Emma Cho Juan De La Torre and Wilson MacRitchie Industrial amp Operations Engineering December 10 th 2021 The Team Emma Cho Juan De La Torre Wilson MacRitchie Industrial amp Operations Engineering ID: 912652
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Slide1
IOE 481 21F3:
Bone Marrow Biopsy Scheduling
Emma Cho, Juan De La Torre, and Wilson MacRitchie
Industrial & Operations Engineering
December 10
th
, 2021
Slide2The Team
Emma Cho
Juan De La Torre
Wilson MacRitchie
Industrial & Operations Engineering
Class of 2022
Industrial & Operations Engineering
Class of 2022
Industrial & Operations Engineering
Class of 2022
2
Insert Headshot
Slide3Clients & Coordinators
Jonathan Lee,
Continuous Improvement Specialist at Michigan Medicine
Kevin Noble,
Continuous Improvement Coach at Michigan Medicine
Mary Duck,
Senior Administrative Manager, Continuous Improvement
David Hyatt,
Intermittent Lecturer, Industrial & Operations Engineering
Michigan Medicine: Coordinators
Michigan Medicine: Client
D
r. Dan Boyer
, Clinical Associate Professor, Department of Pathology at Michigan Medicine
Emily Schwedler
, Administrative Manager, Department of Pathology at Michigan Medicine
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Slide4Agenda
Wilson MacRitchie
Project Background
1
Data Analysis/Findings
2
Deliverables
3
Recommendations
5
Alternatives Considered
4
Next Steps
6
4
Slide5Data Analysis & Findings
Deliverables
Alternatives Considered
RecommendationsNext Steps
Project Background
1. Project Background
Slide6Relevant Parties
Adult Myeloma Clinic
Adult Bone Marrow Transplant
Pediatric Leukemia Group
There are three main clinics (“The Clinics”) at Michigan Medicine which schedule bone marrow biopsies with The Lab
Hematopathology Lab
Bone Marrow Biopsies
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Slide7Illustrative Process Flow Chart
Results Sent to Clinic
Results of Hematopathology Lab work returned to Clinic
The Clinics have an independent internal scheduling process, which The Lab is not a part of. This leads to avoidable difficulties for The Lab when managing unpredictable demand.
Clinic Requires a Biopsy
Adult Myeloma Clinic
Adult Bone Marrow Transplant
Pediatric Leukemia Group
Procedure Components Ordered in MiChart
Procedure Occurs
In location scheduled by the individual clinic
The Lab Tests Sample
Bone Marrow samples brought to Hematopathology Lab for testing
Clinic Calls The Lab
To inform them when & where procedure is taking place
Typically, a day in advance
Clinic Schedules OR for Procedure
Internal process varies by clinic
Pediatric: Occur in C.S. Motts
Adult: Use OR scheduling system
The Lab plans for Biopsy
Lab organizes resources, staffing, and scheduling for procedure
Box indicates areas the 481 team has identified for the most improvement
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Sample Transported
Sample transported to NCRC on Bus
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2
3
6
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4
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8
9
Clinic internally schedules a procedure
Slide8Process Swim Lane Diagram
8
Patient
Clinics
Lab Tech
NCRC
Determined that a patient requires a Bone Marrow Biopsy
Determined that a patient requires a Bone Marrow Biopsy
Clinic schedules an appointment which works for the patient & Clinic Proceduralists
Clinic internally records/schedules procedure in MiChart
Lab Tech’s have access to new procedures in MiChart
Once the Lab Tech’s see the new procedure, they will record it in their internal excel tracker
Patient is at hospital. BMBX may not be the only procedure they are scheduled for
Patient is Prepped for procedure
Call Lab Tech’s to inform them that the patient is ready for BMBX
Available Lab Tech brings supplies to Procedure Room
Procedure Occurs
Procedure Occurs
Procedure Occurs
Sample returned to Lab & Processed to be sent to NCRC
Sample delivered to NCRC transportation bin
Sample driven to NCRC
NCRC receives sample and begins necessary testing
Prior to Procedure
Procedure
Following Procedure
Note:
For Pediatric Clinics, the highlighted steps do not occur
Slide9Project Background
9
Standardize and improve the lead time
Increase procedures performed before 12pm each day
Procedures will be spread out uniformly throughout the week
Desired Impact
Optimize the lab’s bone marrow biopsy scheduling
Develop a system to facilitate communication between the parties
Improve bone marrow biopsy turnaround and lead times
Goals
Lack of coordination between the relevant parties when scheduling
Inconsistent lead times for results
Staffing constraints created by biopsy procedure clustering
Current Issues
Slide10Strategic Plan Development
10
Finalize Project
Brainstorm & Solution Development
Analyzed System
Defining Issues & Fact Finding
Planning approach and developing project proposal
Interviews with Client and hospital staff
In-person observation
Data Analysis of Hospital Records
Literature Search
Discussing Scheduling Tool Improvements
Team meetings to develop solution ideas
Discussing potential solutions with clients
Conduct further research and interviews regarding potential solutions
Finalized Deliverables
Finalized recommendations & planning implementations
Developed Final Report & Presentation& Recommendations
September – October
October
November
November – December
Slide11Data Analysis & Findings
Deliverables
Alternatives Considered
RecommendationsNext Steps
Project Background
2. Data Analysis & Findings
Slide12Data Collection Methods
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Interviews with Supervisors
Hospital Records
In-Person Hospital Observation
VBA Scheduling Sheets
Clinic Survey
Literature Search
Slide13Survey Results Analysis
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Notes: n=9 respondents
Slide14Survey Results Analysis
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Notes: n=9 respondents
Slide15Survey Results Analysis
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Notes: n=9 respondents
Slide16Survey Results Analysis
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Notes: n=9 respondents
Slide17Survey Results Analysis
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Notes: n=9 respondents
Slide18Data Analysis
Results
Distribution of Procedures Throughout the Week
Distribution of Procedures Throughout the Day
Distribution of Procedures by Clinic
Historical Procedure Duration
Historical Procedure Deviation from Schedule Time
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Slide19Data Analysis Findings
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The majority of the historical procedures analyzed were part of the Adult Hematology/Oncology Group however there were still statistically enough procedures in the remaining groups to draw accurate conclusions.
Notes: n=1,464 procedures; Analysis time frame: 1/4/2021 – 10/14/2021
Slide20Data Analysis Findings
20
The end of the week has a heavier procedure volume which is not ideal as this can cause procedures to pile up, and ultimately work at the NCRC to overflow into the weekend where there is lower staffing.
Notes: n=1,782 procedures; Analysis time frame: 1/4/2021 – 10/14/2021
Slide21Data Analysis Findings
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54.9% of procedures have occurred before 12PM, leaving a significant number of procedures in the afternoon. The ideal distribution would be for almost all procedures to occur before 12PM (~25% each hour between 8 AM and 12PM).
Notes: n=1,450 procedures; Analysis time frame: 1/4/2021 – 10/14/2021
Slide22Data Analysis Findings
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Adult BMT has the lowest percentage of procedures after 1PM (9.5%) and the two In Patient Clinics, In Patient Hematology/Oncology (71.6%) and Adult In Patient Hematology/Oncology (61.1%), have the highest percentage of procedures after 1PM.
Notes: n=1,450 procedures; Analysis time frame: 1/4/2021 – 10/14/2021
Slide23Data Analysis Findings
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61.1% of procedures are between 50-80 minutes. This is a critical statistic for designing a solution to determine how much time to block off for a given procedure on the schedule.
Notes: n=1,435 procedures; Analysis time frame: 1/4/2021 – 10/14/2021
Slide24Data Analysis Findings
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Although the majority of procedures occur within a 15-minute window of their originally scheduled time, there are significant outliers which cause disruptions in the daily schedule (best mitigated by a resilient and spaced-out schedule).
Notes: n=1,411 procedures; Analysis time frame: 1/4/2021 – 10/14/2021
Slide25Data Analysis & Findings
Deliverables
Alternatives Considered
RecommendationsNext Steps
Project Background
3. Deliverables
Slide26Deliverables
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Microsoft Outlook Solution Demo
Improved Microsoft Excel Scheduling Workbook
Historical Data Analysis & Visualization
Overview of Current Scheduling System
Slide27Excel Tool – Data Log
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The Team preserved the current attributes used by the Hematology Lab as well as added the ‘Expected Duration’, ‘Additional Notes’ and ‘Procedure Cancelled’ features for the Data Log.
Slide28Excel Tool – Procedure Additions, Modifications & Cancellations
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The team created two versions of the document, one with VBA and one without for the client to select based on preferences/desire to use VBA. The main difference is the inclusion of Userforms to Add/Edit/Cancel Procedures versus manually editing or appending entries for schedule changes.
Slide29Excel Tool – Calendar Output View
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All the upcoming procedures are consolidated and summarized (through backend calculations) into a calendar output view for easy synthesis.
Promote scheduling new procedures before 12 PM
Slide30Excel Tool – NCRC Expected Sample Arrivals
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The tool can forecast expected sample arrival times at the NCRC to assist with workflow and planning, as well as summarize a single day of procedures & relevant accompanying data.
Slide31Excel Tool – Brief ‘Under the Hood’ Explanation
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There is a significant amount of work done ‘under the hood’ to drive the simple calendar view output.
Every procedure is assigned a unique Date Key based on its scheduled date and procedure time in the day (early to late)
There are seven ‘Date Mapping’ (Data_Log – Date_<#>) tabs to pulling the first 100 procedures on a given date (historically less than 20 per day), used to create full week in the calendar output
There are seven “Daily Mapping’ (Mapping_<#>) tabs used to generate the calendar output view for each day
In each ‘Daily Mapping’ Tab, the procedures need to be assigned a starting time & ending time based on either their scheduled time, or when the procedure began, and the expected duration (ignore cancelled procedures)
All times need to be assigned to the nearest 15 minutes to allow for equality & mapping to the output calendar
Simply stated:
There are 10 procedure slots at a given time of day (three Lab Techs and seven Overbookings)
If a lab tech is available at any point in the day, they should look for a procedure starting at that time of day to assign themselves too
Tie breaker in case there are multiple lab techs available to select a certain procedure
Tie breaker to select a procedure if multiple procedures start at the same time
If a Worker (Lab Tech or Overbooked) picked up a procedure, they are busy until the procedure is completed
Once the procedure completes the Worker is immediately freed and able to pickup more procedures
Rather than replicating each tab multiple times – get it right with one tab
Use a simple naming convention for each tab
Make a copy of the tab (don’t change a singly thing other than reference date)
Use ‘Replace All’ to change correct formulas to reference new tabs
Hide all tabs with driving calculations – simplify it down to a small amount of input assumptions
Slide32Outlook for Michigan Medicine
Individual calendars for each department, lab tech, provider
Overlay calendars to see availability across the board
Request and schedule procedures based off availability -> better distribution of procedure volume
Simple interface
Easy sharing between teams
Instant communication
Automatic updates after editing
No editing interference
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Slide33Illustrative Weekly Schedule
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Slide34Overlay Mode
View multiple calendars at once
Overlay to see availability across different calendars
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Slide35Data Analysis & Findings
Deliverables
Alternatives Considered
RecommendationsNext Steps
Project Background
4. Alternatives Considered
Slide36Potential Solutions Considered
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Excel Tool with VBA
Excel Tool w/o VBA
Microsoft Outlook
Excel & Outlook in Tandem
MiChart System Upgrades
Team developed Excel Scheduling Tool with VBA functionality included
Team developed Excel Scheduling Tool
Manage BMBX scheduling through outlook by creating a central hematology lab schedule shared with all clinic schedulers. Proceduralist schedules can be overlayed with Hem Lab as well
Combination of Excel Tool and Outlook scheduling system to capture features of both solutions
Work with MiChart development team to request system upgrades to include desired scheduling features
Slide37Analysis - Excel Tool with VBA
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Utilization & Implementation
Master document ‘owned’ by the Hematology Lab but shared with clinic schedulers
Used to Add/Edit/Cancel procedures
Consulted when adding or changing dates/times of procedures
Benefits
Creates visibility into the Hematology Lab’s schedules for clinics
Generates master list of all procedures
Data friendly for future analysis
Limited backend VBA Code
Supports proper data entry to facilitate schedule visualization
Schedule Visualization feature to assist with planning for new procedures
Excel allows for future customization & addition of more live analysis / tracking tools
Can add instructions / visual features to incentivize scheduling procedures in the morning
Limitations
Less user friendly than Microsoft Outlook
Need to toggle between tabs to visualize
Difficulty in portraying all relevant procedure information on the schedule visualization
Does not directly promote communication between Hematology Lab & Clinics
Presence of VBA and Excel calculations has a potential risk of future maintenance needs
Summary:
Helpful tool to manage and schedule upcoming procedures. Will require scheduler training and buy in to transition to this system. Does not directly promote communication between labs and Clinics.
Score:
2.1
Slide38Analysis - Excel Tool w/o VBA
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Utilization & Implementation
Master document ‘owned’ by the Hematology Lab but shared with clinic schedulers
Used to Add/Edit/Cancel procedures
Consulted when adding or changing dates/times of procedures
Benefits
Creates visibility into the Hematology Lab’s schedules for clinics
Generates master list of all procedures
Data friendly for future analysis
Limited backend VBA Code
Supports proper data entry to facilitate schedule visualization
Schedule Visualization feature to assist with planning for new procedures
Excel allows for future customization & addition of more live analysis / tracking tools
Can add instructions / visual features to incentivize scheduling procedures in the morning
Limitations
Less user friendly than Microsoft Outlook
Need to toggle between tabs to visualize
Difficulty in portraying all relevant procedure information on the schedule visualization
Does not directly promote communication between Hematology Lab & Clinics
Presence of VBA and Excel calculations has a potential risk of future maintenance needs
Summary:
Helpful tool to manage and schedule upcoming procedures. Will require additional scheduler training and buy in to transition to this system. Does not directly promote communication between labs and Clinics.
Score:
2.1
Slide39Analysis – Microsoft Outlook
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Utilization & Implementation
Central Outlook account for the Hematology Lab BMBX procedures shared with all Clinic Schedulers
To Add/Edit/Cancel procedures, schedulers will send a request to the Lab Calendar for the new procedure
Clinic Schedulers can overlay various calendars to find open availabilities when scheduling new procedures
Benefits
Creates visibility into the Hematology Lab’s schedules for clinics
Leverages Outlook’s built-in, user-friendly calendar management features
Enables communication as Lab will see who is scheduling which procedures (establishes a point of contact)
Lab has increased input on procedures with the ability to Accept/Cancel procedures (call point of contact to resolve issues)
Limitations
Limited ability to track historical procedures to capture data
Proceduralist schedules need to be maintained on Outlook for the most convenient schedule comparison (overlay), otherwise schedulers will need to cross-reference multiple schedules
Difficult to incentivize schedulers to schedule new procedures in the morning / the optimal times for the Hematology Lab’s workflow
Summary:
Very effective at managing the schedule & facilitating communication between Clinics & Hematology Lab but requires updated Proceduralist schedules. Difficult to log & track historical procedure data.
Score:
3.2
Slide40Analysis – Excel Tool & Outlook
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Utilization & Implementation
Master Excel document ‘owned’ by the hematology lab to be used for internal procedure tracking
Outlook calendar shared between clinics to be used for calendar additions and to enable communication channels
Benefits
Visibility into the Hematology Lab’s schedules for clinics
Master list of all procedures
Data friendly for future analysis
Excel allows for future customization & addition of live analysis/tracking
Leverages Outlook’s built-in, user-friendly calendar management features
Enables communication as Lab will see who is scheduling which procedures (establishes a point of contact)
Lab has increased input on procedures with the ability to Accept/Cancel procedures (call point of contact to resolve issues)
Limitations
Proceduralist schedules need to be maintained on Outlook for the most convenient schedule comparison (overlay), otherwise schedulers will need to cross-reference multiple schedules
Presence of VBA and Excel calculations has a potential risk of future maintenance needs
Summary:
Commination of Excel Tool & Outlook Solution which leverages strengths of each system. If system is followed correctly the team believes this will be a very effective solution at addressing design objectives.
Score:
3.6
Slide41Analysis – MiChart Upgrades
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Utilization & Implementation
All clinics would use MiChart to schedule and manage upcoming procedures
Hematology Lab could work with the MiChart development team to request desired features be implemented into MiChart
Each Clinics could see all procedures from all Clinics when adding/editing procedures, and hematology lab would have all procedures complied into one place
Benefits
Creates visibility into the Hematology Lab’s schedules for clinics
Generates master list of all procedures
MiChart development team may be able to show recommended procedures, which focuses on optimizing the schedule based on project design goals and proceduralist availabilities
Limitations
MiChart team has significant queue of other requests for system upgrades
Implementation delay and uncertainty for the quality of interface the development team would create
Would not facilitate more communication between the Clinics & the Hematology Lab
Summary:
Potential to address the design objectives, however there is significant uncertainty to the timing for upgrades and ability of a new system that would be implemented to address design objectives.
Score:
2.2
Slide42Pugh Decision Matrix
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Biopsy Scheduling Procedure
Alternatives
Criteria
Weighting
Current State
Excel Scheduling Tool w/VBA
Excel Scheduling Tool w/o VBA
Microsoft Outlook
Excel Tool & Outlook
MiChart System Upgrades
(1) The Lab's Usability & Convenience
20%
1.0
4.0
4.0
3.0
5.0
3.0
(2) Ability to Display the Lab's Scheduling Preferences
30%
1.0
2.0
2.0
3.0
3.0
3.0
(3) Level of Communication Facilitated
30%
1.0
2.0
2.0
5.0
5.0
1.0
(4) Ease of Clinic Adaptation
20%
1.0
0.5
0.5
1.0
1.0
2.0
Totals
100%
1.0
2.1
2.1
3.2
3.6
2.2
(1) Lab’s Usability & Convenience
User friendly solution
No duplicative work
Ability to convey/visualize upcoming procedures
(2) Display Lab’s Scheduling Preferences
Incentivize procedures in morning
Limit procedure clustering
Spread procedures throughout day & week
(3) Facilitate Communication
Built in conflict resolution
Establish scheduling point of contacts
Display to each clinic the Lab’s commitments across all clinics
(4) Ease of Clinic Adaptation
Minimize disruption to clinic’s current process
Limit duplicative work
Solution which benefits Clinics as well as Lab
Based on the evaluation criteria the team decided upon below, the team concludes that the Excel Tool & Outlook used in Tandem will best accomplish the project design objectives
Criteria Explanations
Slide43Consideration of Impact & Effort
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Represents best performing solution (recommended solution)
Taking the level of effort to implement each design solution into account, the combination of the Excel Tool & Outlook is again the best solution for the design objectives.
Slide44Data Analysis & Findings
Deliverables
Alternatives Considered
RecommendationsNext Steps
Project Background
5. Recommendations
Slide45Recommended Solution
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Displays upcoming biopsy procedures for Clinics to consult when scheduling new procedures
Overlay multiple schedules so availability can be compared across multiple parties
Leverages Outlooks calendar management features & stablishes points of contact for communication channels
The Team recommends a system using a combination of the Excel Scheduling Tool for internal procedure tracking and Microsoft Outlook for external calendar management and scheduling with the clinics.
Excel Scheduling & Tracking Tool
Outlook – Master Shared Calendar
Hematology
Lab ‘owned’ document used to track and analyze upcoming procedures
Maintains master log of historical procedures and key data
SharePoint file sharing enables live collaboration between multiple users
Slide46Process Flow of New System
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Clinic Requires BMBX
Schedules Procedure through Outlook
Selects schedules for proper proceduralist(s) for the procedure, and the compiled Hematology Lab BMBX schedule
If the procedure needs to be on a certain day, the scheduler will find the earliest time which works for the Patient, Proceduralist & Hematology Lab
If the procedure can occur in a small window of days, scheduler selects earliest time in window which works for Patient, Proceduralist & Hematology Lab
Hematology Lab Receives Invite for new Procedure
Likely, almost all the time the requested invite will work for The Hematology Lab, if there is a conflict the Lab knows who exactly scheduled the procedure and can reach out ASAP to gauge the flexibility
Lab Accepts Calendar Invite & Logs in Excel
Procedure Changes Time/Date or is Cancelled
Procedure Occurs – Clinic Contacts Hematology Lab
Hematology Lab inputs the procedure information for the newly schedule appointment into the Excel Scheduling Tool for internal tracking
Clinic can simply adjust the original calendar appointment with the new data or time, or delete the appointment
When adjusting time/date, the Clinic again has access to the full availabilities of the Proceduralist & Lab
Hematology Lab will receive an instant update on the change (and again has a point of contact if there is a conflict)
With Outlook utilized, the Lab has a much more accurate sense of when the procedure will occur as there is less friction at the Clinics for adjusting the Outlook appointment with time updates (reduces amount of phone calls with status updates)
Clinic will call Lab Techs to inform them of the procedure starting (conscious of when the Lab Techs have other procedures to attend to)
Lab Tech Records New Post Procedure info in Excel
After the procedure occurs, the Lab Tech records the same info as they currently do into the Excel Document
The NCRC and anyone else who wants to view the document has live access to any updates in the document
Updates on Peripheral Blood
NCRC has live access to any status updates on certain patient peripheral blood tests if needed
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3
6
5
4
1
7
8
Slide47Combined Solution Expected Impact
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Design Requirements:
Reduce level of procedure clustering
Spread out the distribution of procedures throughout the week
Maximize the number of procedures before noon
Minimize the turnaround time between completion & returning laboratory results
Solution Improvement
Impact on Design Requirements
I. Clustering
II. Distribution
III. Before Noon
IV. Turnaround Time
Communication Facilitated between Lab & Clinics
Conflict resolution
Lab has point of contact
Ability to express preferences
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Clinic Visibility into the Lab’s Schedule
Improved original scheduling times
Improved original scheduling times
Select best dates where possible
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Standardized Scheduling Process Across Clinics (no cross-referencing)
Reduced friction to modify procedures & notify Lab
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Streamlined process, increasing visibility
Live Tracking of Future Procedures with Greater Advanced Notice
Foresight enables preparation
Foresight enables preparation
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Improved workflow with accurate understanding of demand
Holistic Solution
Slide48Data Analysis & Findings
Deliverables
Alternatives Considered
RecommendationsNext Steps
Project Background
6. Next Steps
Slide49Future Work & Next Steps
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Meetings with schedulers & decision makers at each clinic to encourage buy in for the new scheduling system
Ability to use materials / work from this project to share with Clinics
Share the importance and burden the current scheduling system has on the Hematology Lab and how the new system can alleviate these issues without disrupting the Clinics
Encourage Clinic Buy In
Solution Implementation
Implementation of the solution with each of the Clinics and internally at the Hematology Lab
Training Clinic Schedulers with the Excel & Outlook ‘How to Use’ guides created and shared by the team
Begin use of SharePoint for file sharing and collaboration as UofM switches to the new system
Slide50User Guides
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The team created two comprehensive ‘How to Use’ guides for both the Excel Scheduling Tool & Outlook calendar system to assist with solution implementation and scheduler training.
Outlook Calendar System Overview
Slide51Thank You
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