The and earliest definition is “services are intangible

The central purpose of this document is to discuss the various aspects
of Operations Management related to the Specialist Pre-operation Consultation (SPoCS),
a small semi-autonomous unit within the Good Health Hospital (GHH), located in
the UK. The SPoCS’ purpose was to provide an assessment of patients to
determine their fitness for pre-operative anaesthesia. Critical issues will be
considered and possible solutions will be proposed to address the OM issues. Operations
management involves the applications of business practices to attain the
highest level of efficiency possible within an organization. (Friedman and
Miles 2006). According to Slack et al. (2016 p. 689),
“Operations Management is the activities, decisions and responsibilities of
managing production and delivery of products and services”.  “It is the systematic design, direction, and
control of processes that transform inputs into services and products for
internal, as well as external, customers”. (Ritzman et al. 2007 p.3). The
operations function is central to the organisation because it produces the
services which are its reason for existing. Russell and Taylor (2011) stated
that one of the most pervasive, and earliest definition is “services are intangible

The first section will discuss the theoretical background of the
proposed framework as well as a proper consideration of its stakeholders and
their perspectives in relation to their performance and operational issues. The
second part will identify the process flow of the patient’s journey in SPoCS. The
OM issues affecting Specialist Pre-operation Consultation Service in the Hospital,
along with some OM methods will then be described in the third part of this
study. Finally, the last section will examine valuable suggestions and
recommendations for addressing these OM issues, justifying all of them. The
focus in this paper has been on addressing the dissatisfaction of patients caused
by the long wait hours spent in queues, which lead to a long-time duration of
work for Doctors (MDs) and Registered Nurses (RNs). This document will refer to
the Theory of queuing for the mathematical treatment of the issue and
verification of proposed alternatives for improvement. Due to the complexity of
the rigorous mathematical treatment for the case of SPoCS, where many sequences
and many servers are presented, this study adopted simplification on the
calculations treating the unit as an overall


Section 1: Nature of the Business and its


Although the safety of anaesthesia has improved considerably due
to advancements in technology and research, risks are still present, and GHH
operation room (OR) surgeons, therefore, need to know before surgery that a
patient’s system was strong enough to endure anaesthesia. The Good Health Hospital
(GHH) is located in the UK, with an outpatient clinic with 12 exam rooms, a
lab, and a waiting room. Stakeholders, which are “any person or group of people
with a significant interest in services provided, or who will be affected by
any planning changes” (Friedman and Miles 2006 p.30), can be internal, connected or external to the
Local Health Community, and include staff, patients, trade union, MPs, members
of the public and community groups”. (NHS 2012 p.9). It can be argued that the
internal stakeholders of the GH Hospital are the employees of the hospital,
including Registered Nurses, Laboratory technicians, Anaesthesiologists, and
Attendants. In addition, Director of Public Health, the Procurement, the
Director of Nursing, Public Health Management Analyst and Strategists, Research
Scientist, Board committee members and Director of Programmes and Services are
classified as stakeholders of the hospital. The connected stakeholders include
Local Authority/council, Patients, Customers, Suppliers, Funders, Health
visitors or school nurses, Media. Lastly, the external stakeholders cover other
parties that can impact on the organization, the most important of which is
usually the Government.

From the case study given, it can be argued that both Registered
Nurses (RNs) and Doctors (MDs) are affected about the long wait hours endured
by their patients because they had to stay more time in the hospital in order
to clean queues. They also realized the low level of satisfaction of their patients.
Extra hours would result in higher costs for the business and this impact on
the financial prospects, affecting the Management of the Hospital. Furthermore,
the high percentage (35%) of the assessment done in the precious spaces of the
OR reduces the capacity of the Hospital, influencing its economical results and
again its management. The level of satisfaction of customers of this service is
very low due to the long-time hours spent in the queue, which tends to be a
cause of leaving the hospital in the middle of the appointment.


Section 2: Process Flow of Patient’s Journey


Figure 1:
Patient’s journey flow diagram






As referring to a service industry, the process involves both
physical processes and the people that deliver the services to the customer. A
service process lies on all the routines and tasks that are accomplished to
deliver service to customers along with the jobs and training for service
employees. The
main inputs of this process are patients, doctors, nurses, building, medical supplies,
equipment and laboratories. The transformation process includes examination, surgical
procedures, administering medication, changes in the location of materials,
information of customers, administering patient. The outputs produced
involve healthy patients. The process included information flows which consists
of the record the patient’s results on an index card attached to their chart
and patient chart in the holding bin.


Section 2.1:  Daily Capacity Calculation



Task Time per min

No. of Resources

Daily Capacity

Check-in Capacity




Check-out Capacity




Reception Capacity





Lab Capacity





RN Assessment Capacity




Blood sampling Capacity




RN activities




MD Capacity






Exam Room Capacity




Figure 2: Daily Capacity


The Good
Health Hospital’s open time was from 9am to 4pm. However, both RNs and MDs
stayed till 7pm to clear queues that had built up during the day. Therefore,
the time available in a day was 7 hours, 420 minutes per day, and the doctor’s
total working hours were 9 hours. The cycle times in the process is an average of 69 minutes, which is 1,15
hours. The check-in process usually took about 4 minutes per patient, the
Vitals and ECG’s process averaged about 15 minutes, the nurse took around 20
minutes to prepare the patient for examination. Moreover, the anaesthesiologist
spent a further 30 minutes on average to examine the patient. In case a patient
would require a blood test, this process would take about 5 minutes. Finally,
the check-out phase lasted about 5 minutes.

The throughput of the attendants is 93.3 patients per
day, while the maximum capacity of Lab is 56 patients per day; the MD maximum
capacity is 28 patients per day and the Exam Room Capacity is 112 patients per

lead time is 94 minutes for each patient who is also required to do a blood
test, whereas 79 minutes for a person who does not need to do the blood test. The
time between the initiation and completion of the check-in process is around 4 minutes,
the Vitals and ECG process averaged about 15 minutes per patient. The patient
has to wait for about 10 minutes to then be assigned in a room. After 5 minutes
the nurse took about 10 minutes to prepare the patient for examination and further
30 minutes on average were spent to provide a detailed examination of the
patient. If a patient was required to do a blood test, other 15 minutes were added
on the processing time, divided in 10 minutes of wait and 5 minutes to complete
the process. Finally, the check-out process averaged around 5 minutes.  

Looking at the daily capacity’s data
of each department of the Hospital, it is evident that the bottleneck in the system can be
found in the MD Capacity. Waits and delays are caused due to the insufficient
staff, which lead to interrupt the natural flow and hinders movement along the
care pathway.

 It can be argued that process type choice is strategic because it can
represent a large amount of capital investment in terms of equipment and workforce.
The process type used in the system is the service shop process, which operate
with a medium amount of variety and volume. It is characterised by having a
certain amount of customization of the service and a mix of staff and equipment
used to deliver the service. There is an emphasis both on the service delivery
process itself and any tangible items that are associated with the service.
Service shops can be distinguished by a high degree of customer involvement in
the process of generating the service. It may be subdivided into those that lie
on the professional service boundary relating to professional services. Professional
service processes operate with high variety and low volume. They are
characterized by high levels of customization in that each service delivery
will be tailored to meet individual customer needs.  This customization requires communication
between the service provider and customer and so professional services are
characterized by high levels of customer contact and a relatively high
proportion of staff supplying the service in relation to customers. The
emphasis here is on producing a service through personal attention to the

Lovelock (1992) developed an
alternative service process type classification: The Service Process Mix, based
on the degree of labour intensity against the degree of interaction and
customization. In this model, labour intensity refers to the ratio of labour
cost incurred in relation to the value of plants and equipment used to deliver
the service. The degree of interaction and customization refers to a joint
measure of the degree to which the customer interacts with the service process
and the degree to which the service is customized.

Professional services are defined
as having a high degree of both variables and include doctors; service shops
are defined as having high labour intensity and low interaction and includes
hospitals. (A. Greasley, 2013).

The layout type choice is linked to the process type
choice and so provides the context around which the operation performs across
its performance objectives. The layout concerns the physical placement of
resources such as equipment and storage facilities and is designed to
facilitate the efficient flow of customers or materials through the operations
system. Layout is important because it can have a significant effect on the
cost and efficiency of an operations and can entail substantial investment in
time and money.

Process Layout, also termed a
functional layout, is one in which resources which have similar processes or
functions are grouped together. Process layouts are used when there is a large
variety in the products or services being delivered and it may not be feasible
to dedicate facilities to each individual product or service. It allows the
products or customers to move to each group of resources in turn, based on
their individual requirements. One advantage is that they allow a wide variety
of routes that may be chosen by customers depending on their needs. Another
advantage is that the service range may be extended and, as long as no new
resources are required, may be accommodated within the current layout. However,
an issue related with process layouts is the management of the flow of services
between the resource groups. In addition, the transportation between process
group can be a significant factor in terms of transformation time and the
number of services involved and the fact that each service can follow an
individual route between the process groups makes it difficult to provide when
a particular product will be delivered or a service completed. This is because
at certain times the number of customers arriving at a particular process group
exceeds its capacity and so a queue might be formed until resources are
available. This behaviour can lead to long throughput time, which is the time
taken for a product or customer to progress through the layout. … the process
is characterized by six sequences: Check-in, Vital Measurement, RN Assessment,
MD Assessment and Check-out, with an optional phase of blood test. In addition,
there are 4 service categories: ATT, LT, , RN and MD, and there are more than
one server per each category.


Section 3: OM Methods

Before expanding the capacity of any
process, it is critical to ensure that existing resources are used efficiently
and effectively. The fundamental idea underlying the Theory of Constraints
(TOC) is to focus on bottleneck resources because increasing their output
increases the output of the entire process. Managers should minimize the idle
time lost at bottlenecks because jobs or customers are delayed at upstream
operations in the process. They should also minimize the time spent
unproductively for setup time, which is changing over from one service to
another. When a changeover is made at a bottleneck operation, the number of
units or customers processed before the next changeover should be large
compared to the number processed at less critical operations.

Optimised Production Technology
(OPT) is an operations control system based on the identification of
bottlenecks within the production process. According to Goldratt (1997), these
bottlenecks are “any resource whose capacity is less than or equal to the demand
placed on it”.  Analysing where the
bottleneck is helps an organisation to identify the area in which changes must
be made in order to improve the process. As described before, the bottleneck
in the system is the MDs Capacity and the best way to remove the bottleneck
would be complete the work shortly or addressing the work to the …

Furthermore, another method
useful to control the size of the queues at processes is the Input – output
control. The method measures the actual flow of work into a work centre and the
actual flow of work from that work station. The difference will result in the
amount of work-in-progress (WIP) at that process. By monitoring these figures
using input/output reports, capacity is adjusted in order to ensure queues do
not become too large and average actual lead time equals planned lead time as
closely as possible.

Six Sigma is
another OM method that can be considered in order to address the SPoCS’s
operations problems. It is a comprehensive and flexible system for achieving,
sustaining, and maximizing business success by minimizing defects and
variability in processes. Lean
Six Sigma is a mindset for solving specific problems surrounding the three
demons of quality: delay, defects and devotion (Arthur 2016). It is driven by a close understanding of customer
needs (Ritzman, L.P., et al. 2007). It
can be argued that it is easy to get a better hospital using a few key tools
from Six Sigma. …


Section 4: Methodology


The data given from the case
study shown that additional 2 hours are required to clear queues that had built
up during the day. Therefore, the service processed 36 patients per day
(28*9/7). It is important to remember that the service processed only the 65%
of desired clients and the other 35% took the assessment directly in the OR.

The actual patients per day,
without taking account of the commercial developments or recover of the people
who left the hospital, are 55. (36/0.65).


Section 4.1: Evaluation of the Queuing Theory

It may be useful to evaluate the
improvement in performances, increasing the number of Doctors from 2 to 4.
Results are summarized in the following table.


4 doctors

? = average users arrival rate



µ = average capacity



p = utilization


L = average users into the service


Lq = average users queing


W = average time in the service



Wq = average time in the queues




Having 4 doctors allows to align
the lab capacity with the MDs capacity, resulting on achieving the benefits in
terms of cost of service and increasing the utilisation rates of the subservices. Subsequently, an
evaluation of the benefits derived from the extension of the open hours of the
service will be discuss.

It can be argued that despite the
increase of resources, the utilization is very high and service delivery time
and queuing time are too high. In addition, the number of rooms seems
inadequate at this rate.

Based on observations we check
the model for 6 MD. Results are in the following table


6 doctors

? = average users arrival rate



µ = average capacity



p = utilization


L = average users into the service


Lq = average users queing


W = average time in the service



Wq = average time in the queues



The daily customers subject to operations are
55/0.44= 126. This number is relevant because if SPoCs will perform
efficiently, these can use the time to do operations rather than assessment and
they can do other operations in the recovered time. Therefore, x + y = 44% *
126     x = 35% ( x+ y) so x is 19.4 and
this number represent the assessments done in OR. If the assessments last half
of the operation it can be argued that 11 operations per day can be recovered,
therefore 44% * 11= 5 patient each lab. RN capacity is now equal to MD capacity.
It seems that an increase of the LT capacity from 56 to 84 p/day is needed.
Therefore, a third technician is needed but in this case space for lab and lab
equipment have to be verified. In general term, the solution consists to
uniform the capacity of various servers (ATTs, RNs, MDs) avoiding idling time
of the high designed and increasing the overall capacity attending the lowest
cost.  There is a trade-off between the
utilization, waiting queues and costs. It seems that a low utilisation leads to
low cost but the average users queuing is high. When utilisation is high, the
average of users queuing decreases but costs arise. OR
ONLY WRITE: With simple calculations, it is possible to show that with this
assumption the additional number of patients for the SPOCS is 5 per day.

Image 4: Queuing Theory



Patients wait for long time in the hospital before they are
attended to by the health personnel. It seems that this trend is increasing and
that it is a potential threat to healthcare services. Specialist, teaching and
general hospitals with large number of patients have cases where patients may
not be attended to on time while others may end up going home without receiving
medical attention. (Obulur and Eke 2016). The appointment queuing system
determines major utilization of resources and reduces patients waiting times in
the general outpatient department before consultation with the Registered
Nurses and Doctors. The term of “appointment” refer to the period
of time allocated in the schedule to a particular patient’s visit and “service
time” refer to the amount the physician actually spends with the patient (Mardiah
and Basri).

According to Collier and Evans (2007), queueing theory is the
analytical study of waiting lines. Long waiting queues are symptomatic of
inefficiency in hospital services. (QUEUING theory). Also, the use of queuing
analysis and simulation to enhance performance at various hospital departments
has been widely researched (Green, 2002), (Kim et al., 1999). This established
theory helps us to quantify the appropriate service capacity to meet the
patient demand, balancing system utilization and the patient’s wait time. It
considers four key factors that affect the patient’s wait time: average patient
demand, average service rate and the variation in both.  (PROQUESTDOCUMENTS 4.26)


Section 5: Process
Improvement Solution


It can be stated that
a good solution would be to extend the span of time in which the service is
open. For instance, delivering services not only from 9am to 4pm but from 6am
to 10pm with two shifts, using a different organisation of the personnel: on
the first shift, 6am to 2pm, 1 attendant, 2 nurses and 1 anaesthesiologist; on
the second shift (2pm to 10 pm) 1 attendant, 1 nurse and 1 anaesthesiologist
and the attendant for calls and general office work will keep working on daily
basis. This strategy allows to reduce drastically the number of patients per
hour and then avoid queuing for limited rooms available. A first step in this proposal could be
to extend timing on Saturday but the result wouldn’t be of the necessary
magnitude. The revamp available is only 20 % (6/5 = +20 % ) that doesn’t look
enough to address substantially the SPoCs problem. 

first modification to investigate is the possibility to shorten the cycle time
increasing the efficiency of the various server or using the resource that are
not fully utilized to support the job of the current bottlenecks. Looking at
the data of the problem it seems that the Assessment of MD could be made only
by them and they cannot be replaced by RN. Then the other possible area of
improvement consists in the modification of the worktime and opening time.
It is possible to conceive the
service opening 6.00am and closing at 10.00pm with the existing personnel in
two shifts. Unfortunately, this modification has the only benefit to reduce the
utilization of the exam rooms but being the bottlenecks the numbers of MD the
overall capacity would not be impacted.

also in the situation with the increased number of MD and LT the change of
shift doesn’t improve sensibly the quality of service. The quality is already
good with the labor on daily basis and utilization of the Exam rooms is not the
bottleneck also now.


Improve communication
between Surgeons department in order to plan better activities in SPoCs as poor
communication in surgeon assessment resulted in surgeon appointments made
without recourse to SPoCS availability. As a result, Hospitals
are usually adopting electronic medical
record (EMR) systems. EMR systems record all the information generated by
the health care facility and its patients in electronic form. The doctor uses a
tablet PC or a wireless PDS instead of a paper-based medical chart for each
patient. It allows to reduce costs, improve administrative efficiency as well
as clinical efficiency and partner care. (Collier and Evans 2007). However, it
is not always easy to adopt these systems and one challenge of the EMR involves
getting a large medical staff trained in the use of the EMR. (Alpert 2016). The
high cost of these systems is another disadvantage for hospitals.


The best solution would be to
increase the MRs working in the hospital from two to six. As discussed before,
the MRs daily capacity is not sufficient, compared to the other divisions, to
process the system. Two doctors are able only to 28.0 patients per day and

scheduling aims to ensure that available staff are deployed to maximise the
quality of service delivery to the customer. The amount of staff available need
to be determined by long-term and more strategic decisions taken on the amount
of staff required. This recommendation has various impact on stakeholders. In
terms of customers, their satisfaction will increase due to the decrease of the
times spent on queues. However, the utilisation will arise and therefore the
costs will increas