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-The case study will be on Massachusetts General Hospital Pre-Admission Testing Area (PATA); the case is attached.
– Title page, table of contents, executive summary, problem statement, Problem data analysis, alternativess, key decision criteria, alternatives analysis and evaluation +Swot analysis charts, key decision criteria chart with results, weighed decision criteria chart with results, recommendation, action and implementation plan with chart, and project plan cost chart are all to be included. An example of a past case study is attached, the case study rubric and directions is also attached. Other sources are also attached.

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Case Study Summary

The Pre-Admissions Testing Area (PATA) is an outpatient clinic at Massachusetts General Hospital responsible for conducting pre-operative assessments of surgical patients prior to their procedures. The assessments have three primary goals:

  1. Determine whether the patient is in sufficiently good health to receive anesthesia and identify potential medical issues that might affect the course of the surgery.
  2. Educate the patient about what to expect before, during, and after surgery, and the risks associated with the procedure and anesthesia, as well as guiding the patient’s preparations for the surgery (e.g., stop taking certain medication).
  3. Meet regulatory and hospital requirements by completing the necessary paperwork for goals 1 and 2.

The PATA case study describes the conditions of this busy outpatient clinic prior to a process improvement effort by a collaborative team of MIT Sloan students and faculty, and MGH clinicians and administrative staff that took place in July 2009. The case describes the complete PATA experience from both the patient and provider perspective. The importance of improving PATA is emphasized through a description of how this relatively small clinic has a very large downstream effect on the MGH operating rooms (ORs) and the entire perioperative care system.

The patient value-added work time for these assessment goals is approximately 80-90 minutes, however patients are in the clinic for an average of 2 1⁄2 hours (4 hours for some patients) due to long waiting times. In addition, providers are required to put in significant overtime to get through all the patients scheduled in a day. Also, because the clinic is not able to see all surgical patients, the OR is experiencing an unwelcomed downstream impact of needing to conduct the pre-operative assessment for the remainder of the patients in the OR on the day of surgery.

Learning Objective

This case study serves two primary educational goals: 1) expose students to concrete operational challenges in health care delivery; and 2) illustrate both the application and the potential benefits of quantitative process analysis and process reengineering in this environment.


Analyze the Case Study Information Provided to You

Make sure you understand the situation at Massachusetts General Hospital’s Pre-Admission Testing Area (PATA). The case is written from the perspective of the chief of anesthesia and the anesthesia executive director who must determine why these problems exist and what to do about them. For purposes of this case study, you are playing the role of Dr. Jeanine Wiener-Kronish, the chief of anesthesia and leader of the PATA.

Please understand your role for the case study!  Read the entire case study, understand the exhibits and possibly watch the video.  It is also very important that your use this HELP document and the rest of the tools provided for you!

Video

The case can be complemented by a video about MGH and PATA. It provides a broad overview about MGH’s history and mission, as well as a closer, visual perspective on the facilities and patient experience in PATA. The video is available at:

https://mitsloan.mit.edu/MSTIR/operations-management/PATA/Pages/Teaching-Video.aspx.

The following information contains some of the key points to know and recognize as important to the overall issue: (I would definitely note specific information about these key points for context and understanding.)

What is the perspective of the key stakeholders involved in PATA’s current operational performance?

The perspectives of the patients and their families, the PATA providers, the surgeons, and the hospital management are all clearly described in the case and can be summarized in the table behold. This table, complete with information from the case and exhibits can serve as the foundation and outline of the Problem Analysis section.

Problem Statement:

How is the problem affecting these key stakeholders?

Patients Providers (nurses, lab, etc.) Surgeons Hospital Management

In addition, it is useful to understand the fairly broad impact and important financial implications that the operating performance of a relatively small and low-tech clinic such as PATA can have on the entire MGH system. In fact, surgeries are the hospital’s single most significant source of revenue, and any delays and cancellations have major financial implications, not to mention an impact on quality of care and the MGH brand name.

Another aspect to be aware of is that both nurses and anesthesiologists jointly lead PATA: nurses are responsible for most of the operational aspects, and the anesthesiologists are responsible for the professional outcomes.

Draw a process flow diagram of the PATA patient visit process.

The flowchart is a diagram which visually presents how the patients flow through the Pre-Admission Testing Area (PATA) before they have surgery. The flowchart is a graphical representation of this process. This means by seeing a flow chart one can know the operations performed and the sequence of these operations in a system. A flowchart will be important to the problem analysis section to describe the operations in sequence including wait times to understand the patient experience to solve the given problem. It will be important to be able to view the flowchart and other information provided in the Case Study to find the “bottleneck” in the process, which is the biggest contributor to the problem.

The most difficult part of creating this diagram is to understand how the RN and MD responsibilities impact the patient. In the current system, providers are not notified that they are assigned to a patient until that patient is waiting in an exam room. Therefore, even though the pre-visit chart review should not affect a patient’s total time in PATA, under the current design it does. The chart write-up, on the other hand, does not directly affect the patient’s total time in PATA because once the RN or MD leave the exam, the patient moves along to the next step in the process.

The beginning of the process map is

It is your responsibility to fill in the rest of the process steps as started below:

How much time for Check-In?   (Waiting Room)

What is next?  It is important to keep track of time in each process step including waiting time.

The end of the process map is

Please note: You will not be graded on the “appearance” of your process flowchart, because I don’t want you spending a lot of time creating and developing the process map in Word or have to learn how to use a mapping program.  It is more important that you fully understand the process that a patient flows through in the PATA, then a beautiful process map.  You may draw the process map with the appropriate symbols as best as you can or use post-it notes (they can be all one color; you do not have to purchase multiple colors) as a tool and then take a picture and insert process map into your paper.  Everything must be legible for me to see and read!!!

Video Resources for You about Process Maps

What factors contribute to variability in PATA process flow and what control, if any, does the clinic have to eliminate it? (I would definitely note specific information about these key points for context and understanding.). Use the exhibits and the Excel PATA Analysis tool I created for you to better understand patient and provider variability by doing some analysis of the data.

A careful reading of the case will reveal that there is a lot of variability in the clinic that could be eliminated; we call this artificial variability. For example, there is evidence that there is high variability in the exam times of patients and among different providers, but it is not clear what the main variability drivers are. It could be varying patient needs, patient personalities, arrival times, individual provider styles or preferences, or the lack of a standard process design. Some of this variability could/should be eliminated. The more variability that exists, the less control the providers and patients have over the PATA experience. What type of alternatives can you come up with to reduce variability? Remember patients don’t experience averages of wait time, they experience actual waiting time.

What else from your perspective is important to understand about the situation?

  • Have you had the chance to review all of the exhibits?  Have you reviewed the patient intake, nursing assessment or the physician evaluation forms in the appendices?  What do you notice about them?  How are they used in the actual PATA process?
  • What type of information do they provide to understand the problem? Read the case study carefully and notice little nuggets of gold to help you better understand the problem. Patient Management by the Charge Nurse – Use the Exhibits to understand differences in how Charge Nurses manage patient flow.

Alternatives

What alternatives or changes would you recommend improving PATA? These alternatives need to directly align with tackling the problem.  It is important that the alternatives provide a mini overview of the alternative including answering the questions, of who, what, why, how, how much.  Review the Case Study Example from last year that was provided in the Announcements in your Canvas course this summer.  This student did an excellent job of providing the necessary detail to understand the alternative.

Two potential solutions were proposed in the Case Study: 1) change the appointment schedule; 2) add more staff MD or RN and more exam rooms or see fewer patients. You may use these as alternatives, but you will need to be very specific how who, how, when, etc.

I have required Cost as a Decision Criteria and have given the parameters for how much an alternative can cost and how to assess cost. I would look for Alternatives that don’t require more resources and develop your own creative improvement ideas and propose solutions for the clinic.

Decision Criteria (Please Note Important information about Decision Criteria)

Cost – is a required decision criterion and you need to come up with 2 additional decision criteria.

What might be some additional decision criteria for this project?

For the remaining sections of the Case Study assessment, please move forward to page 7 of this document and also review the Case Study assessment example given to you in the Announcements section of this course.

What’s next?

Okay, so now what?

Do you think you have a good understanding of the case study situation? Did you develop a comprehensive outline of the situation using the Help document? If not, go back and do it because it will help you develop a clear, concise and logical case study and you have a better chance of passing the comprehensive exam the first time.

Problem Statement (Learning with Cases, pg. 41)

The problem statement should be a clear, concise statement of exactly what needs to be addressed. The problem statement should be one sentence and needs to be indicative of the underlying business problem, NOT the technical problem. You need to state why this problem is important to Massachusetts General Hospital.

Getting the problem statement correct is very important because every section is directly connected with the problem facing the organization.

Many students indicate that the problem is the manager needs to make a decision about some issue. If that were the case, the solution is fairly simple—replace the manager with someone who will make a decision.  As an example, you could state that a server has failed. From a business perspective, that isn’t much of a problem. However, if you reworded the problem to state that the business would not be able to process any customer payments because of a server failure, that would be a problem that would grab the business’ attention a lot faster. It is also important to note that there are no questions included in a problem statement because it is a statement not a question.

It is also important not to include a solution in your problem statement. If you wrote a problem statement like this:

Customer payments cannot be processed because a server failed and needs to be replaced.

By stating that the server needs to be replaced, you are providing a solution that may not be the best. What if the customer payment application could be moved to a virtual machine? What if the customer payment application needs to be replaced, regardless of the state of the server? What if the customer payment application could be collocated on another server? By stating that the solution is to replace the server, you have precluded any investigation into other possible solutions.

Problem Statement:
Problem statement should quantitatively describe the pain in the current process

  • What is the pain?
  • Where is it hurting?
  • When – is it current? How long it has been?
  • What is the extent of the pain?

    Problem Statement Example:
    “In the last 3 months (when), 12% of our customers are late, by over 45 days in paying their bills (what). This represents 20%(magnitude) of our outstanding receivables & negatively affects our operating cash flow (consequence).

Problem and Data Analysis (Learning with Cases, pg. 43)

When analyzing the case, you should determine how the issues in the case came about, who in the organization is most affected by the issues, any constraints, and any opportunities for improvement. You should NOT be generating or discussing any alternatives. This analysis should further develop and substantiate your problem statement. This section should be used to summarize the basics of your case analysis. It should not be used to simply retell the case scenario.

A decent analysis of a case this size cannot happen in a paragraph or two. There are quite a few things that need to be brought up and discussed. The business will be spending millions of dollars because of the problem. A one or two paragraph description of the problem is not sufficient.

As you are conducting an analysis of the problem, you should be highlighting the major parts of the problem. Each of these parts needs to be fully developed and explained in detail. Continuing on with the example of the server failure, there may be several underlying issues. What if the server is very old? If so, parts not be readily available. Additionally, the application could have been written for an old operating system and may require significant rewriting for it to work on a modern operating system. Each of these issues should be a level 2 heading and will need significant development. As you develop these issues, always be sure to keep the business impact in mind.

Be accurate in your description of the problem. Be sure that you fully understand what the case is discussing. You may need to read material outside of the case if you don’t understand the business environment at the time of the case or if you don’t understand any of the technologies mentioned in the case. You may also need to ask your instructor for clarification. The bottom line is that you need to write factual statements.

Do not use hyperbole. It’s doubtful that the problem is endless, the risk is uncalculatable, or the desired state is unattainable. If any of those were the case, we wouldn’t have a case to analyze. State facts without embellishing.

As you complete the problem analysis and learn more about the case, you may find that you need to rewrite your problem statement.

Alternatives (Learning with Cases, pg. 46)

Each alternative you develop should offer a different way in which the problem could be resolved. Typically, there are many alternatives that could solve the problem in the case. Some alternatives may even be discussed in the case. You should also develop your own alternative(s) as well. It is very likely that the alternatives presented in the case are not sufficient to solve the entire problem.

Each alternative should have a level two heading.

Fully describe each alternative. There should be no description of any alternative in future sections; it all should be described here. As you continue with your analysis, you may find yourself adding to these descriptions as you continue to refine your alternatives.

In the alternative descriptions, you should address all issues that you identified in the problem analysis. For each of those issues, create a level three heading, and discuss how the alternative does or does not address each issue.

You should also discuss cost for each alternative. As you discuss cost of the alternative, you should indicate what will be capitalized. Additionally, you should take total cost of ownership into account for any new systems that you may be recommending. You should also be taking the time value of money into account if any of your alternatives will take more than a year to implement.

You should also discuss schedule for each alternative. How long will it take to implement each alternative? Anything that takes more than three years needs to have a very good justification. If a project takes fewer than six months, you should reevaluate your estimation. Very few projects of any size will be completed that fast.

Each alternative should fully address all parts of a problem. For example, let’s say a problem has two major issues. Don’t have an alternative that addresses the first issue, another alternative that addresses a second issue, and a third alternative that is simply a combination of the first two alternatives and fully addresses the problem. In this case, the first two alternatives are not viable as they do not fully address the entire problem.

Each alternative should be realistic and have a reasonable expectation that it could be successfully implemented. If you have an alternative that will take ten years to implement, cost more than the market value of the company, or is beyond the ability of the company to implement, then the alternative is not realistic.

If you present an alternative that recommends making a decision pending further investigation, it is not an acceptable alternative for any case study that you will analyze. All the investigation that is going to take place is presented in the case. No more investigation is possible, and a decision needs to be made.

If you recommend doing nothing as your strategy, you must provide clear reasons why this is an acceptable alternative. This may be an acceptable alternative. In fact, many cases present this as an alternative. However, you need to justify the alternative, and you will need to describe how it does or doesn’t address the issues you identified in the problem analysis. You will also need to analyze the alternative with the key decision criteria that you create.

Avoid providing one desirable alternative and two other clearly undesirable alternatives. This is gaming the system and might not be the best for the company. Do the work necessary to provide at least three viable alternatives.

Do not compare alternatives here; that will be done in a future section. Do not state things like this will be the favorite alternative amongst the employees or this is the cheapest alternative. Those type of statements imply that you have already done a comparison. This section is for fully describing alternatives, not for comparing alternatives.

Key Decision Criteria (Learning with Cases, pg. 47)

Once the alternatives have been identified, a method of evaluating them and selecting the most appropriate one needs to be used to arrive at a decision. The key decision criteria you develop now will be used later to evaluate all alternatives and will form the basis for your recommendation. These criteria should take into account the issues you have previously identified. Additionally, the key decision criteria should include cost and schedule.

Each criterion should be a level two heading. A description of the criterion and how it will be used should follow each heading.

As you develop your criteria, do not mention any alternatives. You should only be describing the criteria. The criteria will be used to evaluate each alternative in the next section.

Each criterion you develop should be atomic. In other words, don’t combine several things into one criterion. For example, some students use Time and Money as a single criterion. These are two different criteria and are usually opposing. If you find yourself using a conjunction in the name of a criterion, you could most likely split that into two separate criteria.

For cost, you should explain what expenses will be included in the cost evaluation, e.g. salaries, equipment costs, maintenance fees. You should explain how you will account for the time value of money. Additionally, you should indicate what type of depreciation schedule you will use for any capitalizable expenses.

Each criterion needs to be measureable, and you need to state exactly how you will use each criterion to evaluate the alternatives. Here is an example of a criterion that is explained, but not measureable:

Secure solution. The most important decision criterion is if the proposed alternative offers a secure solution. The best solution will be the one which helps keep the company’s data and intellectual property safe and secure. Alternatives will be measured by analyzing whether the proposed solution is more secure than the current environment. The security analyzation will consider hardware, software, and the human user aspect.

There are several things wrong with this description. First, what hardware, software, and human user aspects will one look at to determine if it’s the best solution to keep Intel’s data and intellectual property safe and secure? If we could determine that, what measurement scale would we use to rate the alternatives? Here’s an example of a criterion that is measureable:

Remote wipe. Having the capability to remotely wipe a device increases the security of the device in the case of it being lost or stolen. This criterion will be scored as follows:

  • If Intel can enforce remote wipe on all devices, 2 points will be given for this criterion.
  • If remote wipe is possible, but not enforceable, 1 point will be given.
  • If remote wipe is not possible at all, then 0 points will be given.

Compared to the first description, this description is significantly better. Any reasonable person could read an alternative’s description, apply the remote wipe criterion, and come up with the same score. The same can’t be said for the first criterion.

As you are developing these criteria, you may find yourself adding to you alternative descriptions. You might need to do this to ensure the criteria can be used to evaluate each of your alternatives.

Alternatives Analysis and Evaluation (Learning with Cases, pg. 49)

Measure each alternative against the key decision criteria. Describe how each of the alternatives do not meet, meet, or exceed all of the key decision criteria. You should explicitly state the score each alternative achieves for all of the key decision criteria.

Each alternative should also be a level two heading. Underneath each level two heading, provide an analysis of the alternative. Under this analysis, have a level three heading for each of the key decision criteria. Under these level three headings, state the score the alternative achieved and explain why it achieved that score.

Do not compare alternatives in this section. You should be only measuring the alternatives against the key decision criteria.

Do not describe or explain any part of an alternative here. The descriptions should have been written earlier.

Do not evaluate an alternative against any criteria that are not part of the key decision criteria. For example, if you wrote a statement that indicated that employee satisfaction would be highest for an alternative, employee satisfaction should be a key decision criterion and all alternatives should be evaluated against it.

PLEASE NOTE:  An Excel file named “Weighted Decision Criteria Template” has been given to you to support the creation of the summary table and/or a chart to be included in your case study. At the end of this section in your case study, include a summary table that lists each alternative, the key decision criteria, and how the alternatives scored against the criteria. The table should look something like this:

KDC KDC KDC Total Score
Alternative
Alternative
Alternative

Replace Alternative and Key Decision Criteria (KDC) with the titles of the alternatives and the names of the criteria, respectively. If you have more than three alternatives, add a row. If you have more than three KDC, add a column.

Recommendation (Learning with Cases, pg. 52)

Clearly recommend one, and only one, of your alternatives. This should be the first statement in this section, and it should read something like this:

The XYZ alternative is recommended for implementation.

Don’t beat around the bush or try to put in a lot of “flowery” words. Make it clear which alternative you recommend.

After that, you need to justify your recommendation. You need to explain why the alternative was chosen. Use the key decision criteria as the basis for the explanation.

You should also state why the other alternatives were not chosen. You should also compare each of these unchosen alternatives to the chosen alternative. Again, use the key decision criteria as the basis for the explanation.

Do NOT include in your explanation any criterion that wasn’t listed as one of the key decision criteria. If you think a criterion is important enough to mention here, it should be one of the key decision criteria and all alternatives should have been evaluated against it.

Action and implementation plan. (Learning with Cases, pg. 53)

Discuss how the recommended course of action will be implemented. Include costs, schedule, and scope in this plan. Include any stakeholders and their responsibilities.

Here is an approach to developing your plan:

  • Develop a Gantt chart with the high-level tasks needed to implement your recommendation.
  • Determine if there are any dependencies between the tasks
  • Estimate which type of people or roles (manager, systems admin, programmer, etc.)  and how many of each type would be needed to perform the task
  • Estimate the duration and effort would be needed by those individuals to complete their work
    • Duration is how long it will take to complete a task. Not everyone is available 24 hours per day to work on a task. Also, some tasks may have external dependencies that might delay completion.
    • Effort is how many hours of actual work it will take to complete the task
  • Use that estimate to determine the length of the project
    • The duration of the tasks along with the dependencies between tasks will determine how long it will take to implement the project
  • Use the effort estimation to determine the cost of the employees working on the project
    • At the financial services company I worked for, we used an internal labor rate of $65/hour on our internal employee costs. Unfortunately, we didn’t actually get paid at this rate L. The rate was an average of salaries, plus a percentage cost for our parking garage, cafeteria, rest rooms, hallways, etc. As employees used those facilities when they worked on a project, our Accounting department wanted us to include those costs in the internal labor rate.
    • For your estimate, pick a reasonable internal labor rate
  • Estimate the costs of any hardware/software
    • As we don’t know what the contract rate that the company has with equipment and software suppliers, just pick reasonable costs.
  • Combine the labor, hardware, and software costs to come up with an overall cost

Once you have the Gantt chart created, you will need to explain, in detail, each task. I would recommend that you have a paragraph for each task. Within each paragraph, include the following:

  • State what will be accomplished by the task
  • List any dependencies the task has on other tasks
  • State the type and number of people needed to accomplish the task
  • State the effort needed to complete the task
  • State the duration of the task
  • State the overall cost of the task

Besides the above guidance, you may also want to review some of the material from ADMG 574 Global Project Management. Additionally, here are a few links below that might also help:

http://smallbusiness.chron.com/methods-estimating-project-times-cost-43036.html

Executive summary (Learning with Cases, pg. 109)

The executive summary should summarize the entire analysis and should be written last. NB, this summary should be directed towards a C-level executive in the organization that is being analyzed.

This is NOT a summary of the case; it is a summary of your analysis

The executive summary should stand on its own. This means that the summary should contain all the facts it needs to make its point without referring to the rest of the report. At a minimum, you should provide a high-level description of the problem, the recommendation, and a summary of the implementation plan. You may include a brief summary of the other alternatives if you wish

The executive summary should be on its own page, and it should NOT be longer than one page. The goal of an executive summary is for an executive to be able to read it and make a decision. If the executive wishes more detail, the executive will then read the more detailed analysis.

Table of Contents

Use Word to generate the table of contents. If you used the appropriate level for each of your headings, the table of contents can be created with the Table of Contents function on the References tab in Word.

Process for Analyzing a Case Study (Erskine, Leenders, & Mauffette-Leenders, 2007)

The Short Cycle Process

  1. Quickly read the case. If it is a long case, at this stage you may want to read only the first few and last paragraphs. You should then be able to answer the following questions:
    1. Who is the decision maker in this case, and what is their position and responsibilities?
    1. What appears to be the issue (of concern, problem, challenge, or opportunity) and its significance for the organization?
    1. Why has the issue arisen and why is the decision maker involved now?
    1. When does the decision maker have to decide, resolve, act, or dispose of the issue?
    1. What is the urgency to the situation?
  2. Take a look at any exhibits to see what numbers have been provided.
  3. Review the case subtitles to see what areas are covered in more depth.
  4. Review the case questions, if any have been provided.

The Long Cycle Process

The Long Cycle Process consists of:

  1. A detailed reading of the case
  2. An analysis of the case.

When you are doing the detailed reading of the case study, look for the following sections:

  1. Opening paragraph: introduces the situation.
  2. Background information: industry, organization, products, history, competition, financial information, and anything else of significance.
  3. Specific area of interest: marketing, finance, operations, human resources, IT, or integrated
  4. The specific problem or decision(s) to be made.
  5. Alternatives open to the decision maker, which may or may not be stated in the case.
  6. Conclusion: sets up the task, any constraints or limitations, and the urgency of the situation.

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