Background Adams-Kumar-Keller (AKK) is a healthcare facility located in Massachusetts where basic medical check-ups are provided. The unique characteristic of this facility is that patients cannot make an appointment, they just head to the clinic. The three physicians who manage the clinic (Dr. Jessica Adams, Dr. Maya Kumar, and Dr. Robert Keller) have recently decided to examine the facility's processes because patients complain about waiting times. The patient's journey starts with checking in at the registration desk. It continues with a stop in the waiting room(time varies), taking vitals, the physical exam (varies depending on the needs/urgency of the patient; further details are provided below), and ends with the checkout. Two analysts (Mr. Carey and Ms. Reynolds) observed the process during February 2019 for two consecutive days (on the 18th and the 19th) and provided the following details.

Process Description

Patients experiencing various health problems, or because they just need to have their annual checkup, head to AKK, at 115 Health Road, weekdays from 7:30 am to 4:30 pm (open hours). Carey and Reynolds' report highlights that, at the check-in desk, about 18% of the patients need to come back because of various problems (they do not carry a valid ID, they do not have/remember their SSN, their insurance is not accepted by the facility, and so on). This initial screening takes 5 minutes and is performed by the desk personnel (DP). Seven people are employed as DP's and normally three are on duty. The patients admitted - about 4 per hour on average (as few as none and no more than 8) - take a seat in the waiting room (right next to the check-in desk) where they wait to be called for vitals. Three nurses take vitals, which takes 6 minutes per patient. Each nurse has an equipped room assigned (exam rooms 1, 2, and 3). Right after vitals are taken, patients are directed to the doctors. The patients whose vitals are fine (81%) go straight to Dr. Adams (doctor room 1), who performs a general physical exam in about 20 minutes. Then, the patient is picked up by one of the three nurses and taken to the blood test lab where blood work is performed (4 minutes); after the blood test, the patient heads to the checkout, generally taking 3 minutes since all insurance information and copays are checked ahead of the admission. The checkout occurs at the front desk and is performed by one of the DP's. The blood test lab is an open space with three stations where blood work can be performed (at the same time if three nurses are available). Some patients' readings show high blood pressure (15%) and are taken care of by Dr. Kumar (doctor room 2) - her specialty is cardiology. Dr. Kumar performs the exam in 25 minutes, and then the patient is picked up by a nurse for the blood test. After the blood test, these patients also head to the checkout. Unfortunately, some patients (4% on average) have vitals severely out of the ordinary: the nurses consider several parameters for this evaluation, e.g., patients with a very high temperature (over 103F) in combination with high blood pressure reading of 200 or more (systolic) or 120 or more (diastolic). [No more details about these parameters are provided in this process description because they would go beyond the aim of this narrative and are not needed to appropriately analyze this process.] In these cases, patients are taken immediately to Dr. Keller, whose office is equipped for these types of quasi-emergency situations. Dr. Keller performs further medical tests (45 minutes), and then three types of patients are identified based on the test results. Type-A patients: After Dr. Keller's careful evaluation, he determines that the patient can be discharged (62% of patients). In this case, the patient has a blood test (with the same procedure followed by Dr. Adams' and Dr. Kumar's patients), and then checks out. Type-B patients: For safety reasons, these patients need to stay in the facility for three hours of observation (28% of patients). This happens with patients who have a high temperature and symptoms of dehydration. These patients are sent to another area of the facility where there are six rooms dedicated for these quasi-emergency cases. In these observation rooms, the patient is monitored by an IT system for the entire stay (3 hours); if the conditions (according to the system reports) improve, the patient is sent for a blood test and then checks out (as per all other patients). A nurse, after the three hours, checks the conditions of the patients from where they are (room 1, 2, or 3) and evaluates whether the patient can proceed to have the blood test (90% of the cases), or whether the patient becomes Type-C. It takes the nurse 1 minute to check the condition of each of these patients. Type-C patients: This patient needs to be sent to a hospital (10% of patients). In this last case, either Dr. Keller, or a nurse if the patient was originally Type-B, makes this decision. A phone call (2 minutes) is made by Dr. Keller, or by one of the DP's if Dr. Keller is busy, to inform the patient's emergency contact about the hospital transfer.