Emergency department (ED) overcrowding has been a common complaint in Emergency Medicine in Canada for many years. Its adverse effects of prolonged waiting times cause patient dissatisfaction and unsafety. Previous studies indicate that adding a physician in triage (PIT) can increase accuracy and efficiency in the initial process of patient evaluation. However, the scientific evidence of the PIT impact on ED is far away from sufficient before its widespread implementation. This research is to search solutions using PIT to identify areas of improvement for the ED patient flow, based upon a validated discrete-event simulation (DES) model. As an efficient decision-making tool, the DES model also helps to develop an understanding of the current ED performance and quantitatively test various design alternatives for ED operations. / February 2017

Aim: The aim of this study was to describe what nurses experienced in connection with waiting time related frustration among patients and relatives in the emergency department and also what strategies nurses use to manage waiting time related frustration.Background: The numbers of emergency department visits are increasing and lead to waiting times which can cause frustration among patients and relatives, a frustration that nurses encounter in their everyday work and need strategies to deal with.Methods: This is a descriptive qualitative study. Interviews are conducted with five nurses, transcribed and analyzed by qualitative content analysis.Findings: The nurses feel inadequate and powerless when they meet patients and relatives frustration. In order to deal with patients and relatives frustration, they use the strategy of participation, which implies to involve and meet patients and relatives needs for information and to be seen. In order to prevent themselves becoming frustrated they use adaptability, by creating an inner calm, not take it personally and to distance themselves from the frustration.Conclusion: The result highlights the importance of managing the activity to reduce waiting time related frustration, for example through reflection and working for reducing waiting times. Further research is also needed. / Program: Magisterprogram i vårdvetenskap med inriktning mot akutsjukvård

<p>The pressure is getting tougher on Accident and Emergency departments. Therefore it is crucial to study how the patient’s perceive their visit to the Emergency department. Knowledge about this enables improvement of routines, patient participation and patient safety. The purpose of the study was to investigate patient’s experiences of their visit at the Emergency department.</p><p>A descriptive design was used. Patients (n=91) who visited the Emergency department at Uppsala University Hospital during two weeks in October 2009, answered a questionnaire. The questionnaire consisted of 13 questions about the visit, waiting time and information.</p><p>The result showed that most of the patients found that the waiting time was acceptable and they perceived that the staff was competent and professional. On the other hand most patients perceived that they did not receive enough information of the prioritization of the patients in the Emergency department and information about expected waiting time.</p><p>The study result shows that one part of the patient didn´t get information about expecting waiting time and the order of priority and the conclusion was that the study shows that the majority of the patients perceived their Emergency department visit as positive.</p>

<p><em>Syfte:</em> Utvärdering av hur patienter upplever den förbokade återbesökstiden, väntetiden samt personalens bemötande vid återbesöket. Syftet är även att undersöka hur personal på ortopedens nyinrättade ”snabbmottagningen” vid AS upplever stress, patientflöde samt telefonförfrågningarna, efter införandet enligt Lean-modellen</p><p><strong></strong><em>Metod:</em> Deskriptiv kvantitativ enkätstudie. Slumpmässigt urval utfördes på patienter och av hundra procent (n=55) tillfrågade, deltog fyrtionio procent (n=27). Av hundra procent tillfrågad personal (n=14), deltog sextiofyra procent (n=9). Urvalet utförde avdelningschefen.</p><p><strong></strong><em>Resultat<strong>:</strong></em> Utvärderingen av patienternas upplevelser av planerad återbesökstid, bemötande och väntetid på snabbmottagningen var generellt mycket bra. Personal på ortopedmottagningens snabbmottagning upplevde ingen större förändring efter införandet enligt Lean-modellen.</p><p><strong></strong><em>Slutsats:</em> Resultatet visar att patienterna upplevde den planerade återbesökstiden generellt mycket bra. Personalens upplevde inte att arbetet förändrats. Fler och större studier behövs för att utvärdera organisationsförändringar som initierats av Lean-modellen.</p> / <p><em>Aim:</em> Evaluation of paitents’ experiences of the prebooked time for next appointment, the waiting time and the staff’s treatment at the next appointment. The aim is also to examine how the staff at the newly established orthopedic “quickreception” at the Uppsala University hospital experience stress, patientflow and the telephonerequests, after the introduction according to the Lean-model.</p><p><em>Method</em>: Descriptive quantitative inquirystudy. Patients were selected randomly and out of one hundred percent (n=55) who were asked, fortynine percent (n=27) participated. Out of one hundred percent (n=14) of the staff asked, sixtyfour percent (n=9) participated. The selection was made by the head of the ward.</p><p><em>Results</em>: Evaluation of the patients’ experiences of the planned time for next appointment, treatment and waiting time at the “quickreception” was generally very good. The staff at the orthopedic “quickreception” did not experience a big change after the introduction according to the Lean-model.</p><p><em>Conclusion:</em> The results show that the patients experienced the planned time for next appointment generally very good. The staff did not experience that the work had changed. More and larger studies are needed to evaluate changes of organisations that were initiated by the Lean-model.</p>

The pressure is getting tougher on Accident and Emergency departments. Therefore it is crucial to study how the patient’s perceive their visit to the Emergency department. Knowledge about this enables improvement of routines, patient participation and patient safety. The purpose of the study was to investigate patient’s experiences of their visit at the Emergency department. A descriptive design was used. Patients (n=91) who visited the Emergency department at Uppsala University Hospital during two weeks in October 2009, answered a questionnaire. The questionnaire consisted of 13 questions about the visit, waiting time and information. The result showed that most of the patients found that the waiting time was acceptable and they perceived that the staff was competent and professional. On the other hand most patients perceived that they did not receive enough information of the prioritization of the patients in the Emergency department and information about expected waiting time. The study result shows that one part of the patient didn´t get information about expecting waiting time and the order of priority and the conclusion was that the study shows that the majority of the patients perceived their Emergency department visit as positive.

The problem of overcrowding is one of the serious issues that almost every emergency department (ED) in Taiwan has to face on daily basis. ED crowding results in adverse medical outcomes, decline in quality of care, and lack of the ability to provide instant medical care. One of the viable (but not necessarily preferable) solutions to ED overcrowding is ambulance diversion (AD). That is, ambulances would bypass the ED¡¦s unable to provide emergency medical service, and send patients to another emergency department. In many medical systems, ambulance diversion is being seen as a standard operating procedure, whose effectiveness needs to be carefully studied before making a sound policy. In this research, an input-throughput-output simulation model is proposed for simulating ED operation. A computer simulation program is developed based on this model to evaluate various AD initiating criteria, patient-blocking rules, and AD intervals. The crowdedness index, the patient waiting time for service, and the percentage of adverse patients were assessed to determine the impact of various AD policies. By appropriate parameter settings, this simulation model can represent medical resource providers of different scales. The results we obtained may offer insights for making effective AD policies.

Today great efforts are made to record and reduce waiting times in cancer care. Long and variable turnaround times (TATs) delay the start of treatment and waiting contributes to mental anguish. The purposes of the QI intervention were to establish an effective and streamlined histopathology process with shorter TATs, to extend customer collaboration and to build knowledge of internal processes in order to lay the foundation for a learning environment. The goal was to raise the proportion of reported tissue samples from 50% to 90% within a 15 day period, ending 31th December 2014. The study of the QI intervention intended to identify factors that affect the introduction of novel working methods. Both quantitative and qualitative methods were used to achieve the goals. Improvement knowledge was combined with lean-inspired methods, and two focus groups were arranged in which data were analysed using qualitative content analysis. The goal to report 90% of tissue samples within 15 days was not achieved for all sample types, but improved TATs were clearly noted. Customer collaboration and visualisation of the processes had a positive effect on staff. The study resulted in six key factors important working with QI interventions; competence, compliance, feedback, interaction, patient- and customer focus and resources. Having motivated and dedicated staff is a key success factor for improvement work, in contrast to a lack of resources, and people that oppose change. To achieve future ambitious goals requires continuous improvement initiatives that involve optimisation of both human resources and equipment. / Stort fokus riktas idag på att kartlägga och reducera väntetider inom cancervården. För långa och variabla svarstider fördröjer behandlingsstart och väntan innebär dessutom psykiskt lidande. Syftet med förbättringsarbetet var att etablera en effektiv och stabil patologiprocess med kortare svarstider, utöka kundsamverkan samt bygga kunskap om interna processer för att lägga grunden till en lärandemiljö. Målet var att senast den 31 december 2014 höja andelen besvarade vävnadsprover från 50 % till 90 % inom 15 dagar. Studien av förbättringsarbetet syftade till att identifiera faktorer som påverkar införandet av nya arbetssätt. Såväl kvantitativa som kvalitativa metoder användes för att uppnå målen; förbättringskunskap kombinerades med lean-inspirerade metoder och två fokusgrupper där data analyserades med kvalitativ innehållsanalys. Målet att höja andelen vävnadsprover som besvarades inom 15 dagar på 90 % uppnåddes inte för samtliga provtyper, men tydligt förbättrade svarstider noterades. Kundsamverkan och visualisering av processerna hade en positiv effekt på personalen. Studien resulterade i sex viktiga faktorer; kompetens, inställning, återkoppling/feedback, interaktion, patient- och kundfokus och resurser. Motiverad och engagerad personal är nyckelframgångsfaktorer i förbättringsarbeten i motsats till resursbrist och människor som motsätter sig förändring. För att på sikt uppnå högt uppsatta mål krävs fortsatta förbättringsinitiativ som involverar optimering av både personalresurser och instrumentering.

Hospital ambulatory patients are seen in outpatient departments (OPDs) located in the hospital. 83.3 million visits were made to these departments in 2002. Many sources of patient waiting time exist including: poor coordination of information, inefficient scheduling, inaccurate time estimation and others. Well-designed and executed patient scheduling has the potential to remedy some of these problems. To properly schedule patients, variability in demand must be addressed. Patients may cancel appointments, arrive late and arrive without appointments. We address this problem based on a Multi-attribute Decision Making (MADM) approach. Decision models are developed using the Simple Additive Weighting (SAW) method to address scheduling decisions for late-arrival and walk-in patients and the operational decision of calling back patients from the waiting room.The models are developed as part of a case study at H. Lee Moffitt Cancer Center and tested in a single-clinic computer simulation against the current clinic system decision process with respect to various performance measures.The proposed decision models successfully made walk-in and late patient scheduling decisions. The contributions of this research include identifying, defining and weighting of relevant decision making criteria at H. Lee Moffitt. Our decision models guaranteed all of the defined criteria are included every time a walk-in or late patient decision must be made. Based on the findings, implementation of the models with no reduction in number of patients would improve scheduling and operational decisions while not affecting clinic output measures.Using criteria to restrict the number of late and walk-in patients, on average, the clinic closed between 36.20 minutes and 47.95 minutes earlier. However, practitioner and room utilization suffered. The tradeoff among number of patients seen, resource utilization, waiting time and clinic close time should be considered but cannot be fully assessed solely on the information gathered in this research. As a case study of H. Lee Moffitt Cancer Center, the decision models successfully incorporated all relevant patient criteria without adversely affecting the clinic system. Future research is needed to better understand what factors will impact system measures and expand the decision models to other outpatient clinic settings.

Syfte: Utvärdering av hur patienter upplever den förbokade återbesökstiden, väntetiden samt personalens bemötande vid återbesöket. Syftet är även att undersöka hur personal på ortopedens nyinrättade ”snabbmottagningen” vid AS upplever stress, patientflöde samt telefonförfrågningarna, efter införandet enligt Lean-modellen Metod: Deskriptiv kvantitativ enkätstudie. Slumpmässigt urval utfördes på patienter och av hundra procent (n=55) tillfrågade, deltog fyrtionio procent (n=27). Av hundra procent tillfrågad personal (n=14), deltog sextiofyra procent (n=9). Urvalet utförde avdelningschefen. Resultat: Utvärderingen av patienternas upplevelser av planerad återbesökstid, bemötande och väntetid på snabbmottagningen var generellt mycket bra. Personal på ortopedmottagningens snabbmottagning upplevde ingen större förändring efter införandet enligt Lean-modellen. Slutsats: Resultatet visar att patienterna upplevde den planerade återbesökstiden generellt mycket bra. Personalens upplevde inte att arbetet förändrats. Fler och större studier behövs för att utvärdera organisationsförändringar som initierats av Lean-modellen. / Aim: Evaluation of paitents’ experiences of the prebooked time for next appointment, the waiting time and the staff’s treatment at the next appointment. The aim is also to examine how the staff at the newly established orthopedic “quickreception” at the Uppsala University hospital experience stress, patientflow and the telephonerequests, after the introduction according to the Lean-model. Method: Descriptive quantitative inquirystudy. Patients were selected randomly and out of one hundred percent (n=55) who were asked, fortynine percent (n=27) participated. Out of one hundred percent (n=14) of the staff asked, sixtyfour percent (n=9) participated. The selection was made by the head of the ward. Results: Evaluation of the patients’ experiences of the planned time for next appointment, treatment and waiting time at the “quickreception” was generally very good. The staff at the orthopedic “quickreception” did not experience a big change after the introduction according to the Lean-model. Conclusion: The results show that the patients experienced the planned time for next appointment generally very good. The staff did not experience that the work had changed. More and larger studies are needed to evaluate changes of organisations that were initiated by the Lean-model.

In our daily life, we often experience waiting in a queue to receive some kind of service. Some customers do not join the queue at the end like other normal customers, and try to cut in the queue hoping to have a shorter waiting time and a higher level of satisfaction. This behaviour is called customer interjection. Some of these customers only try to cut in queue, while some others try to find excuses for interjection. For instance, the first-come-first-served (FCFS) service discipline is usually assumed in public places like restaurants, banks, airports, and supermarkets. However, customer interjections can still be seen in these places. In telecommunications networks, to test the efficiency of transmission, artificial packages are inserted into the normal traffic in a random manner. These interjections can affect the waiting time of other customers in queue. Such interjections may reduce the waiting time of interjecting customers, but increase the waiting time and dissatisfaction of others. In this work, an M/M/1 queueing system with customer interjection is investigated. The arrival of customers to the system is assumed to be a Poisson process with arrival rate . The service times for customers are independent and identically distributed random variables with an exponential distribution with rate . Customers are dispersed into normal customers and interjecting customers. A normal customer joins the queue at the end, and an interjecting customer tries to cut in the queue and occupy a position as close to the head of the queue as possible. Two parameters are introduced to describe the interjection behaviour: the percentage of customers interjecting and the tolerance level of interjection by individual customers who are already waiting in the queue. Using matrix-analytic methods and stochastic comparison methods, the waiting times of normal customers and interjecting customers are being studied. The impacts of the two parameters on the waiting times are analyzed in detail, and the implications of the results are discussed with numerical examples. It is found that the waiting times are sensitive to the tolerance level of interjection by individual customers. It is also found that eliminating customer interjection would be always beneficial to normal customers and arbitrary customers though it would not always be so for interjecting customers.