@prefix vivo: . @prefix edm: . @prefix ns0: . @prefix dcterms: . @prefix skos: . vivo:departmentOrSchool "Science, Faculty of"@en, "Statistics, Department of"@en ; edm:dataProvider "DSpace"@en ; ns0:degreeCampus "UBCV"@en ; dcterms:creator "Chase, Mark Gordon"@en ; dcterms:issued "2010-02-16T02:09:08Z"@en, "1977"@en ; vivo:relatedDegree "Master of Science - MSc"@en ; ns0:degreeGrantor "University of British Columbia"@en ; dcterms:description "In this work, the admissions and scheduling system at St. Paul's Hospital was examined by means of modelling and computer simulation. The Hospital is an acute-care facility with very high occupancy and a policy of admitting all of the emergency patients who require hospitalization. It now faces the problem of providing space for these patients without seriously disrupting scheduled admissions. After investigation of the literature, it was decided to model the Hospital's admissions and scheduling system and use computer simulation to investigate its behaviour. Patients, operating rooms, and bed areas were classified by \"hospital service\". A GPSS simulation model which uses empirical data and a one-day time unit was developed. The model was verified and validated. Several experiments were performed to suggest different methods to regulate occupancy in the various hospital areas, and to alleviate surgical slate disruptions, under existing or hypothetical arrival patterns for patients. These experiments were only a sample of those for which the model may be used. Suggestions for extensions of this project are included. In conclusion, two points are made: first, there are several contrasts between formal hospital policy and actual practice as revealed by the data; second, it appears that simulation can be useful in a hospital context."@en ; edm:aggregatedCHO "https://circle.library.ubc.ca/rest/handle/2429/20257?expand=metadata"@en ; skos:note "A COMPOTES SIMULATION OF THE ADMISSIONS AND SCHEDULING SYSTEM AT ST. PAUL'S HOSPITAL by MARK GORDON CHASE B.Sc.,Mount A l l i s o n U n i v e rsity,1975 A THESIS SUBMITTED IN PABTIAL FULFILLMENT OF THE REQUIREMENTS FOR THE DEGREE OF MASTER OF SCIENCE i n THE FACULTY OF GRADUATE STUDIES I n s t i t u t e o f A p p l i e d Mathematics and S t a t i s t i c s We accept t h i s t h e s i s as conforming to the r e q u i r e d standard THE UNIVERSITY OF BRITISH COLUMBIA September,1977 <£) Mark Gordon Chase, 1977 In present ing th is thes is in p a r t i a l fu l f i lment of the requirements for an advanced degree at the Un ivers i ty of B r i t i s h Columbia, I agree that the L ibrary shal l make it f ree ly ava i l ab le for reference and study. I fur ther agree that permission for extensive copying of th is thes is for scho la r ly purposes may be granted by the Head of my Department or by his representa t ives . It is understood that copying or pub l i ca t ion of th is thes is fo r f i n a n c i a l gain sha l l not be allowed without my writ ten pe rm i ss i on . Department of J^t^La^L'.y & £ t U ^ j £ j £ <2a*^£~«-vBED^ DONE NO ^TATIEN YES (5) ADMIT MEDICAL BED POOL INFORMATION t (10) (6) (11) (7) DISCHARGE F i g . 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 Statements {IV A) Note: Scheduled s u r g i c a l i n v e s t i g a t i v e 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 bed. 1. A queue forms, ordered by p a t i e n t admission d i a g n o s t i c category and l e n g t h of wait. The s t a f f l e v e l of the p h y s i c i a n and whether or not the p a t i e n t i s out-of-town may a l s o be f a c t o r s . . In p r a c t i c e , the gueue i s almost mental - forms are a c t u a l l y f i l e d with the date of r e c e i p t stamped on them, i n order of the p h y s i c i a n s • l a s t names. Pressure from the p h y s i c i a n i s a a r e a l but unprogrammable f a c t o r . [ 6 ] 2. Each morning, i n - h o s p i t a l t r a n s f e r s must be processed before c o n s i d e r i n g s c h e d u l a b l e admissions. 1 1 ] 3. The admitting c l e r k s attempt 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 postpone. [Not Implemented] 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. [23,24] 6. Medical bed pool i n f o r m a t i o n i s updated by admissions, t r a n s f e r s , and d i s c h a r g e s . . 7. The p a t i e n t no longer occupies a h o s p i t a l bed. 8. , From Medical s e r v i c e admission requests. 9. From emergency Medical admissions V A3 and t r a n s f e r s to the Medical area VI A3. 10. To i n - h o s p i t a l t r a n s f e r s from the Medical area VI A1 and bed i n f o r m a t i o n f o r t r a n s f e r s VI A2. 11. From s u r g i c a l d i s c h a r g e s I I I A9 and s p e c i a l u n i t d i s c h a r g e s VI A9, 81 F i g . 6.5 Emergency U n i t f l o w c h a r t (VA) 82 Operations Statements {V A) 1. T h i s o v e r a l l process i s the r o u t i n g of emergency p a t i e n t s . P a t i e n t s i n c l u d e d are e i t h e r emergencies or are \" d i r e c t urgent\" p a t i e n t s from the p h y s i c i a n ' s o f f i c e who are e i t h e r c r i t i c a l or, i n h i s o p i n i o n , need to circumvent the slow admission queue.. I t i s s a f e t o assume that the Emergency U n i t ' s bed c a p a c i t y i s s u f f i c i e n t - o l d beds are a v a i l a b l e i n s t o r a g e i f needed. [2,6] 2. Does the p a t i e n t r e q u i r e c l o s e enough monitoring and / or the s p e c i a l care t o be i n the I n t e n s i v e {and Coronary) Care Un i t ? [Not implemented], 3. I s the p a t i e n t c l a s s i f i e d as Medical or s u r g i c a l ? [ 4 ] 4. I f Medical beds are f u l l ( i n c l u d i n g semi-closed, perhaps c l o s e d , and some \"overflow\" beds) the p a t i e n t may occupy a s u r g i c a l bed.. These p a t i e n t s probably cause i n - h o s p i t a l t r a n s f e r s soon. The s e m i - c l o s e d , c l o s e d , and overflow beds used at t h i s p o i n t w i l l probably cause t r a n s f e r s soon., [18,20,21,22] 5. Is surgery needed immediately? [23] 6. Does the p a t i e n t i n f a c t r e q u i r e any o p e r a t i o n s , or only the care provided i n a s u r g i c a l area? [23,24] 7. I s t h i s a c a r d i a c emergency or one of another s e r v i c e ? [ 4 ] 8. From emergent admission r e g u e s t s . 9. To the ICU. (Perhaps a t r a n s f e r should be arranged.) 10. To a Medical bed. (Some w i l l cause t r a n s f e r s . ) 11. A Medical p a t i e n t i s placed i n a s u r g i c a l bed, . . . w h i c h probably causes a t r a n s f e r . 12. To modify OP data f o r today., 83 13. Surgery i s r e q u i r e d l a t e r , so the s l a t e must be modified. 14. To a s u r g i c a l bed. 15. To a c a r d i a c u n i t bed. 84 IN-HOSPITAL TRANSFERS ROUTING (1) Fig. 6.6 In-hospital variations flowchart (VIA) 85 Operations Statements (VI A) 1. The process which f o l l o w s i s the r o u t i n g of i n - h o s p i t a l t r a n s f e r s . , 2. The admitting c l e r k attempts t o match the p a t i e n t to the a p p r o p r i a t e bed, which may be anywhere., I f t h e r e i s such a shortage of beds t h a t t h i s cannot be done y e t , i t w i l l be done l a t e r . I f matched, the p a t i e n t must be removed from h i s former l o c a t i o n to the new one. 3. To a Medical bed? (the bed might otherwise be s u r g i c a l or s p e c i a l ) [ 4 ] 4. A p a t i e n t at t h i s point may need a s p e c i a l o r s u r g i c a l care u n i t although not r e q u i r i n g any o p e r a t i o n , or may be r e t u r n i n g to a s u r g i c a l bed from a s p e c i a l u n i t . These cases would not imply a need f o r surgery. 5. Demands may come from s u r g i c a l o r c a r d i a c p a t i e n t s who have already had one o p e r a t i o n or who s u f f e r some \"ward c a t a s t r o p h e \" ( i n which case a bed t r a n s f e r may not be a d d i t i o n a l l y i m p l i e d ) , or from i n v e s t i g a t i v e , M e d i c a l , o r ICU p a t i e n t s found to r e q u i r e surgery. 6. For today or not ... see I I I A note 13., [23,24] 7. To a s p e c i a l u n i t bed or a s u r g i c a l area bed? [Not implemented] 8. \" S p e c i a l u n i t s \" (ICU and c a r d i a c unit) bed i n f o r m a t i o n i s updated by admissions to the c a r d i a c u n i t , and a c o n s i d e r a b l e amount of t r a n s f e r r i n g and d i s c h a r g i n g . , [Not implemented] 9. From Medical t r a n s f e r s 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 bed i n f o r m a t i o n IV A3 and s u r g i c a l bed i n f o r m a t i o n I I I A9. 11. To a Medical bed. 12. From s u r g i c a l u n i t OR demands. 13. To today's OR data. 14. To modify the s l a t e . 15. From s l a t e - m o d i f y i n g s p e c i a l u n i t r e q u e s t s I I I A3, scheduled admissions to the c a r d i a c u n i t I I I A5, updating of s p e c i a l u n i t p a t i e n t s by today's OR run I I I A7, emergency admissions needing ICU monitoring and care V A2, and emergency c a r d i a c admissions V A8. , 16. To a s u r g i c a l bed. 17. From c a r d i a c bed i n f o r m a t i o n to the s u r g i c a l admissions match I I I A4, p a t i e n t s t o today's OR data I I I A6, and d i s c h a r g e s IV A4. 87 CHAPTER 7 THE DATA AND INFORMATION USE-The u n a v a i l a b i l i t y of data i s a prime c o n s t r a i n t i n the d e f i n i t i o n of the model and i n the determination of the depth of the study., In t h i s work, a v a r i e t y of data sources was u t i l i z e d : a magnetic data tape of p a t i e n t census data, c o p i e s of completed s u r g i c a l s l a t e s , emergency admissions forms. Medical and s u r g i c a l admission booking forms i n the course o f being processed, as well as the 1976 Admitting O f f i c e r e p o r t (see Appendix 2.1) and, t o some extent, a p a t i e n t t r a n s f e r study (Scroggs, 1970) . 7.1 D e s c r i p t i o n of Data-Sets The d e s c r i p t i o n o f the data gathered, and t h e i r s o u r c e s , w i l l serve to c l a r i f y the scope of t h i s study and to a s s i s t any f u t u r e data c o l l e c t i o n e f f o r t s . Defined a c c o r d i n g to t h e i r sources, the four d a t a - s e t s d e s c r i b e d below were the most important f o r t h i s work. 7.1.1 Waiting L i s t s As i t has been mentioned, s u r g i c a l admission booking forms are r e c e i v e d by the OR Booking O f f i c e and, u s u a l l y , stamped with the date of r e c e i p t . Once the p a t i e n t i s scheduled f o r surgery, another copy of the form i s sent t o the Admitting O f f i c e . 88 Medical forms and p r e - i n v e s t i g a t i v e surgery forms a l s o go to the Admitting O f f i c e , In order to gather data on w a i t i n g times f o r admission t o a feed, i t i s necessary t o observe the appearance (or at l e a s t presence) and disappearance of these forms. The h o s p i t a l keeps no records of waits! The best way to observe these data i s to r e c o r d and f o l l o w a l l forms on f i l e over a long p e r i o d of c o n s e c u t i v e days. U n f o r t u n a t e l y , i t i s not always convenient t o the h o s p i t a l s t a f f to have someone c o l l e c t i n g data from these forms d a i l y . (A s u g g e s t i o n i n t h a t regard may be found i n S e c t i o n 11.3.) Because o f t h i s d i f f i c u l t y , the data gathered here are sparse. One part s e r v e s to supplement other data (age, sex, a r r i v a l r a t e s ) , another part s e r v e s to v a l i d a t e w a iting times (output), and yet another p a r t i s the only source f o r c e r t a i n parameters (p r e - o p e r a t i v e LOS, d i a g n o s t i c c a t e g o r y ) . The data items a v a i l a b l e from observing the admission booking forms are l i s t e d and t h e i r use commented on, i n Table V I I I . 7.1.2 Operations One copy of the f i n a l s l a t e i s kept i n the OH Booking O f f i c e a f t e r use. To t h i s copy, the d u r a t i o n of scheduled o p e r a t i o n s , and the presence and d u r a t i o n of a l l emergency o p e r a t i o n s have been added. The s l a t e s from 1974 were used because p a t i e n t LOS data f o r 1974 were c o n v e n i e n t l y a v a i l a b l e . Since l e n g t h of surgery was the primary v a r i a b l e of i n t e r e s t , a s t r a t i f i e d random sample was c o l l e c t e d . The days of 89 TABLE V I I I DATA COLLECTION GROUPS Data Group Item Use WAITING Date form r e c e i v e d Date of admission C a n c e l l a t i o n s Postponements \"No Beds\" S e r v i c e P h y s i c i a n P r e - o p e r a t i v e LOS Age Sex D i a g n o s t i c category Date requested P o t e n t i a l week d i s t r Rate of sc Waiting t i P o t e n t i a l week d i s t r S e l f - e x p l a Schedulable p a t i e n t s per s e r v i c e P a t i e n t vo Booking pa S e r v i c e ' s tt ft P r o p o r t i o n P a t t e r n of P o t e n t i a l it Teaching bed? Accomodation T h i s group c o u l d a l s o be used t o show v a r i a s l a t e and placement of p a t i e n t s as per date d i a g n o s t i c category, t e a c h i n g bed, accomoda s e r v i c e . use i n day-of-the-i b u t i o n hedulable admissions me v a l i d a t i o n use i n day-of-the-i b u t i o n natory lume per p h y s i c i a n t t e r n d i s t r i b u t i o n II it ti f o r s e r v i c e use use f o r p r o p o r t i o n n n ti t i o n s made i n the r e g i e s t e d , t i o n , sex, and OPERATIONS Number per room L i m i t D i s t r i b u t i Length of S e r v i c e ' s ti Booker's time Age Sex Surgeon Room use p C a n c e l l a t i o n s P o t e n t i a l A note i s now made on the s l a t e s of a c t u a l not j u s t the booker's estimate plus t u r n a r o s t a r t i n g time of each procedure was a l s o no turnaround and surgery time c o u l d be c a l c u l the p h y s i c i a n ' s estimate was added, then a accuracy of h i s and the booker's estimates Instead of r e c o r d i n g a l l emergencies togeth u s e f u l t o note those which \"broke\" the s l a t 5.3.9). I t would be u s e f u l f o r the data-co f e a t u r e s , i f any, which cause some o p e r a t i o s e r v i c e to be done i n one OR and other oper i n another OR a l s o used f o r t h a t s e r v i c e . on, f o r v a l i d a t i o n surgery d i s t r i b u t i o n d i s t r i b u t i o n II a t t e r n use f o r p a t t e r n \" s k i n - t o s k i n \" time, und. I f the ted, a c t u a l ated. A l s o , i f study of the coul d be of value, e r , i t might be e (see s e c t i o n H e c t o r to note ns of a p a r t i c u l a r a t i o n s to be done 90 TABLE VI I I {cont.) LOS Admission date O v e r a l l admissions rate P o t e n t i a l use i n day-of-the-week 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 of st a y P o t e n t i a l use i n study o f occupancy c o n t r o l v i a LOS S e r v i c e P a t i e n t s per s e r v i c e C l a s s i f i c a t i o n o f p a t i e n t s Age S e r v i c e ' s d i s t r i b u t i o n Sex \" \" Number of o p e r a t i o n s U s e f u l only i f decoded t o i d e n t i f y OR procedures Although not a v a i l a b l e on the tape used, CPHA could provide i n f o r m a t i o n on the use of s p e c i a l c a r e u n i t s and dis c h a r g e s t a t u s , as w e l l as diagnoses. EMERGENCIES Time of a r r i v a l A r r i v a l r a t e Time that Admitting P r o p o r t i o n placed i n morning was informed o f d a y - s h i f t Time t h a t p a t i e n t P o t e n t i a l use i n study o f was p l a c e d of delay S e r v i c e Emergency p a t i e n t s per s e r v i c e P h y s i c i a n P a t i e n t volume per p h y s i c i a n Bed r e c e i v e d Ward / s e r v i c e p a t t e r n To OR? P o t e n t i a l use f o r p r o p o r t i o n Age S e r v i c e ' s d i s t r i b u t i o n Sex \" *' 91 the year were l i s t e d a c c o r d i n g to the number of procedures done on t h a t day. These s e t s of days were d i v i d e d i n t o roughly egual s i z e d groups ( s t r a t a ) a l i g n e d by the number of procedures. The d e s i r e d number of days to sample was determined, and from each stratum the same p r o p o r t i o n of days was chosen at random. ; T a b l e VIII l i s t s the data items and uses. 7.J.3 Length of Stay The l a r g e s t block of data was a magnetic tape of PAS case a b s t r a c t data f o r 1974 obtained from the Commission on P r o f e s s i o n a l and H o s p i t a l A c t i v i t i e s (CPHA). For each p a t i e n t discharged from the h o s p i t a l , the H e d i c a l Records L i b r a r y prepares a case a b s t r a c t of demographic, d i a g n o s t i c and treatment i n f o r m a t i o n , and submits i t to the CPHA. T h i s commission assembles the data on magnetic tape f i l e s , and a n a l y z e s i t . The tape which we obtained contained some 21,000 p a t i e n t records of data items which we had requested, with the r e s t o f the o r i g i n a l a b s t r a c t * s i n f o r m a t i o n d e l e t e d . T a b l e VIII d e t a i l s the i n f o r m a t i o n we e x t r a c t e d from those r e c o r d s . 7.1.4 Emergency Admissions The emergency u n i t maintains a d a i l y r e c o r d of admissions as well as a form on each p a t i e n t admitted. (These forms are l i a b l e to disappear i f the p h y s i c i a n wants them.) For t h i s study, r e c o r d s c o v e r i n g the peri o d of the 92 waiting-time data were used. A sample drawn from a l o n g e r time p e r i o d could a l s o have been used. The data usage i s d e s c r i b e d on Table V I I I . 7.2 The S p e c i f i c a t i o n of Data and Information Most of the data i n c o r p o r a t e d i n the model have been converted t o e m p i r i c a l f u n c t i o n s which d e s c r i b e the c h a r a c t e r i s t i c s f o r each of the v a r i o u s h o s p i t a l s e r v i c e s . However, some c h a r a c t e r i s t i c s are i d e n t i c a l over a l l s e r v i c e s , and could be r e p r e s e n t e d by s i m p l e r s i n g l e d e s c r i p t i o n s . Other i n f o r m a t i o n , obtained from St., Paul's, determined the s t r u c t u r e of the model i n such d e t a i l s as the seguence of events or the numbers of beds. A b r i e f d e s c r i p t i o n of the data i n c o r p o r a t e d i n the model f o l l o w s . In cases f o r which the d e r i v a t i o n of data used by the s i m u l a t i o n model from the raw c o l l e c t e d data i s r a t h e r i n v o l v e d , a f u l l e r e x p l a n a t i o n may be found i n Appendix 2., The f i n a l form of a l l f u n c t i o n s may be found i n the program l i s t i n g , i n Appendix 3., Table IX l i s t s the types of data and i n f o r m a t i o n used i n the model, and i n d i c a t e s those f o r which f u r t h e r d i s c u s s i o n may be found i n the appendix. Except f o r a couple of program book-keeping items, event p r i o r i t i e s were arranged to cause the f o l l o w i n g sejuence ( r e f e r a l s o to F i g u r e 8.1}. Each day, the reguests f o r admission were creat e d f i r s t . Emergency and DU r e g u e s t s were processed up t o , but not i n c l u d i n g admission. Orgeat, semi-urgent and e l e c t i v e 93 TABLE IX DATA AND INFORMATION OSED Item More In Number Type Appendix ? 1 Event sequencing 2 P r o p o r t i o n of morning d a y - s h i f t emergencies 3 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 4 D a i l y p a t i e n t a r r i v a l s (non-schedulable Yes and schedulable) by s e r v i c e 5 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 6 P a t i e n t admission d i a g n o s t i c category Yes 7 P a t i e n t sex Yes 8 P a t i e n t age group Yes 9 P a t i e n t length of st a y Yes 10 P a t i e n t p r e - o p e r a t i v e LOS 11 P a t i e n t l e n g t h of surgery Yes 12 P r o p o r t i o n r e q u e s t i n g an admission date 13 Time u n t i l reguested admission date 14 D a i l y bed l i m i t f o r s l a t e 15 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) 16 Scheduling p r i o r i t y f e a t u r e s 17 Turnaround time 18 Medical bed l i m i t f o r morning emergencies 19 Medical beds allowed f o r sc h e d u l a b l e p a t i e n t s 20 A l t e r n a t e areas 21 L i m i t on use of o f f - s e r v i c e beds 22 P a t i e n t s to stay i n o f f - s e r v i c e areas 23 P r o p o r t i o n of p a t i e n t s r e q u e s t i n g emergency surgery 24 P r o p o r t i o n of p a t i e n t s with i n - h o s p i t a l o p e r a t i o n reguests 9H requests were processed i n t h a t order as f a r as being scheduled and queued up. Discharges (which f r e e d beds f o r the day) were processed next. The f i r s t c l a i m on these beds were t r a n s f e r s . A number of emergency p a t i e n t s equal t o the p r o p o r t i o n which would appear during the morning of the d a y - s h i f t made the next c l a i m on beds. I f there was s t i l l room, scheduled p a t i e n t s were admitted next. (Emergency and other i n - h o s p i t a l o p e r a t i o n requests were generated from the p a t i e n t s admitted.) The remaining emergency p a t i e n t s ( a l l those not \" i n the morning\") were then placed wherever i t was p o s s i b l e . F i n a l l y , the c a l c u l a t i o n s r e g a r d i n g the day's o p e r a t i o n s were done. T h i s arrangement i s b e l i e v e d to c l o s e l y represent the bed-claim sequence at S t . Paul's. In p a r t i c u l a r , the p r o p o r t i o n of immediate p a t i e n t s to be handled i n the morning of the d a y - s h i f t was obtained by comparing the number of emergency p a t i e n t s being placed between 6 am and 11 am plus an a r b i t r a r y 50% of DO p a t i e n t s with the t o t a l number of immediate p a t i e n t s . The p r o p o r t i o n of p a t i e n t s c a n c e l l i n g each week, of those who waited over seven weeks, i s f a i r l y a r b i t r a r y , based on observed w a i t i n g times. The \" P a t i e n t Generation Segment\" of the model uses a l a r g e amount of data. 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 items i s based on a d i f f e r e n t f u n c t i o n ( s e r i e s of proportions) f o r each s e r v i c e . For the a r r i v a l d i s t r i b u t i o n s , the observed p a t t e r n of d a i l y a r r i v a l s f o r each of emergency (with DU) and schedulable c a t e g o r i e s was smoothed and t a i l o r e d to a c c e p t a b l e r a t e s f o r 95 y e a r l y t o t a l s . These d i s t r i b u t i o n s were used to g i v e the d a i l j a r r i v a l r a t e f o r each type of p a t i e n t (see Appendix 2.3). The number of Bl,l§icians per s e r v i c e was taken on the b a s i s of an a r b i t r a r y \"average a c t i v e \" p h y s i c i a n . The number of p a t i e n t s f o r each p h y s i c i a n and t h e i r c h a r a c t e r i s t i c s were sampled from the same d i s t r i b u t i o n s , so t h a t , i n e f f e c t , a \"composite\" p h y s i c i a n was used. In Orthopedics, f o r example, the r e were nine a c t i v e s t a f f l i s t e d . Most were q u i t e busy during the time observed - so the model evened the p a t i e n t l o a d and kept nine p h y s i c i a n s . At the other extremity, i n Medicine, some 33 p h y s i c i a n s each admitted from 1 to 35 p a t i e n t s during the time observed. I t was decided that at a l e v e l of 22 p h y s i c i a n s , each could be c o n s i d e r e d to have a reasonable lo a d . The value of i n c l u d i n g these composite p h y s i c i a n s i s p a r t i a l l y i n i d e n t i f y i n g p h y s i c i a n ' s b l o c k s on the s l a t e , and p a r t i a l l y i n d e f i n i n g an \"average p a t i e n t l o a d \" to g i v e an i d e a of the e f f e c t of i n c r e a s e d or decreased s t a f f . The p r o p o r t i o n of p a t i e n t s i n each p_atient d i a g n o s t i c category was based on the observed number of emergency cases, known t o t a l s o f emergency and DU p a t i e n t s , known s l a t e d numbers of s c h e d u l a b l e p a t i e n t s , and known o v e r a l l t o t a l s . For d e t a i l s , see Appendix 2.2. The PAS data, together with observed data from s l a t e d and emergency cases was used to g i v e the p r o p o r t i o n of p a t i e n t s by sex, and, f o r each sex, the p r o p o r t i o n i n each §,a§ SEoup. (see Appendix 2.4). Length of stay, was o b t a i n e d by a more complex c a l c u l a t i o n . 96 From the PIS data, LOS was s u b d i v i d e d by sex, age group, and 3 s e a s o n a l l y - r e l e v a n t groups of months. I t was observed t h a t LOS was dependent on age, but not s i g n i f i c a n t l y on time-of-year. The average f o r each sex was s i g n i f i c a n t l y d i f f e r e n t , but a simple c a l c u l a t i o n ( i n c l u d e d i n Appendix 2.5) showed t h a t t h i s was almost e n t i r e l y accounted f o r by age-sex p a t t e r n s ( i . e . there were many more e l d e r l y females - which boosted the female average s t a y ) . Hence age groups were assigned by sex, then LOS by age group. Furthermore, 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 the e x i s t i n g l i t e r a t u r e suggested t h a t the best parametric d i s t r i b u t i o n to rep r e s e n t LOS would be the log-normal. A rough t e s t of t h i s hypothesis was done by p l o t t i n g p o i n t s on l o g a r i t h m i c p r o b a b i l i t y paper. Although not g i v i n g an ac c e p t a b l y s t r a i g h t l i n e (to support the log-normal h y p o t h e s i s ) , these p l o t s were h e l p f u l . A c t u a l l y , f o r some s e r v i c e - a g e groups, the graph and even a c h i - s q u a r e t e s t supported the log-normal hypothesis. For most groups, however, the data d e v i a t e d s u f f i c i e n t l y from l o g - n o r m a l i t y that the parametric d i s t r i b u t i o n was avoided. E m p i r i c a l d i s t r i b u t i o n s were used f o r LOS, i n c l u d i n g a number of i n t e r m e d i a t e p o i n t s obtained from the graphs of the computer-tabulation of PAS data., (Appendix 2.5 c o n t a i n s a more complete d e s c r i p t i o n . ) P r e - o ^ e r a t i v e stay, was assigned a c c o r d i n g t o d i s t r i b u t i o n s based on the p h y s i c i a n s ' admission forms. The data c o l l e c t e d on l e n g t h of surgery was a l s o t a b u l a t e d by age group and sex. Although i n EENT, the average l e n g t h v a r i e d g r e a t l y by sex i n the f i r s t t h r e e of the age groups, the 97 h o s p i t a l c o u l d o f f e r ao e x p l a n a t i o n . V a r i a t i o n was r e l a t i v e l y s m a l l f o r Orthopedics. Hence, i n the s u r g i c a l s e r v i c e s modelled, age was taken to be the only dependent v a r i a b l e i n a s s i g n i n g l e n g t h of surgery. E m p i r i c a l data was smoothed a r b i t r a r i l y and used as input (see Appendix 2.6). The p r o p o r t i o n of p a t i e n t s r e q u e s t i n g a date f o r surgery (by d i a g n o s t i c category) was based e n t i r e l y on e m p i r i c a l data. When a date was requested, i n r e a l i t y i t was almost always on the day of the week f o r which the p h y s i c i a n was booked. For each request then, t h e r e was a c e r t a i n delay between the next date f o r which the a p p r o p r i a t e p h y s i c i a n was booked, and the date which was requested., The e m p i r i c a l data was processed and smoothed t o determine which p r o p o r t i o n of p a t i e n t s would request a date any given number of weeks from the next booked date. O n f o r t u n a t e l y , the date s e l e c t e d i n the model i s e n t i r e l y random, whereas the p h y s i c i a n would h o p e f u l l y have some idea of h i s next f r e e day, or of whether he wanted to \"bump\" one of h i s own p a t i e n t s (see a l s o Figure 8.2). The bed l i m i t per day and the time lim.it (based on the number of OR's used) were as i n d i c a t e d by the h o s p i t a l . Scheduling, p r i o r i t y was represented by the f o l l o w i n g d e c i s i o n mechanism: (i) p a t i e n t s f o r whom no s p e c i f i c date was requested could be scheduled no l e s s than e i g h t days away (correspondinq to the requirement that the p h y s i c i a n submit h i s forms at l e a s t e i g h t days i n advance), ( i i ) true urgent cases (no requested date or requested w i t h i n two weeks) c o u l d bump lower-category p a t i e n t s of the the same p h y s i c i a n , ( i i i ) bumped 98 p a t i e n t s were r e p l a c e d one week l a t e r ( i f p o s s i b l e ) , (iv) c a n c e l l e d p a t i e n t s were re-scheduled on an urgent b a s i s , (v) p a t i e n t s c o u l d only use OS's of t h e i r own s e r v i c e , (vi) non-urgent cases had to be handled on a c o r r e c t block day. F i g u r e s 8.3 and 8.4 i n c l u d e these c o n s i d e r a t i o n s . S i n c e only the t o t a l d a i l y time per OR was of i n t e r e s t , i n s t e a d of making the time between o p e r a t i o n s dependent on the l e n g t h s of adjacent o p e r a t i o n s , a c o n s t a n t turnaround time of f i f t e e n minutes seemed reasonable (see a l s o S e c t i o n 5.3.7). The placement of Medical p a t i e n t s presented a problem. In r e a l i t y , t e a c h i n g r e s i d e n t s c o n t r o l some o f the M e d i c a l beds, and t h e r e are many emergency Medical admissions beyond the c a p a c i t y of the Medical wards. S i n c e data are not a v a i l a b l e on the p r o p o r t i o n of each category of p a t i e n t using teaching beds, or on the d i f f e r e n c e i n LOS, or on the a c t u a l use made of t e a c h i n g beds, they cannot be d i s t i n g u i s h e d i n the model. In an e f f o r t t o keep i n mind the e f f e c t of the t e a c h i n g beds, and t o \"tune\" the model, morning emergencies were allowed up to a c e r t a i n number of Medical beds., When i t was time t o admit scheduled p a t i e n t s f o r the day, the l e n g t h of the queue and the number of a v a i l a b l e beds were noted. Depending on the number of a v a i l a b l e beds, the number of p a t i e n t s to admit was determined. Furthermore, i f the w a i t i n g l i n e was l o n g , e x t r a p a t i e n t s were admitted. I f i t was s h o r t , l e s s p a t i e n t s were admitted., T h i s was implemented by s p e c i f y i n g an upper and lower l i m i t on a c c e p t a b l e queue l e n g t h , then d e f i n i n g t h r e e f u n c t i o n s (one f o r l o n g , one f o r a c c e p t a b l e , and one f o r s h o r t queues) s p e c i f y i n g 99 the number of p a t i e n t s to admit at each l e v e l of \"remaining c a p a c i t y \" . The l i m i t s and numbers are a r b i t r a r y . When emergency p a t i e n t s cannot be admitted to the proper area, they are p l a c e d i n an a l t e r n a t e - area* There i s an a r b i t r a r y l i m i t d e f i n i n g the number o f beds which may not be used by o f f - s e r v i c e p a t i e n t s . Data suggest which sequence of a l t e r n a t e areas s o u l d be checked f o r empty beds. S e r v i c e area \"2\" i s used i n t h i s model as an overflow area. (Overflow beds are necessary because Medical emergency p a t i e n t s a c t u a l l y use e x t r a beds i n many s e r v i c e areas, not j u s t those implemented i n the model.) For M e d i c a l p a t i e n t s i n s u r g i c a l beds, t r a n s f e r s are arranged to avoid e x c e s s i v e \"No Bed\" s i t u a t i o n s . O f f - s e r v i c e data and c o n s u l t a t i o n with the h o s p i t a l suggest the p r o p o r t i o n of other types of p a t i e n t s allowed to stay i n o f f - s e r v i c e beds. The number of beds per s e r v i c e r e f l e c t s the a c t u a l s i t u a t i o n . . However, the a l l o t m e n t f o r Medicine i n c l u d e s the ICU, and the A c t i v a t i o n beds are d i v i d e d approximately by use as 6 f o r Medicine, 5 f o r Orthopedics, and 5 f o r General Surgery. The t o t a l number of emergency r e q u e s t s on the OR was found from data. The OR Booking O f f i c e , and some data, suggested the number of i ^ h p s p i t a l demands on the OR per day ( i f these c o u l d not be placed w i t h i n a week, they were handled as emergencies). These were i n c l u d e d i n the model by having an a p p r o p r i a t e p r o p o r t i o n of the admitted p a t i e n t s request such s p e c i a l surqery. 100 7.3 Comments The adequacy of the data used i n the model should be d i s c u s s e d . Were the data too o l d ? Were the observed samples too s m a l l , or f a u l t y ? Were any important f e a t u r e s i n c l u d e d or omitted without adequate data s u b s t a n t i a t i o n ? Would other types of data have been h e l p f u l ? Let us c o n s i d e r the f o u r data c o l l e c t i o n groups i d e n t i f i e d . The w a i t i n g l i s t s were d i s a p p o i n t i n g i n that the sample was s m a l l , so S e c t i o n 11.1 i n c l u d e s some su g g e s t i o n s r e g a r d i n g sample c o l l e c t i o n . The Medical a d m i t t i n g forms moved e s p e c i a l l y slowly during the c o l l e c t i o n time - a t about one t h i r d of the normal r a t e ! Furthermore, the f a c t t h a t t e a c h i n g r e s i d e n t s decide whom to admit t o t h e i r area and when, y i e l d s data which deny any a n a l y t i c a l p a t t e r n based on such c r i t e r i a as p a t i e n t admission d i a g n o s t i c category, and FIFO. Data on o p e r a t i o n s were taken from a good sample. However, the OH s u p e r v i s o r y s t a f f suggests that d i f f i c u l t y of o p e r a t i o n s (and hence t h e i r length) has i n c r e a s e d somewhat s i n c e 197 4, so t h a t newer data might show s l i g h t changes., The LOS data were a l s o taken from a l a r g e sample. The removal of the p e d i a t r i c s p e c i a l t y from the h o s p i t a l has probably had a s l i g h t l y d i f f e r e n t e f f e c t than t h a t c a l c u l a t e d , but these data should be q u i t e a c c u r a t e . Emergency admissions gave good data (except that a sample s e l e c t e d from the e n t i r e year might be p r e f e r a b l e ) . . As mentioned before, i t might be p r e f e r a b l e to modify the model so that the l e n g t h of time to a requested admission date 1 0 1 i s not random. T h i s would r e q u i r e a c l o s e r o b s e r v a t i o n of i n d i v i d u a l p h y s i c i a n ' s p r a c t i c e . I t would a l s o be p r e f e r a b l e to have a l e s s r i g i d d a i l y bed l i m i t f o r scheduled s u r g i c a l p a t i e n t s . T h i s would r e g u i r e observance of the f i n a l s l a t e as i t emerges - with a knowledge of which p a t i e n t s are scheduled and which p a t i e n t s are i n - h o s p i t a l . The main u n a v a i l a b l e i n f o r m a t i o n which would be of value i s a study of t r a n s f e r s between s e r v i c e areas - with a knowledge of which were c o r r e c t i o n s of o f f - s e r v i c e placement. The t o t a l number of p a t i e n t s placed o f f - s e r v i c e f o r each s e r v i c e (not j u s t Medicine) would a l s o help. , 102 CHAPTER 8 THE MODEL IMPLEMENTATION-T h i s chapter e x p l a i n s the a c t u a l concepts i n v o l v e d i n the programmed model, and b r i e f l y summarizes i t s c o n t e n t s . The e n t i r e computer program i s l i s t e d i n Appendix 3. At present, t h r e e s e r v i c e s have been implemented i n the model: Medicine, EENT, and Orthopedics. 8.1 General Features There are probably t h r e e f e a t u r e s of the program which should be e x p l a i n e d f i r s t . These are: (i) the i d e a of a \"composite\" p h y s i c i a n , ( i i ) the implementation of the s u r g i c a l s l a t e s , and ( i i i ) the d a i l y sequence of events which the model observes. (i) In order to r e l a t e p a t i e n t l o a d to the number of a c t i v e p h y s i c i a n s , i t was considered d e s i r a b l e t h a t each s e r v i c e have a c e r t a i n number of p h y s i c i a n s , and t h a t each p a t i e n t have a p a r t i c u l a r p h y s i c i a n . In t h i s manner, i t would be e a s i e r to suggest the e f f e c t on p a t i e n t load of i n c r e a s i n g or decreasing the number of p h y s i c i a n s on s t a f f . However, p h y s i c i a n p r a c t i c e p a t t e r n s are by no means s i m i l a r . Some p h y s i c i a n s admit many p a t i e n t s , some very few. Some p h y s i c i a n s c o n s i d e r a l l t h e i r p a t i e n t s t o be semi-urgent, others a l l e l e c t i v e . Some p h y s i c i a n s request s p e c i f i c admission days f o r a l l of t h e i r p a t i e n t s , others f o r a few, others f o r none. Because of t h i s 10 3 variety, and because in increasing or decreasing the active s t a f f only a \" t y p i c a l \" physician can be considered e a s i l y , i t was f e l t that a Ilcomgosite^ physician should be used (already mentioned i n Section 7.2). Hence, except for random variations, a l l physicians in the model have i d e n t i c a l practice patterns. Furthermore, rather than having a specified patient load generated for each physician, the language i s better structured to generate patients, and then to assign a physician to each. As a res u l t , i f the s t a f f s i z e i s to be varied, i n addition to changing the number of physicians for the service i t w i l l be necessary to re-compute the proportion of schedulable and DO patients a t t r i b u t a b l e to the physicians i n guestion, and to re-construct the patient a r r i v a l rate and admission diagnostic category functions., I t may also be necessary to adjust certain l i m i t s on patient flow. Refer to Chapter 10 for examples. ( i i ) The main scheduling device in the OS Booking Office at the hospital i s a six-week v i s u a l s l a t e f i l e . The counterparts of this f i l e i n the program are matrices counting the scheduled number and t o t a l time of patients to be operated on each week, and corresponding chains on which complete patient data f o r each operation are f i l e d . , For each s u r g i c a l service there i s a matrix, the f i r s t row of which gives the \"dates\" of Monday through Friday of the present week. Each of the s i x pairs of rows after that corresponds to a p a r t i c u l a r week in the future. The f i r s t row of each pair stores the number of patients to be admitted and operated on for each day of the week. The second row of each pair accumulates the operating time (and turnaround 104 time) r e q u i r e d by these p a t i e n t s as w e l l as i n - p a t i e n t s . These are the two c r i t i c a l f a c t o r s determining whether another p a t i e n t may have surgery on a given day {refer a l s o t o S e c t i o n 9.1). The time c a l c u l a t i o n s work as f o l l o w s . Each o p e r a t i n q t h e a t r e i s s l a t e d from 8:00 am t o 3:30 pm with a h a l f hour f o r l u n c h , which giv e s 420 minutes to be used. Turnaround time of f i f t e e n minutes i s added between p a t i e n t s . However, i t i s assumed that one turnaround c o u l d proceed durinq the lunch break. Since only t o t a l o p e r a t i n q time per s e r v i c e per day i s of i n t e r e s t , the \" o v e r - l u n c h \" turnaround i s counted as f a l l i n q between the f i r s t p a i r of p a t i e n t s - and no time i s added f o r t h a t . For each of the s i x weeks mentioned above, i n a d d i t i o n to the matrix there i s a l s o a \" c h a i n \" f o r each s e r v i c e . D a t a - e n t i t i e s r e p r e s e n t i n g the p a t i e n t s to be operated on are f i l e d on the c h a i n . , To avoid s h i f t i n g data between rows and between c h a i n s , t h e r e i s a p o i n t e r which i n d i c a t e s which rows and chain are those of the \" p r e s e n t \" week. T h i s p o i n t e r changes weekly, c y c l i n g through the s e t s . { i i i ) The d a i l y se&uenee of events ( e f f e c t e d by p r i o r i t y l e v e l s ) was mentioned i n chapter 7, but i s worthy of r e p e t i t i o n here. F i g u r e 8.1 d e p i c t s the time stream. The f i r s t and l a s t t h i n g s done each day are \"book-keeping\" events. Of the p a t i e n t - r e l a t e d events, the g e n e r a t i o n of p a t i e n t admission requests f o r a l l c a t e g o r i e s of p a t i e n t s i s done f i r s t . P r i o r i t i e s are set i n such a way t h a t , of the s c h e d u l a b l e p a t i e n t s , urgent reguests are processed f i r s t , then semi-urgent 105 W A I T I N G QUEUE S L A T E S T R A N S F E R QUEUE T R A N S F E R QUEUE W A I T I N G QUEUE S L A T E S B O O K - K E E P I N G I T E M S GENERATE A D M I S S I O N REQUESTS P R O C E S S E M E R G E N C I E S & D U ' S U N T I L A D M I S S I O N P R O C E S S U / S U / E L ONTO W A I T I N G L I N E AND S L A T E S D I S C H A R G E S ADMIT S C H E D U L A B L E P A T I E N T S FROM W A I T I N G L I N E MEANWHILE G E N E R A T E EMERGENCY & I N - H O S P I T A L OR DEMANDS T R A N S F E R QUEUE - « * (SOME) R E M A I N I N G E M E R G E N C I E S & D U ' S A D M I T T E D S L A T E S OR C A L C U L A T I O N S B O O K - K E E P I N G ITEMS BEDS A V A I L A B L E T R A N S F E R S . ( S O M E ) \" M O R N I N G \" E M E R G E N C I E S & D U ' S A D M I T T E D - * - CLAIM B E D S -f» CLAIM B E D S . CLAIM B E D S -is- CLAIM BEDS F i g . 8.1 Flowchart f o r d a i l y time stream 106 ones, then the e l e c t i v e s . A l s o , each request i s completely processed before beginning the next. Then, of the events which a f f e c t bed occupancy, dis c h a r g e s are f i r s t . T r a n s f e r s w i t h i n the h o s p i t a l f o l l o w . An a p p r o p r i a t e p r o p o r t i o n of emergencies to be placed during the morning of the d a y - s h i f t come next. Scheduled admissions then make t h e i r c l a i m on beds, followed by the r e s t of the emergencies f o r the day. To c l o s e o f f , the day's OR data i s computed. T h i s seguence i s intended to r e s u l t i n a r e a l i s t i c s i m u l a t i o n of wa i t i n g time, \"No Bed\" c a n c e l l a t i o n s f o r scheduled p a t i e n t s , and o f f - s e r v i c e placement of emergency p a t i e n t s . , 8.2 The Program Segments The program l i s t i n g begins with an e x t e n s i v e t a b l e of d e f i n i t i o n s f o r r e f e r e n c e , f o l l o w e d by d i f f e r e n t c a t e g o r i e s of GPSS d e f i n i t i o n s . The remainder of the l i s t i n g i s d i v i d e d i n t o s e c t i o n s by comment l i n e s . These s e c t i o n s are b r i e f l y e x p l a i n e d below. 8.2.1 Housekeeping Segments The f i r s t segment i n the program updates the s l a t e f i l e each \"Saturday\" (the s i x t h day o f each seven). The p o i n t e r mentioned i n S e c t i o n 8.1 i s moved t o a new \"present week\". Data on the week j u s t completed i s erased. P a t i e n t s whose forms had not been placed on the six-week \" v i s u a l f i l e \" (due t o a s p e c i f i c 107 request or l a c k of space) had been f i l e d i n a separate pl a c e . As many of these as i s a p p r o p r i a t e are now moved onto the new \" f i f t h week\" l o c a t i o n . , Weekly date chanqes are made. The l a s t two program segments are a l s o f o r \"housekeeping\". The f i r s t of these i s t o c o n t r o l p r i n t - o u t s as d e s i r e d . The f i n a l program segment i s a ti m e r . I t keeps tr a c k of how many days the program has run, and helps with some data g a t h e r i n g . 8.2.2 P a t i e n t Generation A t r a n s a c t i o n i s r e l e a s e d d a i l y and marked with the date. (Each e n t i t y which moves through the model i s c a l l e d a t r a n s a c t i o n . As i n t h i s case, use of the term i n t h i s t h e s i s i s normally to i d e n t i f y an i n t e r n a l program e n t i t y , as opposed to a t r a n s a c t i o n which r e p r e s e n t s a p a t i e n t - which w i l l u s u a l l y be c a l l e d a p a t i e n t . ) Then f o r each s e r v i c e , the t r a n s a c t i o n \" s p l i t s \" t o generate f i r s t the non-schedulable then the sch e d u l a b l e p a t i e n t admission reguests i n accordance with the ap p r o p r i a t e a r r i v a l d i s t r i b u t i o n s f o r th a t s e r v i c e . T h i s generating t r a n s a c t i o n leaves the model, and the reguests are sent to be assigned p a t i e n t c h a r a c t e r i s t i c s . , To each p a t i e n t , the model a s s i g n s a p h y s i c i a n , an admission d i a g n o s t i c c ategory, a sex, an age group, and a LOS. Emergency reguests are then d i v e r t e d , as are the remaining Medical and s u r g i c a l requests. 108 8.2.3 S u r g i c a l Request Handling For s u r g i c a l r e q u e s t s , p r e - o p e r a t i v e LOS (makinq sure t o t a l LOS i s longer) and length of surgery must be assigned. Then the p a t i e n t requests are separated a c c o r d i n q to the bookinq method observed by t h e i r s e r v i c e (e.g. block booking, see S e c t i o n 5.3.4). (Only block booking i s implemented i n the model at the time of w r i t i n g . ) As shown i n F i g u r e 8.2, the f i r s t item t o be determined i s a date on which to attempt to schedule surgery. T h i s date may e i t h e r be \"as soon as p o s s i b l e \" or may be requested f o r some time i n the f u t u r e . I t i s necessary to decide which p a t i e n t s are t o have a requested date of surqery. , For these, t h a t date i s determined i n accordance with e m p i r i c a l data {Section 7.2). For the o t h s r s , the e a r l i e s t p o s s i b l e date of surgery which i s blocked f o r the proper surgeon i s determined. I t must be over seven days away s i n c e the p h y s i c i a n i s r e q u i r e d to submit h i s r e q u e s t s at l e a s t e i g h t days i n advance. Having a d e s i r e d date f o r s urgery, one may attempt t o schedule the p a t i e n t , as i n F i g u r e 8.3. I f the date i s over s i x weeks away, the request i s placed on a c h a i n c o r r e s p o n d i n q to the f i l e box - separate from the main six-week f i l e . Another copy of the request i s added to an admission chain to wait f o r the a p p r o p r i a t e day. I f the date i s w i t h i n s i x weeks, the o p e r a t i o n s already scheduled f o r that date are checked. Here t h i s one added, would the bed or time l i m i t s be exceeded? I f there i s room, the 109 NO YES FIND NE PHYSICIAN XT DAY IS BOOKED 1 ADD 1 WEEK f FIND NEXT DAY PHYSICIAN IS BOOKED DETERMINE DESIRED DELAY ADD, FOR DATE TO TRY 1 NO ADD 1 WEEK \" \" V* • TRY THAT DATE YES F i g . 8.2 Flowchart f o r f i r s t d e s i r e d surgery date F i g . 8.3 Flowchart f o r p l a c i n g schedulable s u r g i c a l p a t i e n t s on the s l a t e 111 p a t i e n t i s added t h e r e . I f t h e r e i s no room, a l a t e r date must fee found as f o l l o w s . , For a non-urgent request, there w i l l be an attempt t o schedule i t one week l a t e r . I t i s considered that an urgent request f o r a date beyond two weeks away i s one which i s not r e a l l y t o p - p r i o r i t y , but i s more important than non-urgent requests of the same p h y s i c i a n . Hence, the model w i l l t r y to bump an e l e c t i v e f i r s t , or a semi-urgent, from the d e s i r e d day. I f there i s none which would allow the new p a t i e n t room and time, a week i s added before t r y i n g again. Note t h a t urgent p a t i e n t s are supposed to be admitted w i t h i n two weeks., As a r e s u l t , i f a request i s being handled i n t h i s p a r t of the model i t i s because the p h y s i c i a n submitted i t with a long-term \"urgent\" reguested date. , The model only allows him to bump h i s own p a t i e n t s . , An urgent request which did not come asking s p e c i f i c a l l y f o r admission two or more weeks away i s c o n s i d e r e d t o d e s i r e admission as soon as p o s s i b l e . I f i t cannot be f i t i n t o the proper p h y s i c i a n ' s s l o t , the e a r l i e s t p o s s i b l e date i s found, r e g a r d l e s s of p h y s i c i a n . , The p a t i e n t i s added t o the f i r s t day with enough space and time. I f there are none w i t h i n two weeks, t h i s request bumps another, as above. P a t i e n t s who were bumped must be removed from the s l a t e s and taken out of the admission f i l e . A week i s added to the date o r i g i n a l l y obtained before t r y i n g again. Once a day i s obtained f o r any of these r e q u e s t s , the s u c c e s s f u l surgery date, and hence, admission date i s marked. 112 The request i s added to the s l a t e and to the admission f i l e . 8.2.4 Medical Heguest Handlinq A Medical request i s simply added to the queue of those a w a i t i n g admission. 8.2.5 S u r g i c a l Admissions Once a day, the s u r g i c a l admissions f o r that date are r e l e a s e d from the w a i t i n g queue. Admission proceeds as shown i n F i g u r e 8.4. Some who should be admitted f i n d no room a v a i l a b l e . These are \"No Bed\" p a t i e n t s . T h e i r category l e v e l i s r e s e t so t h a t they w i l l be t r e a t e d as h i g h - p r i o r i t y urgent r e g u e s t s . They are removed from the s l a t e to be t r i e d one week l a t e r . The category i s r e s t o r e d once a new date i s found. For the p a t i e n t s who are admitted, there i s another process. A c e r t a i n p r o p o r t i o n of the p a t i e n t s i n the h o s p i t a l w i l l have e x t r a o p e r a t i o n s - besides t h a t f o r which they were o r i g i n a l l y admitted. In order t o represent these demands on the OR, i t was decided to use the p a t i e n t s being admitted to i n i t i a t e demands f o r emergency and in - r h o s p i t a l o p e r a t i o n s . Emergencies are generated and set f o r the next day ( i f the p a t i e n t ' s LOS warrants using him). I n - h o s p i t a l r e q u e s t s are more complex, as they must be scheduled. For them, checking begins two days from the present time, or i f that day would be on a weekend, checking begins with the f o l l o w i n g Monday). 113 YES SCHEDULE FOR NEXT DAY NO ENTER BED I ARRANGE DISCHARGE TIME YES ADD TO SLATE YES TRY 2 DAYS HENCE DETERMINE PHYSICIAN THEN ADD 1 OPERATING DAY MAKE IT AN EMERGENCY OPERATION NO NO BED! TAKE OFF SLATE CLASSIFY AS IF URGENT 1 ADD 1 WEEK TO ATTEMPTED OPERATION DATE r GO TRY (AS FIG. 8.3] WHEN RE-SCHEDULED, RESTORE CATEGORY YES F i g . 8.4 Flowchart f o r a d m i t t i n g s u r g i c a l p a t i e n t s 114 Having decided the date, the p h y s i c i a n who operates then must be i d e n t i f i e d . , One may now check whether the date i s p o s s i b l e , or go on l o o k i n g u n t i l one i s . {Recall t h a t \" p o s s i b l e \" r e q u i r e s only enouqh time. The p a t i e n t already has a bed).. Once a date i s found, the model checks to be sure that the p a t i e n t w i l l s t i l l be i n the h o s p i t a l (or e l s e i g n o r e s t h i s r e q u e s t ) . I f the p a t i e n t w i l l be i n the h o s p i t a l , the o p e r a t i o n i s scheduled on the s l a t e . Note t h a t i f an i n - h o s p i t a l request cannot be scheduled w i t h i n two weeks, i t i s changed to emergency handling. Now, the remaining d e t a i l s f o r an e n t e r i n g p a t i e n t are taken care of. He i s put i n a bed and a p p r o p r i a t e s t a t i s t i c s are gathered. According t o h i s LOS, he i s scheduled f o r d i s c h a r g e . , 8.2.6 Medical Admissions Each day, when the time comes to admit Medical p a t i e n t s from the w a i t i n g l i n e , the number of beds a v a i l a b l e and the l e n g t h of the gueue are determined. Depending on the amount of space, a d e c i s i o n i s made concerning how many beds to allow these p a t i e n t s to take. Furthermore, i f the w a i t i n g l i n e i s l o n g , e x t r a p a t i e n t s are allowed i n ; i f i t i s s h o r t , l e s s are admitted. (The a l g o r i t h m i s d i s c u s s e d i n S e c t i o n 7.2.), The admitted p a t i e n t s are put i n beds and a p p r o p r i a t e s t a t i s t i c s are gathered. According t o t h e i r LOS, they are f i l e d f o r discharge. 115 8.2.7 Emergency Admissions F i g u r e 8.5 d e p i c t s emergency admissions. Note that both emergency and DO p a t i e n t s are handled i d e n t i c a l l y . , S ince the e n t i r e day i s t r e a t e d as one time u n i t , proper DO p r o c e s s i n g i s not p o s s i b l e . Morning d a y - s h i f t and other a r r i v a l s are d i f f e r e n t i a t e d (by p r o p o r t i o n s ) to a f f e c t sequencing. The morning ones are allowed t o c l a i m beds a f t e r d i s c h a r g e s and t r a n s f e r s , but before scheduled admissions. The r e s t wait u n t i l a f t e r r e g u l a r admissions. As with the other p a t i e n t s admitted, a p r o p o r t i o n of these a r r i v a l s cause emergency and i n - h o s p i t a l o p e r a t i o n r e g u e s t s . These emergencies, however, are c o n s i d e r e d to happen on the same day. I f a bed i s a v a i l a b l e i n the proper area (and the p a t i e n t would not exceed an a l l o w a b l e l i m i t ) the p a t i e n t i s put i n the bed and on the d i s c h a r g e f i l e . Otherwise, admission i s permitted t o an a l t e r n a t e area (except f o r r e s t r i c t i o n s t h e r e a l s o ) . Any Medical p a t i e n t s who must be placed i n s u r g i c a l beds are a l s o put on a s p e c i a l f i l e . (See S e c t i o n 8.2.8 r e g a r d i n g t h e i r t r a n s f e r s . ) Other p a t i e n t s placed i n s u r g i c a l beds are allowed to stay i f a s p e c i f i e d number of beds are s t i l l f r e e i n t h a t area. A p r o p o r t i o n of the p a t i e n t s placed i n the overflow area are allowed to s t a y there. The r e s t are f i l e d to cause t r a n s f e r s the next day. NO YES ARRANGE PRIORITY & BED LIMITS FOR AFTER SCHEDULED ADMISSIONS — \\ r • ARRANGE PRIORITY & BED LIMITS FOR BEFORE SCHEDULED ADMISSIONS JUL GENERATE EMERGENCY & IN-HOSPITAL OPERATIONS SIMILARLY TO FIG, 8.4 MEDICAL ? YES DETERMINE NEXT ALTERNATE AREA ML. . YES > PLACE IN OWN AREA > SCHEDULE FOR DISCHARGE STAY IN EMERGENCY UNIT < ARRANGE TRANSFER NEXT MORNING F i g . 8.5 Flowchart f o r emergency admissions 117 8.2.8 I n - H o s p i t a l T r a n s f e r s These happen r i g h t a f t e r d i s c h a r g e s , a s s u r i n g t h a t t r a n s f e r r i n g p a t i e n t s get f i r s t c l a i m on r e l e a s e d beds \"each morning\". The s u r g i c a l areas are checked t o see whether there are enough beds f r e e t o allow admission of s l a t e d s u r g i c a l p a t i e n t s . I f not, enough Medical p a t i e n t s are t r a n s f e r r e d out of the areas t o avoid e x c e s s i v e \"No Bed\" c a n c e l l a t i o n s . For p a t i e n t s t o be t r a n s f e r r e d , i f there are beds i n the proper a r e a , they are taken from the o f f - s e r v i c e area and placed i n the proper s e r v i c e area. 8.2.9 Discharges T h i s i s the f i r s t change a f f e c t i n g census each day. A l l the p a t i e n t s scheduled to leave today are d i s c h a r g e d , and a p p r o p r i a t e records are kept. 8.2.10 Operating Room Data Note t h a t , as f a r as o p e r a t i o n s go, the l e n g t h of time scheduled i s the a c t u a l l e n g t h of time operated. (Any problem due t o v i o l a t i o n of t h i s assumption warrants and can be covered by an independent, s p e c i f i c study.) Turnaround time i s i n c l u d e d as e x p l a i n e d i n S e c t i o n 7.2, A l l of the day's emergency and r e g u l a r l y scheduled p a t i e n t s to be operated on are r e l e a s e d f o r p r o c e s s i n g . For emergency 118 o p e r a t i o n s and f o r each t o t a l times and p a t i e n t s s e r v i c e ' s scheduled o p e r a t i o n s , the are accumulated and t a b u l a t e d each day. 119 CHAPTER 9 IIALJJftTION OF THE SIMULATION MODEL T h i s chapter d i s c u s s e s the \"behaviour\" of the St. Paul's s i m u l a t i o n model. The form of the r e s u l t s given by the s i m u l a t i o n program i s e x p l a i n e d . T h i s i s f o l l o w e d by an e x p l a n a t i o n of the v e r i f i c a t i o n and v a l i d a t i o n of the model: V e r i f i c a t i o n i s a check that the model behaves i n t e r n a l l y as the modeller i n t e n d s . V a l i d a t i o n i s the process which t e s t s t h a t the model provi d e s a reasonable r e p r e s e n t a t i o n of r e a l i t y . .{Fishman and K i v i a t , 1967) 9.1 Form of the R e s u l t s A s i m u l a t i o n run i n GPSS a u t o m a t i c a l l y generates a \"standard\" s et of s t a t i s t i c a l r e s u l t s d e s c r i b i n g the behaviour of the model. I f the programmer uses any matrices i n the program, or s p e c i f i e s the format of any freguency t a b l e s (of wai t i n g times, f o r i n s t a n c e ) , they w i l l be i n c l u d e d i n the print-out.„ The language a l s o allows the monitoring o f each \" t r a n s a c t i o n \" (normally a p a t i e n t ) on any s p e c i f i e d f i l e or a t any s p e c i f i e d l o c a t i o n i n the model. As the output from such monitoring may be voluminous, i t tends to be u s e f u l only f o r debugging or v e r i f i c a t i o n purposes. In a d d i t i o n , i t i s p o s s i b l e to arrange f o r GPSS to p r i n t out any subset of the t o t a l a v a i l a b l e i n f o r m a t i o n . The f o l l o w i n g d i s c u s s i o n i n c l u d e s a l l r e s u l t s which are provided by GPSS without needing to be 1 2 0 s p e c i f i e d . F i r s t i t should be noted t h a t s e v e r a l of the items are cumulative averages over time (cumulative sums d i v i d e d by the t o t a l t i m e ) . I f a run i s l o n g , the e f f e c t of the most recent time i n t e r v a l i s weighted l e s s and l e s s due to the e f f e c t of preceding ones. To avo i d t h i s , a \"RESET\" between \"START\" blocks allows i n f o r m a t i o n on i n d i v i d u a l time i n t e r v a l s t o be generated and d i s p l a y e d . A l l averages p r i n t e d with the \" t a b l e s \" such as those of w a i t i n g times or LOS r e p r e s e n t p a t i e n t s who have completed the p a r t i c u l a r process being monitored. The averages l i s t e d elsewhere may be s l i g h t l y b i a s e d due to the f a c t t h a t they count a l l p a t i e n t - d a y s spent i n the process s i n c e the s t a r t of the c u r r e n t time i n t e r v a l , and d i v i d e by the elapsed time s i n c e then. I n a c c u r a c i e s r e s u l t i f p a t i e n t s are being processed a t the s t a r t of the time i n t e r v a l and i f any are being processed at the time of p r i n t - o u t . , S c h r i b n e r ' s t e x t S i m u l a t i o n J s i n s GPSS (1974) and the GPSS manual p o i n t out these b i a s e s more completely. The f i r s t items p r i n t e d i n the standard output are \"block counts\". Each f u n c t i o n a l statement (as opposed t o \"comment\" statement) i n GPSS i s a \" b l o c k \" . For each \" b l o c k \" - which i s numbered on assembly - there i s a count of the c u r r e n t and t o t a l number of times i t was used., Since these counts are u s e f u l only f o r c a r e f u l l y f o l l o w i n g the flow through the model, no examples are i n c l u d e d i n t h i s d e s c r i p t i o n . , Any time a \" t r a n s a c t i o n \" (patient) must be f i l e d f o r a 121 p e r i o d of time before being used again, i t i s most e f f i c i e n t to p l a c e the t r a n s a c t i o n on a \"user c h a i n \" . In the p r i n t - o u t , \"user c h a i n \" i n f o r m a t i o n (see Table X), f o l l o w s the \"block\" counts. SLEW1-6 are f o r the s i x one-week c h a i n s o f EENT p a t i e n t s s l a t e d f o r o p e r a t i o n s . The \" c u r r e n t c o n t e n t s \" columns f o r the v a r i o u s weeks i d e n t i f y how many p a t i e n t s are w a i t i n g f o r ope r a t i o n s and when they are scheduled. (The number f o r the present week, probably the l a r g e s t , may not be the f i r s t , due to c y c l i n g as e x p l a i n e d i n S e c t i o n 8.1.) SLEEN g i v e s s i m i l a r i n f o r m a t i o n on EENT p a t i e n t s t o be scheduled beyond s i x weeks away. SL0W1-6 and SLOEN gi v e the same i n f o r m a t i o n f o r Orthopedic p a t i e n t s . , ADMSC i d e n t i f i e s the c u r r e n t , maximum, average and t o t a l number w a i t i n g f o r admission f o r surgery, as w e l l as the average time waited. T h i s i n f o r m a t i o n i s u s e f u l f o r v a l i d a t i o n . A s i m i l a r and very c r i t i c a l s e t of values concerns ADMMC, which i s the c h a i n of Medical p a t i e n t s a w a i t i n g admission. EMSGC provides i n f o r m a t i o n (probably of l i t t l e use) on those i n l i n e f o r emergency surgery. MALTn i d e n t i f i e s the number of Medical p a t i e n t s i n s u r g i c a l bed areas, where n=3 f o r EENT and n=4 f o r Orthopedics. The average numbers may be u s e f u l f o r experiments. XFERC i d e n t i f i e s other p a t i e n t s o f f - s e r v i c e and i n l i n e t o be t r a n s f e r r e d back. DISCH (together with XFERC and MALT3-U) i d e n t i f i e s the t o t a l number of p a t i e n t s i n the h o s p i t a l , a l l of whom are on f i l e t o be di s c h a r g e d . The i n f o r m a t i o n on \"s t o r a g e s \" (bed pools, Table XI) i s g u i t e u s e f u l . I t g i v e s d e t a i l s on the u t i l i z a t i o n o f each bed area (1=Medicine, 2=overflow, 3=EENT, 4=0rthopedics). The TABLE X * * * * * * * * * * * ti * * * USER CHAINS * * * ** ** * ******************************** USER CHAIN TOTAL AVERAGE CURRENT AVERAGE MAXIMUM ENTR IE S TIME/TRANS CONTENTS CONTENTS CONTENTS SIEW1 40 4 .875 9 6. 964 29 SLEW2 35 10.085 6 12.607 29 SLEW3 30 12.000 2 12.857 28 SLEW* 2 9 15.137 ' 2 15.678 27 SLEWS 23 12. 739 23 10.464 23 SLEW6 I 1 6.454 11 2.535 1 1 SLEEM 6 11.833 2. 535 5 SLOWl 36 5.472 14 7.035 21 SLOW2 24 10.500 s 9. 000 18 SLOW3 20 13.349 9.53 5 18 S10W4- 21 11.047 I 8.285 18 SLOW 5 1 6 15.937 16 9. 107 16 SL0W6 V 5 7.599 15 4.071 1 5 SLOEN 5 5.599 .999 3 AOMSC 2 84 10.193 104 103.392 137 ADMMC 124 5.354 24 23.714 34 DISCH 909 8. 102 249 263.035 279 EMRGC 34 .500 .607 6 XFERC 16 1.000 .571 MALT 3 6 1 3.803 17 8.285 17 MALT 4 3a 8.578 5 11.642 21 **************************************** * * TABLE XI * S T O R A G E S * * » »»»*• * * * * * * * * * * *<**«»*** * * * * * *«** * * *»**» - A V E R A G E U T I L I Z A T I O N D U R I N G -S T O R A G E C A P A C I T Y A V E R A G E E N T R I E S A V E R A G E T O T A L A V A I L . U N A V A I L . C U R R E N T P E R C E N T C U R R E N T MAXIMUM C O N T E N T S T I M E / U N I T T I M E T IME T I M E S T A T U S A V A I L A B I L I T Y C O N T E N T S C O N T E N T S 1 165 1 6 4 . 3 2 1 5 2 6 8 . 7 4 7 . 9 9 5 1 0 0 . 0 1 6 5 1 6 5 2 100 9 . 0 0 0 3 5 7 . 2 0 0 . 0 9 0 1 0 0 » 0 10 16 3 35 3 2 . 2 5 0 2 1 0 4 . 3 0 0 . 9 2 1 1 0 0 . 0 3 5 3 5 4 75 71 . 7 5 0 2 1 2 9 . 4 7 6 . 9 5 6 1 0 0 . 0 6 7 7 5 TABLE X I I * * * Q U E U E S * * * O U E U E MAX I MUM A V E R A G E T O T A L Z E R O P E R C E N T A V E R A G E S A V E R A G E T A B L E C U R R E N T C O N T E N T S C O N T E N T S E N T R I ES E N T R I E S Z E R O S T I M E / T R A N S T I M E / TRANS NUMBER C O N T E N T S WMEDU I S l l . 0 7 1 65 . 0 4 . 7 6 9 4 . 7 6 9 7 12 WM EDS 8 4 . 107 22 . 0 5 . 2 2 7 5 . 2 2 7 8 3 WMEOE 15 9 . 1 7 8 50 . 0 5 . 1 3 9 5 . 1 3 9 9 14 WE ENU 3 1 . 3 2 1 4 . 0 9 . 2 50 9 . 2 5 0 10 1 WEENS 2 . 6 7 8 3 . 0 6 . 3 3 3 6 . 3 3 3 11 I WEENE 8 8 6 6 . 3 5 7 1 8 3 1 . 5 1 0 . 1 5 3 1 0 . 2 0 8 12 8 3 WORPU 1 . 392 I . 0 1 1 . 0 0 0 1 1 . 0 0 0 13 WORPS 12 8 . 9 6 4 23 . 0 1 0 . 9 1 3 1 0 . 9 1 3 14 7 UORPE 5 0 4 0 . 4 2 8 109 . 0 1 0 . 3 8 5 1 0 . 3 8 5 15 5 0 L O S M E 1 9 9 1 8 7 . 2 5 0 6 2 0 . 0 8 . 4 5 6 8 . 4 5 6 16 186 LOSMM 114 1 0 1 . 8 5 7 3 2 6 . 0 8 . 7 4 8 8 . 7 4 8 105 L O S M F 9 9 8 5 . 3 9 2 2 9 4 . 0 8 . 1 3 2 8 . 132 81 L O S E E 33 2 2 . 8 5 7 145 . 0 4 . 4 1 3 4 . 4 1 3 17 2 4 1 0 S E M 24 1 1 . 3 2 1 72 . 0 4 . 4 02 4 . 4 0 2 16 L O S E F 18 1 1 . 5 3 5 73 . 0 4 . 4 2 4 4 . 4 2 4 8 1 0 S O R 7B 6 7 . 2 1 4 192 . 0 9 . 8 0 2 9 . 8 0 2 18 6 7 LOSOM 38 3 2 . 5 7 1 97 . 0 9 . 4 0 2 9 . 4 0 2 33 L O S O F 43 3 4 . 6 4 2 95 . 0 1 0 . 2 1 0 1 0 . 2 1 0 34 MI N2 12 7 . 5 0 0 22 . 0 9 . 5 4 5 9 . 5 4 5 5 MIN3 18 9 . 9 6 4 68 . 0 4 . 1 0 2 4 . 1 0 2 1 1 MI N't 14 5 . 4 6 4 2 7 . 0 5 . 6 6 6 5 . 6 6 6 5 E IN2 3 . 392 4 . 0 2 . 7 5 0 2 . 7 5 0 E IN4 2 . 2 8 5 3 . 0 2 . 6 6 6 2 . 6 6 6 01 N2 7 1 . 1 0 7 9 . 0 3 . 4 4 4 3 . 4 4 4 5 01 Hi 1 . 107 3 . 0 1 . 0 0 0 1 . 0 0 0 • A V E R A G E T I M E / T R A N S = A V E R A G E T I M E / T R A N S E X C L U D I N G Z E R O E N T R I E S CO 1 2 4 \"average u t i l i z a t i o n during t o t a l time\" i s the most u s e f u l v a r i a b l e . \"Average c o n t e n t s \" may be i n t e r e s t i n g when compared with o f f - s e r v i c e usage. \"Current c o n t e n t s \" i s u s e f u l f o r day-to-day examination. The queue i n f o r m a t i o n (Table XII) i s s i m i l a r t o that f o r \"user c h a i n s \" . Those queues having an e n t r y under \"Table Number\" are more completely d e s c r i b e d i n a t a b l e . At a glance, the gueue output g i v e s i n f o r m a t i o n on waits f o r urgent, semi-urgent and e l e c t i v e p a t i e n t s of M e d i c a l , EENT and Orthopedic p a t i e n t s (BMEDU, WMEDS, HMEDE, WEENU, ... ,WOSPU, . . . ) . O v e r a l l LOS f o r each s e r v i c e may be found (LOSME, LOS EE, LOSOR), as w e l l as LOS by sex w i t h i n each s e r v i c e (LOSMM, LOSMF, . . . ) . The p i c t u r e by sex, i n g i v i n g the average numbers i n the h o s p i t a l , suggests bed d i s p o s i t i o n . A l s o , a q u a n t i f i c a t i o n of LOS d i f f e r e n c e by sex appears. F i n a l l y , f o r each s e r v i c e there are gueues of those o f f - s e r v i c e . (eg., MIN3 means Medicals i n area 3 - EENT beds). Of these the averages i n each area and o v e r a l l average o f f - s e r v i c e may be i n f o r m a t i v e . The format of a l l the \" t a b l e s \" i s i d e n t i c a l (see T a b l e XIII f o r examples). T h e i r mean and standard d e v i a t i o n f i g u r e s are unbiased. The freguency d i s t r i b u t i o n t a b l e s may be of use. To i d e n t i f y what each \" t a b l e \" shows, see the l i s t i n Table XIV. Information may be f o r v e r i f i c a t i o n , v a l i d a t i o n , or experimentation. TABLE XIII OUTPUT TABLES T A B L E O R P S N E N T R I E S IN T A B L E 20 U P P E R L I M I T 0 I 2 3 4 5 6 MEAN ARGUMENT . 3 . 7 9 9 O B S E R V E D F R E Q U E N C Y 0 1 3 1 10 4 1 R E M A I N I N G F R E Q U E N C I E S A R E A L L Z E R O PER CENT OF T O T A L . 0 0 4 . 9 9 1 4 . 9 9 4 . 99 5 0 . 0 0 1 9 . 9 9 4 . 99 S T A N D A R D D E V I A T I O N 1 . 2 3 8 C U M U L A T I V E P E R C E N T A G E . 0 4 . 9 1 9 . 9 2 4 . 9 7 4 . 9 9 4 . 9 1 0 0 . 0 C U M U L A T I V E R E M A I N D E R 1 0 0 . 0 9 5 . 0 8 0 . 0 7 5 . 0 2 5 . 0 5 . 0 . 0 SUM OF A R G U M E N T S 7 6 . 0 0 0 M U L T I P L E OF MEAN - . 0 0 0 . 2 6 3 . 5 2 6 . 7 8 9 1 . 0 5 2 1 . 3 1 5 1 . 5 7 8 D E V I A T I O N F R O M MEAN - 3 . 0 6 8 - 2 . 2 6 1 - 1 . 4 5 3 - . 6 4 6 . 161 . 9 6 9 1 . 7 7 6 T A 8 L E O R P S T E N T R I E S 1 T A B L E MEAN A R G U M E N T 2 0 2 8 9 . 5 0 0 UPPER O B S E R V E D PER C E N T L I M I T F R E Q U E N C Y OF T O T A L 0 0 . 0 0 60 0 . 0 0 1 2 0 3 1 4 . 9 9 180 2 9 . 9 9 2 4 0 1 4 . 9 9 3 0 0 2 9 . 9 9 360 6 2 9 . 99 4 2 0 6 2 9 . 9 9 S T A N D A R D D E V I A T I O N 1 1 5 . 0 0 0 SUM OF A R G U M E N T S 5 7 9 0 . 0 0 0 R E M A I N I N G F R E O U E N C I E S A R E A L L ZERO C U M U L A T I V E C U M U L A T I V E M U L T I P L E P E R C E N T A G E R E M A I N D E R OF MEAN .0 1 0 0 . 0 - .000 . 0 100.0 . 2 0 7 1 4 . 9 8 5 . 0 . 4 1 4 2 4 . 9 7 5 . 0 .621 2 9 . 9 7 0 . 0 . 8 2 9 3 9 . 9 6 0 . 0 1 . 0 3 6 6 9 . 9 3 0 . 0 1 . 2 4 3 100.0 . 0 1 . 4 5 0 O E V I A T I O N F R O M MEAN - 2 . 5 1 7 - 1 . 9 9 5 - 1 . 4 7 3 - . 9 5 2 - . 4 3 0 . 0 9 1 . 6 1 3 1 . 1 3 4 T A B L E W T U l E N T R I E S IN T A B L E 50 U P P E R L I M I T 0 2 4 6 M E A N ARGUMENT 6. 03 9 O B S E R V E D F R E Q U E N C Y 28 18 R E M A I N I N G F R E Q U E N C I E S A R E A L L Z E R O PER C E N T OF T O T A L .00 .00 7 . 9 9 55 .99 3 5 . 9 9 S T A N D A R D D E V I A T I O N 1 . 0 4 6 C U M U L A T I V E P E R C E N T A G E .0 .0 7 . 9 6 3 . 9 100.0 C U M U L A T I V E R E M A I N D E R 1 0 0 . 0 l oo.o 9 2 . 0 3 6 . 0 . 0 SUM OF A R G U M E N T S 302.000 M U L T I P L E OF MEAN - . 0 0 0 . 3 3 1 . 6 6 2 . 9 9 3 1 . 3 2 4 D E V I A T I O N FROM MEAN - 5 . 7 6 9 - 3 . 8 5 9 - 1 . 9 4 8 - . 0 3 8 1 . 8 / 2 T A B L E WTS1 E N T R I E S IN T A B L E 11 MEAN A R G U M E N T 5 . 9 0 9 U P P E R O B S E R V E D PER C E N T L I M I T F R E Q U E N C Y OF T O T A L 0 0 .00 2 0 .00 4 3 2 7 . 2 7 6 2 1 8 . 1 8 8 6 5 4 . 5 4 R E M A I N I N G F R E Q U E N C I E S A R E A L L Z E R O S T A N D A R D D E V I A T I O N 1 . 5 1 1 C U M U L A T I V E P E R C E N T A G E .0 .0 2 7 . 2 4 5 . 4 1 0 0 . 0 C U M U L A T I VE R E M A I N D E R 100.0 100.0 7 2 . 7 5 4 . 5 .0 SUM OF A R G U M E N T S 6 5 . 0 0 0 M U L T I P L E OF MEAN - . 0 0 0 . 3 3 8 . 6 7 6 1 . 0 1 5 1 . 3 5 3 D E V I A T I O N FROM MEAN - 3 . 9 0 8 - 2 . 5 8 5 - 1 . 2 6 2 . 0 6 0 1 . 3 8 3 T A B L E W T E l E N T R I E S IN T A B L E 46 MEAN A R G U M E N T 6.739 U P P E R L I M I T 0 2 4 6 8 10 R E M A I N I N G F R E U U E N C I E S A R E A L L Z E R O O B S E R V E D F R E Q U E N C Y 18 21 P E R C E N T OF T O T A L . 00 .00 6 . 5 2 3 9 . 13 4 5 . 6 5 8 . 6 9 S T A N D A R D D E V I A T I O N 1 . 3 7 1 C U M U L A T I V E P E R C E N T A G E . 0 . 0 6.5 45.6 9 1 . 3 1 0 0 . 0 C U M U L A T I V E R E M A I N D E R 1 0 0 . 0 1 0 0 . 0 9 3 . 4 5 4 . 3 8 . 6 . 0 SUM OF A R G U M E N T S 3 1 0 . 0 0 0 M U L T I P L E OF MEAN - . 0 0 0 . 2 9 6 . 5 9 3 . 8 9 0 1. 187 1.483 D E V I A T I O N FROM MEAN - 4 . 9 1 5 - 3 . 4 5 6 - 1 . 9 9 7 - . 5 3 9 . 9 1 9 2 . 378 126 TABLE XIV MODEL OUTPUT TABLES LIST Name Pu rjsose EENSN Number of EENT p a t i e n t s s l a t e d each weekday EENST T o t a l time f o r EENT p a t i e n t s s l a t e d each weekday OBPSN Number of Orthopedic p a t i e n t s s l a t e d each weekday ORPST T o t a l time f o r Orthopedic p a t i e n t s s l a t e d each weekday HTU1 Medical urgent p a t i e n t s * w a i t i n g time WTS1 Medical semi-urgent p a t i e n t s ' w a i t i n g time WTE1 Medical e l e c t i v e p a t i e n t s ' waiting time WTU3 EENT urgent p a t i e n t s ' waiting time ITS3 EENT semi-urgent p a t i e n t s * w a i t i n g time WTE3 EENT e l e c t i v e p a t i e n t s * w a i t i n g time WTU4 Orthopedic urgent p a t i e n t s ' w a i t i n g time BTS4 Orthopedic semi-urgent p a t i e n t s * w a i t i n g time ITE4 Orthopedic e l e c t i v e p a t i e n t s ' waiting time STA1 LOS f o r Medical p a t i e n t s STA3 LOS f o r EENT p a t i e n t s STA4 LOS f o r Orthopedic p a t i e n t s EMTBN Number of (combined) p a t i e n t s d a i l y f o r emergency surgery EMTBT T o t a l time f o r (combined) p a t i e n t s d a i l y f o r emergency surgery EMGDU T o t a l d a i l y number of emergency and DU a r r i v a l s NOBED T o t a l d a i l y c a n c e l l a t i o n s f o r \"No Bed\" 127 Following the t a b l e s , the \"halfword s a r e v a l u e s \" are p r i n t e d . Most of these are i n t e r n a l and not too h e l p f u l . However, the f o l l o w i n g three may be u s e f u l : CftNCL = Number who c a n c e l l e d from surgery due to a very long wait. EhDIS = Number of d i s c h a r g e s from the Medical area, s i n c e t h i s i s not i d e n t i c a l t o Medical p a t i e n t s ' d i s c h a r g e s . MEMBN = Number of Medical emergencies and DU's i n the morning. T h i s has an impact on the day-to-day queue. S e v e r a l very important \"halfword m a t r i c e s \" , as i n Table XV, f o l l o w these. There i s a matrix of p a t i e n t numbers f o r each s e r v i c e implemented. Rows 1-5 correspond t o the Emergent / DU / 0 / SO / E l d i a g n o s t i c c a t e g o r i e s . Row 6 i s the t o t a l of those. The columns are as f o l l o w s : 1. P a t i e n t s qenerated, 2. P a t i e n t s admitted, 3., P a t i e n t s r e q u e s t i n g a p a r t i c u l a r date, 4. P a t i e n t s g e t t i n g t h a t date, 5. P a t i e n t s placed o f f - s e r v i c e , 6. P a t i e n t s r e t u r n e d to the proper s e r v i c e area. Note that the number of p a t i e n t s g e t t i n g a reguested date should be lower i n the model than i n r e a l i t y , s i n c e i n the model the date i s e n t i r e l y random and i n r e a l i t y the p h y s i c i a n r e q u e s t i n g a date should know when he has f r e e time. Two more types of matrices are p r i n t e d , but have not been TABLE XV H A L F W O R O M A T R I C E S H A L F W O R O M A T R I X M E O N O R O W / C O L U H N I 1863 472 333 117 321 3106 1863 472 328 116 316 3095 0 0 0 0 0 0 557 145 0 0 0 702 H A L F W O R O M A T R I X EENNO-ROW/COLUMN 1 2 3 . 4 5 1 92 92 0 0 29 2 24 24 0 0 6 3 21 21 10 7 0 4 26 28 27 20 0 5 701 689 478 449 0 6 864 854 515 476 35 HALFWORO M A T R I X ORPNO ROW/COLUMN 1 2 3 4 5 1 333 3 3 3 0 0 46 2 1 1 5 115 0 0 12 3 9 9 8 6 0 4. 87 91 8 0 65 0 5 389 389 96 76 0 6 933 937 184 147 58 129 shown i n the f i g u r e s as t h e i r use i s p r i m a r i l y i n t e r n a l . The f i r s t o f these are the s l a t e matrices f o r the s u r g i c a l s e r v i c e s . They are e x p l a i n e d i n S e c t i o n 8.1. The l a s t item i s a matrix of a l l o w a b l e a l t e r n a t e areas. The rows correspond to the s e r v i c e of the p a t i e n t . The columns correspond to a l l o w a b l e a l t e r n a t i v e areas. That o f column 3 i s t r i e d f i r s t , then column 2, then column 1. In t h i s implementation area \"2\" i s f o r overflow. \"0\" means \"stay i n the emergency u n i t o v e r n i g h t \" . 9.2 V e r i f i c a t i o n S e v e r a l t e s t s were performed to ensure that the model behaved i n a c o n s i s t e n t manner and worked as intended. One concern i n any s i m u l a t i o n based on \"random\" elements i s the accuracy of the pseudo-random number generators used. GPSS provi d e s an a l g o r i t h m f o r e i g h t i d e n t i c a l b u i l t - i n generators. For c e r t a i n procedures, such as those i n which a p r o p o r t i o n of p a t i e n t s are routed one way i n the model and the r e s t another, the system uses generator 1. For o t h e r s , the c h o i c e of a generator i s at the programmer's d i s c r e t i o n . The generators have been a l i g n e d i n such a way that the sequence of p a t i e n t s generated, and t h e i r ' c h a r a c t e r i s t i c s , can be d u p l i c a t e d i n c o n s e c u t i v e experimental runs. The l e n g t h - o f - s u r g e r y f u n c t i o n s , however, have been assigned to generator 1. (This was done s i n c e generator 1 n e c e s s a r i l y determines the p r o p o r t i o n , and hence number and sequence, of p a t i e n t s demanding emerqency and i n - h o s p i t a l o p e r a t i o n s - which r e q u i r e l e n q t h s - o f - s u r g e r y . ) 130 A l s o , generator 1 c o n t r o l s the p a t t e r n of requested dates f o r o p e r a t i o n s . As a r e s u l t , almost any change i n the model w i l l a l t e r the c o n s t r u c t i o n of the s l a t e s . S e v e r a l t e s t s were performed to check t h a t the numbers generated \" f i t \" a u n i f o r m l y f l a t d i s t r i b u t i o n on the 0-1 i n t e r v a l . The p r o p o r t i o n of \"morning d a y - s h i f t \" emergencies was checked, as w e l l as the p r o p o r t i o n of p a t i e n t s t r a n s f e r r i n g and the p r o p o r t i o n s of p a t i e n t s i n the d i f f e r e n t d i a g n o s t i c c a t e g o r i e s . The p r o p o r t i o n o f s u r g i c a l p a t i e n t s r e q u e s t i n g a p a r t i c u l a r date was a l s o t e s t e d . Each was a c c e p t a b l y c l o s e t o the intended value - tending to get c l o s e r the l a r g e r the sample. (e.g. f o r 22,000 \"immediate\" Medical p a t i e n t s , the p r o p o r t i o n i n each d i a g n o s t i c category was accurate to w i t h i n 0. 2%.) The random number seeds were changed and long runs were done, to t e s t the r e p e a t a b i l i t y of the processes d e s p i t e d i f f e r e n t pseudo-random number streams. F i g u r e s 9.1 to 9.6 show the r e s u l t s f o r one f o u r - y e a r run ( a f t e r one year of i n i t i a l i z a t i o n ) with p r i n t - o u t s each three months. F i g u r e s 9.7 to 9.12 show a one-year run with p r i n t - o u t s each f o u r weeks. (These f i g u r e s , which are r e f e r r e d t o s e v e r a l times i n t h i s c h apter, may be found at the end of the chapter.) The one-year run i s a c t u a l l y a c l o s e r look a t the t h i r d of the f o u r years, during which the number of o f f - s e r v i c e Medical placements was near the average and t h e r e were no extreme f l u c t u a t i o n s i n output v a r i a b l e s . The g r a p h i c r e s u l t s show the t y p i c a l v a r i a n c e s i n model performance v a r i a b l e s . Other runs y i e l d e d 131 s i m i l a r r e s u l t s . A d i s c u s s i o n of the i n d i v i d u a l items appears i n S e c t i o n 9.3, but f o r the present purpose the r e s u l t s demonstrate that the model i s s t a b l e . The d i f f e r e n t random number generators were a l s o r e a l l o c a t e d (so t h a t , i n s t e a d of being a l i g n e d by s e r v i c e , the assignment of generators to f u n c t i o n s was s h u f f l e d ) to t e s t any chance of c o r r e l a t i o n i n the streams dependent on a p a r t i c u l a r generator. There 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 output v a r i a b l e s . To check both the generator and the f u n c t i o n s p e c i f i e d , a separate t e s t was done on the Medical a r r i v a l f u n c t i o n s . The mean r a t e s were w i t h i n 1% of those d e s i r e d , and the freguency d i s t r i b u t i o n s u i t a b l y matched t h a t s p e c i f i e d by the f u n c t i o n . For v e r i f i c a t i o n purposes the l e n g t h - o f - s u r g e r y d i s t r i b u t i o n was r e p l a c e d by a constant. T h i s demonstrated that time and bed l i m i t s were being p r o p e r l y observed d u r i n g the development of the s l a t e . As intended, the t o t a l amount of time s l a t e d each day was an i n t e g r a l m u l t i p l e of the constant value s p e c i f i e d per procedure (plus turnaround time). In 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 r a t e s and LOS were r e p l a c e d by constant v a l u e s near the o r i g i n a l mean values. These values showed up as intended on the LOS t a b l e s and \" p a t i e n t s generated\" columns of the \" p a t i e n t numbers matrices\". In a d d i t i o n , the w a i t i n g queues and numbers placed o f f - s e r v i c e s t a b i l i z e d c o n s i d e r a b l y . T h i s was expected, s i n c e the two main sources of v a r i a t i o n had been removed. LOS of p a t i e n t s i n the model depended f i r s t on sex, which 132 was used to determine the age group, which i n tu r n was used to determine the LOS. De s p i t e t h i s c o m p l i c a t i o n , the o v e r a l l d i s t r i b u t i o n matched the e m p i r i c a l data g u i t e w e l l , with one year averages w i t h i n 5% of o r i g i n a l s (as modified to remove P e d i a t r i c p a t i e n t s ) . For both s e t s of data ( e m p i r i c a l and simulated) the standard d e v i a t i o n s are of about the same magnitude as the means, so short-term averages f l u c t u a t e c o n s i d e r a b l y . The average l e n g t h of surgery generated by s i m u l a t i o n , seems to be about 4-7% low compared t o e m p i r i c a l data. However, the surgery d u r a t i o n i n the model i s a l s o based on age groups which are d i v i d e d a c c o r d i n g to sex. These groups are d e f i n e d from l a r g e samples. The l e n g t h - o f - s u r g e r y v a l i d a t i o n sample i s r e l a t i v e l y s m a l l . As a r e s u l t , d i f f e r e n c e s between o b s e r v a t i o n s and simulated r e s u l t s might w e l l be a t t r i b u t e d to the d i f f e r e n t p r o p o r t i o n s of p a t i e n t s i n the d i f f e r e n t age groups. .. T h i s i d e a i s supported by the f a c t t h at s i m u l a t i o n v a l u e s are w e l l w i t h i n the range of e m p i r i c a l averages of the groups. In a d d i t i o n , day-to-day examinations of the flow through the Medical area were c a r r i e d out f o r two four-rweek p e r i o d s . Depending on the number of beds l e f t from the n i g h t b e f o r e , the number of p a t i e n t s r e t u r n i n g from o f f - s e r v i c e beds, and the number of \"morning\" emergencies, the number of scheduled admissions c o u l d be v e r i f i e d . Then the remaining number of emergencies could be checked a g a i n s t the t o t a l number of o f f - s e r v i c e placements. The model performs as intended., 133 9.3 V a l i d a t i o n T h i s s e c t i o n d i s c u s s e s the reasons f o r c o n s i d e r i n g the model to be a p o t e n t i a l l y u s e f u l a d m i n i s t r a t i v e t o o l . The u l t i m a t e q u e s t i o n i s ; How w e l l does the model r e p r e s e n t r e a l i t y ? In t h i s s e c t i o n , remember that only the Medicine, EENT, and Orthopedic s e r v i c e s are p r e s e n t l y implemented i n the model. The data used to determine a r r i v a l r a t e s , LOS, and l e n g t h - o f - s u r g e r y a l l came from l a r g e or c a r e f u l l y s e l e c t e d samples. These data are from 1974, though, and s e v e r a l s i g n i f i c a n t changes have occ u r r e d s i n c e then. The advent of Day Care surgery has had an impact i n r e d u c i n g the number of scheduled i n - p a t i e n t s u r g i c a l cases and, by h a n d l i n g some of the s h o r t e r cases, has a l t e r e d both LOS and l e n g t h - o f - s u r g e r y p a t t e r n s . The removal of the P e d i a t r i c s e r v i c e and the improved handling of placement f o r f u r t h e r c a r e (outside of S t . Paul's) have a l s o changed the system somewhat. The l a t t e r improvement may be p a r t i c u l a r l y s i g n i f i c a n t i n i t s e f f e c t on LOS (see S e c t i o n 12.1). . New d a t a - s e t s f o r a l l three of these v a r i a b l e s would be d e s i r a b l e . Next, c o n s i d e r the u t i l i z a t i o n of the bed areas. In the Medical area, occupancy i s very high - c l o s e to 100%,, In the model i t averaged about 99.5%, dropping below 99% f o r o n l y one three-month average i n f o u r years during a period when disch a r g e s were extremely high.. The EENT and Orthopedic areas are u s u a l l y not f i l l e d with t h e i r own p a t i e n t s , but t y p i c a l week-day occupancy i s s t i l l near c a p a c i t y due to o f f - s e r v i c e 134 p a t i e n t s . In the model, the excess Medical p a t i e n t s served t h i s purpose, and occupancy averaged about 92% i n the EENT area and 95% i n the Orthopedic area. T h i s i s below c a p a c i t y p a r t i a l l y due to the e f f e c t o f weekends and p a r t i a l l y due t o the f a c t t h a t i n the a c t u a l h o s p i t a l , o f f - s e r v i c e p a t i e n t s come from s e v e r a l s e r v i c e s , not j u s t one. (In the s i m u l a t i o n , s u r g i c a l area u t i l i z a t i o n dropped s i g n i f i c a n t l y when o f f - s e r v i c e placement of Medical p a t i e n t s was low due to e x t r a d i s c h a r g e s or fewer emergency a r r i v a l s . ) The high number of Medical emergency p a t i e n t s , f a r beyond the Medical area c a p a c i t y , a l s o causes the Medical w a i t i n g l i s t to r e g u i r e c a r e f u l a t t e n t i o n . As the r e s u l t d e s c r i b e d i n S e c t i o n 10.1 demonstrates, i f the c o n t r o l of t h i s queue i s l e f t independent of gueue le n g t h and h o s p i t a l occupancy f a c t o r s , the queue length f l u c t u a t e s w i l d l y . Since no such extreme f l u c t u a t i o n s are apparent i n the h o s p i t a l , i t i s assumed that s e v e r a l f a c t o r s i n t e r a c t to c o n t r o l the waiting l i s t t h e r e . I f the l i n e i s g e t t i n g l o n g , the Admitting O f f i c e s t a f f w i l l probably make an e x t r a e f f o r t to admit more p a t i e n t s . I f i t i s s h o r t they can r e l a x a b i t . These v a r i a t i o n s may be e f f e c t e d by f o r c i n g more or l e s s of the Medical emergency admissions o f f - s e r v i c e . A c t u a l l y , about h a l f of the M e d i c a l admission booking forms s p e c i f i c a l l y request \" t e a c h i n g beds\". Since the t e a c h i n q r e s i d e n t s e x e r t most of the c o n t r o l over who f i l l s t h e i r beds and how long they s t a y , (see S e c t i o n 5.2.5), they may w e l l be the ones who respond to i n c r e a s e d or decreased pressure to admit. In a d d i t i o n , p h y s i c i a n s may n o t i c e the l e n g t h of the 135 queue and act a c c o r d i n g l y i n t h e i r a d v i c e to p o t e n t i a l e l e c t i v e admissions. One f u r t h e r explanatory note i s i n order. The l e n g t h of the queue was determined by counting the number of forms i n the f i l e box. In some cases a scheduled p a t i e n t may be admitted by d i r e c t communication between the a d m i t t i n g p h y s i c i a n and a r e s i d e n t without ever g e n e r a t i n g a form. A l s o , f o r p a r t i c u l a r l y urgent cases there i s a s l i g h t p o s s i b i l i t y t h a t the form might be \"at the desk\" u n t i l the p a t i e n t i s admitted (as long as a couple of days), and might not be observed by an o u t s i d e r l o o k i n g through the f i l e box. The e m p i r i c a l data appear as f o l l o w s . In a three-week c o l l e c t i o n p e r i o d the l e n g t h of the gueue averaged 28.7 with a small standard d e v i a t i o n of 1.4. , A l a t e r o b s e r v a t i o n r e v e a l e d 36 waiting. In each case, t h e r e was a l a r g e number of long-wait p a t i e n t s . Many of these are expected to have c a n c e l l e d and never to have been admitted. In f a c t , at the s t a r t of the three-week sample, t h e r e were seventeen p a t i e n t s who had waited over one week., A f t e r the t h r e e weeks, f i v e of these had c a n c e l l e d ... none had been admitted! Furthermore, the s l i g h t v a r i a t i o n i n the sample may be a t t r i b u t a b l e t o the f a c t t h a t only one t h i r d of the average volume of requests appeared during those t h r e e weeks. I t i s f e l t t h a t , of the h o s p i t a l queue observed t o range from 26-36, some p o r t i o n - say maybe 20% w i l l probably c a n c e l and are not, i n f a c t , \" a c t i v e \" gueue members. A four-week t e s t on the model y i e l d e d a 23.2 average and 1.5 standard d e v i a t i o n which i s h i g h l y a c c e p t a b l e . The 136 three-month averages over f o u r years themselves average 23.4, with 80% of the values l y i n g w i t h i n f o u r of t h i s number. T h i s se t of averages and the four-week averages f o r one year are graphed at the end of t h i s chapter. ( F i g u r e s 9.1 - 9.3 and 9.7 - 9 . 9 r e l a t e to the l e n g t h of t h e Medical gueue, which i s the v a r i a b l e shown i n F i g u r e s 9.4 and 9.10.) The waiting-time d i s t r i b u t i o n f o r Medical p a t i e n t s i s another matter. The data sample was very s m a l l , but the average was 5.2 days, and was almost i d e n t i c a l f o r a l l three schedulable p a t i e n t c a t e g o r i e s . Although the Admitting O f f i c e c l e r k s attempt to g i v e higher p r i o r i t y t o the urgent and semi-urgent c a t e g o r i e s , the sample showed no d i f f e r e n c e (over t h r e e - q u a r t e r s of those admitted were te a c h i n g p a t i e n t s ) . Thus, i n s t e a d of o r d e r i n g the e n t i r e w a i t i n g l i s t by category, the only use made of the category of a Medical p a t i e n t was to determine the sequence i n which to f i l e each-dayIs forms. , Furthermore, s i n c e no proqrammable a l q o r i t h m c o u l d be d i s t i n q u i s h e d i n the s e l e c t i o n of p a t i e n t s to be admitted, the model has a b a s i c a l l y FIFO queue f o r i t s Medical p a t i e n t s . Postponement (which 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 d i s t r i b u t i o n ) was not implemented i n the model due t o a l a c k of a c c u r a t e data. Hence, a Medical p a t i e n t i n the model has an averaqe w a i t i n q time of about 6.3 days (probably reasonable) with s l i q h t v a r i a t i o n s . A c r o s s - s e c t i o n of waits at any i n s t a n t would show some p a t i e n t s with one day waits, some with two, some with three, and so on up to whatever the c u r r e n t maximum miqht be (no more than f o u r t e e n days i n the one-year r u n ) . The a c t u a l l i s t has a c r o s s - s e c t i o n 137 spreading from one day to as much, as f i v e months {in the case of one \"urgent teaching p a t i e n t \" n o t i c e d ) ! The modelling s i t u a t i o n seems even b e t t e r f o r the s u r g i c a l gueue. D e v i a t i o n s from r e a l i t y i n the s i m u l a t i o n , p a r t i c u l a r l y i n the p a t t e r n of p a t i e n t s s l a t e d any given number of weeks i n advance, may be a t t r i b u t a b l e to d i f f e r e n c e s i n the 1974 data and 1976 p r a c t i c e . In 1974, t h e r e was no Day Care su r g e r y , and i t seems t h a t up to f i v e scheduled procedures f o r Orthopedics and nine f o r EENT were allowed per day {in c o n t r a s t to f o u r and s i x now). The model observes the 1974 l i m i t s and p a t i e n t a r r i v a l r a t e s . Because of the s c h e d u l i n g mechanism e x p l a i n e d i n Chapters 7 and 8, the s u r g i c a l queue i s q u i t e s t a b l e . The three-month averaqes over f o u r years themselves averaqed 111.4, with t h r e e - q u a r t e r s of these values l e s s than 5.5 away. About two-thirds o f t h i s queue i s made up o f EENT p a t i e n t s . The one sampled value of 136 {96 EENT, 40 Orthopedics) i s w e l l w i t h i n the range of the s i m u l a t i o n ' s queue l e n g t h d e s p i t e i t s s t a b i l i t y . As suggested above, the s i m u l a t i o n ' s d i s t r i b u t i o n of the number of p a t i e n t s s l a t e d f o r a given number of weeks away does not q u i t e \" f i t \" the sample d i s t r i b u t i o n , but appears reasonable. Greater accuracy would r e q u i r e a thorough examination of s c h e d u l i n g r u l e s . As suggested by the time stream sequence of F i g u r e 8.1, the c r i t i c a l number of Medical p a t i e n t s t r a n s f e r r e d to the wrong area i s the product of s e v e r a l i n t e r a c t i n g v a r i a b l e s each of which may f l u c t u a t e {Medical d i s c h a r g e s . M e d i c a l area r e t u r n e e s . 138 morning and other emergencies, l e n g t h of the w a i t i n g l i n e ) . Only one data value, the year's t o t a l f o r 1976, i s c u r r e n t l y a v a i l a b l e (see Appendix 2.1). I t suggests t h a t a t the model's l e v e l of Medical admissions, a r a t e of 1460 placed o f f - s e r v i c e per year i s e x c e l l e n t . The s i m u l a t i o n suggests t h a t t h i s v a r i a b l e i s g u i t e s e n s i t i v e t o f l u c t u a t i o n s i n the v a r i a b l e s which determine i t s l e v e l . N e v e rtheless, i t s average over f o u r years i s 1455! The v a l u e s f o r four years and one year are graphed at the end of t h i s chapter (Figures 9.5 and 9.11). The number o f \"No Beds\" f o r EENT and Orthopedics i s d i f f i c u l t t o determine, s i n c e only the d a i l y t o t a l f o r a l l s e r v i c e s has been recorded. T h i s v a r i e d g r e a t l y i n 1974, with an average of 39 per month, but as high as twenty i n one day! The average i n 1976 was 31 per month. I t i s not c l e a r whether the improvement i s random or a r e s u l t of g r e a t e r care i n p a t i e n t placement and t r a n s f e r s . I f the p r o p o r t i o n of \"No Beds\" i s i d e n t i c a l to the p r o p o r t i o n of procedures, EENT and Orthopedics may expect 115 per year (at the 1976 r a t e ) . The model has an average over f o u r years of about 117! The c o n s t r a i n t s i n e f f e c t a r e : the l e v e l to which o f f - s e r v i c e p a t i e n t s may f i l l beds before causing t r a n s f e r s and the l e v e l to which morning emergencies of the proper area (and other areas) are allowed to take o f f - s e r v i c e beds before being placed elsewhere. Figures 9.6 and 9.12 show \"No Bed\" numbers. The f i n a l v a l i d a t i o n item used was the number of p a t i e n t s s l a t e d f o r surgery. For Orthopedics, t h i s averaged about 4 i n the model. 1974 data suggested 4.5. The d i s t r i b u t i o n f o r the 139 model was c o r r e s p o n d i n g l y low. For EENT the model gave 5.7 per day. Heal data gave 6.7, but on a s m a l l sample. These d i f f e r e n c e s may w e l l be a t t r i b u t a b l e t o block booking by \"composite p h y s i c i a n \" and not a l l o w i n g anyone e l s e to f i l l h i s day with any but urgent p a t i e n t s or i n - h o s p i t a l p a t i e n t s . P a r t i c u l a r l y i n the Orthopedic s e r v i c e , f o r which each of fou r days has two p h y s i c i a n s booked and the other has only one, t h i s may be a f a c t o r . As these comments on v a l i d a t i o n i n d i c a t e , the model behaves very s a t i s f a c t o r i l y , p a r t i c u l a r l y f o r s i m u l a t i o n over the long-term. Since a complete range of v a l i d a t i o n data i s not a v a i l a b l e , and the accuracy o f d i f f e r e n t v a r i a b l e s i s not well known, nor i s the s e n s i t i v i t y of the system t o t h e i r changes, I do not f e e l t h a t a q u a n t i f i c a t i o n of the p r e c i s i o n o f the model i n terms such as \"a c c u r a t e to w i t h i n ...\" would be meaningful. To summarize, the r e s u l t s obtained f o r a l l of the c r i t i c a l v a r i a b l e s , i n c u d i n g some which a r e the r e s u l t of s e v e r a l i n t e r a c t i n g f o r c e s , suggest t h a t the model s t r u c t u r e i s good. 140 Uoo-i 2 ui 1 0 8 H VO<«4 F i g . 9.1 f u n c t i o n T Z M e d i c a l o f time T I M E l y e c r s ) \"immediate\" p a t i e n t s (per 3 3 months) as a T I M E Ivje.^v-s1) F i g . 9.3 M e d i c a l a r e a d i s c h a r g e s (per 3 months) as a f u n c t i o n of time TIME ( a «.«.»•*) F i g . 9.4 Average M e d i c a l queue l e n g t h (over 3 months) as a f u n c t i o n o f time 1 4 2 T I M E ( 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 (per 3 months) as a f u n c t i o n o f t i m e 8 0 n 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 (per 3 months) as a f u n c t i o n o f time 143 36 Proc. ACM, pp. 537-579. 46. Robinson, Gordon H., Wing, P a u l , and D a v i s , L o u i s E. (1968) \"Computer S i m u l a t i o n of H o s p i t a l P a t i e n t Scheduling Systems.\" Health S e r v i c e s Research, 3 (Summer):130-141. , 47. , Schmitz, Homer H. , and Kwak, N. K. (1972) \"Monte C a r l o S i m u l a t i o n of Operating-Room and Recovery-Room Usage. , , O p e r a t i o n s Research, 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 Using GPSS. New York, London, Sydney, Toronto: John Wiley & Sons. 176 49. Scroggs, Mrs. D. (1970) Study of P a t i e n t T r a n s f e r s Within St.. Paul's H o s p i t a l . Vancouver, B.C.: Management En g i n e e r i n g Unit of the Greater Vancouver Regional H o s p i t a l s , A p r i l . 50. Shao, D., and Thomas, W. H. (1970) \"A S t o c h a s t i c Model f o r the Study of the Waiting Time of 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. B u l l e t i n , V o l . 18, Sup.,, 2, p. B186. 51. Shonick, W i l l i a m . (1970) \"A S t o c h a s t i c Model f o r Occupancy - Related Random V a r i a b l e s i n General - Acute H o s p i t a l s . \" An._ S t a t . , Assoc. J . , 65:1474-1500. 52. Shonick, W i l l i a m and Jackson, J. R., (1973) \"An Improved S t o c h a s t i c Model f o r Occupancy - Related Random V a r i a b l e s i n General - Acute H o s p i t a l s . \" Operations Research, 21 (July-August):952-965. 53. Shuman, L a r r y J . , Speas, R. Dixon, J r . , and Young, John P. (1975) Operations Research i n Health Care. Baltimore and London: The Johns Hopkins U n i v e r s i t y Press. 5 4 ^ Stimson, David H. , and Stimson, Ruth, H. (1972) Operations Research i n H o s p i t a l s : D i a g n o s i s and Prognosis. Chicago: H o s p i t a l Research 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 Recovery Progress of Coronary P a t i e n t s . \" Health S e r v i c e s Research, 13 (Fall):185-213. 56. Uyeno, Dean. (1976) A Text of Notes on S i m u l a t i o n f o r Commerce 510. Unpublished notes, F a c u l t y of Commerce, U n i v e r s i t y of B r i t i s h Columbia, Vancouver. 57. Young, John P. (1965) \" S t a b i l i z a t i o n of I n p a t i e n t Occupancy Through C o n t r o l of Admissions.\" H o s p i t a l s , 39 (Oct.. 1):41-48. , 58. (1966) \" A d m i n i s t r a t i v e C o n t r o l of M u l t i p l e Channel Queuing Systems with P a r a l l e l Input Streams.\" Operations Research, 14:145-156. APPENDICES APPENDIX 1-(Refers to Chapter 2) .1 E a r l y S p e c i f i c a t i o n s f o r the Model MICRO-SIMULATION MODEL OF ST. PAUL'S HOSPITAL PROJECT OBJECTIVE To model the patient flow in and through St. Paul's Hospital. SUB OBJECTIVES 1. To build a dynamic computerized model \\rfiich can be U3ed to provide guidelines for management action in controlling hospital admissions to effectively 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 in 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 for the year January 1, 1974 to December 31 > 1974: Patient's age, sex Length of stay (or admission date and discharge date) Primary diagnosis Secondary diagnosis Type o f admission Surgical procedure(s) Attending doctor Surgeon(s) Hospital Service Type of Anaesthetic -180 1.2 The B a s i c Information Flow PATIENTS MEDICAL PHYSICIAN SURGICAL SPECIALIST INVFSTIflAT[VFS BED CONFIRMATION ADM & SURG BOOKING FORM BED BOARD FORM BED ALLOCATION ADMITTING OFFICE SURGICAL DATE F I L E MEDICAL / INVESTIGATIVE QUEUE it. •x < L RMULT 5177 ,169 ,27279 ,6343 5 * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * 6 * TABLE OF DEFINITIONS 7 * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * 8 9 * * AD I ST VARIABLE •IDENTIFIES SERVICE/SEX AGE OIST FUNCTION 10 * ADMMC C HA IN *MEDI CAL ADMISSIONS 11 * ADMSC CHAIN * SURGER Y ADMISSIONS 12 * ALTER MATRl X •ALTERNATE AREAS FOR EMERGENCIES 13 * A NEE N FUNCTION • NON-SCHEDULABLE EENT ARRIVALS 14 * ANMED FUNCTI ON * NON-SCHEDUL A BL E MEDICAL ARRIVALS 15 * ANORP FUNCTION! •NON-SCHEDULABLE ORTHOPEDIC ARRIVALS 16 * APRWK VARIABLE •IDENTIFY APPR WEEK ON MATRIX 17 • AR NON FUNCTION * NON-SCHEDULABLE ARRIVALS BY SERVICE 18 * ARSCH FUNCTION •SCHEDULABLE ARRIVALS BY SERVICE 19 * A SEE N FUNCTION •SCHEDULABLE EENT ARRIVALS 20 * ASMEO FUNCTION •SCHEDULA8LE MEDICAL ARRIVALS 21 * ASORP FUNCTION •SCHEDULABLE ORTHOPEDIC ARRIVALS 22 * BTIME 8VAR! ABLE •ENUF TIME IF THIS ONE SUBSTITUTED? 23 * BUNPE BVARIABLE •TO BUMP ELECTIVE OF THIS OOCTOR 24 * BUMPS BVARI ABLE •TO BUMP SEM IURGENT OF THIS DOCTOR 25 * CANCL SAVEVALUE • COUNTS NUMBER OF CANCELLATIONS 26 * CHECK SAVEVALUE • DAY TO CHECK ON SLATES 27 * CHKDR SAVEVALUE •CCCTOR TO CHECK 28 * C MKTM SAVEVALUE •SURGERY TIME TO CHECK FOR 29 • CTPRI VARIABLE • •PRIORITIES U:19 SU:18 EL :17 30 * CWEFK VARIABLE •NUMRER OF WEEKS TO CHECK DATE 31 • * OA SAM VARIABLE •NEW DR REALLY ON SAME DAY? 32 * DISCH CHAIN • DISCHARGE CHAIN 33 * OSTRO VARIABLE •SERVICE/CATEGORY FUNCTION OF DAYS TO REQ 34 * EENNO MATRIX •FOR EENT NUMBERS 35 * EENSL MATRIX •FOR EENT SLATE 36 • EENSN TABLE •EENT SLATE NUMBERS 37 * EENST TABLE • EENT SLATE TIME 3B • EINO QUEUE •EENTS IN EMERG 39 * EIN2 QUEUE • EENT S IN GSG ETC. 40 • EIN4 OUEUE • EENTS IN ORTHO 41 * EMARR SAVEVALUE •COUNTS EMERG AND O.U. ARRIVALS T flDAY K> O LO 42 * EHRED SAVEVALUE •TRACKS EMERGENCY BEDS IN USE 43 • EMGDU TABLE •EMERG AND D . U . ARRIVALS DAILY 44 • EMGNO SAVEVALUE •EMERGENCY NUMBER OPERATED 45 * EMGTM SAVEVALUE •EMERGENCY OPERATING TIME 46 * EMRGC CHAIN •EMERGENCY OPERATIONS CHAIN 47 • FMTBN TABLE •EMERGENCY OPERATED NUMBER 48 * E««TP T TABLE • EMERGENCY OPERATED NUMBER 49 * ENDWK VARIABLE • I S DATE ON WEEKEND? 50 • EOPNO SAVEVALUE • EENT NUMBER OPERATED 51 * EOPTM SAVEVALUE • E E N T OPERATING TIME 52 • GOPTM SAVEVALUE •GENERAL SURGERY OPERATING TIME 53 * GSGNO MA TRIX • F O R GENERAL SURGERY NUMBERS 54 * GSGSN TABLE •GENERAL SURGERY SLATE NUMBERS 55 * GSGST TABLE • GENERAL SURGERY SLATE TIME 56 * HI TBL VARIABLE •NUMBER OF THE HIGHEST OPERATIONS TABLE 57 * HUONG VARIABLE • NUMBER OF WEEKS WAITED FOR OPERATION 58 * W I S T VARIABLE • IDENTIFIES S E R V I C E / A G E LOS OIST FUNCTION 59 * LOSEE QUEUE • E E N T L OF STAY 60 * LOSEF QUEUE • E E N T FEMALES L OF STAY 61 * LOSEM QUEUE •EENT MALES L OF STAY 62 • LOSME OUEUE •MEDICINE L OF STAY 63 * LQSMF OUEUE •MEDICINE FEMALES L OF STAY 64 * LOSMH OUEUE •MEDICINE MALES L OF STAY 65 * LOSOF OUEUE •ORTHOPEDICS FEMALES L OF STAY 66 * LOSCM QUEUE • ORTHOPEDICS MALES L OF STAY 67 * LOSOR QUEUE •ORTHOPEDICS L OF STAY 68 * LOSO VARIABLE • IDENTIFIES S E R V I C E ' S LOS OUEUE 69 * LOSQS VARIABLE • I D E N T I F I E S S E R V I C E / S E X LOS QUEUE 70 * MACHO BVARIABLE • T O MATCH PATIENT ON DISCHARGE CHAIN 71 * \"ACHR BVARIABLE • TO MATCH PATIENT ON ADM OR SURG CHAIN 72 * MACHS 8VAR IABLE • U S E D IN THE ABOVE 73 * MA DI S SAVEVALUE •MEDICAL AREA DISCHARGES 74 * MALT3 CHAIN •MEDICAL PATIENTS IN AREA 3 75 * MALT4 CHA IN • MEDICAL PATIENTS IN AREA 4 76 * MOATE SAVEVALUE •AOMISSION (OR ANOTHER) DATE TO MATCH 77 * \"OGEN SAVEVALUE • D A T E GENERATED TO MATCH 78 * MEDNO MATRIX •FOR MEDICINE NUMBERS 79 * MEMRN SAVEVALUE •MEDICAL EMGOU IN MORNING 80 * MINO QUEUE •MEDICALS IN EMERG 81 * MIN2 QUEUE •MEDICALS IN GSG E T C . 82 * MI N3 QUEUE ' • M E D I C A L S IN EENT 83 * MIN4 QUEUE •MEDICALS IN ORTHO 84 * MLOSG S 6VEVA LUE • L E N G T H OF SURGERY TO MATCH 85 * MLOST SAVEVALUE • LENGTH OF STAY TO MATCH 86 • M0O6 VARIABLE • I D E N T I F Y NEW WEEK 0 SLATES 87 * MOFF VARIABLE • I D E N T I F I E S M E D - O F F - S E R V I C E CHAIN 88 * \"SPAC VARIABLE •NUMBER OF BEOS FOR MED SCHEOS 89 * MSRVC SAVEVALUE • S E R V I C E TO MATCH 90 * NOBD SAVEVALUE •COUNTS NUMBER OF 'NO B E D S ' 91 * ' NOBEO TABLE • T A B U L A T E S NUMBER OF 'NO BEDS' 92 * NOFF VARIABLE •NUMBER TO PUT BACK ON SERVICE 93 * NOWTM SAVEVALUE • T I M E USED BEFCRE A BUMP 94 * QFFSL VARIABLE • O F F S E T TO SLATE MATRIX BY SERVICE 95 * OINO QUEUE • ORTHOS IN EMERG 96 0IN2 QUEUE •ORTHOS IN GSG E T C . 97 • 01 N3 OUEUE •ORTHOS IN EENT 98 * GOP NO SAVEVALUE •ORTHOPEDICS NUMBER OPERATED 99 * OOPTM SAVEVALUE •ORTHOPEDICS OPERATING TIME 100 * ORPNO MATRIX • FOR ORTHOPEDIC NUMBERS 101 * ORPSL MATRIX • F O R ORTHOPEOIC SLATE 102 ORPSN 1 TABLE 103 * QRPSI ' TABLE 104 * PTFWK ; SAVEVALUE 105 * PWEEK : SAVEVALUE 106 * SOIST ' VARIABLE 107 * SEUSC VARIABLE 108 * SGYOl. 1 VARIABLE 109 * SHIFT VARIABLE 110 * SIXWK BVARIABLE 1 1 1 * SIEFN 1 CHAIN 112 * SLEW! CHAIN 113 * SLEW2 CHAIN 114 SLEW3 CHAIN 115 * SLEW4 CHAIN 1 16 * SLEWS CHAIN 117 * SLEW6 CHAIN 118 * SLOEN CHAIN 119 * SL0W1 CHAIN 120 * SL0W2 CHAIN 121 * SLQW3 CHAIN 122 * SLC1W4 CHAIN 123 SL0W5 CHAIN 124 * SL0W6 CHAIN 125 * SLUSC VARIABLE 126 * SR VOP VARIABLE 127 * STAI OTABLE 128 * STA3 OTABLE 129 * STA4 OTABLE 130 * TMFWK SAVEVALUE 131 * TPYOA BVSRIABLE 132 * TRYDR VARIABLE 133 * USRSL SAVEVALUE 134 VTIME VARIABLE 135 * WAIT LOGIC SWITCH 136 WA ITE LOGIC SWITCH 137 * WAI TQ VARIABLE 1 38 * WEEK SAVEVALUE 139 * WEENE OUEUE 140 WEENS OUEUE 141 • WEENU OUEUE 142 * WKDAY VARIABLE 143 * WK END BVARIABLE 144 • WMEDE OUEUE 145 * WMEOS OUEUE 146 * WMEDU OUEUE 147 WORPE OUEUE 148 * WORPS OUEUE 149 * WORPU OUEUE 150 * ViRCNC VARIABLE 151 * WTE1 OTABLE 152 * WTE3 QT ABLE 153 * WTE4 OTABLE 154 * WTS1 OTABLE 155 * WT S3 OTABLE 156 • WTS4 OTABLE 157 * i WTU1 OTABLE 158 * WTU3 OTABLE 159 * WTU4 OTARLE 160 * XFERC CHAIN • ORTHOPEDIC SLATE NUMBERS • ORTHOPEDIC S L A T E TIME •ROW OF PTS 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 END' CHAIN , BY SERVICE • S E R V I C E FUNCTION FOR SURGERY DOW • I D E N T I F I E S DAY OR N IGHT-SHIFT FUNCTION • T H E S E OPNS IN NEW 6TH WEEK • EENT END SLATE •EENT WEEK 1 SLATE •EENT WEEK 2 SLATE • E E N T 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 •ORTHO WEEK 3 SLATE •ORTHO WEEK 4 SLATE • ORTHO WEEK 5 SLATE • ORTHO WEEK 6 SLATE • S L A T E CHAIN TO USE BY WEEK • S A V E V A L U E S OF OPN STATS BY SERVICE • MEDICINE LENGTH OF STAY • E E N T LENGTH OF STAY • ORTHOPEOIC LENGTH OF STAY •ROW OF TIME FCR THE APPROPRIATE WEEK • P T S AND TIME OK THIS DAY? • DESIRED DAY AND DOCTOR'S DAY CORRESPOND? •POINTER FOR SLATES AND CHAINS •T IME AFTER SUBSTITUTING • G A T E ON SURGICAL ARRIVALS • G A T E ON EMERGENCY ARRIVALS • IDENTIFIES SERVICE/CATEGORY WAIT OUEUE • WEEK TO CHECK FOR OPEN SPOTS ON SLATE • EENT E L E C T I V E WAITS • E E N T SEMI-URGENT WAITS • E E N T URGENT WAITS • D A Y - O F - T H E - W E E K (TOMORROW! •WEEKEND? •MEDICAL ELECTIVE WAITS • MEDICAL SEMI-URGENT WAITS •MEDICAL URGENT WAITS •ORTHOPEDICS ELECTIVE WAITS • ORTHOPEDICS SEMI-URGENT WAITS • ORTHOPEDICS URGENT WAITS • I N D I C A T E S WRONG AREA OUEUE •MEOICAL ELECTIVE WAITS • E E N T E L E C T I V E WAITS •ORTHOPEDICS E L E C T I V E WAITS •MEOICAL SEMI-URGENT WAITS • E E N T SEMI-URGENT WAITS •ORTHOPEDICS SEMI-URGENT WAITS •MEDICAL URGENT WAITS •EENT URGENT WAITS •CRTHOPEDICS URGENT WAITS • TRANSFERS' CHAIN 162 163 164 165 166 167 163 169 170 171 172 173 1B2 183 184 1 85 186 1 87 188 199 190 191 192 193 194 195 196 197 193 199 200 201 2 0 ? 203 204 205 206 207 208 209 2!0 211 2 1 2 213 214 2 1 5 2 1 6 217 218 219 2 2 0 221 MATRIX SAVEVALUES MATRIX SAVEVALUE FOR EACH SERVICE. ROW 1-5 CORRESPONDS TO 01 AGNOSTIC CATEGORY. ROW 6 I S THE TOTAL OF ROWS 1-5. THE COLUMNS ARE: 1 NO. GENERATED 2 NO. ADMITTED 3 NO. OF THOSE ADMITTED REOUEST ING PARTICULAR DATE 4 NO. WHO GOT THAT DATE 5 NC. ADMITTED TO WRONG AREA 6 NO. OF THOSE RETURNED TO CORRECT AREA 174 ME CINQ ECU l . Y 175 MEDNO MATRIX H.6,6 * FOR 176 GSGNO EQU 2tY 177 GSGNO MATRIX H.6 ,6 *FOR 178 EENNO EOU 3. Y 1 79 EENNO MATRIX H.6,6 • FOR 180 ORPNO EOU 4 , Y 181 QRPNO MATRIX H.6,6 *FOR COLUMNS CORRESPOND MATRIX SAVEVALUE FOR EACH BLOCK BOOKED SERVICE ( 2 - 6 ) . TO MONDAY THROUGH FRIDAY. THE ROWS ARE: 1 NEXT DAY - I N I T I A L I Z E 2 OUTPATIENTS FOR WEEK 1 3 TIME FOR WEEK 1 4 OUTPATIENTS FOR WEEK 2 13 TIME FOR WEEK 6 NOTE: WEEKS ARE ON A CYCLE. I N I T I A L L Y OTH WEEK I S WEEK 1. THEN 2 . . . *FOR EENT SLATE EENSL EOU 9,Y EENSL MATRIX H,13,5 ORPSL EOU 10,Y ORPSL M&TRIX H,13,5 *FOR ORTHOPEDIC SLATE I N I T I A L MH9-MH10I1.1 I.2/MH9-MH10II,2) ,3/MH9-MH10(I,31,4 I N I T I A L MH9-MH10I 1,4),5/MH9-MH10I1 ,5) ,6 • ALLOW AT MOST THREE ALTERNATE BE C AREAS FOR EMERGENCY PATIENTS. THE ROW CORRESPONDS TO THE PATIENT'S S E R V I C E . THE NUMBER » INSERTED CORRESPONDS TO THE ALTERNATE AREA. COLUMNS ARE USED IN < REVERSE ORDER. 0 INDICATES NO OPTION. (EG. ROW 4...0RTH0, MAY TRY S E R V I C E 3'S BEDS...EENT, OR THE SERVICE 2 BEDS.. .ORTHO). ALTER EOU ALTER MATRIX I N I T I A L I N I T I A L 14, Y H.7,3 *ROWS AS SERVICES MH 1 4 ( 1 , 1 ) , 2 / M j S 1 4 ( l , 2 ) , 4 / M H l 4 ( l , 3 ) , 3 M H 1 4 ( 3 , 2 ) , 2 / M H i 4 ( 3 , 3 ) , 4 / M H 1 4 ( 4 , 2 ) , 2 / M H l 4 ( 4 , 3 l . 3 •COUNTS NUMBER OF CANCELLATIONS CANCL EOU 13,H * OAY TO CHECK FOR OPEN SPOTS ON SLATE CHECK EOU l.H CHKDR EOU CHKTM EOU E\"ARP. EOU EMBED EOU EMGNO EOU 5, H 6, H 14,H 1 1 , H 33,H •DOCTOR TO CHECK • SURGERY TIME TO. CHECK FOR •COUNTS EMERG AND D.U. ARRIVALS TODAY •TRACKS EMERGENCY BEDS I N USE •EMERGENCY NUMBER OPERATED 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 E0 D N 0 EOU 23,H EOPTM EOU 22,H GCPTM EOU 20,H MAOIS EOU 40.H MOATE EOU 7,H MOGEN EOU 38,H MEMRN EOU 41,H MLOSG EOU 9.H MLOST EOU 8,H MSRVC EOU 34,H NORD EOU 12,H NOWTM EOU 37,H OCPNO EOU 25,H OOPTM EOU 24,H PTFWK EOU 35,H PWEEK EOU 3.H SHIFT EOU 39,H TMFWK EOU * WHICH OF USRSL EOU * WEEK TO CHECK WEEK EOU INITIAL T H E • EMERGENCY OPERATING TIME • EENT NUMBER OPERATED •EENT OPERATING TIME •GENERAL SURGERY OPERATING TIME •MEDICAL AREA DISCHARGES • ADMISSION (OR ANOTHER) DATE TO MATCH • DATE GENERATED TO MATCH • MEDICAL EMGOU IN MORNING •LENGTH OF SURGERY TO MATCH • LENGTH OF STAY TO MATCH •SERVICE TO MATCH • COUNTS NUMBER OF 'NO BEDS' •TIME USED BEFORE A BUMP • ORTHOPEOICS NUMBER OPERATED •ORTHOPEDICS OPERATING TIME • ROW OF PTS FCR THE APPROPRIATE WEEK • FIRST DAY OF PRESENT WEEK (SUNDAY) •IDENTIFIES OAY OR NIGHT-SHIFT FUNCTION •ROW OF TIME FOR THE APPROPRIATE WEEK (POINTER FOR SLATES AND CHAINS) 36,H 6 WEEKS IS THE NEXT 4,H FOR OPEN SPOTS ON SLATE 2»H •TAKES VALUES FROM 0 XHSPWEEK,1/XHSUSRSL,1 ********************* BOOLEAN VARIABLES BTIME BVARIABLE VtVTIME'LE'FN241 * ENUF TIME IF THIS ONE SUBSTITUTED? 8UMPE BVARIABLE P5 • E • XH.tCHKDR* P6 • E ' 5*8 V$BTI ME *T0 BUMP ELECTIVE OF THIS OR BUMPS BVARIABLE P5 ' E•XHSCHKDR*P6•E'4*BVSBTIME *T0 BUMP SEMIURGENT. THIS DR • TO MATCH PATIENT ON DISCHARGE CHAIN MACHO BVARIABLE BV tMAC HS4P2' E' XH$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 A O I S T APRWK r. TPRI CWFEK OAS AM DSTRO ENDWK HI T B L HLONG LDI ST LOSO LOSOS M0D6 MOFF MSPAC NOFF O F F S L VARIABLE VAR IABLE VARIABLE VA R I A B L E VARIABLE VARIABLE VAR IABLE VARIABLE VARIABLE VARIABLE VARIABLE VARIABLE VARIABLE VAR IABLE VARIABLE VARIABLE VARIABLE 38»P1^2*P7 * IDENTIFIES SERVICE/SEX AGE DIST FUNCTION l(XH$USRSL+XH$WEEK-l)a6+l)^2 •IDENTIFY APPR WEEK ON MATRIX 22-P6 'PRIORITIES U:19 SU:18 EL:17 IXH$CHECK-XH$PWEEK)/7 •NUMBER OF WEEKS TO CHECK DATE (XH*CHECK-P14)a7 145«-PI*5»P6 P13-XH *PWEEK-5 P1^ 2-2 ( P13-P2I/7 45+P1^ 5+P8 37*P1*3 37+Pl»3+P7 XH*USRSL36+1 47+P14 Rl-3 P2-R*l Pl*6 •NEW DR REALLY ON SAME DAY? •SERVICE/CATEGORY FUNCTION OF DAYS TO REO •IS DATE IN P13 ON WEEKEND? •NUMBER OF THE HIGHEST OPERATIONS TABLE •NUMBER OF WEEKS WAITED FOR OPERATION •IDENTIFIES SERVICE/AGE LOS DIST FUNCTION •IDENTIFIES SERVICE'S LOS OUEUE •IDENTIFIES SERVICE/SEX LOS OUEUE • IDENTIFY NEW WEEK 0 SLATES •IDENTIFIES MED-OFF-SERVICE CHAIN • NUM3ER OF BEDS FOR MED SCHEOS •NUMBER TO PUT BACK ON SERVICE •OFFSET TO SLATE MATRIX BY SERVICE O 282 SD! ST VARIABLE 2 4 5 * P l * 5 t P 8 • IDENTIFIES SERVICE/AGE L OF SURGERY 283 SEUSC VAR IA9LE ( P l - 2 ) * 7 * 7 *FOR 'SLATE END' CHAIN, BY SERVICE 284 SGYOW VARIABLE 198-P1 • SERVICE FUNCTION FOR SURGERY DOW 285 stusr. VARIABLE (Pl-2)*7+(XH$WEEKtXH*USPSL-l!36«-l *SLATE CHAIN TO USE BY WEEK 2 86 SRVOP VARIABLE 16+Pl*2 • SAVEVALUES OF OPN STATS BY SERVICE 287 TRYDR VARIABLE (P13-P14I37 •DESIRED DAY AND DOCTOR'S DAY CORRESPOND? 288 VTIME VARIABLE XHtNOWTM-Pll+XHtCHKTM *TI ME AFTER SUBSTITUTING 289 WAITO VAR IABLE I P1-1»*5*P6 • IDENTIFIES SERVICE/CATEGORY WAIT QUEUE 290 WKDAY VARIABLE P3-XH SPWEEK+I •DAY-OF-THE-WEEK (TOMORROW! 291 WRONG VARIABLE 53*(P1*8)*P14 * INDICATES WRONG AREA QUEUE 292 *************************************** 293 • QUEUES AND OTABLES 294 *************************************** 295 * 296 * FOR WAITS 297 WMEOU EOU 3,0 •MEDICAL URGENT 298 WMEOS EOU 4,0 •MEDICAL SEMI -URGENT 299 WMFOE EOU 5,0 •MEDICAL ELECTIVE 300 WTU1 QTABLE WMEOU.0,2,23 301 WTSl OTABLE WMEDS.O, 2,23 302 WTFl OTABLE WMEOE.0,2.23 303 WEENU EOU 13.0 •EENT URGENT 304 WEENS EOU 14,0 •EENT SEMI-URGENT 305 WEENE EOU 15,0 •EENT ELECTIVE 306 WTU3 OTABLE WEENU,0,2,24 307 WT S3 OTABLE WEENS.0.2.30 308 WTE3 OTARLE WEENE.0.2.37 309 WORPH EOU 18,0 • ORTHOPEDICS URGENT 310 WORPS EOU 19,0 • ORTHOPEDICS SEMI-URGENT 311 WORPE EOU 20.0 •ORTHOPEDICS ELECTIVE 312 WTU4 OTABLE WORPU.0,2,19 313 ' WTS4 OTABLE WORPS,0,2.23 314 WTE4 OTABLE WOP.PE.0.2,27 315 * LENGTH OF STAY 316 LOS ME EOU 40.0 • MEDI CINE 317 • L OSMM EOU 41,0 • MEDICINE MALES 318 LCSMF EOU 42,0 •MEDICINE FEMALES 319 STAI OTABLE L0S«E,0.3,32 320 LCSEE EOU 46,0 •EENT 321 LOSEM EOU 47,0 • EENT MALES 322 LOSEF EOU 48,0 •EENT FEMALES 323 STA 3 OTABLE LOSEE.0.3,17 324 LOSOR E 01.1 49,0 • ORTHOPEDICS 325 LOSOM EOU 50,0 • ORTHOPEDICS MALES 326 LOSOF EOU 51,0 •ORThOPEDICS FEMALES 327 STA4 OTABLE LOSOR.0,3,32 328 * WRONG AREA 329 MINO EOU 61,0 •MEDICALS IN EMERG 330 MIN2 EOU 63,0 •MEDICALS IN GSG ETC. 331 MIN3 EOU 64.0 •MEDICALS IN EENT 332 MIN4 EOU 65,0 •MEOI CALS IN ORTHO 333 EINO EOU 77.0 •EENTS IN EMERG 334 EIN2 EOU 79,0 •EENTS IN GSG ETC. 335 EIN4 EOU 81.0 • EENTS IN ORTHC 336 OINO EOU 85,0 •ORTHOS IN EMERG 337 0IN2 EOU 87, 0 • ORTHOS IN GSG ETC. 338 0IN3 EOU 88,0 •CRTHOS IN EE NT 339 ******************************** *******. 340 • OTHER TABLES 341 *************************************** 342 343 344 345 346 347 348 349 350 351 352 353 354 355 356 357 358 359 360 361 362 363 364 365 366 367 389 39C 391 392 393 394 395 396 397 398 399 400 401 ' OPERATIONS STATISTICS 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 TIPE 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 •*••*•**•*•*••••****•*•••*********••*•• 368 AOMMC EOU 46,C • MEDICAL ADMISSIONS 36 9 AO«SC EOU 43, C •SURGERY ADMISSIONS 370 DISCH EOU 47,C •01 SCHARGE CHAIN 371 EMRGC EOU 48,C •EMERGENCY OPERATIONS CHAIN 372 MA L T3 EOU 50.C •MEDICAL PATIENTS IN AREA 3 373 MALT4 FOU 51,C • MEDICAL PATIENTS IN AREA 4 3 74 SLEEN EOU 14.C • EENT END SLATE 375 SLFW1 EOU 8.C •EENT WEEK 1 SLATE 376 SLEW2 EOU 9,C •EENT WEEK 2 SLATE 377 SLEW3 EOU 10,C •EENT WEEK 3 SLATE 378 SLEW4 EOU 11.C •EENT WEEK 4 SLATE 379 S L EW5 EOU 12, C •EENT WEEK 5 SLATE 380 SLEW6 EOU 13,C •EENT WEEK 6 SLATE 381 SLOEN EOU 21.C •ORTHO END SLATE 382 SLOWl EOU 15,C •ORTHO WEEK 1 SLATE 393 SL0W2 EOU 16,C •ORTHO WEEK 2 SLATE 384 SLOW 3 EOU 17, C •CRTHO WEEK 3 SLATE 385 SL0W4 EOU 18,C •ORTHO WEEK 4 SLATE 336 SL0W5 EOU 19,C • CRTHO WEEK 5 SLATE 387 SL0W6 EOU 20,C • ORTHO WEEK 6 SLATE 388 XFFRC EOU 49 ,C •TRANSFERS' CHAIN ********* *********************** «**•**. • STORAGES *************************************** * • BEDS PER SERVICE STORAGE SI,165/S2,100/S3,35/S4,75 • FUNCTIONS • • • • • • • • • • • • • • • • • • f t * * * * * * * * * * * * * * * * * * * * • DAILY PATIENT ARRIVAL DISTRIBUTIONS ARNON FUNCTION P1.E3 1,FNJANMED/3,FNtANEEN/4,FNSANORP • NON-SCHEDULABLE' ARRIVALS BY SERVICE O _ •SCHEDULABLE ARRIVALS BY SERVICE 402 ARSCH FUNCTION P 1 . E 3 403 1 , F N * A S M E D / 3 , F N * A S E E N / 4 , F N t A S O R P 404 AN«EO FUNCTION R N 2 . 0 1 6 • MF DI C l NE N0N-SCHEDULA8LE 405 . 0 2 0 , 6 / . 0 6 3 . 7 / . 1 3 6 , 8 / . 2 3 5 . 9 / . 3 5 0 , 1 0 / . 4 6 6 , U / . 5 7 3 . 1 2 / . 6 6 5 , 1 3 / . 7 4 4 , 1 4 406 . 8 1 3 , 1 5 / . 8 7 4 , 1 6 / . 9 2 4 , 1 7 / . 9 6 1 , 1 8 / . 9 8 4 , 1 9 / . 9 9 6 , 2 0 / 1 , 2 1 407 . ANEEN FUNCTION RN3.D5 *EENT NON-SCHECULABLE 408 . 6 1 6 , 0 / . 9 0 7 , 1 / . 9 5 9 , 2 / . 9 3 9 , 3 / 1 . 4 409 ANORP FUNCTION RN4.D7 *0RTHOPEDIC NON-SCHEDULABLE 410 . 1 6 2 , 0 / . 3 2 4 , I / . 5 6 8 , 2 / . 7 5 7 , 3 / . 9 1 9 , 4 / . 9 7 3 , 5 / 1 . 6 411 ASMED FUNCTION RN2.D9 *MEDICAL SCHEDULABLE 412 . 2 0 5 , 0 / . 2 2 0 , I / . 2 4 5 , 2 1 . 3 1 0 . 3 / . 4 7 5 , 4 / . 7 2 5 . 5 / . 8 9 0 , 6 / . 9 6 0 . 7 / 1 . 8 413 ASEEN FUNCTION R N 3 . 0 9 *EENT SCHEDULABLE 414 . 3 13, 0 / . 3 76 , 2 / . 4 51 , 3 / . 52 8 , 4 / . 6 19 , 5 / . 7 1 2 . 6 / . 8 19, 7 / . 9 4 0 , 8 / 1 . 9 415 ASORP FUNCTION RN4.06 *ORTHOPEDIC SCHEDULABLE 416 . 2 8 6 , 0 / . 3 1 4 , 1 / . 4 2 9 , 2 1 . 6 5 7 . 3 / . 8 2 9 , 4 / 1 , 5 417 * NUMBER OF OOCTOPS PER S E R V I C E 418 1 FUNCTION RN2 .C2 * S A Y 22 MEDICAL DOCTORS, EOUAL USAGE 419 0 , 1 / 1 .23 420 3 FUNCTION RN3.C2 * SAY 10 EENT COCTORS, EOUAL USAGE 421 0 , 1 / 1 , 1 1 422 4 FUNCTION RN4.C2 • 9 ORTHOPEOIC DOCTORS, EOUAL USAGE 423 0 , 1 / 1 , 1 0 424 * PATIENT DIAGNOSTIC CATEGORY DISTRIBUTIONS 425 10 FUNCTION PI , E 3 • SELECT S E R V I C E ' S FUNCTION 426 I . F N U / 3 . F N 1 3 / 4 , FN14 427 11 FUNCTION RN2.D2 •MEDICINE 428 . 8 0 0 , 1 / 1 , 2 429 13 FUNCTION RN3 .02 • E E N T 430 . 7 8 8 . 1 / 1 , 2 431 14 FUNCTION RN4.D2 •CRTHOPEDICS 432 . 7 5 9 , 1 /1 , 7 433 20 FUNCTION PI . E 3 • S E L E C T S E R V I C E ' S FUNCTION 434 1 . F N 2 1 / 3 . F N 2 3 / 4 , FN24 435 21 FUNCTION RN2 .03 •MEDICINE 436 . 4 1 4 , 3 / . 5 8 5 , 4 / 1 , 5 437 23 FUNCTION RN3.D3 • EENT 438 . 0 3 3 , 3 / . 0 6 6 , 4 / 1 , 5 439 24 FUNCTION RN4.03 •ORTHOPEDICS 440 . 0 2 0 , 3 / . 217 , 4 / 1 , 5 441 * PATIENT SEX 442 30 FUNCTION P 1 . E 3 • • S E L E C T SERVICE 443 1 . F N 3 1 / 3 , F N 3 3 / 4 , FN 34 444 31 FUNCTION RN2,D2 •MEDICINE PROPORTIONS IN SEXES 445 . 5 6 5 , 1 / 1 , 2 446 33 FUNCTION RN3.D2 • E E N T PROPORTIONS IN SEXES 447 . 5 0 0 , 1 / 1 , 2 448 34 FUNCTION RN4,D2 • ORTHO PROPORTIONS IN SEXES 449 . 5 3 5 , 1 / 1 , 2 450 * PATIENT AGE GROUP 451 41 FUNCTION RN2.D5 452 . 0 C 8 . 1 / . 1 4 3 , 2 / . 4 4 5 . 3 / . 8 4 0 . 4 / 1 , 5 453 42 FUNCTION RN2 .05 454 . 0 0 8 . I / . 1 8 5 . 2 / . 4 0 1 , 3 / . 7 4 3 . 4 / 1 , 5 455 45 FUNCTION RN3.05 456 . 0 2 5 . 1 / . 4 2 1 , 2 / . 6 9 6 , 3 / . 9 2 2 . 4 / 1 . 5 457 46 FUNCTION RN3.D5 458 . 0 2 5 , 1 / . 3 5 9 , 2 / . 5 6 7 , 3 / . 8 5 3 , 4 / 1 , 5 459 4 7 FUNCTION RN4.D5 460 . 0 2 , l / . 4 5 . 2 / . 7 8 , 3 / . 9 6 , 4 / l , 5 461 48 FUNCTION RN4.D5 •MEDICINE MALE AGE GROUP PROPORTIONS • MEDICINE FEMALE AGE GROUP PROPORTIONS • EENT MALE AGE GROUP PROPORTIONS •EENT FEMALE AGE GROUP PROPORTIONS •ORTHO MALE AGE GROUP PROPORTIONS •ORTHO FEMALE AGE GROUP PROPORTIONS O 4 6 ? . 0 2 , 1 / . 3 2 , 2 / . 5 2 5 , 3 / . 8 1 5 , 4 / 1 , 5 4 6 3 * P A T I E N T L E N G T H OF S T A Y D I S T R I B U T I O N S 4 6 4 5 1 F U N C T I O N R N 2 . C 1 7 * M E D I C I N E 1 S T A G E G R O U P 4 6 5 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 4 6 6 . 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 4 6 7 5 2 F U N C T I O N R N 2 . C 1 7 * M E C ! C I N E 2ND A G E G R O U P 4 6 8 0 , I / . 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 11 , 1 6 / . 9 4 2 , 2 0 / . 9 6 0 . 2 4 4 6 9 . 9 7 9 , 3 2 / . 9 8 7 , 4 0 / . 9 9 2 , 4 8 / . 9 9 5 , 6 4 / . 9 9 7 , 8 0 / . 9 9 8 , 9 6 / l . 1 2 8 4 7 0 5 3 F U N C T I O N R N 2 . C 1 7 * M E C I C I N E 3RD A G E GROUP 4 7 1 0 , 1 / . C 0 7 , 2 / . 33 0 , 4 / . 4 9 2 , 6 / . 6 1 7 , 8 / . 7 0 4 , 1 0 / . 7 6 8 . 1 2 / . 8 5 5 , 1 6 / . 9 0 9 , 2 0 / . 9 3 2 , 2 4 4 7 2 . 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 8 4 7 3 5 4 F U N C T I O N R N 2 . C 1 7 * M E D I C I N E 4 T H A G E G R O U P 4 7 4 0 , 1 / . 0 0 5 , 2 / . 1 8 2 , 4 / . 3 2 7 , 6 / . 4 3 0 , 8 / . 5 5 0 , 1 0 / . 1 3 0 , 1 2 / . 7 4 2 , 1 6 / . 8 1 8 , 2 0 / . 8 7 8 . 2 4 4 7 5 . 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 4 7 6 5 5 F U N C T I O N R N 2 . C 1 7 * M E D I C I N E 5 T H A G E G R O U P 4 7 7 0 , I / . 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 / . 701 , 2 0 / . 7 7 0 . 2 4 4 7 8 . 8 5 2 , 3 2 / . 9 G 0 , 4 0 / . 9 3 5 , 4 8 / . 9 6 0 , 6 4 / . 9 7 5 . 8 0 / . 9 8 4 , 9 6 / 1 , 1 2 8 4 7 9 6 1 F U N C T I O N R N 3 . C 1 5 + E E N T 1 S T A G E G R O U P 4 8 0 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 , 2 4 4 8 1 . 9 9 5 , 3 2 / . 9 9 7 , 4 0 / . 9 9 3 , 4 8 / . 9 9 9 , 6 4 / 1 , 8 0 4 8 2 6 2 F U N C T I O N R N 3 . C 1 3 * E E N T 2 N D A G E G R O U P 4 3 3 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 , 2 4 4 8 4 . 9 9 8 , 3 2 / . 9 9 9 , 4 0 / 1 . 8 0 4 8 5 6 3 F U N C T I O N R N 3 . C 1 2 * E E N T 3 R D A G E G R O U P 4 8 6 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 / . 9 9 2 , 2 0 / . 9 9 6 , 2 4 4 8 7 . 9 9 9 , 3 2 / 1 . 4 0 4 8 8 6 4 F U N C T I O N R N 3 . C 1 5 * E E N T 4 T H A G E G R O U P 4 8 9 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 4 9 0 . 9 9 0 , 3 2 / . 9 9 4 , 4 0 / . 9 9 6 , 4 8 / . 9 9 7 , 6 4 / 1 , 8 0 4 9 1 6 5 F U N C T I O N R N 3 . C 1 5 * E E N T 5 T H A G E G R O U P 4 9 ? 0 , 1 / . 0 1 8 , 2 / . 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 4 9 3 . 9 9 4 , 3 2 / . 9 9 6 , 4 0 / . 9 9 7 , 4 8 / . 9 9 8 , 6 4 / 1 , 8 0 4 9 4 6 6 F U N C T I O N R N 4 . C 1 4 * O R T H O 1 S T A G E G R O U P 4 9 5 0 , 1 / . 1 2 2 , 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 . 2 4 4 9 6 . 9 8 3 , 3 2 / . 9 9 3 , 4 0 / . 9 9 7 , 4 8 / 1 , 6 4 4 9 7 6 7 F U N C T I O N R N 4 . C 1 7 * O R T H O 2 N D A G E G R O U P 4 9 8 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 , 1 6 / . 9 2 6 . 2 0 / . 9 4 0 , 2 4 4 9 9 . 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 5 0 0 6 8 F U N C T I O N R N 4 . C 1 7 * 0 R T I I O 3 R D A G E GROUP 5 0 1 0 , 1 / . 0 2 8 , 2 / . 1 8 7 . 4 / . 3 7 0 , 6 / . 5 3 2 . 8 / . 6 2 0 , 1 0 / . 6 8 7 , 1 2 / . 7 8 3 , 1 6 / . 8 5 2 , 2 0 / . 8 8 9 , 2 4 5 02 . 9 4 4 , 3 2 / . 9 6 6 , 4 0 / . 9 7 7 , 4 8 / . 9 8 9 , 6 4 / . 9 9 5 . 8 0 / . 9 9 7 . 9 6 / 1 , 1 2 8 5 0 3 6 9 F U N C T I O N R N 4 . C 1 7 \" C R T H O 4 T H A G E G R O U P 5 0 4 0 , 1 / . 0 2 8 , 2 / . 1 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 / . 7 6 6 , 2 4 5 0 5 . 8 5 3 , 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 , 128 5 0 6 7 0 F U N C T I O N R N 4 . C 1 7 * O R T H O 5 T H A G E G R O U P 5 0 7 0 , I / . 0 0 5 . 2 / . 0 3 5 , 4 / . 0 7 8 , 6 / . 1 3 0 , 8 / . 171 , I 0 / . 2 11 . 1 2 / . 2 8 5 . 1 6 / . 3 9 2 . 2 0 / . 4 8 5 , 2 4 5 0 8 . 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 5 0 9 * P A T I E N T P R E O P E R A T I V E L O S 5 1 0 1 2 0 F U N C T I O N P I , E 2 * S P E C I F Y BY S E R V I C E 5 1 1 3 , 1 / 4 , 1 5 1 2 * T O O B T A I N F R A C T I O N O F P T S N O T A S S I G N E D A ' R E Q U E S T E D D A T E O F A D M I S S I O N \" 5 1 3 1 4 0 F U N C T I O N P 1 . E 2 * S E L E C T S E R V I C E 5 1 4 3 . F N 1 4 3 / 4 . F N 1 4 4 5 1 5 1 4 3 F U N C T I O N P 6 . 0 3 * E E N T 5 1 6 3 , 5 0 0 / 4 , 1 0 0 / 5 , 3 0 0 5 1 7 1 4 4 F U N C T I O N P 6 . D 3 * O R T H O P E D I C S 5 1 8 3 , 5 0 / 4 , 1 0 0 / 5 , 7 5 0 . 5 1 9 * O A Y S T O R E Q U E S T E D A D M I S S I O N D A T E S DAY OF WEEK OF SURGERY 805 ASSIGN 13.MH*V»0FFSL« 1.P14) •NEXT DATE OF SURGERY FOR DOCTOR 806 ASSIGN 15-.P10 •P15=-VE OF NEXT POSSIBLE TIME 807 ASSIGN 15*,P13 • P15=FREE MARGIN TO NEXT SLATED DAY 808 TEST L P15.0,AFEAS • I F NEGATIVE, CUST FIX 809 ASSIGN 13 + , 7 • INCREASE BY 1 WEEK 810 AFEAS ASSIGN 15.0 •CLEAR NUMBERS FROM P15 811 ASSIGN 13+.7 •START CHECKING SPOT I WEEK FR EARLIEST 812 SAVEVALUE CHECK. PI 3.H • CHECK DATE WAS COMPUTED IN P13 813 814 * SEGMENT READY TO TRY A PARTICULAR DAY 815 * AT THIS POINT , XHJCHKOR AND XHSCHECK MUST BE SET 8 1 6 817 A TRY SAVEVALUE WEEK ,V tCWEEK ,H • WEEK CHECKED DETERMINED FROM CHECK DATE 818 TEST GE XHSWEEK.6.LO0K • IF 'L» 6 WEEKS AWAY. LOOK AT SLATE 819 * THESE ONES 6 OR MORE WEEKS AWAY, PUT ON SLATE END 820 ASSIGN 4,XH*CHECK *P4=CHECK DATE FOR SURGERY 821 ASSIGN 3.P4 • SAME TO P3 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 TEST LE ASSIGN ASSIGN ASSIGN P0S1 SPLIT TRANSFER SLCH1 L INK 3-.P10 P6,0,P0S1 13, P6 6,0 6-.P13 l . S L C H l .FILE V$SEUSC,6 LOOK FOR THESE MUST LOOK AT DESIRED SPOT ON SLATE *P3 = ADMISSI0N DATE I SURG - PREOP) * WANT POSITIVE CATEGORY •PUT ANY NEGATIVE CATEGORY IN P13 •SET TO 0 •NOW POSITIVE •CREATE COPY FOR SLATE CHAIN •ORIGINAL TO ADMISSION FILE •LINK TO SLATE-END CHAIN BY DOCTOR ASSIGN SAVEVALUE SAVEVALUE SAVEVALUE ASSIGN ASSIGN ASSIGN SAVEVALUE ASSIGN SAVEVALUE TEST NE TEST LE 15.1,V$SGYDW •P15=SURGERY DCW FOR DOCTOR PTFWK.VtAPRWK.H •IDENTIFY ROW FOR APPROPRIATE WEEK'S PTS TMFWK,XH$PTFWK,H •SET THIS THE SAME TMFWKt-.l.H *APPROPRIATE WEEK'S TIME IS 1 ROW LATER 13, MH*VtOFFSL(XHtPTFWK,Pl5) •P13=PTS FOR DATE BEING CHECKED l 3 * » l •P13=PTS IF THIS ONE ADDED 14, MH^VtOFFSL(XH$TMFWK,Pl5) *P14=TIME FOR DATE BEING CHECKED N P U T M . D I A - U h T t I i r nrmnr- . OW , P14.H 14+.P11 CHKTM.PH.H BVtTRYDA,1.GOTDA P6.3.N0TUR •TIME BEFORE A BUMP •P14=TIME IF THIS ONE ADDED •SETTING SURGERY TIME TO TRY TO FIND • I F TRUE, THE DAY IS GOOD •UNLESS P6 IS 3 (OR SET NEG) NOT URGENT NOE NOS THE FOLLOWING SECTION OEALS WITH URGENT PATIENTS TEST GE XH$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 ELECTIVE OF THIS DR TRANSFER .GOTDA • PUT THIS ONE ON IN HIS PLACE V$SLUSC,BUMPD,1,BVJBUMPS,,NOS •NO EL - TRY TO BUMP SEMI-URGENT ,GOTDA *PUT THIS ONE ON IN HIS PLACE CHECK*,7,H *NOONE TO BUMP, SO TRY 1 WEEK LATER TRY • +G0 TRY AGAIN UNLINK TRANSFER SAVEVALUE TRANSFER THESE TO BE TREATED AS URGENTS FOR WITHIN 2 WEEKS USOON MARK ASSIGN ASSIGN TEST LE THWK SAVEVALUE TRANSFER NEWK TEST L ASSIGN ASSIGN PROPR SAVEVALUE WANTD SAVEVALUE 1 3 •START CHECKING AT EARLIEST POSSIBLE TIME 1 3 * » 1 ^TRY TOMORROW ADM AT EARLIEST 1 3 * ' P 1 ° •NOW HAVE EARLIEST DAY OF SURGERY P13.MH^V$0FFSLf 1,5),NEWK *DATE BY THIS FRIDAY? V.EEK,0,H ,WANTD V*ENDWK,3,PR0PR 13,XHtPWEEK 13*.8 WEEK,I,H CHECK. PI 3.H •BY FRIOAY, SO IT IS THIS WEEK •WANT TO FIND A DOCTOR •WAS DATE SET ON WEEKEND? HAVE DATE, FIND CORRESPONDING DOCTOR •YES, SO SET TO NEXT MONDAY •HAVE PROPER CATE NEXT WEEK •CHECK DATE IS EARLIEST POSSIBLE SAVEVALUE GETDA ASSIGN ASSIGN TEST NE SAVEVALUE TRANSFER CHKDR,1,H •COULD 1ST DOCTOR POSSIBLY 00? 15,l,VtSGYDW •FIND THIS DOCTOR'S DAY OF THE WEEK 14,MH*VtOFFSL{I.P15) •NEXT DAY OF SURGERY FOR THAT DOCTOR U t T B v n o . n n * w n i / _ -v/^ n • . — — . . . . . . V RYDR.O,DAYOKCHKDR*,I,H ,GETDA DATE AND DOCTOR CORRESPOND, SEE IF THE DAY IS OK •TO DAYOK IF THIS ONE MIGHT DO •TRY NEXT DOCTCR •GO TO GET HI S DAY DAYOK SAVEVALUE SAVEVALUE SAVEVALUE ASSIGN ASSIGN ASSIGN ASSIGN TEST NE PTFWK,VtAPRWK.H TMFWK,XHtPTFWK.H TMFWK*,I ,H •IDENTIFY ROW FOR APPROPRIATE WEEK'S PTS •SET THIS THE SAME •APPROPRIATE WEEK'S TIME IS 1 ROW LATER 13. MH*V$OFFSL(XH$PTFWK,P15) *P13 = PTS FOR DATE BEING CHECKED l 3 + ' 1 'PTS IF THIS ONE ADDED 14, MH*V$0FFSL(XHJTMFWK,P15) • P14=TIME FOR THAT DATE l * + . p l l *TIME IF THIS ONE ADDED BVtTRYDA,1,GOTDA * I F TRUE, GOT DAY - 1 882 TEST NE P15.5.WKDON * I F THAT WAS FRIDAY, WEEK DONE 883 NEWDR SAVEVALUE CHKDR*,1,H * ADD 1 TO CHECKED DOCTOR 88 * ASSIGN 15, l ,VtSGYDW *P15=SURGERY DOW OF THIS DOCTOR 335 ASSIGN 14, MH*VtOFFSLCI.P151 *NEXT DATE OF SURGERY FOR THAT DOCTOR 886 TEST NE VtO ASA M, 0, NE WOR * I F THIS DR ON SAME DAY GO FOR ANOTHER 887 SAVEVALUE CHECK*,1,H ' TO TRY DAY LATER 888 TRANSFER ,DAYOK *G0 SEE IF THIS DAY IS OK 889 WKOON SAVEVALUE WEEK + . l . H ' * TRY NEXT WEEK 890 * TREAT SPECIALLY IF THIS IS TOO FAR AWAY 891 TEST GE XHt WEE K, 3 , CL0S1 *ARE THERE NO SPOTS NEARBY7 892 SAVEVALUE CHKDR,P5,H *N0 , GET PROPER DOCTOR AGAIN 893 ASSIGN 15, l ,VtSGYDW 'H I S DAY OF THE WEEK FOR SURGERY .894 SAVEVALUE CHECK,MH*V$OFFSL11.P15),H ' H I S NEXT SURGERY DAY 895 SAVEVALUE CHECK*, 14,H * 2 WEEKS AWAY 896 TRANSFER ,TPY * FE WILL NOW BUMP ANOTHER 897 * ST ILL CLOSE ENOUGH 898 CLOS l SAVEVALUE CHECK* ,3 ,H 'ADVANCE DAY FRIDAY TO MONDAY 899 SAVEVALUE CHKDR, 1 ,H ' START AGAIN WITH FIRST DOCTOR 900 ASSIGN 15,1 ' TH I S DOCTOR'S DAY OF THE WEEK 901 TRANSFER ,CAYOK . ' G O SEE IF THE DAY IS OK 902 * 903 * THE FOLLOWING SECTION DEALS WITH NON-URGENT PATIENTS 904 * 905 NOTUR SAVEVALUE CHECK* , 7.H ' FOR SEMI-U AND EL , TRY 1 WEEK LATER 906 TRANSFER ,TRY 'GO TRY AGAIN 907 * 908 * 8UMPE0 PATIENTS ARE HANDLED HERE 939 * 910 RUMPD SAVEVALUE CHECK,P4,H * DAY BUMPED PT STARTED FROM 911 SAVEVALUE CHKDR,P5.H *DR THIS PATIENT WAS SLATED FOR 912 ASSIGN 15, l .VtSGY0W 'THAT DOCTOR'S DAY OF THE WEEK 913 SAVEVALUE PTFWK.VtAPRWK.H ' I DENT IFY ROW REMOVED FROM 914 SAVEVALUE TMFWK,XHtPTFWK.H ' S E T THIS THE SAME 915 SAVEVALUE TMFWK+.l.H ' I DENT IFY ROW FOR TIME REMOVED 916 TEST GE MH'VtOFF SL(XHtPTFWK.PI 51.FN242.NRTPN *1 OR MORE PER OR THERE? 917 MSAVEVALUE VtOFFSL-.XHtTMFWK.P15.15.MH 'REMOVE TURNAROUND WHICH FOLLOWS 918 NRTRN MSAVEVALUE VtOFFSL - .XHtPTFWK.P15 . l.MH 'REMOVE PATIENT 919 MSAVEVALUE VtOFFSL- ,XHtTMFWK,P I 5,PI I,MH 'REMOVE HIS TIME 920 SAVEVALUE CHECK* ,7 .H ' TRY 1 WEEK FROM THAT SPOT 9?1 SAVEVALUE MDATE. P3 .H * ADM DATE I FOR MATCHING FROM ADM CHAIN) 922 SAVEVALUE MSRVC.P l .H 'WANT SERVICE TO MATCH 923 SAVEVALUE MDGEN,P2,H 'WANT DATE GEN ERA TEO TO MATCH 924 SAVEVALUE ML0ST.P9.H * ALSO MATCH LENGTH OF STAY 925 SAVEVALUE MLOSG.P l l .H 'ALSO MATCH LENGTH OF SURGERY 926 UNLINK ADMSC,TRY,1,BVSMACHR,,FAIL0 'GET PT OFF ADMISSION CHAIN 927 « THEN GO TRY IT FOR LATER WEEK 928 TRANSFER .CSPOS ' TH I S COPY OF PT NOT NEEDED 929 * 930 * PATIENTS HERE HAVE GOTTEN A OAY OK FOR SURGERY 931 » 932 GOTDA ASSIGN 4,XHtCHECK 'SURGERY DATE TO P4 933 ASSIGN 3.P4 'SAME TO P3 934 ASSIGN 3- .P10 *P3=ADMISSION DATE (SUBTR PRE-OP» 935 ASSIGN 15, l ,VtSGYDW *P15=00CTCR\"S SURGERY DOW 936 SAVEVALUE PTFWK.VtAPRWK.H ' I DENT IFY ROW FOR APPROPRIATE WEEK'S PTS 937 SAVEVALUE TMFWK,XHtPTFWK.H ' S E T THIS THE SAME 938 SAVEVALUE TMFWK*,1,H 'APPROPRIATE WEEK'S TIME IS 1 ROW LATER 939 MSAVEVALUE Vt OFFS L* ,XHt PT FWK, PI 5, I, MH 'ADD I TO PATIENTS SLATEO THERE ^ 940 MSAVEVALUE VtOFF S L * . XH1 TMFWK, P15, PI 1, MH 'ADD SURGERY TIME TO THAT SLATED J \" , 941 TEST GE MH*VtOFFSL«XHtPTFWK,P15 I .FN242,PUT2 * 2 * PER OR SLATEO THERE? 942 MSAVEVALUE V S O F F S L * . X H i T M F W K , P I 5 ,15 ,MH * A 0 0 TURNAROUND BEFORE NEXT PT 943 PUT2 TEST LE P 6 . 0 . P 0 S *WANT POSIT IVE CATEGORY 944 ASSIGN 1 3 , P 6 *PUT ANY NEGATIVE CATEGORY IN P13 945 ASSIGN 6 , 0 * S E T TO 0 946 ASSIGN 6 - . P 1 3 *NOW POSITIVE 947 POS SPLIT 1 .SLCH2 * CREATE COPY FOR S L A T E CHAIN 948 TRANSFER . F I L E *ORIGINAL TO ADMISSION F I L E 949 SLCH2 LINK V t S L U S C . 5 *PUT ON SLATE CHAIN BY OOCTOR 950 * PATIENTS HERE ARE Ft LEO ON ADMISSION OUEUE 951 F I L E LINK ADMSC.3 *0N ADMISSION CHAIN BY DATE 1353 ************.**.*****.************* *.*«**«* 953 * MEDICAL REQUEST HANDLING 954 j . * * * * * * * * * * * * * * * * * * * * * * . * * . * « * » . * * * * * . * * * . * * . 955 * 956 * PUT THESE RE3UESTS ONTO THE MEDICAL ADMISSIONS CHAIN 957 * 958 MEDIC LINK ADMMC.FIFO *CNTO MEDICAL ADMISSION CHAIN 959 «****.« ***.** ************ ********* *.*»*.*** 960 * TRANSACTION TO INSTIGATE ADMISSIONS 96 1 A************************************** 962 * 963 * FOR SURGICAL ADMISSIONS. ADMIT ALL SCHEDULED FOR TODAY (ACCORDING 964 * TO THEIR S L A T E ) . MEDICAL ADMISSIONS GET SPECIF IED NUMBER OF 965 * REMAINING B E D S . LAST FEW ARE SAVED FOR EMERGENCIES. 966 * 967 GENERATE 1 , , , , 1 0 +SINGLE TRANSACTION PER DAY TO INSTIGATE 968 MARK 3 * T O D A Y ' S DATE IN P3 969 UNLINK A D M S C , A D M S . A L L , 3 * A L l SURG. ADMISSIONS TODAY TO ADMS 970 ASSIGN I .FN231 •NUMB ER MED S TO ADMIT 971 UNLINK ADMMC.ADMM,PI * ADMIT MEDICAL PATIENTS 972 TERMINATE *REMOVE INSTIGATING TRANSACTION 973 ************************************** 974 * SURGERY ADMISSION PATH 975 ***«******+*****••********»*********** 976 * 977 * FOR NOW, ALLOW ONLY INTO A BED OF THE PROPER SERVICE AREA. IGNORING SEX 978 * BASED ON AVERAGE NUMBERS ENTERING EMERGENCY AND INHOSPITAL OPERATIONS 979 * PER DAY, NOW GENERATE•THESE REQUESTS. SAY EMERGENCIES ARE NEXT DAY, 980 * INHOSPITAL REQUESTS AS SOON AS POSSIBLE FROM 2 DAYS AWAY. 991 * ' 9f>2 ADMS GATE LR WAIT * ALLOWED TO BE PROCESSED? 993 TEST L R * 1 , 1 , A 0 K *ROOM IN S E R V I C E ' S BEDS ? 984 SAVEVALUE N 0 B 0 * , 1 , H *ONE MORE 'NO BED' 985 ASSIGN 13, P6 +XATEGORY IN P13 986 ASSIGN 6 , 0 *WANT TO SET NEGATIVE 987 ASSIGN 6 - . P 1 3 *NOW NEG, PROCESSED AS URGENT 998 * 'NO B E D S ' TRY CVER 989 ASSIGN 13.XHSPWEEK * F I P S T DAY OF PRESENT WEEK IN P13 990 ASSIGN 1 3 * . 7 *ADVANCE THAT TO NEXT WEEK 991 LOGIC S WAIT *STCP FURTHER ADMISSIONS NOW 992 PRIORITY 1 9 , B U F F E R * F I N I S H WITH OTHERS FIRST 993 PRIORITY 20 *RE STORE PRIORITY 994 LOGIC R WAIT *ALLOW FURTHER ADMISSIONS NOW 995 * NEED TO LOCATE THEM ON SURGERY SLATE 996 TEST L P13,P4 .THSWK *WH1CH WEEK SURGERY? THIS OR NEXT 997 SAVEVALUE W E E K . l . H *CHECK 1 WEEK AWAY FOR SURGERY TIME 998 TRANSFER , O F F S G * NEED PT OFF SURGERY CHAIN 999 THSWK SAVEVALUE W E E K . O . H *CHECK ON THIS WEEK'S SLATES 1000 OFFSG SAVEVALUE M 0 A T E . P 3 . H * F I P S T , TAKE CATE TO MATCH 1001 SAVEVALUE M S R V C . P 1 . H *WANT SERVICE 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 'FINALLY, LENGTH OF SURGERY UNLINK VtSLUSC.OSPOS,l.BVtMACHR,.FAILO '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 'IDENTIFY ROW REMOVED FROM SAVEVALUE TMFWK,XHtPTFWK.H 'SET THIS THE SAME SAVEVALUE TMFWK*,I ,H * IDENTIFY ROW FOR TIME REMOVAL TEST GE MH'VtOFFSLIXHtPTFWK.Pl 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 IS A BED... ACK LOGIC S PR I ORIT Y DEPART WAIT 10,BUFFER VtWAITO 'NO MORE ADMISSIONS JUST NOW 'RESET PRIORITY LEVEL 'LEAVE WAITING TIME OUEUE GENERATE EMERGENCY AND INHOSPITAL OPERATION REQUESTS TRANSFER SPLIT MARK ASSIGN TEST GE ASSIGN LINK NOEMG TRANSFER SPL! T ASSIGN INHRO MARK ASSIGN TEST GE TEST LE SAVEVALUE TRANSFER NEWEK TEST L ASSIGN ASSIGN PROPE SAVEVALUE WCNTD SAVEVALUE .FN247,,NOEMG I, NOEMG 4 4*,1 P9,2,DSPOS I I , 1,V$SDIST EMRGC,4 ,FN248,,N0INH I . NOINH I I . 1.V1SDIST 13 13*.2 P9,3,DSPOS 'SEND PROPORTICN NOT GENERATING EMERG OP 'OBTAIN ENTITY TO FOLLOW THIS PATH 'PRESENT DAY IN P4 •HENCE EMERG CP TOMORROW 'IGNORE IF LOS 1 L ' 2 DAYS *P1 l^LENGTH OF EMERG SURGERY * PUT ON EMERGENCY CHAIN FOR TOMORROW 'SEND THE PROPORTION NOT PLACING INH REO 'GET ENTITY TO EFFECT INHOSPITAL REQUEST »P11 = LENGTH OF SURGERY 'PRESENT DAY IN P13 'EARLIEST POSS DAY 2 AWAY 'IGNORE IF LOS 'L' 3 DAYS P13.MH*VtOFFSL(l,51,NEWEK 'DATE BY THIS FR IOAY? WEEK,0,H .WONT D VtENDWK,3,PR0PE 13,XHtPWEEK 13*.8 WEEK.l ,H CHECK,PI 3,H HAVE DATE. FIND CORRESPONDING DOCTOR 'YES, SO IT IS THIS WEEK 'WANT TO FINO A DOCTOR 'WAS DATE SET CN WEEKEND? 'YES, SO SET TO NEXT MONDAY 'HAVE PROPER DATE NEXT WEEK 'THIS GIVES CHECK DATE SAVEVALUE GETSG ASSIGN ASSIGN TEST NE SAVEVALUE TRANSFER CHKDR, l.H 15,1.VSSGYDW 'CAN 1ST DOCTOR POSSIBLY DO 'FIND THIS DR'S DAY OF WEEK 14,MH*VtOFFSLI1.P15) 'FIND HIS NEXT SURGERY DAY VtTRYDR.O,DAYKO CHKDR*,I,H ,GET SG ' I F HIS TIME IS OK TO CHECK, TO DAYKO •OTHERWISE, TRY NEXT DOCTOR 'GO TO GET HI S OAY DATE AND DOCTOR CORRESPOND, SEE IF THE DAY IS OK DAYKO SAVEVALUE PTFWK.VtAPRWK.H 'IDENTIFY ROW FOR APPROPRIATE WEEK'S PTS TMFWK,XHtPTFWK.H 'SET THIS THE SAME TMFWK+.l.H 'APPROPRIATE WEEK'S TIME IS I ROW LATER 13, MH*VtOFFSLIXHtTMFWK,P15) *P13 = TIME FOR THAT DAY 13+.P11 *ACD TIME OF THIS ONE TOO P13.FN241 ,GTDAY *GCT DAY IF TIME OK THERE P15.5.WKOUN 'WEEK DONE IF THAT WAS FRIDAY C.HKDR + . l . H *AOD 1 TO CHECKED DOCTOR 15,l,VtSGYDW *DR'S SURGERY CAY OF THE WEEK IN P15 14, MH*VtOFFSLI 1.P151 'NEXT DAY OF SURGERY FOR THAT DOCTOR SAVEVALUE SAVEVALUE ASSIGN ASSIGN TEST G TEST NE NWDOC SAVEVALUE ASSIGN ASSIGN K> O 1062 TEST NE VtDASAM.O.NWDOC *G0 FOR ANOTHER IF THIS DR SAME DAY 1063 SAVEVALUE CHECK*,1,H •TO TRY DAY LATER 1064 TRANSFER .DAYKO *G0 SEE IF THIS DAY IS OK 1065 * PATIENTS HERE HAVE GOTTEN A DAY FOR THEIR INHOSPITAL SURGERY I 066 WKOUN SAVEVALUE WEEK*,1,H •TRY NEXT WEEK 1067 * TREAT SPECIALLY IF TOO FAR AWAY 1068 TEST GE XHtWEEK,2,CL0S2 •ARE THERE NO SPOTS NEARBY? 1069 MARK 4 • NO, SO MAKE THIS OPERATION EMERGENCY 1070 ASSIGN 4*,I •FOR TOMORROW I 071 LINK EMRGC.4 •PUT ON EMERGENCY CHAIN 1072 * THESE ARE SOON ENOUGH 1073 CL0S2 SAVEVALUE CHECK*,3,H •ADVANCE DAY FRIDAY TO MONDAY I 074 SAVEVALUE CHKDR,I .H • START AGAIN WITH FIRST DOCTOR 1 075 ASSIGN 15,1 • THIS DOCTOR'S DAY OF THE WEEK 1076 TRANSFER ,DAYKO •GO SEE IF THE DAY IS OK 1077 GTOAY ASSIGN 4.XHSCHECK • SURGERY DATE TO P4 1078 ASSIGN 13,P3 •PRESENT OAY TC P13 1 079 ASSIGN 13+.P9 •P13=TIME OF DISCHARGE NOW 1 080 TEST L P4.P13.DSPOS • OISPOSE IF SURG TIME SET BEYOND DISCHARG 1081 ASSIGN 6,0 •ENSURE NO BUMPING 1082 ASSIGN 15,1.VtSGYDW •P15=SURGERY CAY OF WEEK 1033 SAVEVALUE TMFWK,VtAPRWK.H •SET AS ROW FOR APPROPRIATE WEEK'S PTS 1 084 SAVEVALUE TMFWK+,1,H •APPROPRIATE WEEK'S TIME IS 1 ROW LATER 1085 MSAVEVALUE VtOFFSL* .XHtTMFWK ,P15,Pll.MH *ADD SURGERY TIME TO SLATED TIME 1086 MSAVEVALUE VtOFFSL*,XHtTMFWK ,P15,15,MH *ADD TURNAROUND BEFORE NEXT PT 1 087 LINK VtSLUSC,5 • PUT ON SLATE USER CHAIN 1098 * I 089 * NOW THE PATIENT ENTERS A HOSPITAL BED 1090 * 1091 NOINH ENTER PI •ENTER BEDS FCR SERVICE 1 092 LOGIC R WAIT •CAN ALLOW OTHERS NOW 109 3 SAME MSAVEVALUE P1+,P6,2,1,MH • ADD 1 TO PATIENTS ADMITTED 1094 MSAVEVALUE PI*,6,2,l.MH •ADD 1 TO PATIENTS ADMITTED I 095 TEST NE P12.0.NOTRQ • I F 0, NOT A PT WHO REQUESTED DATE 1096 MSAVEVALUE PI*.P6,3,l.MH • COUNT AS REQUESTING 1097 MSAVEVALUE P1*,6,3,1,MH •COUNT AS REQUESTING 1098 TEST E P12 , P4,NOTRO • I F EQUAL. GOT THE RIGHT DAY 1099 MSAVEVALUE PI*.P6,4,l.MH •COUNT SUCCESSFUL ONES 1100 MSAVEVALUE PI*.6,4,l.MH • COUNT SUCCESSFUL ONES 1101 NOTRO ASSIGN 13.P3 •P13=TIME OF ACMISSION 1102 ASSIGN. 13*.P9 *P13=TIME OF DISCHARGE (ADD LOS) 1103 QUEUE VtLOSQ • ENTER OUEUE FOR LOS I 104 OUEUE VtLOSQS • ENTER QUEUE FCR LOS BY SEX I 105 ASSIGN 15,0 • ZERO P15 FCR C PE RATI ON COUNT 1106 PRIORITY 16 • PRIORITY LEVEL FOR DISCHARGES 1107 ASSIGN 14,PI •AREA TO DISCHARGE FROM 11 08 LINK CISCH,13 • PUT ONTO DISCHARGE CHAIN 1 109 DSPOS TERMINATE • FOR UNWANTED TRANSACTIONS 1110 FAILO TRACE • FOR FAILURE TO OBTAIN MATCH 1 111 UNTRACE 1112 TERMINATE 1113 ************************************** 1114 * MEDICINE ACMISSIONS PATH 1115 ************************************** 1116 • 1117 * FOR NOW, 00 NOT CAUSE ANY TRANSFERS TO OTHER HOSPITAL SERVICES, 1118 * HENCE NO OPERATIONS (EMERGENCY OR INHOSPITALI 1119 * I 120 ADMM ENTER PI •ENTER BEDS FOR SERVICE 1121 MARK 3 • ADMISSION TODAY. . . TO P3 1122 DEPART VJWAITQ *L E AVE WAITING TIME QUEUE 1123 TRANSFER ,SAM E *G0 COMPLETE AS SURGICAL H24 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 'OTHER 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? [V 1179 TEST NE Pl.l.MDOFF \"MEDICALS HANDLED SPECIALLY J~ 1180 TEST LE R*14,FN239,CNSTA \"IF MORE SPACE THERE, NO XFER 1181 TRANSFER ,NMALI \"IF LESS, AN IN-HOSPITAL XFER 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 ASSIGN PRIORITY ASSIGN LINK 13,P3 13*,P9 14 15,0 VtM0FF,13 THESE MUST TRANSFER SOON V.tWRONQ 15,0 13,P3 13*,P9 14 XFERC, FIFO IN PROPER AREA P14 EMBED-,l.H 13,P3 13+ ,P9 15,0 16 0ISCH.13 *******•****>***»*****»»***»*****»**»*,*. INHOSPITAL TRANSFERS NMALT QUEUE NMAL1 ASSIGN ASSIGN ASSIGN PRIORITY LINK * THESE PLACED PUTIN ENTER SAVEVALUE CNSTA ASSIGN ASSIGN ASSIGN PRIORITY LINK •25* ATTEMPT TRANSFER TO PROPER AREA •READY TO DISCHARGE GET SPECIAL CHAINS •P13=TIME OF ADMISSION • P13=TIME OF DISCHARGE • IN CASE OF TRANSFER •ZERO OPERATION COUNT • INCREASING DISCHARGE ORDER • 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 PT IN APPROPRIATE WARO •REMOVE 1 FROM EMERGENCY BEDS •P13=TIME OF ADMISSION *P13=TIME OF DISCHARGE • ZERO P15 FOR OPERATION COUNT • PRIORITY LEVEL FOR DISCHARGES •PUT ONTO THE 01SCHARGE CHAIN GENERATE I , . ,.14,3 • TRANSACTION TO INSTIGATE TRANSFERS DAILY UNLINK XFERC,TRYIN,ALL • UNLINK ALL TRANSACTIONS TO TRYIN MARK 3 •TODAY'S DATE TO P3 TEST NE BV1WKEND,l.WEOK ' •WEEKENDS OK IDON'T XFERI SAVEVALUE WEEK.O.H •THIS WEEK SAVEVALUE PTFWK.VtAPRWK.H •GIVES ROW FOR PATIENTS ASSIGN 1,3 •EENT BEDS ASSIGN 2.MH^V10FFSL(X HtPTFWK » VtWKDAY) *# OF BEDS NEEDED THERE ASSIGN 2-.1 • ALLOW I LESS TEST G VtNOFF,O.DOORT •DOES EENT GET BEDS? UNLINK MALT3,BACKl,VtNOFF .BACK * S END LONG-STAY MEDS BACK DOORT ASSIGN 1.4 •DO ORTHOPEDICS ASSIGN 2,MH^VtOFFSL(XHtPTFWK,VtWKDAY) *# OF BEOS NEEDED THERE TEST G VtNOFF,O.WEOK •DOES ORTHO GET BEOS? UNLINK MALT4,BACKl,VtNOFF • BACK •SEND LONG-STAY MEDS BACK WEOK TERMINATE • REMOVE INSTIGATOR TRANSACTION BACKl TEST E Rl.O.TXFER •ANY BEDS IN MED AREA? LI NK VtM0FF,13 • I F NOT, STAY PUT TRYIN PRIORITY TEST E LINK 14,BUFFER R+l.O.TXFER 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 +, P6, 6, I , MH MSAVEVALUE PI*.6.6.l.MH TODIS ASSIGN 13.P3 ASSIGN 13*,P9 DEPART VtWRONQ • RESET PRIORITIES FOR TRANSFER • TRANSFER PT IF ANY ROOM THERE • I F NOT, BACK ON XFER CHAIN •ONE MORE PATIENT THERE •UNLESS P14=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 PATIENTS 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 D I S C H , 1 3 \"PRIORITY LEVEL FOR DISCHARGES •AREA TO DISCHARGE FROM •PUT ONTO THE DISCHARGE CHAIN TRANSACTION TO INSTIGATE DISCHARGES GENERATE 1.... 16, 13 MARK 13 UNI INK DISCH,LEAVE,ALL, 13 UNLINK XFERC,LEAVP,ALL, 13 UNLI NK MALT3,LEAVP,ALL, 13 UNLINK MALT4,LEAVP,ALL, 13 TERMINATE LEAVP PRIORITY 16,BUFFER LEAVE DEPART VtLOSO DEPART VtLOSOS TEST NE P14.P1.N0NEM DEPART VtWRONO TEST E P14.0.N0NEM SAVEVALUE EM3ED-,1,H TRANSFER .ONOUT NCNEM LEAVE P14 CNOUT TEST E P14.1.8YE SAVEVALUE MAD I S * , l . H BYE TERMINATE * O P E R A T I N G R O O M O A T A *****•*«*«»*«** 4«, • TRANSACTION PER DAY TO INSTIGATE DISCH • TODAY'S DATE IN P13 • ALL PTS TO BE DISCHARGED TODAY TO LEAVE •INCLUDE THOSE WAITING FOR XFER • HEOICAL PATIENTS STILL OFF-SERVICE • MEDICAL PATIENTS STILL OFF-SERVICE • REMOVE INSTIGATOR FROM MODEL • MUST RAISE 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 •STIL L IN EMERG BEO IF 0 • REMOVE FROM THERE • SEND ON OUT •REMOVE ONE PT FROM THAT BEO POOL • A MEDICAL AREA DISCHARGE? •YES, COUNT •REMOVE PATIENT FROM MODEL L F V E L 0F^TIMI CDEL • 2 1/2 YEAR MOOEL •3 YEAR MODEL •3 1/2 YEAR MCDEL •4 YEAR MODEL •4 1/2 YEAR MODEL • 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 "@en ; edm:hasType "Thesis/Dissertation"@en ; edm:isShownAt "10.14288/1.0093975"@en ; dcterms:language "eng"@en ; ns0:degreeDiscipline "Statistics"@en ; edm:provider "Vancouver : University of British Columbia Library"@en ; dcterms:publisher "University of British Columbia"@en ; dcterms:rights "For non-commercial purposes only, such as research, private study and education. Additional conditions apply, see Terms of Use https://open.library.ubc.ca/terms_of_use."@en ; ns0:scholarLevel "Graduate"@en ; dcterms:title "A computer simulation of the admissions and scheduling system at St. Paul’s hospital"@en ; dcterms:type "Text"@en ; ns0:identifierURI "http://hdl.handle.net/2429/20257"@en .