergencies. The 18,853  total  (from PAS).  consider To  the  PAS  to  DU  reliable.  check  there are total  the 250  total  admissions  service totals  totals  from  t o be  overall  For s u r g i c a l number  of  of  Collected  For recorded.  the  f o r Orthopedic scheduled  Hence, t h e  totals,  one  can  the s l a t e s can by  ( s l a t e d ) and the  arrival  Hence,  subtract  each o f t h e s e  being  be  used  noting that  reducing  estimated d a t a may  the  number a l s o be  of used  patients.  p a t i e n t s appear i n Table  patients,  waiting l i n e  the p r o p o r t i o n s of urgent,  by  were  reliable.  patients,  year  c h e c k t h e number o f s c h e d u l a b l e These data  20,577.  schedulable patients,  operations  procedures.  were  guite  services,  o p e r a t i n g days per  number  in-hospital to  1976  ( e x c l u d i n g O b s t e t r i c s ) i n 1974  g e t t h e number o f s c h e d u l a b l e  emergency and fairly  admissions  data  semi-urgent,  diagnostic  XVII.  category  may  be u s e d  and  elective  to  was  determine  patients.  188  TABLE ORTHOPEDIC  XVII PATIENTS  Estimated per year  Group  Data  Total  1738  Emergencies  57 i n 32 d a y s g i v e s 650 i n a y e a r .  675  Direct  57 o f 611 e m e r g e n c i e s were Orthopedic, a s i m i l a r proportion o f 2152 DO's would be 201.  215  100 O r t h o p e d i c p r o c e d u r e s i n 25 days - 13 e s t . i n - h o s p i t a l ( a t 1 p e r 2 days) = 87 i n 25 d a y s o r 870 i n 250 d a y s . A l s o , 33 w a i t i n g l i n e a d m i s s i o n s i n 11 d a y s would be 750 i n 250 o p e r a t i n g days.  850  Urgents  Schedulable  Of t h e 51 40 The  from  PAS  data  17 40  waiting Orthopedic patients  t h e r e were;  1  U;  10  SU;  El. results  for diagnostic  category  proportions  of  Orthopedic  patients are; o f emergency and .759  DO  patients:  Emergent / .241  Direct  Urgent  of schedulable patients: .020  Urgent  / .197  Semi-Urgent  /  .783  Elective.  189  2.3  Patient Arrival  The  1974  slates  scheduled  arrival  example,  if  scheduled  admissions  The  Medicine, a  and  on  totals  of  The given  used  LOS  2/7  of  arrival  smoothed  to  is  the  DO  distribution  individual  preceding  data  number  which of  may  added. will  the For  be  no  p a t i e n t s may  be  that  was  arbitrarily.  to  In  admissions,  hypothesized  o f emergency  arrival need  -  number of DU  f o r them  with  idea of  days.,  arrivals  patients*  rates  is  p a t t e r n o f emergency  by  multiplicatively  the  o b t a i n an  constant, there  where t h e r e i s a s i g n i f i c a n t  give the non-schadulable The  be  pre-operative  possible arrival  combined  may  p a t t e r n , i f a weekend e f f e c t  observed  incremented  Distributions  and  p a t i e n t s to  distribution. be  modified  to  match  times  for a  section. determined  arrivals  immediate c l a s s i f i c a t i o n s ,  per  the p r o p o r t i o n of day,  in  appear i n Table  the  schedulable  XVIII.  and  190  TABLE  XVIII  ORTHOPEDIC  schedulable number  ARRIVALS  p r o p o r t i o n J emergency of times  |  number  with  proportion  D# 0.  o f times  I _________  If  .2857  6  6  .1622  1  .0286  9  6  . 1622  4  . 1143  6  9  .2432  8  .2285  7  7  .1892  6  .1714  1  6  .1622  6  . 1714  2  2  .0541  1  .0270  the  distribution, should  10  yield  random a  number  calculation  1745.7 O r t h o p e d i c  enough t o t h e a p p r o x i m a t e l y  generator reveals  that  yields these  p a t i e n t s per year,  1740  desirable.  a  uniform  proportions  which i s c l o s e  191  2.4  Patient  First patients count  of a l l ,  and  be  data,  is  similarly  PAS  age  group a t a  Compute  the  values  These data  other  total to  category  for  collected  percentages  these  percentages  again  of  stage  f o r Orthopedic  with so  the  that  values  OF  XIX  ORTHOPEDICS  PAS  54.3755 male  1976  51.26% male  USE  53.5  %  Slate  and  o f each  sex  The the  male  PAS  smaller In  the  are  no  useful.  patients in 1976  data.  they  fill  the  Use  this  set  for a f i n a l  patients follow i n Tables  TABLE SEX  1976  and  is  of  same p r o p o r t i o n s a s b e f o r e .  combine w i t h t h e  data,  t o use.  f i x the percentage compatible  of  p a t i e n t s which  group, a f u r t h e r  level  number  samples.  direction  includes Pediatric  arbitrarily  i n the  a l l  i n the  the  f o r t h e PAS  s e t of p e r c e n t a g e s  Paul's s e r v i c e  t h e 0-14  tabulate  C a l c u l a t e the  modified s l i g h t l y  since  to  for  g r o u p w i t h i n sex  data,  of  useful  g r o u p / sex  PAS  remaining  Groups  to give a f i n a l  longer a St. the  Age  (of 1 9 7 6 ) .  o f e a c h age  sample d a t a ,  In  it  tabulate  data should  age  and  i n e a c h age  Emergency d a t a and  Sex  XIX  figure. -  XXI.  TABLE  XX  ORTHOPEDIC HALE AGE GROUPS  Age  PAS  group  %  PAS w i t h 1 s t gp s e t  1976  0-14  7.20  2.00  1.64  15-34  39.37  41.57  44.26  35-54  31.01  32.75  34.43  55-74  18.20  19.22  16.39  75 +  4.23  4.45  3.28  TABLE  XXI  ORTHOPEDIC FEMALE AGE GROUPS  Age  PAS  group  %  PAS w i t h 1 s t gp s e t  1976  0-14  5.93  2.00  0.00  15-34  24.09  25.10  39.66  35-54  21.82  22.74  29.31  55-74  27.99  29.17  29.31  20.18  21.03  15.22  75 +  193  2.5  P a t i e n t Length of Stay  The  age g r o u p  / sex t a b u l a t i o n  PAS d a t a a p p e a r s on t h e n e x t page Clearly than  that  for  in  proportion average  males  older  o f males  (longer  i n each  with t h e e f f e c t  could  17.61  ( 172 / 945 ) * 31.79  12.06  .... m o d i f i e d  68 / 945 ) + 9.04  group  was  To t e s t  more  t h i s , the  multiplied  by  the  T h i s was t h o u g h t t o  t o t h e male o v e r a l l  ( 372 / 945 ) + 11.13  average  ( 293 / 945 ) +  ( 40 / 945 ) =  f e m a l e a v e r a g e vs  i t was d e c i d e d t h a t  a g e group  on age g r o u p o n l y  the  age  are  average  As a r e s u l t ,  sampled  higher  o f age removed. „  (  assigned  stay) groups.  be compared  7.02  male  the  I n s t e a d o f b e i n g b a s e d on s e x ,  o f f e m a l e s i n e a c h age group.,  g i v e a v a l u e which  12.38 ...  (16.36) i s much  can be e x p l a i n e d by age - s i n c e t h e r e  the  LOS  (12.38).  from  (Table XXII).  t h e a v e r a g e LOS f o r f e m a l e s  this difference females  f o r LOS, p r o d u c e d  by s e x , i t would  since  the  already  s u f f i c e t o a s s i g n LOS  ( i . e . r e g a r d l e s s o f sex,  from t h e d i s t r i b u t i o n  model  the  LOS  based  would  be  c o r r e s p o n d i n g t o t h e age g r o u p o f  patient). To  see  particular  how  age  the group,  LOS  distribution  consider  Orthopedics i n Table XXIII.  the  was  35-54  obtained age  for  group  a of  )  194 TABLE PAS AGE CROUP/SEX  MALE •  18 8 11 2 0  • • • • *  68 560 10656  * • • *  47 * 330 * 4226 »  7.02  *  15-3*  .  372 3211 124109 8.63  • » •  * «  • • • * 11.51  35-54  * :  :  _  t  55-74  '_  • • • «  • • • *  0 1 1 6 4 9 9 10  • •  •  *  • • • • • * •  ALL  42.52  563 « 493 7 « 167473 «  *  173 1926 45386 11. 13  • • • • * •  '  • • • *  • * *  1 » 6 * 30 * 58 * 37 * 56 28 6  • • *  * *  « *  222 3909 172467  0 0 5 13 27 60 40 15  • • * *  • • • •  40 1701 * 141359 *  * 31.79  160 5086 277956  * *  * • * *  * *  *  *  * *  •  4 9 74 161 117 75 21 5  • » * * * * •  ' «  466 « 5298 « 144082 * 11.37 * 3 8 57 92 80 96 46 12  * * » * • * * »  *  394 « 6766 * 274582 « 17.17 * 0 1 6 19 31 69 49 25  *  • » * • * « * •  •  200 * 6787 • « 419315 « • * 33 .93  •  »••*»• *»*******•*.**•*•*»***#*.**.*.*»*•***«*,*.* * 7 • 4 • 11 • 31 18 • 49 • • • * 175 115 290 • • • 342 • 226 * 568 • • 19 3 * 158 • 351 • • 120 • 165 • 285 * • * 53 • 83 136 • • 24 24 48 • • • •  ' *  • • »  •  945 11701 476933 12.38  •  • • •  793 12977 543399 16.36  * * * *  •  1738 2*678 1020334 14.20  -day:  days days days days days  Average Days ******** * ***************************  18 « 6 *  *  •  * 17.61  16.61  *  *  *  • •«  STAY  Total patients T o t a l days Sum o f squares o f days  8.77  •  293 » 3372 * 9 8696 *  115 890 14882  OF  days  2-3 4-7 8-15 16-31 32-63 —64+  4 17 119 266 104  2 * 4 26 54 * 46 * 34 6 1  2 5" * 48 * 107 * 71 * 41 * 15 * 4  172 2857 102115  V  75  191 1726 43364  * «  •  •  GE  • *•  2 * 2 27 * 34 * 43 40 18 6  *  •  9 2  •  * *  •  7 . 74  1 5 38 89 37  *  Patients .atayingi—  34 30 19 16 2 0  o o  3 12 81 177 67  LENGTH o 14  u 11 5  **»'  9 4  ALL  3_ To'  0-14  8.24  TABULATION  0  la •  • •* •* •  LOS  FEM ALB 0  X X I I  • • • * •  195  TABLE X X I I I  : AGE 3 5 - 5 4 ORTHOPEDICS  EMPIRICAL LOS  1 Days  No. o f  |  Ii  C u m u l a t i v e J Time Percentage | than  j  p a t i e n t s { Percentage  IJ  1  ________  II  I  1  _——__.  0-1  13  2.79  2.79  2  2-3  74  15.88  18.67  4  4-7  161  34.55  5 3 . 22  8  8-15  1 17  2 5 . 11  78.33  16  16-31  75  16.09  9 4 . 42  32  32-63  21  4. 51  98.93  64  100.oo  • • •  64 +  1.07  5  (arbitrarily ended  about  128)  These logarithmic curves,  points,  which  had been s e l e c t e d  i n an e f f o r t  i n t e r v a l s i n order t o t e s t a lognormal  were  plotted  F i g u r e A 2.2 w h i c h  on  follows.)  logarithmic  t o have  f i t to the  p r o b a b i l i t y paper.  (See  197  These o r i g i n a l  points  segments {or approximated  were  by a smooth c u r v e ) . .  were t h e n t a k e n from t h e c u r v e . 35-54 O r t h o p e d i c s a p p e a r  connected  by  straight  Additional  The p o i n t s f i n a l l y  i n T a b l e XXIV. TABLE XXIV  PROCESSED LOS : AGE 35-54  ORTHOPEDICS  Up t o  Cumulative  n days  percentage  1  0.0  2  2.8  4  18.7  6  37.0  8  53.2  10  62.0  12  68.7  16  78.3  20  85.2  24  88.9  32  94.4  40  96.6  48  97.7  64  98.9  80  99.5  96  99.7  128  100.0  used  line points  f o r age  198  Note:  No  there  patients  i s a separate  patients The graph  would not large were  interpolates smooth done  were Day  c o u n t on  value  linearly  interpolation against  straighter.  Care  number o f of  a  considered surgery  the  because  the  between a d j a c e n t  logarithmic  on  have 0 d a y s s t a y ,  service  now,  and  as  such  census.  intermediate  done  to  the scale  points GPSS  taken  function  points.  The  from  generator  "linear"  graph paper i s b e t t e r , for  which  the  the  or  being  curve  is  199  2.6  Length  of Surgery  From t h e 1974 s l a t e s , T a b l e s were each  age  length-of-surgery  made i n which t h e v a r i o u s group  /  number o f p a t i e n t s  sex  lengths  classification.  and a v e r a g e  time  d a t a were  were r e c o r d e d  From t h i s ,  ( i n minutes)  could  (see T a b l e XXV).  TABLE  XXV  ORTHOPEDIC LENGTH OF SURGERY  Age  0-14  M  F  ALL  4  5  9  41  49  46  patients  21  10  31  avg.  70  60  67  patients  27  18  45  avg.  71  67  69  patients  13  18  31  avg.  79  75  76  1  13  14  60  111  108  66  64  130  70. 3  75.5  patients avg.  15-34  35-54  55-74  75 +  time  time  time  patients avg.  ALL  time  time  patients avg.  time  obtained.  72.9  for  a table of be  made  200  as  noted p r e v i o u s l y ,  considered For  relevant,  each  sex  smoothed t o g i v e  the  but  i t  was  not  group,  decided  that  age  would  be  sex. empirical  function  used  data  (see T a b l e  were  recorded  XXVI).  and  201  TABLE  XXVI  LENGTH OF SURGERY : AGE 15-54 ORTHOPEDICS  Ii  Empii r i c a l  Processed  I I nutes  Patients  Ii  Minutes  Patients  %  Cum.  •] 1 \ 15  2  30  3  9.74  9.7  25  1  45  2  6.45  16. 1  i*5  2  50  4  12.9  29.0  50  4  55  4  12.9  41.9  55  4  60  3  9.74  51.6  60  2  65  3  9.74  61.3  65  3  70  2  6.45  67.7  70  2  75  2  6. 45  74.2  75  3  80  1  3. 23  77.4  80  1  90  2  6.45  83.9  85  1  100  2  6. 45  90.3  90  1  110  1  3. 23  93.5  95  1  120  1  3.23  96.8  100  1  130  1  3.23  100.0  110  1  120  1  140  APPENDIX 3  PSQGSAM  LISTING  1 2 3 *> 5 6 7 8 9 10 11 12 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 3B 39 40 41  REALLOCATE BLO, 1000 , FAC , 1 0 , ST 0, 10 ,OUE , 2 0 0 , T AB, 5 0 , VAR, 1 0 0 . F S V . 1 0 REALLOCATE COM,146440 SIMULATE RMULT 5177,169,27279,6343 *************************************** * TABLE OF D E F I N I T I O N S ***************************************  * * * * * * * * *  AD I ST ADMMC ADMSC ALTER A NEE N ANMED ANORP APRWK AR NON * ARSCH * A SEE N * ASMEO * ASORP * BTIME * BUNPE * BUMPS * CANCL * CHECK * CHKDR * C KTM CTPRI * CWEFK • * OA SAM * DISCH * OSTRO * EENNO * EENSL EENSN * EENST EINO * EIN2 EIN4 * EMARR  •  M  •  • • •  VARIABLE C HA IN CHAIN MATRl X FUNCTION FUNCTI ON FUNCTION! VARIABLE FUNCTION FUNCTION FUNCTION FUNCTION FUNCTION 8VAR! ABLE BVARIABLE BVARI ABLE SAVEVALUE SAVEVALUE SAVEVALUE SAVEVALUE VARIABLE VARIABLE VARIABLE CHAIN VARIABLE MATRIX MATRIX TABLE TABLE QUEUE QUEUE OUEUE SAVEVALUE  •  • I D E N T I F I E S SERVICE/SEX AGE OIST FUNCTION *MEDI CAL ADMISSIONS * SURGER Y ADMISSIONS •ALTERNATE AREAS FOR EMERGENCIES • NON-SCHEDULABLE EENT ARRIVALS * NON-SCHEDUL A BL E MEDICAL ARRIVALS •NON-SCHEDULABLE ORTHOPEDIC ARRIVALS •IDENTIFY APPR WEEK ON MATRIX * NON-SCHEDULABLE ARRIVALS BY SERVICE •SCHEDULABLE ARRIVALS BY SERVICE •SCHEDULABLE EENT ARRIVALS •SCHEDULA8LE MEDICAL ARRIVALS •SCHEDULABLE ORTHOPEDIC ARRIVALS •ENUF TIME IF THIS ONE SUBSTITUTED? •TO BUMP ELECTIVE OF THIS OOCTOR •TO BUMP SEM IURGENT OF THIS DOCTOR • COUNTS NUMBER OF CANCELLATIONS • DAY TO CHECK ON SLATES •CCCTOR TO CHECK •SURGERY TIME TO CHECK FOR • P R I O R I T I E S U:19 SU:18 E L : 1 7 •NUMRER OF WEEKS TO CHECK DATE •NEW DR REALLY ON SAME DAY? • DISCHARGE CHAIN •SERVICE/CATEGORY FUNCTION OF DAYS TO REQ •FOR EENT NUMBERS •FOR EENT SLATE •EENT SLATE NUMBERS • EENT SLATE TIME •EENTS IN EMERG • EENT S IN GSG E T C . • EENTS IN ORTHO •COUNTS EMERG AND O . U . ARRIVALS T flDAY  K> O LO  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 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  *  EHRED  SAVEVALUE TABLE SAVEVALUE SAVEVALUE * EMRGC CHAIN FMTBN T A B L E * E««TP T TABLE * ENDWK V A R I A B L E EOPNO S A V E V A L U E * EOPTM S A V E V A L U E GOPTM S A V E V A L U E * GSGNO MA TRIX * GSGSN T A B L E * GSGST T A B L E * HI TBL V A R I A B L E * HUONG V A R I A B L E * W I S T VARIABLE * L O S E E QUEUE * L O S E F QUEUE * LOSEM QUEUE LOSME OUEUE * LQSMF OUEUE * LOSMH OUEUE * LOSOF OUEUE * LOSCM QUEUE * LOSOR QUEUE * LOSO V A R I A B L E * LOSQS V A R I A B L E * MACHO B V A R I A B L E * "ACHR B V A R I A B L E * MACHS 8VAR I A B L E * MA DI S S A V E V A L U E * MALT3 C H A I N * MALT4 CHA IN * MOATE S A V E V A L U E * "OGEN SAVEVALUE * MEDNO MATRIX * MEMRN S A V E V A L U E * MINO QUEUE * MIN2 QUEUE * MI N3 QUEUE * MIN4 QUEUE * MLOSG S 6VEVA LUE * MLOST SAVEVALUE M0O6 VARIABLE * MOFF V A R I A B L E * "SPAC VARIABLE * MSRVC S A V E V A L U E * NOBD S A V E V A L U E * 'NOBEO T A B L E * NOFF V A R I A B L E * NOWTM S A V E V A L U E * QFFSL V A R I A B L E * OINO QUEUE 0IN2 QUEUE 01 N3 OUEUE * GOP NO S A V E V A L U E * OOPTM S A V E V A L U E * ORPNO MATRIX * ORPSL MATRIX EMGDU • EMGNO • * EMGTM  •  • •  •  •  •  • T R A C K S EMERGENCY BEDS IN USE • E M E R G AND D . U . ARRIVALS DAILY •EMERGENCY NUMBER OPERATED •EMERGENCY OPERATING TIME •EMERGENCY OPERATIONS CHAIN •EMERGENCY OPERATED NUMBER • EMERGENCY OPERATED NUMBER • I S DATE ON WEEKEND? • EENT NUMBER OPERATED • E E N T OPERATING TIME • G E N E R A L SURGERY OPERATING TIME • F O R GENERAL SURGERY NUMBERS • G E N E R A L SURGERY S L A T E NUMBERS • GENERAL SURGERY S L A T E TIME •NUMBER OF THE HIGHEST OPERATIONS T A B L E • NUMBER OF WEEKS WAITED FOR OPERATION • I D E N T I F I E S S E R V I C E / A G E LOS O I S T FUNCTION • E E N T L OF STAY • E E N T FEMALES L OF STAY • E E N T MALES L OF STAY • M E D I C I N E L OF STAY • M E D I C I N E F E M A L E S L OF STAY • M E D I C I N E MALES L OF STAY • O R T H O P E D I C S FEMALES L OF STAY • ORTHOPEDICS MALES L OF STAY • O R T H O P E D I C S L OF STAY • I D E N T I F I E S S E R V I C E ' S LOS OUEUE • I D E N T I F I E S S E R V I C E / S E X LOS QUEUE • T O MATCH P A T I E N T ON DISCHARGE C H A I N • TO MATCH PATIENT ON ADM OR SURG CHAIN • U S E D IN THE ABOVE • M E D I C A L AREA DISCHARGES • M E D I C A L PATIENTS IN AREA 3 • MEDICAL P A T I E N T S IN AREA 4 • A O M I S S I O N (OR ANOTHER) DATE TO MATCH • D A T E GENERATED TO MATCH • F O R MEDICINE NUMBERS • M E D I C A L EMGOU IN MORNING •MEDICALS IN EMERG •MEDICALS IN GSG E T C . '•MEDICALS IN EENT • M E D I C A L S IN ORTHO • L E N G T H OF SURGERY TO MATCH • LENGTH OF STAY TO MATCH • I D E N T I F Y NEW WEEK 0 SLATES • I D E N T I F I E S M E D - O F F - S E R V I C E CHAIN •NUMBER OF BEOS FOR MED SCHEOS • S E R V I C E TO MATCH •COUNTS NUMBER OF 'NO B E D S ' • T A B U L A T E S NUMBER OF ' N O B E D S ' •NUMBER TO PUT BACK ON S E R V I C E • T I M E USED BEFCRE A BUMP • O F F S E T TO S L A T E MATRIX BY S E R V I C E • ORTHOS IN EMERG •ORTHOS IN GSG E T C . •ORTHOS IN EENT •ORTHOPEDICS NUMBER OPERATED • O R T H O P E D I C S OPERATING TIME • FOR ORTHOPEDIC NUMBERS • F O R ORTHOPEOIC S L A T E  102 103 104 105 106 107 108 109 110 11 1 112 113 114 115 1 16 117 118 119 120 121 122 123 124 125 126 127 128 129 130 131 132 133 134 135 136 137 1 38 139 140 141 142 143 144 145 146 147 148 149 150 151 152 153 154 155 156 157 158 159 160  ORPSN1 T A B L E QRPSI' T A B L E * PTFWK ; S A V E V A L U E PWEEK: SAVEVALUE * SOIST ' V A R I A B L E * SEUSC V A R I A B L E * SGYOl.1 V A R I A B L E * SHIFT VARIABLE * SIXWK B V A R I A B L E * S I E F N1 C H A I N * S L E W ! CHAIN SLEW2 C H A I N * SLEW3 CHAIN * SLEW4 CHAIN * SLEWS C H A I N * SLEW6 CHAIN * SLOEN CHAIN * SL0W1 CHAIN * SL0W2 CHAIN * SLQW3 C H A I N * SLC1W4 CHAIN SL0W5 CHAIN * SL0W6 C H A I N * SLUSC V A R I A B L E * SR VOP V A R I A B L E * STAI OTABLE * S T A 3 OTABLE * STA4 OTABLE * TMFWK SAVEVALUE * TPYOA B V S R I A B L E * TRYDR V A R I A B L E USRSL SAVEVALUE * VTIME V A R I A B L E WAIT LOGIC SWITCH * WA ITE LOGIC SWITCH * WAI TQ V A R I A B L E * WEEK SAVEVALUE WEENE OUEUE * WEENS OUEUE WEENU OUEUE * WKDAY V A R I A B L E * WK END B V A R I A B L E WMEDE OUEUE * WMEOS OUEUE WMEDU OUEUE * WORPE OUEUE * WORPS OUEUE * WORPU OUEUE * ViRCNC V A R I A B L E * WTE1 OTABLE * WTE3 QT ABLE * WTE4 OTABLE * WTS1 O T A B L E * WT S3 O T A B L E WTS4 OTABLE * iWTU1 OTABLE * WTU3 O T A B L E * WTU4 OTARLE * XFERC CHAIN  *  *  *  * *  * •  • *  •  • ORTHOPEDIC S L A T E NUMBERS • ORTHOPEDIC S L A T E T I M E •ROW OF P T S FOR THE APPROPRIATE WEEK • FIRST DAY OF PRESENT WEEK ISUNDAYI • I D E N T I F I E S S E R V I C E / A G E L OF SURGERY • FOR ' S L A T E E N D ' C H A I N , BY S E R V I C E • S E R V I C E FUNCTION FOR SURGERY DOW • I D E N T I F I E S DAY OR N I G H T - S H I F T FUNCTION • T H E S E OPNS IN NEW 6TH WEEK • EENT END S L A T E • E E N T WEEK 1 S L A T E • E E N T WEEK 2 S L A T E • E E N T WEEK 3 S L A T E • EENT WEEK 4 S L A T E • E E N T WEEK 5 S L A T E • E E N T WEEK 6 S L A T E •ORTHO END S L A T E • ORTHO WEEK 1 S L A T E • ORTHO WEEK 2 S L A T E • O R T H O WEEK 3 S L A T E •ORTHO WEEK 4 S L A T E • ORTHO WEEK 5 SLATE • ORTHO WEEK 6 S L A T E • S L A T E CHAIN TO USE BY WEEK • S A V E V A L U E S OF OPN S T A T S BY S E R V I C E • MEDICINE LENGTH OF STAY • E E N T LENGTH OF STAY • ORTHOPEOIC LENGTH OF S T A Y •ROW OF TIME FCR THE APPROPRIATE WEEK • P T S AND TIME OK T H I S D A Y ? • DESIRED DAY AND DOCTOR'S DAY CORRESPOND? • P O I N T E R FOR S L A T E S AND CHAINS • T I M E AFTER S U B S T I T U T I N G • G A T E ON SURGICAL ARRIVALS • G A T E ON EMERGENCY A R R I V A L S • I D E N T I F I E S S E R V I C E / C A T E G O R Y WAIT OUEUE • WEEK TO CHECK FOR OPEN SPOTS ON S L A T E • EENT E L E C T I V E WAITS • E E N T SEMI-URGENT WAITS • E E N T URGENT WAITS •DAY-OF-THE-WEEK (TOMORROW! •WEEKEND? • M E D I C A L E L E C T I V E WAITS • MEDICAL SEMI-URGENT WAITS • M E D I C A L URGENT WAITS • O R T H O P E D I C S E L E C T I V E WAITS • ORTHOPEDICS SEMI-URGENT WAITS • ORTHOPEDICS URGENT WAITS • I N D I C A T E S WRONG AREA OUEUE • M E O I C A L E L E C T I V E WAITS • E E N T E L E C T I V E WAITS • O R T H O P E D I C S E L E C T I V E WAITS • M E O I C A L SEMI-URGENT WAITS • E E N T SEMI-URGENT WAITS • O R T H O P E D I C S SEMI-URGENT WAITS • M E D I C A L URGENT WAITS • E E N T URGENT WAITS • C R T H O P E D I C S URGENT • TRANSFERS' CHAIN  WAITS  162 163 164 165 166 167 163 169 170 171 172 173 174 175 176 177 178 1 79 180 181 1B2 183 184 1 85 186 1 87 188 199 190 191 192 193 194 195 196 197 193 199 200 201 20? 203 204 205 206 207 208 209 2!0 211 212 213 214 215 216 217 218 219 220 221  MATRIX SAVEVALUES  M A T R I X S A V E V A L U E FOR E A C H S E R V I C E . ROW 1-5 C O R R E S P O N D S TO 01 A G N O S T I C C A T E G O R Y . ROW 6 I S T H E TOTAL OF ROWS 1 - 5 . T H E COLUMNS A R E : 1 NO. G E N E R A T E D 2 NO. A D M I T T E D 3 NO. OF THOSE A D M I T T E D REOUEST I N G P A R T I C U L A R DATE 4 NO. WHO GOT THAT DATE 5 NC. A D M I T T E D TO WRONG AREA 6 NO. OF THOSE RETURNED TO CORRECT A R E A ME CINQ MEDNO GSGNO GSGNO EENNO EENNO ORPNO QRPNO  ECU MATRIX EQU MATRIX EOU MATRIX EOU MATRIX  l.Y H.6,6  * FOR  2tY  H.6 ,6 3. Y H.6,6 4,Y H.6,6  *FOR • FOR *FOR  M A T R I X S A V E V A L U E FOR E A C H B L O C K BOOKED S E R V I C E T O MONDAY THROUGH F R I D A Y . THE ROWS A R E : 1 NEXT DAY - I N I T I A L I Z E 2 O U T P A T I E N T S F O R WEEK 1 3 T I M E FOR WEEK 1 4 O U T P A T I E N T S FOR WEEK 2 13 NOTE:  TIME WEEKS ARE ON  E E N S L EOU EENSL MATRIX O R P S L EOU ORPSL M&TRIX INITIAL INITIAL • » <  6 INITIALLY  OTH WEEK  I S WEEK  COLUMNS  CORRESPOND  1. T H E N  2...  9,Y H,13,5 *FOR EENT S L A T E 10,Y H,13,5 *FOR O R T H O P E D I C S L A T E MH9-MH10I1.1 I.2/MH9-MH10II,2) ,3/MH9-MH10(I,31,4 M H 9 - M H 1 0 I 1 , 4 ) , 5 / M H 9 - M H 1 0 I 1 ,5) ,6  ALLOW AT MOST THREE A L T E R N A T E BE C AREAS FOR EMERGENCY P A T I E N T S . THE ROW C O R R E S P O N D S TO THE P A T I E N T ' S S E R V I C E . THE NUMBER I N S E R T E D C O R R E S P O N D S TO T H E A L T E R N A T E A R E A . COLUMNS ARE USED I N R E V E R S E O R D E R . 0 I N D I C A T E S NO O P T I O N . ( E G . ROW 4 . . . 0 R T H 0 , MAY TRY S E R V I C E 3'S B E D S . . . E E N T , OR THE S E R V I C E 2 B E D S . . . O R T H O ) .  ALTER ALTER  *  FOR WEEK A CYCLE.  (2-6).  EOU MATRIX INITIAL INITIAL  CANCL EOU OAY TO CHECK CHECK EOU CHKDR EOU CHKTM E O U E"ARP. EOU EMBED EOU EMGNO E O U  14, Y H.7,3 *ROWS AS S E R V I C E S MH 1 4 ( 1 , 1 ) , 2 / M j S 1 4 ( l , 2 ) , 4 / M H l 4 ( l , 3 ) , 3 MH14(3,2),2/MHi4(3,3),4/MH14(4,2),2/MHl4(4,3l .3  13,H FOR O P E N SPOTS ON l.H 5, H 6, H 14,H 11, H 33,H  •COUNTS NUMBER OF C A N C E L L A T I O N S SLATE •DOCTOR TO C H E C K • SURGERY T I M E TO. CHECK FOR •COUNTS EMERG AND D.U. A R R I V A L S • T R A C K S EMERGENCY B E D S I N USE •EMERGENCY NUMBER O P E R A T E D  TODAY  O  222 223 224 225 226 227 228 229 230 231 232 233 234 235 236 237 238 239 240 241 242 243 244 245 246 247 248 24 9 250 251 252 253 254 255 256 257 258 259 260 261 262 263 264 265 266 267 268 269 270 271 272 273 2 74 275 276 277 278 2 79 280 281  E HG TM EOU  32,H  • EMERGENCY OPERATING TIME • EENT NUMBER OPERATED EOPTM EOU 22,H •EENT OPERATING TIME GCPTM EOU 20,H •GENERAL SURGERY OPERATING TIME MAOIS EOU 40.H •MEDICAL AREA DISCHARGES MOATE EOU 7,H • ADMISSION (OR ANOTHER) DATE TO MATCH MOGEN EOU 38,H • DATE GENERATED TO MATCH MEMRN EOU 41,H • MEDICAL EMGOU IN MORNING MLOSG EOU 9.H •LENGTH OF SURGERY TO MATCH MLOST EOU 8,H • LENGTH OF STAY TO MATCH MSRVC EOU 34,H •SERVICE TO MATCH NORD EOU 12,H • COUNTS NUMBER OF 'NO BEDS' NOWTM EOU 37,H •TIME USED BEFORE A BUMP OCPNO EOU 25,H • ORTHOPEOICS NUMBER OPERATED OOPTM EOU 24,H •ORTHOPEDICS OPERATING TIME PTFWK EOU 35,H • ROW OF PTS FCR THE APPROPRIATE WEEK PWEEK EOU 3.H • FIRST DAY OF PRESENT WEEK (SUNDAY) SHIFT EOU 39,H •IDENTIFIES OAY OR NIGHT-SHIFT FUNCTION TMFWK EOU 36,H •ROW OF TIME FOR THE APPROPRIATE WEEK * WHICH OFT H E 6 WEEKS IS THE NEXT (POINTER FOR SLATES AND CHAINS) USRSL EOU 4,H * WEEK TO CHECK FOR OPEN SPOTS ON SLATE WEEK EOU 2»H •TAKES VALUES FROM 0 XHSPWEEK,1/XHSUSRSL,1 INITIAL ********************* BOOLEAN VARIABLES E 0 N 0 EOU D  23,H  BTIME BVARIABLE VtVTIME'LE'FN241 * ENUF TIME IF THIS ONE SUBSTITUTED? 8UMPE BVARIABLE P5 • E • XH.tCHKDR* P6 • E ' 5*8 V$BTI ME *T0 BUMP ELECTIVE OF THIS OR BUMPS BVARIABLE P5 ' E•XHSCHKDR*P6•E'4*BVSBTIME *T0 BUMP SEMIURGENT. THIS DR • TO MATCH PATIENT ON DISCHARGE CHAIN MACHO BVARIABLE BV tMAC HS P2' E' XH$M DG EN^P 3 ' E 'XHSMOA TE+P9'E • XH $HLO ST • TO MATCH TRANSACTION ON ADMISSION CHAIN OR SURGERY CHAIN M AC HR BVARIABLE BV*MACHD*P11'E'XHtMLOSG MACHS BVARIABLE PI•E'XHSMSRVC *USEO IN THE ABOVE SIXWK BVARIABLE (P4'LE'XH$MDATE) •THESE OPNS IN NEW 6TH WEEK TRY'lA BVARIABLE P 13 • LE'F N240^P 14'LE • FN 241 *PTS AND TIME OK THIS DAY? WKENO BVARIABLE V$WKDAY*E'6*V$WKDAY'E'0 •TODAY FRICAY OR SATURDAY? *********** • VARIABLES 4  VARIABLE 38»P1^2*P7 * IDENTIFIES SERVICE/SEX AGE DIST FUNCTION VAR IABLE l(XH$USRSL+XH$WEEK-l)a6+l)^2 •IDENTIFY APPR WEEK ON MATRIX VARIABLE 22-P6 'PRIORITIES U:19 SU:18 EL:17 CWFEK VA R I A B L EIXH$CHECK-XH$PWEEK)/7 •NUMBER OF WEEKS TO CHECK DATE OAS AM VARIABLE (XH*CHECK-P14)a7 •NEW DR REALLY ON SAME DAY? D S T R O VARIABLE 145«-PI*5»P6 •SERVICE/CATEGORY FUNCTION OF DAYS TO REO ENDWK VAR IABLE P13-XH *PWEEK-5 •IS DATE IN P13 ON WEEKEND? H I T B L VARIABLE P1^2-2 •NUMBER OF THE HIGHEST OPERATIONS TABLE H L O N G VARIABLE ( P13-P2I/7 •NUMBER OF WEEKS WAITED FOR OPERATION L D I ST VARIABLE •IDENTIFIES SERVICE/AGE LOS DIST FUNCTION 45+P1^5+P8 LOSO VARIABLE 37*P1*3 •IDENTIFIES SERVICE'S LOS OUEUE L O S O S VARIABLE •IDENTIFIES SERVICE/SEX LOS OUEUE 37+Pl»3+P7 M0D6 VARIABLE XH*USRSL36+1 • IDENTIFY NEW WEEK 0 SLATES MOFF VAR IABLE 47+P14 •IDENTIFIES MED-OFF-SERVICE CHAIN MSPAC VARIABLE Rl-3 • NUM3ER OF BEDS FOR MED SCHEOS NOFF VARIABLE P2-R*l •NUMBER TO PUT BACK ON SERVICE O F F S L VARIABLE Pl*6 •OFFSET TO SLATE MATRIX BY SERVICE AOIST APRWK r. T P R I  O  282 283 284 285 2 86 287 288 289 290 291 292 293 294 295 296 297 298 299 300 301 302 303 304 305 306 307 308 309 310 311 312 313 314 315 316 317 318 319 320 321 322 323 324 325 326 327 328 329 330 331 332 333 334 335 336 337 338 339 340 341  SD! ST SEUSC SGYOW stusr. SRVOP TRYDR VTIME WAITO WKDAY WRONG  VARIABLE VAR IA9LE VARIABLE VARIABLE VARIABLE VARIABLE VARIABLE VAR I A B L E VARIABLE VARIABLE  245*Pl*5tP8 • I D E N T I F I E S SERVICE/AGE L OF SURGERY (Pl-2)*7*7 *FOR 'SLATE END' CHAIN, BY SERVICE 198-P1 • SERVICE FUNCTION FOR SURGERY DOW (Pl-2)*7+(XH$WEEKtXH*USPSL-l!36«-l *SLATE CHAIN TO USE BY WEEK 16+Pl*2 • SAVEVALUES OF OPN STATS BY SERVICE (P13-P14I37 •DESIRED DAY AND DOCTOR'S DAY CORRESPOND? XHtNOWTM-Pll+XHtCHKTM * T I ME AFTER SUBSTITUTING I P1-1»*5*P6 • I D E N T I F I E S SERVICE/CATEGORY WAIT QUEUE P3-XH SPWEEK+I •DAY-OF-THE-WEEK (TOMORROW! 53*(P1*8)*P14 * INDICATES WRONG AREA QUEUE  ***************************************  •  QUEUES AND OTABLES  *************************************** * *  FOR WAITS WMEOU EOU 3,0 WMEOS EOU 4,0 WMFOE EOU 5,0 WTU1 QTABLE WMEOU.0,2,23 WTSl OTABLE WMEDS.O, 2,23 WTFl OTABLE WMEOE.0,2.23 WEENU EOU 13.0 14,0 WEENS EOU WEENE EOU 15,0 WTU3 OTABLE WEENU,0,2,24 WT S3 OTABLE WEENS.0.2.30 WTE3 OTARLE WEENE.0.2.37 WORPH EOU 18,0 WORPS EOU 19,0 WORPE EOU 20.0 WTU4 OTABLE WORPU.0,2,19 ' WTS4 OTABLE WORPS,0,2.23 WTE4 OTABLE WOP.PE.0.2,27 * LENGTH OF STAY LOS ME EOU 40.0 • L OSMM EOU 41,0 LCSMF EOU 42,0 STAI OTABLE L0S«E,0.3,32 LCSEE EOU 46,0 LOSEM EOU 47,0 LOSEF EOU 48,0 STA 3 OTABLE LOSEE.0.3,17 LOSOR E 01.1 49,0 LOSOM EOU 50,0 LOSOF EOU 51,0 STA4 OTABLE LOSOR.0,3,32 * WRONG AREA MINO EOU 61,0 MIN2 EOU 63,0 MIN3 EOU 64.0 MIN4 EOU 65,0 EINO EOU 77.0 EIN2 EOU 79,0 E I N 4 EOU 81.0 OINO EOU 85,0 0IN2 EOU 87, 0 0IN3 EOU 88,0  •MEDICAL URGENT •MEDICAL SEMI -URGENT •MEDICAL ELECTIVE  •EENT URGENT •EENT SEMI-URGENT •EENT E L E C T I V E  • ORTHOPEDICS URGENT • ORTHOPEDICS SEMI-URGENT •ORTHOPEDICS ELECTIVE  • MEDI CINE • MEDICINE MALES •MEDICINE FEMALES •EENT • EENT MALES •EENT FEMALES • ORTHOPEDICS • ORTHOPEDICS MALES •ORThOPEDICS FEMALES •MEDICALS IN EMERG •MEDICALS I N GSG ETC. •MEDICALS IN EENT •MEOI CALS IN ORTHO •EENTS I N EMERG •EENTS IN GSG ETC. • EENTS IN ORTHC •ORTHOS IN EMERG • ORTHOS IN GSG ETC. •CRTHOS I N EE NT  ******************************** *******. •  OTHER TABLES  ***************************************  342 343 344 345 346 347 348 349 350 351 352 353 354 355 356 357 358 359 360 361 362 363 364 365 366 367 368 36 9 370 371 372 373 3 74 375 376 377 378 379 380 381 382 393 384 385 336 387 388 389 39C 391 392 393 394 395 396 397 398 399 400 401  ' OPERATIONS S T A T I S T I C S GSGSN EOU l.T •GENERAL SURGERY NUMBERS GSG ST EOU 2.T •GENERAL SURGERY TIME EENSN EOU 3,T •EENT NUMBERS EENST EOU 4.T •EENT TIME EENSN TABLE XHiEOPNO.0,1,11 EENST TABLE XHJ.EOPTM, 0,60, 18 ORPSN EQU 5.T •ORTHOPEDIC NUMBERS ORPST EOU 6.T •ORTHOPEDIC T I P E ORPSN TABLE XH$OOPNO,0, 1,11 ORPST TABLE XH»00PTM,0,60,12 EMTBN EOU 35,T * EMERGENGY NUMBERS CMTRT EOU 36.T • EMERGENGY TIME EWT8N TABLE XH$EMGNO,0,1,15 EMTBT TABLE XH t EMGTM , 0, 30, 22 EMERGENCY AND DIRECT URGENT ARRIVALS EMGOU EOU 37,T EMGOU TABLE XHtEMARR.O, 1,32 •NO BEO' OCCURANCES NO BED EOU 38,T NOREO TABLE XHtNOBO.O, 1,22 *•«*««**•******««**«**««*«***«*«*«***** • USER CHAINS  •*••*•**•*•*••••****•*•••*********••*•• AOMMC AO«SC DISCH EMRGC MA L T3 MALT4 SLEEN SLFW1 SLEW2 SLEW3 SLEW4 S L EW5 SLEW6 SLOEN SLOWl SL0W2 SLOW 3 SL0W4 SL0W5 SL0W6 XFFRC  EOU EOU EOU EOU EOU FOU EOU EOU EOU EOU EOU EOU EOU EOU EOU EOU EOU EOU EOU EOU EOU  46,C 43, C 47,C 48,C 50.C 51,C 14.C 8.C 9,C 10,C 11.C 12, C 13,C 21.C 15,C 16,C 17, C 18,C 19,C 20,C 49 ,C  • MEDICAL ADMISSIONS •SURGERY ADMISSIONS •01 SCHARGE CHAIN •EMERGENCY OPERATIONS CHAIN •MEDICAL PATIENTS IN AREA 3 • MEDICAL PATIENTS IN AREA 4 • EENT END SLATE •EENT WEEK 1 SLATE •EENT WEEK 2 SLATE •EENT WEEK 3 SLATE •EENT WEEK 4 SLATE •EENT WEEK 5 SLATE •EENT WEEK 6 SLATE •ORTHO END SLATE •ORTHO WEEK 1 SLATE •ORTHO WEEK 2 SLATE •CRTHO WEEK 3 SLATE •ORTHO WEEK 4 SLATE • CRTHO WEEK 5 SLATE • ORTHO WEEK 6 SLATE •TRANSFERS' CHAIN  ********* *********************** «**•**.  •  STORAGES  *************************************** * •  BEDS PER S E R V I C E STORAGE SI,165/S2,100/S3,35/S4,75  • FUNCTIONS ••••••••••••••••••ft******************** •  D A I L Y PATIENT ARRIVAL DISTRIBUTIONS ARNON FUNCTION P1.E3 • NON-SCHEDULABLE' ARRIVALS BY SERVICE 1,FNJANMED/3,FNtANEEN/4,FNSANORP  O _  402 403 404 405 406 407 . 408 409 410 411 412 413 414 415 416 417 418 419 420 421 422 423 424 425 426 427 428 429 430 431 432 433 434 435 436 437 438 439 440 441 442 443 444 445 446 447 448 449 450 451 452 453 454 455 456 457 458 459 460 461  ARSCH FUNCTION P1.E3 • S C H E D U L A B L E ARRIVALS BY S E R V I C E 1,FN*ASMED/3,FN*ASEEN/4,FNtASORP AN«EO F U N C T I O N RN2.016 • MF DI C l NE N 0 N - S C H E D U L A 8 L E .020, 6/.063. 7/.136,8/.235.9/.350,10/.466,U/.573.12/.665,13/.744,14 .813,15/.874,16/.924,17/.961,18/.984,19/.996,20/1,21 ANEEN FUNCTION RN3.D5 *EENT NON-SCHECULABLE .616,0/.907,1/.959 ,2/.939,3/1.4 ANORP F U N C T I O N RN4.D7 *0RTHOPEDIC NON-SCHEDULABLE . 162,0/.324, I/.568,2/.757,3/. 9 19,4/. 973,5/1.6 ASMED F U N C T I O N RN2.D9 * M E D I C A L SCHEDULABLE .205, 0/.220,I/.245,21. 310.3/.475,4/.725.5/.890,6/.960.7/1.8 A S E E N FUNCTION RN3.09 * E E N T SCHEDULABLE . 3 1 3 , 0 / . 3 7 6 , 2 / . 4 51 , 3 / . 52 8 , 4 / . 6 19 , 5 / . 7 1 2 . 6 / . 8 1 9 , 7 / . 9 4 0 , 8 / 1 . 9 ASORP FUNCTION RN4.06 * O R T H O P E D I C SCHEDULABLE .286,0/.314,1/.429,21.657.3/.829,4/1,5 * NUMBER OF OOCTOPS PER S E R V I C E 1 FUNCTION RN2.C2 * S A Y 22 MEDICAL DOCTORS, EOUAL USAGE 0 , 1 / 1 .23 3 FUNCTION RN3.C2 * SAY 10 EENT COCTORS, EOUAL USAGE 0,1/1,11 4 FUNCTION RN4.C2 • 9 ORTHOPEOIC DOCTORS, EOUAL USAGE 0, 1 / 1 , 1 0 * P A T I E N T D I A G N O S T I C CATEGORY D I S T R I B U T I O N S 10 FUNCTION PI , E 3 • S E L E C T S E R V I C E ' S FUNCTION I . F N U / 3 . F N 1 3 / 4 , FN14 11 FUNCTION RN2.D2 •MEDICINE .800,1/1,2 13 FUNCTION RN3.02 •EENT .788.1/1,2 14 FUNCTION RN4.D2 •CRTHOPEDICS . 7 5 9 , 1/1, 7 20 FUNCTION PI . E 3 • S E L E C T S E R V I C E ' S FUNCTION 1 . F N 2 1 / 3 . F N 2 3 / 4 , FN24 21 FUNCTION RN2.03 •MEDICINE .414,3/.585,4/1, 5 23 FUNCTION RN3.D3 • EENT .033,3/.066,4/1 ,5 24 FUNCTION RN4.03 •ORTHOPEDICS . 0 2 0 , 3 / . 217, 4 / 1 , 5 * P A T I E N T SEX 30 FUNCTION P1.E3 • •SELECT SERVICE 1 . F N 3 1 / 3 , F N 3 3 / 4 , FN 34 31 FUNCTION RN2,D2 • M E D I C I N E PROPORTIONS IN SEXES .565, 1/1,2 33 FUNCTION RN3.D2 • E E N T PROPORTIONS IN S E X E S .500, 1/1, 2 34 FUNCTION RN4,D2 • ORTHO PROPORTIONS IN SEXES .535,1/1,2 * P A T I E N T AGE GROUP 41 FUNCTION RN2.D5 • M E D I C I N E MALE AGE GROUP PROPORTIONS .0C8.1/.143,2/.445.3/.840.4/1,5 42 FUNCTION RN2.05 • MEDICINE FEMALE AGE GROUP PROPORTIONS .008.I/.185.2/.401,3/.743.4/1,5 45 FUNCTION RN3.05 • EENT MALE AGE GROUP PROPORTIONS .025.1/.421,2/.696,3/.922.4/1.5 46 FUNCTION RN3.D5 • E E N T FEMALE AGE GROUP PROPORTIONS .025, 1/.359,2/.567,3/. 853,4/1, 5 47 FUNCTION RN4.D5 •ORTHO MALE AGE GROUP PROPORTIONS .02,l/.45.2/.78,3/.96,4/l,5 48 FUNCTION RN4.D5 •ORTHO F E M A L E AGE GROUP PROPORTIONS  O  46?  . 0 2 , 1 / . 3 2 , 2 / . 5 2 5  463  *  464 465  PATIENT 51  ,3/.815  LENGTH  FUNCTION  OF  ,4/1,5  STAY  DISTRIBUTIONS  RN2.C17  * M E D I C INE  1ST  466  . 9 8 4 , 3 2 / . 9 9 1 , 4 0 / . 9 9 4 , 4 8 / . 9 9 7 , 6 4 / . 9 9 8 , 8 0 / . 9 9 1 , 9 6 / 1 , 1 2 8  467  52  468  0 , I/.  469  .979,32/.987,4  470  FUNCTION  RN2.C17  *MEC!CINE  2ND  1 2 5 , 2 / . 3 8 8 , 4 / . 5 9 1 , 6 / . 71 7 , 8 / . 7 9 9 , 1 0 / . 8 5 2 . 1 2 / . 9  53  FUNCTION  RN2.C17  *MECICINE  3RD  0, 1/.C07,  . 9 6 5 , 3 2 / . 9 3 0 , 4 0 / . 9 8 8 , 4 8 / . 9 9 5 , 6 4 / . 9 9 8 , 8 0 / . 9 9 9 . 9 6 / 1 , 1 2 54  A G E GROUP  2 / . 33 0 , 4 / . 4 9 2 , 6 / . 6 1 7 , 8 / . 7 0 4 , 1 0 / . 7 6 8 . 1 2 / . 855 , 1 6 / . 9 0 9 , 2 0 /  FUNCTION  0, 1/.005,  475  24  0/.992,48/.995,64/.997,80/.998,96/l.128  472 473  AGE GROUP  11 , 1 6 / . 9 4 2 , 2 0 / . 9 6 0 .  471  474  AGE GROUP  0 , II. 1 2 1 . 2 / . 3 9 1 , 4 / . 6 0 0 , 6 / . 7 3 7 , 8 / . 8 1 9 ,1 0 / . 8 7 4 , 1 2 / . 9 3 3 . 1 6 / . 9 5 8 , 2 0 / . 9 7 1 . 2 4  RN2.C17  2 / . 1 8 2 , 4 / . 3 2 7 , 6 / .  *MEDI CINE  .932,24  8  4TH  AGE GROUP  430,8/.550,10/.130,12/.742,16/.818,20/.878.24  . 9 2 6 , 3 2 / . 9 5 6 . 4 0 / . 9 7 3 . 4 8 / . 9 8 5 , 6 4 / . 9 9 1 , 8 0 / . 9 9 4 . 9 6 / 1 , 1 2 8  476  55  477  0 , I/.  4 78  . 852, 32/.9G0, 4 0 / . 9 3 5 , 4 8 / . 9 6 0 , 6 4 / . 9 7 5 . 8 0 / . 9 8 4 , 9 6 / 1 ,  479  FUNCTION  RN2.C17  *MEDI CINE  5TH  AGE GROUP  0 0 5 , 2 / . 11 0 , 4 / . 1 9 6 , 6 / . 2 9 1 , 8 / . 4 0 5 , 1 0 / . 4 8 7 , 1 2 / . 6 1 3 , 1 6 / . 7 0 1 , 2 0 / .  61  FUNCTION  RN3.C15  + EENT  1ST  770.24  128  A G E GROUP  480  0 , I / . 0 7 3 , 2 / . 8 5 1 , 4 / . 9 2 0 . 6 / . 9 4 9 , 8 / . 9 6 7 , 1 0 / . 9 7 4 , 1 2 / . 9 8 6 , 1 6 / . 9 9 0 ,2 0 / . 9 9 3 , 24  481  . 9 9 5 , 3 2 / . 99 7,4 0 / . 993 ,4 8 / . 9 9 9 , 6 4 / 1 , 80  482 433 484  62  485 486 487  FUNCTION  RN3.C13  *EENT  2ND  AGE GROUP  0, 1 / . 0 2 5 , 2 / . 5 6 0 , 4 / . 8 7 0 . 6 / . 9 5 7 . 8 / . 9 8 0 , 1 0 / . 9 8 9 , 1 2 / . 9 9 4 , 1 6 / . 9 9 6 , 2 0 / . 9 9 7 . 9 9 8 , 3 2 / . 9 9 9 , 4 0 / 1 . 8 0 63  FUNCTION  RN3.C12  *EENT  3RD  , 24  AGE GROUP  0 , 1 / . 0 3 2 , 2 / . 4 0 5 , 4 / . 7 1 2 , 6 / . 8 6 3 , 8 / . 9 2 5 , 1 0 / . 9 5 6 , 1 2 / . 9 8 2 , 1 6 / . 992 ,2 0 / . 9 9 6 , 24 .999,32/1.40  488  64  489  0 , 1 / . 0 1 4 , 2 / . 2 5 1 , 4 / . 5 6 1 , 6 / . 7 5 1 , 8 / . 8 5 1 , 1 0 / . 9 1 2 , 1 2 / . 9 5 7 , 1 6 / . 9 7 2 , 2 0 / . 9 8 1 , 2 4  490  . 9 9 0 , 3 2 / . 9 9 4 , 4 0 / . 9 9 6 , 4 8 / . 9 9 7 , 6 4 / 1 , 8 0  491 49?  65  RN3.C15  *EENT  RN3.C15  4TH  AGE GROUP  * EEN T 5 T H A G E GROUP  13 6 , 4 / . 4 4 0 , 8 / . 6 9 8 , 8 / . 8 4 0 , 1 0 / . 9 14 , 1 2 / . 9 6 9 , 1 6 / . 9 8 2 , 2 0 / . 9 8 9 , 2 4  . 9 9 4 , 3 2 / . 9 9 6 , 4 0 / . 9 9 7 , 4 8 / . 9 9 8 , 6 4 / 1 , 8 0  494  66  FUNCTION  RN4.C14  *ORTHO  1ST  A G E GROUP  0, 1/. 122, 2 / . 4 1 8 . 4 / . 5 6 8 , 6 / . 6 7 9 , 8 / . 7 3 7 , 1 0 / . 7 8 I . 1 2 / . 8 4 4 , 1 6 / . 9 1 3 , 2 0 / . 9 5 2 .  496  67  FUNCTION  RN4.C17  *ORTHO  2ND  A G E GROUP  0, 1 / . 0 3 7 . 2 / . 2 4 8 , 4 / . 5 2 4 , 6 / . 7 2 0 , 8 / . 7 9 6 , 1 0 / . 8 4 5 , 1 2 / . 9 0 5  499 500  68  FUNCTION  RN4.C17  *0RTIIO  3RD  A G E GROUP  0, 1 / . 0 2 8 , 2 / . 1 8 7 . 4 / . 3 7 0 , 6 / .  5 02  .944,32/.966,4 0 / . 9 7 7 , 4 8 / . 9 8 9 , 6 4 / . 9 9 5 . 8 0/.997.96/1,12  503  69  FUNCTION  532.8/.620,10/.687,12/.783,16/.852,20/.889,24  RN4.C17  "CRTHO 4TH  504  0, 1/.028, 2/.1  505  .853, 3 2 / . 9 0 6 , 4 0 / . 9 3 6 , 4 8 / . 9 7 0 , 6 4 / . 9 8 4 , 8 0 / . 9 9 0 . 9 6 / 1 ,  506  70  507  0 , I/.  508 *  7 3 , 4 / . 3 0 2 , 6 / . 4 0 6 , 8 / . 4 7 2 , 1 0 / . 5 2 3 , 1 2 / . 6 0 9 , 1 6 / . 701 ,2 0 / . 766 , 2 4  FUNCTION  RN4.C17  *ORTHO  5TH  128 AGE GROUP  0 0 5 . 2 / . 0 3 5 , 4 / . 0 7 8 , 6 / . 1 3 0 , 8 / . 1 7 1 , I 0 / . 2 11 . 1 2 / . 2 8 5 . 1 6 / . 3 9 2 . 2 PATIENT  0/.485,24  PREOPERATIVE LOS  120 FUNCTION 3,1/4,1 *  513 514 515 516  TO  OBTAIN  PI,E2  FRACTION  *SPECIFY OF  P T S NOT A S S I G N E D  A  SERVICE  'REQUESTED  140 FUNCTION 3.FN143/4.FN144  P1.E2  *SELECT  143  P6.03  *EENT  FUNCTION  BY  DATE  OF  ADMISSION"  SPOT  FOR DR)  SERVICE  3,500/4,100/5,300  517  144  FUNCTION  518  3,50/4,100/5,750  519  *  520 521  8  AGE GROUP  . 6 3 0 , 3 2 / . 7 2 2 , 4 0 / . 7 9 0 , 4 8 / . 8 7 5 , 6 4 / . 9 2 4 , 8 0 / . 9 5 2 , 9 6 / 1 , 1 2 8  510 511 512  ,16/.926.20/.940,24  . 9 5 7 , 3 2 / . 9 7 2 , 4 0 / . 9 8 1 , 4 8 / . 9 8 9 , 6 4 / . 9 9 4 , 8 0 / . 9 9 6 . 9 6 / 1 . 1 2 8  501  509  24  . 9 8 3 , 3 2 / . 9 9 3 , 4 0 / . 9 9 7 , 4 8 / 1 , 6 4  497 498  FUNCTION  0, 1 / . 0 1 8 , 2 / .  493 495  FUNCTION  OAYS  TO  P6.D3  .  REQUESTED  163 FUNCTION . 3 3 3 , 0 / 1 , 7  *ORTHOPEDICS  ADMISSION  RN1.D2  DATE  <FROM  NEXT  *EENT  BLOCKEO  URGENTS  \Z ,_  522 523 524 525 526 527 528 529 530 531 532 533 534 535 536 537 538 539 540 541 542 543 544 545 546 547 548 549 550 551 552 553 554 555 556 557 558 559 560 561 56? 563 564 565 566 567 568 569 570 571 572 5 73 5 74 575 576 577 57R 5 79 580 581  164 FUNCTinN . 3 3 3 . 0 / 1 ,7  RN1.D2  165 FUNCTION RNl.Dll .060.0/.360,7/.480,14/.640,21/.8 . 9 8 0 , 6 3 / 1 ,70 168 FUNCTION RN1.D3 . 2 5 , 0 / . 7 5 , 7 / 1 , 14  * EENT  SEMI-URGENTS  * EENT EL ECT IVES 00,28/.880,35/.920,42/.940,49/.960,56 • O R T H O URGENTS  169 FUNCTION PNl,D7 *ORTHO SEMI-URGENTS .1,0/.3.7/.5.14/.7,21/.8,28/.9,35/I,42 170 FUNCTION RN1.08 •ORTHO E L E C T I V E S . 1 , 0 / . 2 . 7 / . 5 . 1 4 / . 6 , 2 1 / . 7 . 2 8 / . 8 , 3 5 / . 9 , 4 2 / 1 , 49 * SURGERY DAYS OF THE WEEK BY DOCTOR 201 FUNCTION XH*CHKDR,D5 * EENT 2,1/4,2/6.3/8,4/10,5 202 FUNCTION XH$CHKDR,05 *ORTHOPEDICS 2,1/4,2/6,3/7,4/9,5 * FUNCTIONS TO DETERMINE HOW MANY QUEUED MEDICAL P A T I E N T S TO ADMIT 231 FUNCTION CHtA0MMC,E3 * FN DEPENDS ON MED OUEUE LENGTH 26,FN232/33,FN233/150,FN234 * NUMBERS ARE BASED ON REMAINING C A P A C I T Y 232 FUNCTION R1.D6 •SLOW IT DOWN 6 , C / 9 . 1 / 1 0 . 2 / 1 2 . 3 / 1 5 . 4 / 5 0,5 233 FUNCTION R1»D6 • SUITABLE 6,0/8,3/10,4/12,5/15,6/50.7 234 FUNCTION R1.D6 • S P E E D I T UP 6,0/8,5/10,6/12,7/15.8/50,9 • FOR EMERGENCY P A T I E N T S 235 FUNCTION P14.D4 •MORNING R E S E R V E , OWN AREA 1,8/2,0/3.4/4.3 736 FUNCTION P14.D4 • MORNING R E S E R V E , OTHER AREAS 1,20/2.0/3,7/4,4 237 FUNCTION Pt4,D4 •NON-MORNING R E S E R V E , OWN AREA 1,0/2,0/3.0/4,0 238 FUNCTION P14.04 •NON-MORNING R E S E R V E . OTHER AREAS 1,0/2,0/3.0/4,0 239 FUNCTION P14.04 • A N Y MORE O F F - S E R V I C E C A U S E XFER 1,20/2.0/3,7/4,4 •  SCHEDULED P A T I E N T S PERMITTED PER DAY BY S E R V I C E 240 FUNCTION PI,02 3,9/4,5 • SCHEDULED TIME P E R M I T T E D PER DAY BY S E R V I C E 241 FUNCTION PI , 0 2 • D E P E N D S ON NUMBER CF O R ' S 3,840/4,420 •  NUMBER BEFORE TURNAROUNDS (DEPENDS ON NUMBER OF O R ' S I 242 FUNCTION PI,02 3,4/4,2 • DOCTORS PER S E R V I C E 243 FUNCTION PI,03 1,22/3,10/4.9 • PROPORTION NOT C A N C E L L I N G FOR LONG WAIT 245 FUNCTION P1.D2 3.990/4,500 • PROPORTION OF THOSE ADMITTED NOT GENERATING EMERGENCY OPERATIONS REQUESTS 247 FUNCTION PI,02 3,934/4,838 • PROPORTION NOT G E N E R A T I N G INHOSPITAL OPERATIONS REOUESTS 248 FUNCTION PI,02 3,968/4,897 • P A T I E N T LENGTH OF SURGERY D I S T R I B U T I O N S 261 FUNCTION RNWDIO • E E N T 1ST AGE GROUP  K5  582 583 584 585 586 587 588 589 590 591 592 593 594 595 596 597 598 599 600 601 602 6 03 604 605 606 607 6 08 609 it, 10 611 (,12 613 614 615 616 617 618 619 620 621 622 623 624 625 626 627 628 629 630 631 632 633 634 635 536 637 638 639 640 641  .111.30/.259,35/.444,40/.630,45/.778,50/.852.55/.889,60/.926.70/.963,90 1,110 262 FUNCTION RN1.023 * EENT 2ND AGE GROUP . 0 5 1 , 2 5 / . 15 3 , 3 0 / . 2 7 1 , 3 5 / . 3 5 6 , 4 0 / . 4 2 4 , 4 5 / . 4 7 5 . 5 0 / . 5 2 5 . 5 5 / . 5 7 6 , 6 0 / . 6 1 0 . 6 5 . 6 4 4 , 7 0 / . 6 7 8 , 7 5 / . 7 1 2 , 8 0 / . 7 4 6 , 8 5 / . 7 8 0 , 9 0 / . 8 1 4 , 1 0 0 / . 8 4 7 , 1 1 0 / . 8 8 1 .120 . 9 1 5 , 1 3 0 / . 9 3 2 . 1 4 0 / . 9 4 9 , 1 5 0 / . 9 6 6 , 1 6 0 / . 9 8 3 , 1 7 0 / 1 , 200 263 FUNCTION RN1.017 *EENT 3RD AGE GROUP .051, 3 0 / . 1 0 3 , 4 0 / . 1 5 4 , 5 0 / . 2 0 5 , 5 5 / . 3 3 3 , 6 0 / . 4 1 0 . 6 5 / . 4 6 2 , 7 0 / . 5 9 0 . 7 5 / . 6 4 1 ,80 . 6 9 2 , 8 5 / . 7 4 4 , 9 0 / . 7 9 5 , 9 5 / . 8 2 1 , 1 0 0 / . 8 7 2 , 1 1 5 / . 9 2 3 , 1 3 0 / . 9 7 4 , 1 6 0 / 1 . 210 264 FUNCTION RNl.Dll *EENT 4TH AGE GROUP .042,25/.125,40/.250,50/.417,55/.583,60/.708.65/.792,70/.875.80/.917,90 .958,100/1,120 265 FUNCTION RN1.07 *EENT 5TH AGE GROUP .167,30/.333.45/.500.55/.667,60/.833,65/.917,70/1.80 266 FUNCTION RN1.D6 *CRTHO 1ST AGE GROUP . 1 , 2 0 / . 2 , 3 0 / . 4 , 4 C / . 6 , 5 0 / . 9 , 6 0 / 1 , 70 267 FUNCTION RN1.Q14 *ORTMO 2ND AGE GROUP .097. 30/.161 , 4 5 / . 2 9 0 . 5 0 / . 4 1 9 , 5 5 / . 5 16,60/.613,65/.677,70/.742.75/.774.80 .839,90/.903,100/.935, 110/.968,120/1.130 268 FUNCTION RN1.D17 *0RTHO 3RD AGE GROUP . 0 6 8 , 1 5 / . 136, 3 0 / . 2 2 7 , 4 5 / . 3 1 8 , 5 0 / . 4 0 9 , 5 5 / . 5 0 0 , 6 0 / . 5 9 1 , 6 5 / . 6 8 2 , 7 0 / . 7 5 0 , 7 5 .818,80/.864.90/.8 86.100/.909. 115/.932,130/.955, 145/.977,160/1,200 269 FUNCTION RN1.D12 *GFTHO 4TH AGE GROUP . 0 3 3 , 3 0 / . 0 6 7, 4 0 / . 2 C , 4 5 / . 3 6 7 , 5 0 / . 4 3 3 , 6 0 / . 5 3 3 , 7 0 / . 6 0 0 , 8 0 / . 7 6 7 , 9 0 / . 8 3 3 , 1 0 0 . 9 0 0 , 1 2 0 / . 9 6 7 , 1 3 5 / 1 ,150 270 FUNCTION RNl.Dll *CRTHO 5TH AGE GROUP .07 I , 3 0 / . 1 4 3 , 4 5 / . 2 8 6 , 6 0 / . 3 5 7 , 7 5 / . 4 2 9 , 9 0 / . 5 7 1 , 1 0 5 / . 6 4 3 . 1 2 0 / . 714,130 .857,140/.929,180/1,240 *************************************** * EXPLANATION OF G A R Y EVENT P R I O R I T I E S *«*****************+******************* * * THE SLATE-UPDATING 'BOOKKEEPER* IS HIGHEST PRIORITY - 2 1 . * * THE DETERMINATION OF ADMISSION REQUESTS TO APPEAR ON T H I S DATE I S * HIGHEST PRIORITY OF THE P A T I E N T - R E L A T E D EVENTS I N I T I A T E D - 1 9 . * A PATIENT BEING GIVEN CHARACTERISTICS AND BEING F I L E D IS RAISED « TO PRIORITY 2 0 SO THAT IT IS DONE BEFORE WORKING ON ANOTHER. * . * DISCHARGES ARE SECOND PRIORITY - 16 * * TRANSFERS ARE NEXT - 14 * * MORNING EMERGENCIES ARE NEXT - 12 * * THE AOMISSION PROCESSING FOR T H I S CATE IS P R I O R I T Y 1 0 . A L L ADMITTED * PATIENTS ARE CONSIOEREO I N GENERATING EMERGENCY AND INHOSPITAL OPERATIONS * * ALL NCN-MORNING EMERGENCIES COME THEN - 6 * * OR DATA IS CALCULATED LAST - 2 * * A TIMER TRANSACTION COMPLETES EACH DAY - PRIORITY 1 * ***************»».«»*»******•.•**«*.*.••*«* * TRANSACTION TO UPDATE SLATE F I L E EACH WEEKENO *************************************** GENERATE 1...1,21.2 *GENERATE SINGLE ENTITY AS BOOKKEEPER SUN ASSIGN 2.6 * S E T PARAMETER 2 TO LOOP T I L L SATURDAY DAY ADVANCE 1 * L E T DAY PASS 1  642 643 644 645 646 647 648 649 650 651 652 653 654 655 656 657 658 659 660 661 662 663 664 665 666 667 668 669 670 671 672 673 674 675 676 677 678 679 680 681 682 683 684 685 686 687 638 689 690 691 692 693 694 695 696 697 698 699 700 701  •DECREMENT P2 (UNTIL 0) AND GO TO DAY LOOP 2,CAY FIRST THING EACH SATURDAY • ADD 1 WEEK TO NEXT SURGERY DATES MSAVEVALUE 9-1 0* 11.1-5 .7 , NH •ADD 1 MOD 6 TO XHSUSRSL VIA PI 1,VtM006 ASSIGN •RESET XHtUSRSL USRSL,PI,H SAVEVALUE •HENCE, WORKING 5 WEEKS AWAY WEEK,5,H SAVEVALUE • I D E N T I F Y ROW FOR APPROPRIATE WEEK'S PTS PTFWK.VtAPRWK.H SAVEVALUE •SET THIS THE SAME TMFWK,XH$PTFWK,H SAVEVALUE — TMFWK+ ,_. 1 ,H •APPROPRIATE WEEK'S TIME IS I ROW LATER SAVEVALUE MSAVEVALUE 9-10,XHtPTFWK,1-5,0,MH *FOR WHOLE WEEK, « PTS SET TO 0 MSAVEVALUE 9-10,XHiTMFWK,1-5,0,MH *FOR WHOLE WEEK.TIME SET TO 0 SAVEVALUE MDATE. XH$PWEEK ,H • F I R S T DAY OF PRESENT WEEK TO MDATE MDATE*,47,H •FRIDAY OF WEEK TO BE BROUGHT IN SAVEVALUE 1,4 •P1=HIGHEST SERVICE ASS IGN P1.2.NDAY •DON'T 00 SERVICE 2 TCMOV TEST NE V t S E U S C , O N F I L , A L L , B V $ S I X W K •UNLINK THAT WEEK TO F I L E UNLINK l.TOMOV •DECREMENT SERVICE NUMBER AND REPEAT LOOP •FIRST DAY OF NEW SLATE WEEK NDAY SAVEVALUE PWEE K* ,7 ,H 1 •OVER SATURDAY ADVANCE ,SUN 'ANOTHER WEEK...GO TO SUNDAY TRANSFER • BRINGING APPROPRIATE PART OF END CHAIN TO 5TH WEEK CHAIN •DOCTOR TO CHECK FOR THIS PATIENT ONFIL SAVEVALUE CHKDR,P5,H • WORK ING 5 WEEKS AWAY WEEK,5,H SAVEVALUE • P15=DAY OF WEEK FOR THAT OOCTOR 15,1,V$SGYDW ASSIGN • I D E N T I F Y ROW FOR APPROPRIATE WEEK'S PTS PTFWK.VtAPRWK.H SAVEVALUE • SET THIS THE SAME TMFWK,XHtPTFWK.H SAVEVALUE •APPROPRIATE WEEK'S TIME IS I ROW LATER TMFWK*,1,H SAVEVALUE IS THERE SPACE CN THAT DAY? 1 3 , MH*V$OFFSL(XH$PTFWK,P15 I •P13 = PTS FOR DATE BEING CHECKED ASSIGN 13*, 1 •P13=PTS IF THIS ONE ADDED ASSIGN 14, MH*V$0FFSL(XH$TMFWK,P15 I *P14=TIME FOR DATE BEING CHECKED ASSIGN • P14=TIME I F THIS ONE ADDED 14*,P11 ASSIGN •TES1ING FOR SPACE BV$TRYDA,1,DAYES TEST NE •NO SPACE, MARK PRESENT DAY 13 MARK •WAITED OVER 7 WEEKS UNSUCCESSFULLY? TEST GE V IHLONG,7,NLONG •YES, MANY CANCEL TRANSFER .FN245,,NLONG • ONE MORE SAVEVALUE CANCL*,l,H • WANT SERVICE TO MATCH SAVEVALUE MSRVC.P1.H •WANT DATE GENERATED TO MATCH SAVEVALUE M0GEN.P2 ,H •WANT ADM DATE TO MATCH SAVEVALUE MDATE,P3,H • ALSO MATCH LENGTH OF STAY SAVEVALUE ML0ST,P9,H * AL SO MATCH LENGTH OF SURGERY SAVEVALUE M L_O S G . P l l . H UMLINK ADMSC. OFFFQ. I . BV SMACHR * « FA ILD *TAKE OFF ADM CHAIN TRANSFER .DSPOS * REMOVE FROM MODEL OFFFO DEPART VtWAITQ * BETTER TAKE FROM WAIT QUEUE ,DSPOS *R EMOVE FROM MOOEL TRANSFER *NOT TOO LONG, ADM DATE TO MATCH NLONG SAVEVALUE MDATE.P3..H MSRVC.Pl.H *WANT SERVICE TO MATCH SAVEVALUE MDGEN, P2 »H •WANT DATE GENERATED TO MATCH SAVEVALUE ML0ST.P9.H * AL SO MATCH LENGTH OF STAY SAVEVALUE MLOSG.Pll.H *ALSO MATCH LENGTH OF SURGERY SAVEVALUE ADMSC,UPWK,1.BVtMACHR,.FAILO *GET PT OFF ADM CHAIN UNLINK 3*,7 *ADD 1 WEEK TC ADMISSION DATE ASSIGN ASSIGN 4*,7 •ADD 1 WEEK TO SURGERY DATE LINK V$SEUSC,6 •BACK ON SLATE END CHAIN 3*. 7 *AD0 1 WEEK TO ADM DATE UPWK ASSIGN ASSIGN 4*.7 *ADC 1 WEEK TO SURGERY DATE LINK ADMSC i 3 *BAGK ON ADMISSION CHAIN • THERE IS SPACE FOR THESE OA YE S MSAVEVALUE VSOFFSL* , XHt PTFWK. PI 5 , 1. MH *ADD 1 TO PTS THAT WEEK/DOW/SERV ICE :  to  702 703 70* 705 706 707 70B 70" 710 711 712 713 714 715 716 717 718 719 720 721 722 723 724 725 726 727 728 729 730 731 732 733 734 735 736 737 738 739 740 741 742 743 744 745 746 747 748 749 750 751 752 753 754 755 756 757 758 759 760 761  MSAVEVALUE VtOFFSL+.XHtTMFWK,PI 5.P11.MH *A00 SURGERY TIME S I M I L A R L Y TEST GE MH*V$OFFSL(XH$PTFWK,PI 5 I,FN242,PUT1 * 2 * PTS PER OR SLATE07 MS AVEVALUE V t O F F S L +,XHtTMFWK,PI 5.15,MH *AOD TURNAROUND BEFORE NEXT PT PUT1 LINK V*SLUSC,5 *PUT ON SLATE USER CHAIN »***.*************»**********+*****.*** * PATIENT GENERATION SECTION ***•*»«*«»»*»**«*»•«*«********«***»«*** * * EACH DAY AN ENTITY IS GENERATED AN0 MARKED WITH THE T I M E . * IT I S THEN S P L I T INTO THE APPROPRIATE NUMBER OF PATIENTS FOR EACH SERVICE * FOR THAT OAY. THESE P A T I E N T S HAVE PARAMETERS AS FOLLOWS! * PI S E R V I C E AS FOLLOWS: * 1-MEDICINE * 2-GENERAL SURGERY * 3-E.E.N.T. * 4-0RTH0PEDICS * P2 TIME I DAY) OF ADMISSION REOUEST * P3 TIME OF ADMISSION * P4 TIME OF (NEXT) OPERATION * P5 NUMBER OF OOCTOR * EG. 1-9 FOR ORTHOPEDICS * P6 PATIENT DIAGNOSTIC CATEGORY: * 1-EMERGENT * 2-DIRECT URGENT * 3-URGENT * 4-SEMI-URGENT * 5-ELECTIVE * P7 SEX: * 1-V6LE * 2-FEMALE * P8 AGE GROUP: * 1- 0-14 * 2- 15-34 * 3- 3 5 - 5 4 * 4- 55-74 * 5- 75 OR ABOVE * P9 LENGTH OF STAY * P10 PRF-OPERATIVE LOS * PI I LENGTH OF (NEXT) SURGERY * P12 REQUESTED ADMISSION DATE (SURG.OATE FOR SURGICAL S E R V I C E S ) * P13 WORK...FOR DISCHARGES OR TRANSFERS, TIME OF DISCHARGE * P14 WORK...FOR TRANSFER AN 0 DISCHARGE P A T I E N T S , AREA IN * P15 WORK * * GENERATE 1,,,,19,15 * D A I L Y . F I R S T THING DONE RE. PATIENTS ASSIGN 1,4 *P1=HIGHEST HOSPITAL SERVICE MARK 2 *P2=TIME OF ADMISSION REOUEST REAL TEST NE P1.2.L00P1 . *OCN'T 00 SERVICE 2 SPLIT FNtARNCN,PTS1 *MAKE NON-SCHEDULABLE REOUESTS SPLIT FNtARSCH.PTSZ * MAK E SCHEDULABLE REQUESTS L O O P l LOOP I,REAL *DECREMENT SERVICE AND GO TO REAL OUT TERMINATE *R EMOVE XACT GENERATING PTS FROM MODEL * SEGMENT ASSIGNING CHARACTERISTICS TO PATIENTS PTS1 ASSIGN 6.1,10 *P6=PT DIAGNOSTIC CATEGORY ( V I A FN10) TRANSFER .CHAR *G0 ASSIGN OTHER CHARACTERISTICS PTS2 ASSIGN 6,1,20 »Pfc=PT DIAGNOSTIC CATEGORY ( V I A FN20) CHAR ASSIGN 5.1.PI *P5=NUMBER OF PATIENT'S DOCTOR ( V I A F N * l ) ASSIGN 7,1,30 *P7=PATIENT SEX. ( V I A FN30) ASSIGN B.l.VtAOIST *P8=PATIENT AGE GROUP ( V I A FN*V»ADIST)  ^ LL ^  76? 763 764 765 766 767 768 76 9 770 771 772 773 774 7 75 776 777 778 779 780 781 782 783 734 785 786 73 7 788 789 790 791 792 793 794 795 796 797 798 799 800 801 302 803 804 805 806 807 808 809 810 811 812 813 814 815 816 817 818 819 820 821  ASSIGN MSAVEVALUE MSAVEVALUE TEST GE PRIORITY PRIORITY OUEUE TEST NE TRANSFER  *****************  •  9,l,VtLDIST Pl+,P6,l,l.MH P1+,6,1,1,MH P6,3,EMERG VSCTPRI,BUFFER 20 VtWAI TO P I , 1, MEDIC ,SURG  *********************  *P9 = PATIENT"S L OF STAY ( V I A F N * V $ L 0 I S T ) •ADD 1 TO » GENERATED (SERVICE/CATEGORY) • ADD 1 TO # GENERATED ( B Y S E R V I C E ) •SEND EMERG AND DIRECT URGENTS TO HANDLE • PROCEED IN ORDER BY CATEGORY • RAISE TO PROPER CATEGORY •GATHER WAIT TIME STATS (SERVICE/CATEGORY •SEND MEDICAL REQUESTS TO HANDLE •SEND SURGICAL REQUESTS TO HANDLE  SURGICAL REOUEST HANDLING  **************************************  w  • * *  CONSIDER E.E.N.T.,ORTHOPEDICS,UROLOGY, AND GYNECOLOGY TO BE PROPERLY BLOCK BOOKED BY DAY FOR DOCTOR, GENERAL SURGERY BY SUB-SERVICE. AND NEURO/PLASTICS NOT AT A L L .  *  • TEMPORARY 8LN0T TERMINATE •TEMPORARY BLSRV TERMINATE • P10=PRE-0PERATIVE LOS ( V I A FN120 I 10,1.120 SURG ASSIGN • I F PRE-OP LOS I S * L' L O S , CAN BE DONE P10.P9,CANDO TEST GE • IF NOT, PUT PRE-OP LOS I N LOS SPOT 9.P10 ASSIGN •AND ADD I ASSIGN 9*,1 • P I 1= LENGTH OF NEXT SURG (VIA FN*V*SDIST» U.l.VtSDIST CANDO ASSIGN •FOR SERVICE 2 GO BLOCK BOOK BY A/B/C. P I , 2,BLSRV TEST G • FOR SERVICE 7 GO TREAT AS NOT BLOCK BOOK P 1 , 7,BLNQT TEST L • DOCTOR TO CHECK IN XHSCHKDR CHKDR.P5.H SAVEVALUE •XFER PROPORTICN NOT REQUESTING A DATE .FN140,, NOREQ TRANSFER * ASSIGN A REQUESTED DATE TO AN APPROPRIATE PROPORTION OF PATIENTS • P12=DAYS TO REO. DATE FROM NEXT BLOCK 12,l,V»DSTRQ ASSIGN • P13=0CCT0R« S DAY OF WEEK FOR SURGERY 13,1 ,V$SGYDW ASSIGN 12+,MH*VtOFFSL(1.P13I *P 12=REQUESTEO DATE CF SURGERY ASSIGN • IS S EQ. DAT E PCSS I BLE7 P13=PRESENT TIME 13 MARK •P13=EARL1EST POSS DATE FOR PRE-OP LOS 13*,P10 ASSIGN • IF THIS DATE ' L E ' REQ. DATE O.K. TEST G P13.P12.FEAS •OTHERWISE INCREMENT REO. DATE SO O.K. A S SIGN 12+. 7 • CHECK DATE (FOR SURGERYI FROM REO. DATE CHECK,P12.H FEAS SAVEVALUE • GO TRY TO PLACE ON SLATE . TRY TRSNSFER * NO PARTICULAR DATE REQUESTED FOR THESE PATIENTS •P13=PRESENT TIME 13 NOREO MARK • ZERO P15 ASSIGN 15,0 •P15=-PRESENT TIME 15-.P13 ASSIGN • P14=D0CT0R>S DAY OF WEEK OF SURGERY 14,1 .VSSGYDW ASSIGN 13.MH*V»0FFSL« 1.P14) •NEXT DATE OF SURGERY FOR DOCTOR ASSIGN •P15=-VE OF NEXT POSSIBLE TIME 15-.P10 ASSIGN • P15=FREE MARGIN TO NEXT SLATED DAY 15*,P13 ASSIGN • I F NEGATIVE, CUST F I X TEST L P15.0,AFEAS • INCREASE BY 1 WEEK 13 + , 7 ASSIGN •CLEAR NUMBERS FROM P15 15.0 AFEAS ASSIGN •START CHECKING SPOT I WEEK FR EARLIEST 13+.7 ASSIGN • CHECK DATE WAS COMPUTED IN P 1 3 SAVEVALUE CHECK. PI 3.H SEGMENT READY TO TRY A PARTICULAR DAY AT THIS POINT , XHJCHKOR AND XHSCHECK MUST BE SET  * *  A  • WEEK CHECKED DETERMINED FROM CHECK DATE SAVEVALUE WEEK ,V tCWEEK ,H • IF 'L» 6 WEEKS AWAY. LOOK AT SLATE XHSWEEK.6.LO0K TEST GE THESE ONES 6 OR MORE WEEKS AWAY, PUT ON SLATE END *P4=CHECK DATE FOR SURGERY 4,XH*CHECK ASSIGN • SAME TO P3 ASSIGN 3.P4  TRY  *  822 8?3 824 825 826 82 7 828 829 830 831 832 833 834 835 836 837 838 839 340 841 842 843 844 845 346 847 34 8 849 850 851 852 853 854 855 856 857 858 859 860 861 862 963 864 865 865 867 e68 869 870 971 872 873 874 875 876 877 878 879 880 881  ASSIGN 3-.P10 *P3 = ADMISSI0N DATE I SURG - PREOP) TEST LE P6,0,P0S1 * WANT P O S I T I V E CATEGORY ASSIGN 13, P6 •PUT ANY NEGATIVE CATEGORY I N P13 ASSIGN 6,0 •SET TO 0 ASSIGN 6-.P13 •NOW POSITIVE P0S1 SPLIT l.SLCHl •CREATE COPY FOR SLATE CHAIN TRANSFER .FILE •ORIGINAL TO ADMISSION F I L E SLCH1 L INK V$SEUSC,6 • L I N K TO SLATE-END CHAIN BY DOCTOR FOR THESE MUST LOOK AT DESIRED SPOT ON SLATE LOOK ASSIGN 15.1,V$SGYDW •P15=SURGERY DCW FOR DOCTOR SAVEVALUE PTFWK.VtAPRWK.H • I D E N T I F Y ROW FOR APPROPRIATE WEEK'S PTS SAVEVALUE TMFWK,XH$PTFWK,H •SET THIS THE SAME SAVEVALUE TMFWKt-.l.H *APPROPRIATE WEEK'S TIME IS 1 ROW LATER ASSIGN 13, M H * V t O F F S L ( X H t P T F W K , P l 5 ) •P13=PTS FOR DATE BEING CHECKED ASSIGN *» •P13=PTS I F THIS ONE ADDED ASSIGN 14, MH^VtOFFSL(XH$TMFWK,Pl5) *P14=TIME FOR DATE BEING CHECKED SAVEVALUE N P U T M . DP14.H I A - U h T t Ii r nrmnr. NOWTM, •TIME BEFORE A BUMP ASSIGN 14+.P11 •P14=TIME I F THIS ONE ADDED SAVEVALUE CHKTM.PH.H •SETTING SURGERY TIME TO TRY TO F I N D TEST NE BVtTRYDA,1.GOTDA • I F TRUE, THE DAY IS GOOD TEST L E P6.3.N0TUR •UNLESS P6 I S 3 (OR SET NEG) NOT URGENT l 3  THE FOLLOWING  l  SECTION OEALS WITH URGENT PATIENTS  TEST GE XH$WEEK,2,US00N • I F TRYING ' L ' 2 WEEKS AWAY. DO SOON URGENTS OVER 2 WEEKS AWAY TRY TO BUMP UNLINK VtSLUSC.BUMPD.l.BV*BUMPE..NOE *0/W TRY TO BUMP E L E C T I V E OF THIS DR TRANSFER .GOTDA • PUT THIS ONE ON IN HIS PLACE NOE UNLINK V$SLUSC,BUMPD,1,BVJBUMPS,,NOS •NO EL - TRY TO BUMP SEMI-URGENT TRANSFER ,GOTDA *PUT THIS ONE ON IN HIS PLACE NOS SAVEVALUE CHECK*,7,H *NOONE TO BUMP, SO TRY 1 WEEK LATER TRANSFER TRY • +G0 TRY AGAIN THESE TO BE TREATED AS URGENTS FOR WITHIN 2 WEEKS USOON MARK •START CHECKING AT E A R L I E S T P O S S I B L E TIME ASSIGN *»1 ^TRY TOMORROW ADM AT EARLIEST ASSIGN *' ° •NOW HAVE E A R L I E S T DAY OF SURGERY TEST L E P13.MH^V$0FFSLf 1,5),NEWK *DATE BY THIS F R I D A Y ? THWK SAVEVALUE V.EEK,0,H •BY FRIOAY, SO IT IS THIS WEEK TRANSFER ,WANTD •WANT TO FIND A DOCTOR NEWK TEST L V*ENDWK,3,PR0PR •WAS DATE SET ON WEEKEND? ASSIGN 13,XHtPWEEK ASSIGN 13*.8 •YES, SO SET TO NEXT MONDAY PROPR SAVEVALUE WEEK,I,H •HAVE PROPER CATE NEXT WEEK WANTD SAVEVALUE CHECK. PI 3.H •CHECK DATE I S E A R L I E S T POSSIBLE HAVE DATE, FIND CORRESPONDING DOCTOR SAVEVALUE CHKDR,1,H •COULD 1ST DOCTOR POSSIBLY 0 0 ? GETDA ASSIGN 15,l,VtSGYDW • F I N D THIS DOCTOR'S DAY OF THE WEEK ASSIGN 1 4 , M H * V t O F F S L { I . P 1 5 ) •NEXT DAY OF SURGERY FOR THAT DOCTOR TEST NE U t T B v n o . n n*wni/ _ -v/^ n • . — — . . . . .. VtTRYDR.O,DAYOK •TO DAYOK I F THIS ONE MIGHT DO SAVEVALUE CHKDR*,I,H •TRY NEXT DOCTCR TRANSFER ,GETDA •GO TO GET HI S DAY DATE AND DOCTOR CORRESPOND, SEE IF THE DAY IS OK DAYOK SAVEVALUE PTFWK,VtAPRWK.H • I D E N T I F Y ROW FOR APPROPRIATE WEEK'S PTS SAVEVALUE TMFWK,XHtPTFWK.H •SET THIS THE SAME SAVEVALUE TMFWK*,I ,H •APPROPRIATE WEEK'S TIME IS 1 ROW LATER ASSIGN 13. MH*V$OFFSL(XH$PTFWK,P15) *P13 = PTS FOR DATE BEING CHECKED ASSIGN ' 'PTS IF THIS ONE ADDED ASSIGN 14, MH*V$0FFSL(XHJTMFWK,P15) • P14=TIME FOR THAT DATE ASSIGN l*+. ll *TIME I F THIS ONE ADDED TEST NE BVtTRYDA,1,GOTDA * I F TRUE, GOT DAY 1 3  1 3  1 3  l 3 +  P 1  1  p  -1  882 883 88* 335 886 887 888 889 890 891 892 893 .894 895 896 897 898 899 900 901 902 903 904 905 906 907 908 939 910 911 912 913 914 915 916 917 918 919 920 9?1 922 923 924 925 926 927 928 929 930 931 932 933 934 935 936 937 938 939 940 941  TEST NE P15.5.WKDON * I F THAT WAS F R I D A Y , WEEK DONE SAVEVALUE C H K D R * , 1 , H * ADD 1 TO CHECKED DOCTOR ASSIGN 15,l,VtSGYDW *P15=SURGERY DOW OF THIS DOCTOR ASSIGN 14, M H * V t O F F S L C I . P 1 5 1 *NEXT DATE OF SURGERY FOR THAT DOCTOR TEST NE VtO ASA M, 0 , NE WOR * I F THIS DR ON SAME DAY GO FOR ANOTHER SAVEVALUE CHECK*,1,H ' T O TRY DAY LATER TRANSFER ,DAYOK * G 0 SEE IF THIS DAY IS OK WKOON SAVEVALUE WEEK + . l . H ' * TRY NEXT WEEK * TREAT S P E C I A L L Y IF THIS IS TOO FAR AWAY TEST GE XHt WEE K, 3 , CL0S1 * A R E THERE NO SPOTS NEARBY7 SAVEVALUE CHKDR,P5,H * N 0 , GET PROPER DOCTOR AGAIN ASSIGN 15,l,VtSGYDW ' H I S DAY OF THE WEEK FOR SURGERY SAVEVALUE C H E C K , M H * V $ O F F S L 1 1 . P 1 5 ) , H ' H I S NEXT SURGERY DAY SAVEVALUE CHECK*, 14,H * 2 WEEKS AWAY TRANSFER ,TPY * FE WILL NOW BUMP ANOTHER * S T I L L CLOSE ENOUGH C L O S l SAVEVALUE C H E C K * , 3 , H 'ADVANCE DAY FRIDAY TO MONDAY SAVEVALUE CHKDR, 1 ,H ' S T A R T AGAIN WITH FIRST DOCTOR ASSIGN 15,1 ' T H I S DOCTOR'S DAY OF THE WEEK TRANSFER ,CAYOK . ' G O SEE I F THE DAY IS OK * * THE FOLLOWING SECTION DEALS WITH NON-URGENT PATIENTS * NOTUR SAVEVALUE CHECK* , 7.H ' F O R SEMI-U AND E L , TRY 1 WEEK LATER TRANSFER ,TRY ' G O TRY AGAIN * * 8UMPE0 P A T I E N T S ARE HANDLED HERE * RUMPD SAVEVALUE CHECK,P4,H * DAY BUMPED PT STARTED FROM SAVEVALUE CHKDR,P5.H *DR THIS PATIENT WAS SLATED FOR ASSIGN 15,l.VtSGY0W ' T H A T DOCTOR'S DAY OF THE WEEK SAVEVALUE PTFWK.VtAPRWK.H ' I D E N T I F Y ROW REMOVED FROM SAVEVALUE TMFWK,XHtPTFWK.H ' S E T THIS THE SAME SAVEVALUE TMFWK+.l.H ' I D E N T I F Y ROW FOR TIME REMOVED TEST GE M H ' V t O F F S L ( X H t P T F W K . P I 51.FN242.NRTPN *1 OR MORE PER OR THERE? MSAVEVALUE V t O F F S L - . X H t T M F W K . P 1 5 . 1 5 . M H 'REMOVE TURNAROUND WHICH FOLLOWS NRTRN MSAVEVALUE V t O F F S L - . X H t P T F W K . P 1 5 . l.MH 'REMOVE PATIENT MSAVEVALUE V t O F F S L - , X H t T M F W K , P I 5,PI I,MH 'REMOVE HIS TIME SAVEVALUE C H E C K * , 7 . H ' T R Y 1 WEEK FROM THAT SPOT SAVEVALUE MDATE. P3 .H * ADM DATE I FOR MATCHING FROM ADM CHAIN) SAVEVALUE MSRVC.Pl.H 'WANT SERVICE TO MATCH SAVEVALUE MDGEN,P2,H 'WANT DATE GEN ERA TEO TO MATCH SAVEVALUE ML0ST.P9.H * ALSO MATCH LENGTH OF STAY SAVEVALUE MLOSG.Pll.H ' A L S O MATCH LENGTH OF SURGERY UNLINK A D M S C , T R Y , 1 , B V S M A C H R , , F A I L 0 ' G E T PT OFF ADMISSION CHAIN « THEN GO TRY IT FOR LATER WEEK TRANSFER .CSPOS ' T H I S COPY OF PT NOT NEEDED * * PATIENTS HERE HAVE GOTTEN A OAY OK FOR SURGERY » GOTDA ASSIGN 4,XHtCHECK ' S U R G E R Y DATE TO P4 ASSIGN 3.P4 ' S A M E TO P3 ASSIGN 3-.P10 *P3=ADMISSION DATE (SUBTR PRE-OP» ASSIGN 15,l,VtSGYDW * P 1 5 = 0 0 C T C R " S SURGERY DOW SAVEVALUE PTFWK.VtAPRWK.H ' I D E N T I F Y ROW FOR APPROPRIATE WEEK'S PTS SAVEVALUE TMFWK,XHtPTFWK.H ' S E T THIS THE SAME SAVEVALUE TMFWK*,1,H ' A P P R O P R I A T E WEEK'S TIME IS 1 ROW LATER MSAVEVALUE Vt OFFS L* ,XHt PT FWK, PI 5, I, MH ' A D D I TO PATIENTS SLATEO THERE MSAVEVALUE V t O F F S L * . XH1 TMFWK, P 1 5 , PI 1, MH ' A D D SURGERY TIME TO THAT SLATED TEST GE M H * V t O F F S L « X H t P T F W K , P 1 5 I . F N 2 4 2 , P U T 2 * 2 * PER OR SLATEO THERE? NEWDR  ^ J",  942 943 944 945 946 947 948 949 950 951  MSAVEVALUE TEST LE ASSIGN ASSIGN ASSIGN POS SPLIT TRANSFER SLCH2 L I N K * P A T I E N T S HERE FILE LINK PUT2  V S O F F S L * . X H i T M F W K , P I 5 , 1 5 , M H * A 0 0 TURNAROUND BEFORE NEXT PT P6.0.P0S *WANT P O S I T I V E CATEGORY 13,P6 * P U T ANY N E G A T I V E CATEGORY IN P13 6,0 * S E T TO 0 6-.P13 *NOW P O S I T I V E 1.SLCH2 * CREATE COPY FOR S L A T E CHAIN .FILE * O R I G I N A L TO ADMISSION F I L E VtSLUSC.5 * P U T ON S L A T E CHAIN BY OOCTOR ARE F t LEO ON ADMISSION OUEUE ADMSC.3 * 0 N ADMISSION C H A I N BY DATE  1353  ************.**.*****.************* *.*«**«*  953  *  954  j . * * * * * * * * * * * * * * * * * * * * * * . * * . * « * » . * * * * * . * **.**.  955 956 957 958  * * *  MEDICAL  REQUEST  HANDLING  PUT T H E S E R E 3 U E S T S ONTO MEDIC L I N K  THE MEDICAL  ADMISSIONS C H A I N  ADMMC.FIFO  * C N T O MEDICAL  959  «****.« ***.** ************ ********* *.*»*.***  96 1  A**************************************  960  962 963 964 965 966 967 968 969 970 971 972  TRANSACTION  * * * * *  ADMISSIONS  FOR S U R G I C A L A D M I S S I O N S . ADMIT A L L SCHEDULED FOR TODAY (ACCORDING TO THEIR S L A T E ) . M E D I C A L ADMISSIONS GET S P E C I F I E D NUMBER OF REMAINING B E D S . LAST FEW ARE SAVED FOR E M E R G E N C I E S . 1,,,,10 3 ADMSC,ADMS.ALL,3 I.FN231 ADMMC.ADMM,PI  973  **************************************  974  *  975 976 977 978 979 980 991 9f>2 993 984 985 986 987 998 989 990 991 992 993 994 995 996 997 998 999 1000 1001  CHAIN  *  GENERATE MARK UNLINK ASSIGN UNLINK TERMINATE  TO I N S T I G A T E  ADMISSION  SURGERY ADMISSION  +SINGLE TRANSACTION PER DAY TO I N S T I G A T E * T O D A Y ' S DATE IN P3 * A L l SURG. ADMISSIONS TODAY TO ADMS •NUMB ER MED S TO ADMIT * ADMIT MEDICAL PATIENTS *REMOVE I N S T I G A T I N G T R A N S A C T I O N  PATH  ***«******+*****••********»*********** * * * * * *  FOR NOW, ALLOW ONLY INTO A BED OF THE PROPER S E R V I C E A R E A . IGNORING SEX BASED ON AVERAGE NUMBERS E N T E R I N G EMERGENCY AND INHOSPITAL OPERATIONS PER D A Y , NOW G E N E R A T E • T H E S E R E Q U E S T S . SAY EMERGENCIES ARE NEXT D A Y , I N H O S P I T A L R E Q U E S T S AS SOON AS P O S S I B L E FROM 2 DAYS AWAY. ' ADMS GATE LR WAIT * ALLOWED TO BE PROCESSED? TEST L R*1,1,A0K *ROOM IN S E R V I C E ' S BEDS ? SAVEVALUE N0B0*,1,H * O N E MORE 'NO B E D ' ASSIGN 1 3 , P6 +XATEGORY IN P13 ASSIGN 6,0 *WANT TO SET N E G A T I V E ASSIGN 6-.P13 *NOW N E G , PROCESSED AS URGENT * ' N O B E D S ' TRY CVER ASSIGN 13.XHSPWEEK * F I P S T DAY OF PRESENT WEEK IN P13 ASSIGN 13*.7 * A D V A N C E THAT TO NEXT WEEK LOGIC S WAIT * S T C P FURTHER ADMISSIONS NOW PRIORITY 19,BUFFER * F I N I S H WITH OTHERS F I R S T PRIORITY 20 * R E STORE PRIORITY LOGIC R WAIT *ALLOW FURTHER ADMISSIONS NOW * NEED TO L O C A T E THEM ON SURGERY S L A T E TEST L P13,P4.THSWK *WH1CH WEEK SURGERY? T H I S OR NEXT SAVEVALUE WEEK.l.H * C H E C K 1 WEEK AWAY FOR SURGERY T I M E TRANSFER ,OFFSG * NEED PT OFF SURGERY CHAIN THSWK S A V E V A L U E WEEK.O.H * C H E C K ON T H I S W E E K ' S S L A T E S O F F S G SAVEVALUE M0ATE.P3.H * F I P S T , TAKE CATE TO MATCH SAVEVALUE MSRVC.P1.H *WANT S E R V I C E TO MATCH  1002 1003 1004 1005 I 006 1007 IOOR I 009 1010 1011 1012 1013 1014 1015 1016 1017 1018 1 019 1020 1021 1022 1023 1024 1025 1026 1 027 1028 1029 1 03 0 1031 1032 1033 1034 1035 1036 1037 1038 1039 1 04 0 1041 1042 1043 1044 1045 1046 1047 1048 1049 1050 1051 105? 1053 1054 1055 1 056 1057 1058 1 059 1060 1061  SAVEVALUE HOG-EN,P2.H * WANT DATE GENERATEO TO MATCH SAVEVALUE ML0ST,P9,H *ALSO LENGTH GF STAY SAVEVALUE MLOSG.Pll.H ' F I N A L L Y , LENGTH OF SURGERY UNLINK V t S L U S C . O S P O S , l . B V t M A C H R , . F A I L O 'GET PT OFF SURGERY CHAIN SAVEVALUE CHKDR,P5.H * DR THIS PATIENT WAS SLATED FOR ASSIGN 15,l,VtSGY0W * THAT OOCTOR'S DAY OF THE WEEK SAVEVALUE PTFWK.VtAPRWK.H ' I D E N T I F Y ROW REMOVED FROM SAVEVALUE TMFWK,XHtPTFWK.H 'SET THIS THE SAME SAVEVALUE TMFWK*,I ,H * IDENTIFY ROW FOR TIME REMOVAL TEST GE M H ' V t O F F S L I X H t P T F W K . P l 5) .FN242.NRMTN *2+ PER OR THERE? MSAVEVALUE VtOF FS L- .XHtTMFWK, PI 5, 15, MH 'REMOVE TURNAROUND WHICH FOLLOWS NRMTN MSAVEVALUE VtOFFSL-,XHtPTFWK,P15,1,MH 'REMOVE PATIENT MSAVEVALUE VtOFFSL-,XHtTMFWK.P15.P11.MH 'REMOVE HIS TIME ASSIGN 4*.7 * ADO 1 WEEK TO ATTEMPTED OPERATION DATE SAVEVALUE CHECK,P4.H 'PUT THIS DATE IN CHECK OATE TRANSFER .TRY 'GO TRY, SAME RULES AS NEW REQUESTS IF THERE I S A BED... ACK LOGIC S WAIT 'NO MORE ADMISSIONS JUST NOW PR I ORIT Y 10,BUFFER 'RESET PRIORITY LEVEL DEPART VtWAITO 'LEAVE WAITING TIME OUEUE GENERATE EMERGENCY AND INHOSPITAL OPERATION REQUESTS TRANSFER .FN247,,NOEMG 'SEND PROPORTICN NOT GENERATING EMERG OP SPLIT I , NOEMG 'OBTAIN ENTITY TO FOLLOW THIS PATH MARK 4 'PRESENT DAY IN P4 ASSIGN 4*,1 •HENCE EMERG CP TOMORROW TEST GE P9,2,DSPOS 'IGNORE IF LOS L ' 2 DAYS ASSIGN I I , 1,V$SDIST *P1 l^LENGTH OF EMERG SURGERY LINK EMRGC,4 * PUT ON EMERGENCY CHAIN FOR TOMORROW NOEMG TRANSFER ,FN248,,N0INH 'SEND THE PROPORTION NOT PLACING INH REO SPL! T I . NOINH 'GET ENTITY TO EFFECT INHOSPITAL REQUEST ASSIGN I I . 1.V1SDIST »P11 = LENGTH OF SURGERY INHRO MARK 13 'PRESENT DAY IN P 1 3 ASSIGN 13*.2 ' E A R L I E S T POSS DAY 2 AWAY TEST GE P9,3,DSPOS 'IGNORE IF LOS ' L ' 3 DAYS TEST LE P13.MH*VtOFFSL(l,51,NEWEK 'DATE BY THIS FR IOAY? SAVEVALUE WEEK,0,H 'YES, SO IT I S THIS WEEK TRANSFER .WONT D 'WANT TO FINO A DOCTOR NEWEK TEST L VtENDWK,3,PR0PE 'WAS DATE SET CN WEEKEND? ASSIGN 13,XHtPWEEK ASSIGN 13*.8 'YES, SO SET TO NEXT MONDAY PROPE SAVEVALUE WEEK.l ,H 'HAVE PROPER DATE NEXT WEEK WCNTD SAVEVALUE CHECK,PI 3,H 'THIS GIVES CHECK DATE HAVE DATE. FIND CORRESPONDING DOCTOR SAVEVALUE CHKDR, l . H 'CAN 1ST DOCTOR P O S S I B L Y DO GETSG ASSIGN 15,1.VSSGYDW ' F I N D T H I S DR'S DAY OF WEEK ASSIGN 1 4 , M H * V t O F F S L I 1 . P 1 5 ) 'FIND HIS NEXT SURGERY DAY TEST NE VtTRYDR.O,DAYKO ' I F H I S TIME IS OK TO CHECK, TO DAYKO SAVEVALUE CHKDR*,I,H •OTHERWISE, TRY NEXT DOCTOR TRANSFER ,GET SG 'GO TO GET HI S OAY DATE AND DOCTOR CORRESPOND, SEE IF THE DAY IS OK DAYKO SAVEVALUE PTFWK.VtAPRWK.H ' I D E N T I F Y ROW FOR APPROPRIATE WEEK'S PTS SAVEVALUE TMFWK,XHtPTFWK.H 'SET THIS THE SAME SAVEVALUE TMFWK+.l.H 'APPROPRIATE WEEK'S TIME IS I ROW LATER ASSIGN 1 3 , MH*VtOFFSLIXHtTMFWK,P15) *P13 = TIME FOR THAT DAY ASSIGN 13+.P11 *ACD TIME OF THIS ONE TOO TEST G P13.FN241 ,GTDAY *GCT DAY IF TIME OK THERE TEST NE P15.5.WKOUN 'WEEK DONE IF THAT WAS FRIDAY NWDOC SAVEVALUE C.HKDR + . l . H *AOD 1 TO CHECKED DOCTOR ASSIGN 15,l,VtSGYDW *DR'S SURGERY CAY OF THE WEEK IN P15 ASSIGN 14, MH*VtOFFSLI 1.P151 'NEXT DAY OF SURGERY FOR THAT DOCTOR 1  K>  O  1062 1063 1064 1065 I 066 1067 1068 1069 1070 I 071 1072 1073 I 074 1 075 1076 1077 1078 1 079 1 080 1081 1082 1033 1 084 1085 1086 1 087 1098 I 089 1090 1091 1 092 109 3 1094 I 095 1096 1097 1098 1099 1100 1101 1102 1103 I 104 I 105 1106 1107 11 08 1 109 1110 1 111 1112 1113 1114 1115 1116 1117 1118 1119 I 120 1121  *G0 FOR ANOTHER I F THIS DR SAME DAY VtDASAM.O.NWDOC TEST NE •TO TRY DAY LATER SAVEVALUE CHECK*,1,H *G0 SEE I F THIS DAY IS OK .DAYKO TRANSFER * P A T I E N T S HERE HAVE GOTTEN A DAY FOR THEIR INHOSPITAL SURGERY •TRY NEXT WEEK WKOUN SAVEVALUE WEEK*,1,H * TREAT S P E C I A L L Y I F TOO FAR AWAY •ARE THERE NO SPOTS NEARBY? TEST GE XHtWEEK,2,CL0S2 • NO, SO MAKE THIS OPERATION EMERGENCY MARK 4 •FOR TOMORROW 4*,I ASSIGN •PUT ON EMERGENCY CHAIN LINK EMRGC.4 * THESE ARE SOON ENOUGH •ADVANCE DAY FRIDAY TO MONDAY C L 0 S 2 SAVEVALUE CHECK*,3,H • START AGAIN WITH FIRST DOCTOR SAVEVALUE CHKDR,I .H • THIS DOCTOR'S DAY OF THE WEEK ASSIGN 15,1 •GO SEE I F THE DAY I S OK TRANSFER ,DAYKO • SURGERY DATE TO P4 4.XHSCHECK GTOAY ASSIGN •PRESENT OAY TC P13 ASSIGN 13,P3 •P13=TIME OF DISCHARGE NOW 13+.P9 ASSIGN • OISPOSE IF SURG TIME SET BEYOND DISCHARG TEST L P4.P13.DSPOS •ENSURE NO BUMPING ASSIGN 6,0 •P15=SURGERY CAY OF WEEK ASSIGN 15,1.VtSGYDW •SET AS ROW FOR APPROPRIATE WEEK'S PTS TMFWK,VtAPRWK.H SAVEVALUE •APPROPRIATE WEEK'S TIME IS 1 ROW LATER TMFWK+,1,H SAVEVALUE MSAVEVALUE V t O F F S L * .XHtTMFWK , P 1 5 , P l l . M H *ADD SURGERY TIME TO SLATED TIME ,P15,15,MH *ADD TURNAROUND BEFORE NEXT PT MSAVEVALUE VtOFFSL*,XHtTMFWK • PUT ON SLATE USER CHAIN LINK VtSLUSC,5  * *  *  NOW  THE P A T I E N T ENTERS A HOSPITAL BED  NOINH  ENTER LOGIC R SAME MSAVEVALUE MSAVEVALUE TEST NE MSAVEVALUE MSAVEVALUE TEST E MSAVEVALUE MSAVEVALUE NOTRO ASSIGN ASSIGN. QUEUE OUEUE ASSIGN PRIORITY ASSIGN LINK DSPOS TERMINATE F A I L O TRACE UNTRACE TERMINATE  PI WAIT P1+,P6,2,1,MH PI*,6,2,l.MH P12.0.NOTRQ PI*.P6,3,l.MH P1*,6,3,1,MH P12 , P4,NOTRO PI*.P6,4,l.MH PI*.6,4,l.MH 13.P3 13*.P9 VtLOSQ VtLOSQS 15,0 16 14,PI CISCH,13  •ENTER BEDS FCR SERVICE •CAN ALLOW OTHERS NOW • ADD 1 TO PATIENTS ADMITTED •ADD 1 TO PATIENTS ADMITTED • I F 0, NOT A PT WHO REQUESTED DATE • COUNT AS REQUESTING •COUNT AS REQUESTING • I F EQUAL. GOT THE RIGHT DAY •COUNT SUCCESSFUL ONES • COUNT SUCCESSFUL ONES •P13=TIME OF ACMISSION *P13=TIME OF DISCHARGE (ADD LOS) • ENTER OUEUE FOR LOS • ENTER QUEUE FCR LOS BY SEX • ZERO P15 FCR C PE RATI ON COUNT • PRIORITY LEVEL FOR DISCHARGES •AREA TO DISCHARGE FROM • PUT ONTO DISCHARGE CHAIN • FOR UNWANTED TRANSACTIONS • FOR FAILURE TO OBTAIN MATCH  **************************************  *  MEDICINE ACMISSIONS PATH  **************************************  •  * *  *  FOR NOW, 0 0 NOT CAUSE ANY TRANSFERS TO OTHER HOSPITAL SERVICES, HENCE NO OPERATIONS (EMERGENCY OR INHOSPITALI  ADMM  ENTER MARK  PI 3  •ENTER BEDS FOR SERVICE • ADMISSION TODAY. . . TO P3  1122 1123  H24  DEPART TRANSFER  VJWAITQ ,SAM E  *L E AVE WAITING TIME QUEUE *G0 COMPLETE AS SURGICAL  A**************************************  1125 * EMERGENCY ADMISSIONS UNIT 1126 *************************************** 1127 EMERG SAVEVALUE EMREO*.l.H *A0O I TO EMERG BEOS IN USE 1128 SAVEVALUE EMARR • »1 , H *0NE MORE HERE TODAY 1120 MARK 3 *A0MISSION TODAY...TO P3 1130 MSAVEVALUE P1*.P6,2,1,MH "ADO 1 TO PATIENTS ADMITTED 1131 MSAVEVALUE P1*.6,2,1,MH *ADD 1 TO PATIENTS ADMITTED 113? * DIFFERENTIATE DAY SH I FT ARRIVALS AND OTHERS (FOR PROCESSING SEOUENCE I 1133 TRANSFER .200..M0RNG "TRANSFER TO ARRIVE IN MORNING 1134 PRIORITY 6,BUFFER "PRIORITY FOR NON-MORNING EMERGENCIES 1135 GATE LR WAITE * ALLOWED TO PROCEED? 1136 SAVEVALUE SHIFT,237,H *FOR NON-MCRNING FUNCTION (OWN BEDSI 1137 TRANSFER ,BRING *G0 BRING THEM IN 1138 MORNG PRIORITY 12,BUFFER 'PRIORITY FOR MORNING EMERGENCIES (6-111 1139 GATE LR WAITE "ALLOWED TO PROCEED? 1140 SAVEVALUE SHIFT,235,H *FOR MORNING FUNCTION (OWN BEDS I 1141 • TEST E PI,1,BRING *A MEDICAL PATIENT? 1142 SAVEVALUE MEMRN+ »1» H *YES, COUNT 1143 * PROCESSING BEGINS AGAIN HERE 1144 BRING LOGIC S WAITE *STOP OTHERS NOW 1145 TEST NE Pl.l.NOEIN * SEND EMERG MECICAL REQUESTS TO PROCESS 1146 * GENERATE EMERGENCY AND INHOSPITAL OPERATION REQUESTS 1147 TRANSFER .FN247,,NOEOP *SENO PROPORTION WITH NO EMERG OP REQUEST 114B ASSIGN ll.l.VSSOIST * PI1 = LENGTH OF SURGERY 1149 SPLIT 1,NOEOP "OBTAIN ENTITY TO FOLLOW THIS PATH 1150 MARK 4 *SAY PRESENT OAY OPERATION 1151 LINK EMRGC.LIFO *PUT ON HEAD OF EMERG CHAIN FOR TODAY 1152 NOEOP TRANSFER .FN248,,NOEIN "SEND THOSE NOT PLACING INHOSPITAL OR REO 1153 ASSIGN ll.l.VSSDIST *P11=LENGTH OF SURGERY 1154 SPLIT l.NOEIN "OBTAIN ENTITY TO FOLLOW THIS PATH 1155 TRANSFER , INHRQ "GO HANDLE INHOSPITAL OR REQUEST 1156 * NOW TRY TO PLACE IN PROPER BEDS 1157 * IF IMPROPER, MAY ARRANGE FOR TRANSFER TOMORROW MORNING 1158 NOE IN LOGIC P. WAITE * ALLOW OTHERS NOW 1159 QUEUE VILOSQ "ENTER THE QUEUE FOR LOS 1160 OUEUE VtLOSOS "ENTER QUEUE FOR LOS BY SEX 1161 ASSIGN 14,PI , *P14 = BFD AREA 1162 TEST LE R*14,FN*XH$SHIFT,PUT IN "PUT PT IN IF ANY ROOM THERE 1163 SAVEVALUE SHIFT*,1,H * NOW READY FOR O ' THER AREA' CHECK 1164 ASSIGN 15,3 "UP TO 3 ALTERNATE AREAS 1165 ALT ASSIGN 14,MHtALTER(PI,P151 *P14 = ALTERNATE BED AREA 1166 TEST NE P14,0,NMALT "IF 0, NO MORE ALTERNATIVES 1167 TEST LE R*l 4,FN" XHSSHI FT.ALTOK "ALTERNATE OK IF ROOM THERE 1168 LOOP 15.ALT "ANOTHER ALTERNATIVE? 1169 ASSIGN 14.0 "NO ROOM, STAY IN EMERG 1170 TRANSFER ,NMALT "WILL NEED TRANSFER 1171 * TRANSFERS ARE FROM P14 AREA ... 0 IS EMERG 1172 * THESE PATIENTS ARE PUT IN THE WRONG AREA 1173 ALTCK ENTER P14 "PUT PATIENT IN ALTERNATE AREA 1174 SAVEVALUE EM8E0-,1,H * REMOVE FROM E*ERG BED 1175 MSAVEVALUE P1+,P6,5,1,MH "INCREMENT NUMBER IN WRONG AREA 1176 MSAVEVALUE Pl*.6,5.1,MH "INCREMENT NUMBER IN WRONG AREA 1177 OUEUE VSWRONQ "CCUNT PATIENTS BY WRONG AREA 1178 TEST NE P14,2,T0VER "IN OVERFLOW AREA OR NOT? 1179 TEST NE Pl.l.MDOFF "MEDICALS HANDLED SPECIALLY 1180 TEST LE R*14,FN239,CNSTA "IF MORE SPACE THERE, NO XFER 1181 TRANSFER ,NMALI "IF LESS, AN IN-HOSPITAL XFER -  [V J~  1182 1183 1184 1185 1196 1 187 1188 1189 1 190 1191 1192 1193 1194 1195 1 196 1197 1 198 I I 99 1200 1201 1202 1203 1204 1205 1206 1207 1208 1209 1210 1211 1212 1213 1214 1215 1216 1217 1218 1219 1220 1221 1222 1223 1224 1225 1226 1227 1228 1229 1230 1231 1232 1233 1234 1235 1236 1237 1238 1239 1240 1241  TOVER  TRANSFER .250..NMALI TRANSFER .CNSTA MEOICAL PATIENTS IN SURGICAL AREAS MOOFF ASSIGN 13,P3 ASSIGN 13*,P9 PRIORITY 14 ASSIGN 15,0 LINK VtM0FF,13 THESE MUST TRANSFER SOON NMALT QUEUE V.tWRONQ NMAL1 A S S I G N 15,0 ASSIGN 13,P3 ASSIGN 13*,P9 PRIORITY 14 LINK XFERC, FIFO * THESE PLACED IN PROPER AREA PUTIN ENTER P14 SAVEVALUE EMBED-,l.H CNSTA ASSIGN 13,P3 ASSIGN 13+ ,P9 ASSIGN 15,0 PRIORITY 16 LINK 0ISCH.13 *******•****>***»*****»»***»*****»**»*,*. INHOSPITAL TRANSFERS  • 2 5 * ATTEMPT TRANSFER TO PROPER •READY TO DISCHARGE GET SPECIAL CHAINS •P13=TIME OF ADMISSION • P13=TIME OF DISCHARGE • IN CASE OF TRANSFER •ZERO OPERATION COUNT • INCREASING DISCHARGE ORDER  AREA  • COUNT PTS STAYING IN EMERG • ZERO P15 FOR OPERATION COUNT •P13=TIME OF ADMISSION *P13=TIME OF DISCHARGE • SET PRIORITY LEVEL FCR TRANSFERS •PUT ON CHAIN TO TRANSFER ASAP •ONE MORE •REMOVE 1 •P13=TIME *P13=TIME • ZERO P15 • PRIORITY •PUT ONTO  PT IN APPROPRIATE WARO FROM EMERGENCY BEDS OF ADMISSION OF DISCHARGE FOR OPERATION COUNT LEVEL FOR DISCHARGES THE 01SCHARGE CHAIN  GENERATE UNLINK MARK TEST NE SAVEVALUE SAVEVALUE ASSIGN ASSIGN ASSIGN TEST G UNLINK DOORT ASSIGN ASSIGN TEST G UNLINK WEOK TERMINATE  I , . ,.14,3 • TRANSACTION TO INSTIGATE TRANSFERS DAILY XFERC,TRYIN,ALL • UNLINK ALL TRANSACTIONS TO T R Y I N 3 •TODAY'S DATE TO P3 BV1WKEND,l.WEOK ' •WEEKENDS OK IDON'T XFERI WEEK.O.H •THIS WEEK PTFWK.VtAPRWK.H •GIVES ROW FOR PATIENTS 1,3 •EENT BEDS 2.MH^V10FFSL(X HtPTFWK » VtWKDAY) *# OF BEDS NEEDED THERE 2-.1 • ALLOW I LESS VtNOFF,O.DOORT •DOES EENT GET BEDS? MALT3,BACKl,VtNOFF .BACK * S END LONG-STAY MEDS BACK 1.4 •DO ORTHOPEDICS 2,MH^VtOFFSL(XHtPTFWK,VtWKDAY) *# OF BEOS NEEDED THERE VtNOFF,O.WEOK •DOES ORTHO GET BEOS? MALT4,BACKl,VtNOFF • BACK •SEND LONG-STAY MEDS BACK • REMOVE INSTIGATOR TRANSACTION  B A C K l TEST E LI NK  Rl.O.TXFER VtM0FF,13  TRYIN P R I O R I T Y 14,BUFFER TEST E R+l.O.TXFER LINK XFERC,LIFO • THESE GET INTO RIGHT BED NOW TXFER ENTER PI TEST E P14.0.NEMG SAVEVALUE EMBED- ,1 ,H TRANSFER ,TOOIS NEMG LEAVE P14 MSAVEVALUE P1 +, P 6 , 6, I , MH MSAVEVALUE P I * . 6 . 6 . l . M H TODIS A S S I G N 13.P3 ASSIGN 13*,P9 DEPART VtWRONQ  •ANY BEDS IN MED AREA? • I F NOT, STAY PUT • RESET P R I O R I T I E S FOR TRANSFER • TRANSFER PT IF ANY ROOM THERE • I F NOT, BACK ON XFER CHAIN •ONE MORE PATIENT THERE •UNLESS P 1 4 = 0 , NOT FROM EMERG •REMOVE 1 FROM EMERG BEDS •PROCEED TO ARRANGE DISCHARGE • OUT OF ALTERNATE AREA'S BED •AO.D 1 TO NUMBER CORRECTED • AOO 1 TO NUMBER CORRECTED • P13=TIME OF ADMISSION • P13 = TIME OF DISCHARGE •COUNT P A T I E N T S FROM WRONG AREA  K> PNJ CO  1242 1243 1244 1245 1246 1247 1248 1249 12 50 1251 1252 125 3 1254 1255 1256 1257 1258 1259 1260 1261 1 26? 1263 1264 1265 1266 1267 1268 1269 1270 1271 127? 1273 12 74 1275 1276 1277 1278 1279 1280 1231 1 282 1283 1284 1285 1286 1287 1288 1289 1290 1291 1292 1293 1294 1295 1296 1297 1298 1299 1300 1301  PRIORITY ASSIGN LINK  16 14,PI DISCH,13  TRANSACTION  LEAVP LEAVE  NCNEM CNOUT BYE *  TO  GENERATE MARK UNI INK UNLINK UNLI NK UNLINK TERMINATE PRIORITY DEPART DEPART TEST NE DEPART TEST E SAVEVALUE TRANSFER LEAVE TEST E SAVEVALUE TERMINATE  OPERATING  " P R I O R I T Y LEVEL FOR DISCHARGES •AREA TO DISCHARGE FROM •PUT ONTO THE DISCHARGE CHAIN  INSTIGATE  DISCHARGES  1.... 16, 13 13 D I S C H , L E A V E , A L L , 13 X F E R C , L E A V P , A L L , 13 M A L T 3 , L E A V P , A L L , 13 M A L T 4 , L E A V P , A L L , 13  • TRANSACTION PER DAY TO INSTIGATE DISCH • TODAY'S DATE IN P 1 3 • ALL PTS TO BE DISCHARGED TODAY TO LEAVE •INCLUDE THOSE WAITING FOR XFER • HEOICAL PATIENTS S T I L L OFF-SERVICE • MEDICAL PATIENTS S T I L L OFF-SERVICE • REMOVE INSTIGATOR FROM MODEL • MUST R A I S E PRIORITY FOR THESE •LEAVE THE QUEUE FOR LOS • LEAVE THE OUEUE FOR LOS BY SEX •PATIENT IN RIGHT AREA? • NO, COUNT PATIENTS FROM WRONG AREA • S T I L L IN EMERG BEO I F 0 • REMOVE FROM THERE • SEND ON OUT •REMOVE ONE PT FROM THAT BEO POOL • A MEDICAL AREA DISCHARGE? •YES, COUNT •REMOVE PATIENT FROM MODEL  16,BUFFER VtLOSO VtLOSOS P14.P1.N0NEM VtWRONO P14.0.N0NEM EM3ED-,1,H .ONOUT P14 P14.1.8YE MAD I S * , l . H  ROOM  OATA  *****•*«*«»*«** «, 4  LFVEL  LhVEL  F  <  OF  i n n J L . c ARE  ? nIv DAY,  0F^TIMI Nr*TH4N TIMING  P  !  0  USED ^  ™ *  T  D  0  C  E  I  THAN T  0  R  ,  S  HENCE  ™ IT  TIME  C  A  IS  L  -  NOT  T H E A T R E S WOULD E E I N G D O N E IN  ESTIMATES  ACTUAL  (NOT  WOULO  INVOLVE DETAIL.  I f PROVE,  ESTIMATED!  TZi  AS  A  MORE  WOULD  THE  DFSTR^BU^IONS  MEAN TURNAROUND IS C O N S I D E R E D T O B E 15 M I N U T E S . IF 4 OPERATIONS FOR E X A M P L E , T H E R E WERE 3 TURNAROUNDS ONE OVER L U N C H , SO THIS I S D O N E F O R E A C H O P E R A T I N G ROOM R E P R E S E N T E D .  DONF ISAOOFn  WERF  2* 15  GENERATE ASSIGN MARK SAVEVALUE TEST G ROOM TEST NE ASSIGN SAVEVALUE ASSIGN SAVEVALUE UNLINK LOOP TRANSFER ZPOSL ASSIGN TABULATE ASSIGN TABULATE LOOP NOWEM SAVEVALUE SAVEVALUE UNLINK TERMINATE  MICRO  t.,.,2.5 • S I N G L E TRANSACTION FOR OR RECORDS 1.4 • P l = H O S P I T A L S E R V I C E , 4 IS HIGHEST 4 • TODAY'S DATE IN P4 WEEK,0,H •DOING THIS WEEK'S OPERATIONS P4,XHiPWEEK,NOWEM •ON WEEKEND, CNLY EMERGENCIES PI,2,NOWEM •DON'T DO SERVICE 2 5.VISRV0P • P5=SERVICE'S CP TIME SAVEVALUE P5.0.H •SET IT TO 0 5-.1 •P5 = S ERVICE'S NUMBER OP SAVEVALUE P5,0,H •SET IT TO 0 V t S L U S C , P R F R M , A L L , 4,.ZROSL "FOR THIS DATE/SERVICE. REMOVE 1. ROOM •DECREMENT S E R V I C E AND GO TO ROOM ,NOWEM • AFTER THE LAST SERVICE 2 , V»H!TBL *P2 = NUM8ER OF HIGHEST TABLE OF SERVICE P2 •RECORD 0 TIME 2-, 1 • SUBTRACT 1 P2 • RECORD 0 PATIENTS I,ROOM •DECREMENT SERVICE AND GO TO ROOM EMGTM.O.H •SET EMERG OP TIME TO 0 EMGNO.O.H •SET EMERG OPERATED NUMBER TO 0 EMRGC, AFTER «ALL«4,,ZROEM • A L L TODAY'S EMERG OPN OFF THAT CHAIN • REMOVE I N S T I G A T I N G TRANSACTION  to  1302 1303 1304 1305 1306 1307 1308 1309 1310 I 311 1312 1313 1314 1315 1316 1317 1318 1319 1320 1321 1322 1323 1 324 1 325 1326 132 7 1328 1329 1330 1331 1 332 1333 1334 1335 1336 1337 1338 1339 1340 1341 1342 1343 1344 I 345 1346 1347 1348 1349 1350 1351 1352 1353 1354 1355 1 356 1357 1358 1 359 1360 1361  *•  *  ZROEM TABULATE TABULATE TERMINATE  EMTBN EMTBT  •RECORD 0 PATIENTS •RECORD 0 TIME • REMOVE INSTIGATING TRANSACTION  HERE THE PATIENT'S OPERATION IS ADDEO INTO RECORDS  PRFRM PRIORITY 2.BUFFER •RESET PRIORITY ASSIGN 13,V$SRV0P •P13=SAVEVALUE OF SERVICE OP TIME SAVEVALUE P13+,Pll,H •ADO LENGTH OF THIS SURGERY ASSIGN 13 + .1 •P 13=SAVEVALUE OF SERVICE'S OPERATED NO, SAVEVALUE P13* ,1 ,H •ADD 1 SURGERY TEST G XH*13,FN242»NOTRN •IF 'LE* 2» PER OR, NO TURNAROUND TIME ASSIGN 13-,1 • BACK TO TIME SAVEVALUE SAVEVALUE P13+.15.H •ADD 15 MINUTES TURNAROUND NOTRN TEST E WtPRFRM.O.NOMR •SOME MORE UNLESS NO MORE UNLINKED ASSIGN 14,PI • REAL SERVICE OF THIS PATIENT ASSIGN 1.4 •HIGHEST SERVICE TAB ASSIGN 13,V $HITBL • P13=NUMBER OF HIGHEST TABLE OF SERVICE TEST NE PI.2.ONTAB • DCN'T DO SERVICE 2 TEST NE XH*VSSRVOP,0,SKIP • DO\"T RETABULATE IF 0 TABULATE P13 • TABULATE TIME FOR THIS SERVICE ASSIGN 13- ,1 •SUBTRACT 1 TABULATE P13 •TABULATE NUMBERS FOR THIS SERVICE SKIP LOOP 1 ,TAB • SUBTRACT I FROM SERVICE. GO TO TAB ONTAB ASSIGN 1.P14 •RESTORE REAL SERVICE AFTER PRIORITY 2,BUFFER • RESET PRIORITY SAVEVALUE EMGTM-.Pll ,H *AOD LENGTH OF SURGERY SAVEVALUE EMGNO+,l,H •ADO 1 SURGERY TEST E WtAFTER,0,NOMR •SOME MORE UNLESS NO MORE UNLINKED EMG. TABULATE EMTBN •TABULATE TODAY'S EMERGENGY OP NUMBER TABULATE EMTBT • TABULATE TODAY'S EMERGENGY OP TIME NOMR TERMINATE .it****************.******************* * PRINTER TRANSACTION GENERATE PR I NT PR INT PR INT PR I NT PRINT PRINT PRINT TERMINATE  91,,91,,2.1 ..CN ,.U.N . ..S.N ..O.N 38.38.T.N 1,4,MH,N 40.41.XH.N  '  • CLOCK •USER CHAINS •STORAGES •QUEUES •NOBED TABLE •SERVICE MATRICES •MEDICAL AREA COUNTERS  * TIMER TRANSACTION * * * * * * * * * * * ***************t************ GENERATE I *CNE PER DAY. LAST THING TABULATE EMGDU •TODAY'S EMERG AND D.U.PATIENTS SAVEVALUE EMARR.O.H •RESET FOR TOMORROW TABULATE NOBEO • TOOAY'S 'NO BEO' CANCELLATIONS SAVEVALUE NOBO.O.H •RESET FOR TOMORROW TERMINATE I •REMOVE AND COUNT  *  START RESET START RESET SAVE START  91,NP 91,NP 91, NP  • SAVE 1/2 YEAR MODEL  11362 1363 1364 1365 1366 1367 1368 1369 1370 1371 t 372 1373 1374 1375 1376 1377 1378 1379 1380 1381 13 82 1383 1384 13 85 1386 1397 1383 1389 1390 1391 1392 1393 1394 1395 1 396 1397 1398 13 99 1400 1401 1402 1403 1404 1405 1406 1407 1408 1409 1410 1411 1412 1413  *  *  RESET START RESET SAVE START RESET START RESET SAVE START RESET START RESET SAVE START RESET START RESET SAVE START RESET START RESET SAVE START RESET START RESET SAVE START RESET START RESET SAVE START RESET START RESET SAVE START RESET START RESET GENERATE "SAVEVALUE SAVEVALUE SAVEVALUE TE RMINATE SAVE END  91.NP 2C 91,NP  •SAVE 1 YEAR MODEL  91, NP 3C 91 ,NP  •SAVE 1 1/2 YEAR MODEL  91,NP 4C 91,NP  •SAVE 2 YEAR l>CDEL  91,NP 5C 91,NP  • 2 1/2 YEAR MOOEL  91 ,NP 6C 91,NP  •3 YEAR MODEL  91,NP 7C 91 ,NP  •3 1/2 YEAR MCDEL  91.NP 8C 91,NP  •4 YEAR MODEL  91,NP 9C 91,NP  •4 1/2 YEAR MODEL  91,NP 1...1. 1-4, 1CANCL »< 40-41, 10C  • END OF 5 YEAR RUN • TRANSACTION TO CLEAR SAVEVALUES •ZERO ACCUMULATED NUMBERS FOR PTS • ZERO CANCELLATION COUNTER •ZERO MEOICAL AREA COUNTERS •SAVE ALSO 5 YEAR MODEL  

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