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Designing Queuing System for Public Hospitals in Thailand

Conference Paper · December 2014

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 TICEAS -93
Designing Queuing System for Public Hospitals in Thailand

Ubolrat Wangrakdiskul
Department of Production Engineering, Faculty of Engineering
King Mongkut’s University of Technology North Bangkok, Thailand
Corresponding Author: ubl@kmutnb.ac.th

Abstract
The purpose of this work is to analyze the theory and instances in the use of queuing theory
and lean thinking in healthcare providers with an emphasis on public hospitals in Thailand.
This work is an attempt to reduce waiting time and provide sufficient information to analysts
who are interested in using queuing theory to improve the quality of healthcare services. The
paper investigates the effect of waiting time for medical treatments on patient satisfaction.
The proposed queuing system would lead to potential advantages (higher quality and lower
cost of services, easier administration, and greater patient satisfaction) of waiting time
reduction.

Keyword: Queuing theory, Lean thinking, Patient satisfaction, Waiting time.

1. Introduction
Thailand is one of countries that concerns with the healthcare services of people. Therefore,
in 2001 the Thai government launched a universal health coverage policy or 30-Baht (USD
1$) policy for establishing health security and equal access to quality health services [1]. This
opens the way for better opportunities of medical care through Thai people than they have
had in the past. However, the number of service providers’ personal in Thailand is not
sufficient for serving the number of Thai people. In 2010, the number of physicians in
Thailand is 22,019, while the number of Thai populations is 63,701,703. As such, the ratio
of comparing between physicians and populations is 2,893 [2]. The report of Health Service
Units, Ministry of Public Health showed that the overall number and rates of out-patients
(exclude Bangkok) per 1,000 populations are 163,336,954 and 2,816, respectively [3]. This
means that each physician has a high burden for caring patients. Moreover, many personals in
medical care system tend to work in the private hospitals sector. Therefore, the service
providers in the public sector are not sufficient for serving patients. Furthermore, most of
patients favor to consult with the doctors in the public hospitals with the reasons of a
reasonable treatment cost.
Currently, every organization is trying to improve the operational process for achieving its
setting goals. Not only the industrial sector but also the healthcare services sector has

539
competed to improve its processes, which the main objective is to cut the production costs.
Kujala et al have expressed that healthcare managers who concentrated on the quality of care
have been forced to improve the management systems for cost effectiveness [4]. The costs in
healthcare organizations are both tangible and intangible costs, i.e., capacity costs, waiting
costs, the costs of waiting space, cost to the society and the effects of loss of business to
healthcare organization if patients refuse to wait to go elsewhere [5]. We are interested in the
intangible costs which are waiting costs and the effects of loss of healthcare organization by
refusing of patients to wait and go elsewhere. Moreover, Murray and Berwich have referred
the report of Greenblatt in 2001 about access to urgent medical care that is 43% of adults
reporting an urgent condition were sometimes unable to receive care as soon as they wanted
[6]. However, the evaluation of costs is so difficult, so the waiting time of patients throughout
of the process has been considered instead.
As the reasons mentioned above, this paper aims to propose the queuing model, which
integrating with the lean thinking, the social process, and the cognitive process including the
outpatients departments in the public hospitals.

2. Method
Healthcare systems are complex and risky, while the frail, vulnerable and frightened patients
require high caring and attention from the healthcare providers [7]. There are many research
papers concern with the healthcare services for patients. Yodpijit and Wangrakdiskul propose
the model of the healthcare system which focused on patients’ safety by integrating cognitive
theory and function allocation into the model [8]. The other authors have discussed about
the application of the Virginia Mason Production System and the effects of increased time of
caring patients of nurses [9]. They have adopted the lean thinking into the production system.
In addition, Joosten et al also follow theirs concept and applied the lean thinking to health
care system [10]. However, we have accommodated the concepts from many researchers, i.e.,
queuing theory [5], lean thinking [10-11], time-based management for reducing throughput
time in patient process [4], cognitive process and social process [12], into the proposed model.
These concepts and theories mentioned above can be described in more detailed as below.
2.1 Queuing Theory in Healthcare System
Queuing theory is a mathematical approach applied to the analysis of waiting lines and it can
be applied in healthcare by dealing with patient flow through the system [5]. We adopt his
concepts about types of queuing systems and queuing service disciplines characteristics
integrating into the proposed model. The types of queuing systems can be described as below.

540
2.1.1 Types of Queuing System
There are 4 types of queuing systems which related to healthcare systems.
A. Single Channel-Single Phase System
In this type, there is a single queue of customers waiting for service and only one phase of
services is involved, for example, only on practitioner nurse work for server in a flu
vaccination camp. It is shown in figure 1.

Arrivals Queue Served units

NP
NP = Nurse Practitioner
Figure 1: The single channel- single phase system.

B. Single Channel-Multiple Phase System

The type shown in figure 2 is still a single queue, but the service involves multiple phases.
After patients passing the registration counter, then they have a queue for waiting to see the
physician again.

Arrivals Queue
Queeue Served units
Physician
Registration
office

Figure 2: The single channel- multiple phase system

C. Multiple Channel- Single Phase System

This type is shown in figure 3, customers from multiple queues waiting for the service, which
involves only one phase. Customer can switch from one line to the other. The example of this
type is the patients waiting in queue at pharmacy store.

Figure 3: The multiple channel- single phase system

541
D. Multiple Channel- Multiple Phase System
This type has a complex network because there are numerous queues with multiple phase
services involved. The example system of this type is multi-specialty, outpatient clinic in
hospitals. It is illustrated in figure 4.

2.1.2 Queuing Service Disciplines

When patients arrive at the healthcare service in order to get the treatment, frequently, they
consider waiting in line to be an unpleasant. Long waiting lines make them feel boring and
unsatisfying with the hospitals, even though with the healthcare providers. However, many
hospitals have tried to tackle this problem by improving the service discipline of queuing
system. Fomundam and Hermann have studied the application of queuing theory in
healthcare services and expressed that the queue discipline in most healthcare setting is either
first-in-first-out or a set of patient classes having different priorities [13]. For example, the
emergency department treats patients with life-threatening injuries at first. In addition, they
have mentioned the other researchers’ concepts, i.e., models for preemptive and
non-preemptive discipline of Green in 2006a. Furthermore, they have referred the research of
Siddharten et al in 1996 which propose a priority discipline for different categories of patients
and then a first-in-first-out discipline for each category. We are interested in combining these
service disciplines into the proposed model, which will be described in more detail in the
section 3.

2.1.3 Time Based Management

Healthcare managers and medical professionals who traditionally have concentrated on the
quality of care are forced to review the overall management practices for cost effectiveness
[4]. When waiting times are very long, there might be an increase in the resources needed for
repeated examinations of patients (since their status might change during the course of the
waiting), an increase in treatment costs and in length of stay (if severity deteriorates while
waiting), and an increase in cancellation rates [14].The most important measurements should
take place at the out-patient department. For each division and clinic type monthly statistics
should be available on the mean access time, waiting time, and processing time. Currently,
experiments are carried out with a badge per patient and a built-in chip. In this way values are
automatically registered in the computer system. Monthly statistics on mean resource
occupancy levels and resource utilisation rates should be annually available for each clinic
and specialty in the out-patients department [15].

542
2. 2 Lean Thinking
The widely adopted Japanese manufacturing concepts came to be known as ‘lean production’.
In time, the abstractions behind lean production spread to logistics, and from there to the
military, to construction, and to the service industry. As it turns out, principles of lean
thinking are universal and have been applied successfully across many disciplines [16].
While the principles of lean thinking were developed in the manufacturing sector, there is
increasing interest in its application in health care. Therefore, lean thinking may play an
important role in the reform of health care in elsewhere [17]. Lean Thinking, addressed by
Wormack and Jones [18], is aim to remedy wastes which composed of 5 principles. The other
researchers have added one more principle after the five first principles [19]. They can be
explained below.

• Specify Value. Value is defined as the capability to deliver the product or service for the
requirement of customers with minimal time between the start times of customer orders for
the products or services and the actual delivery at an appropriate price [9].
• Identify the Value Stream and Eliminate Waste. The Value Stream is all the actions needed
to bring a product to the customer. The key is to eliminate the non-value-added waste in the
value stream.
• Flow. Make the value-creating steps flow, flow through the planned and streamlined value-
adding steps and processes, without stopping or idle time, unplanned rework, or back flow.
• Pull. Let the customer pull the product from you. Sell, one. Make one.
• Pursue Perfection. There is no end to the process of reducing time, space, cost and mistakes
• Respect People. In a lean enterprise, people can share their ideas with the leader without
fear, plan together, identify problem, and solve problems in real time.
From these principles, we are interested in integrating them into our proposed model, which
will be described in detail in the section 3.

2.3 Social Cognitive Approach

Cognition is the act of knowing, and cognitive psychology is the study of all human activities
related to knowledge. These activities include attention, creativity, memory, perception,
problem solving, thinking, and the use of language [20]. An agentic perspective is
incorporated in the social cognitive theory, focusing on human development, adaptation, and
change. It consists of three agency modes: (1) direct personal agency, (2) proxy agency, and
(3) collective agency. This perspective is implemented by blending three agency modes,
which so-called self- efficacy beliefs. These beliefs can affect individuals in self-enhancing,
which can be self-motivation, preservation when facing problems, the quality of emotional
life, and making decision on the choices of their life [21].

543
In this regard, there is a survey research reported by Strecher et al, which recognized
self-efficacy in a smoking cessation program. This research reported that a summary of some
researchers showed that the subjects electing to join a smoking cessation program showed
higher levels of self-efficacy than did nonjoiners [22]. Also, we deeply emphasize that the
self-efficacy belief in social cognitive approach is feasible and can be accommodated into the
work systems of health care services in order to increase patients’ satisfaction. All of these
concepts as described above will be integrated into the proposed model and illustrated in the
model as following.

3. Results of this Study

After reviewing the researches which relate to health care services, we have constructed the
model integrating the three concepts i.e. queuing theory, leaning thinking, and socio cognitive
approach for reducing waiting time and increase patients’ satisfaction. As such, the proposed
model is shown in figure 5. It consists of three phases which are inputs, management process
and outcomes. For more understanding, it can be described as follow.

Figure 5: The proposed model of queuing system for public hospitals in Thailand

3.1 Inputs
In this model, we focus on the healthcare service of out-patients clinic of public hospitals in
Thailand. Many patients prefer public hospitals rather than private hospitals with the reasons
of reasonable prices of treatment. The input resources in figure 5, we consider in technical
subsystem, personnel subsystem, and organizational and managerial structure. These can be
described in more detail as below.

544
3.1.1 Organization and Managerial Subsystems
In the organization and managerial subsystem, the levels of management, tasks or
responsibility of each position should be clearly identified. Manpower planning in human
resources is necessity to perform for supporting patients’ needs, such as considering the
number of physicians for adequately patients’ treatment within the right time. Currently,
some departments in the public hospitals set the number of physicians with inadequately
serving the patients. As such, the investigation of cycle time for each patient’s treatment,
patients’ arrival time, throughput time of patients in the system, and waiting time should be
performed. Further, allocation the number of service providers for serving the patients will be
sufficient.
3.1.2 Technical Subsystem
Technical subsystem is one of factors that have an effect on treatment time of patients. The
technology, such as equipment, electronics should be considered by integrating in the
treatment process. The electronics equipment which can show the queuing number should be
installed in the clinic. Furthermore, using the machine that rapidly diagnoses the disease of
patients should be recognized, such as electronics blood pressure equipment, tool kit for
detecting the sugar for diabetes disease, etc. Using these equipments is not only reducing
patients’ waiting time, but also relieving the service providers’ tasks.
3.1.3 Personnel Subsystem
Personnel subsystem in the model refers to the healthcare providers and including all of
patients in the system. This relates to organization and managerial structure, but in the
personnel subsystem we combine the patients into considering. A lot of patients may lead to
the poor service, if the number of service providers is not sufficiency. Therefore, allocation
the number of service providers in each department for supporting patients’ treatment is very
essential.
3.2 Management Process
Within the management process, we propose three main approaches; queuing system, lean
thinking, and social cognitive approach. They are described as below.
3.2.1 Queuing System
The system types of queuing have been mentioned in the sub section 2.2. There are four types
which can be implemented in the public hospitals. However, in this model we focus on
out-patients clinic. Because this type, Multiple Channel - Multiple Phase, is more appropriate
and should be adopted in this model. From this basic type, it has been adjusted in more
detail, as shown figure 6.

545
 Figure 6: Queuing system within the management process
According to figure 6, there are numerous queues with multiple phase services. The
procedure of queuing system in the proposed model is can be described as follow.
First, when the patients arrive at the reception desk of outpatient clinic in the public hospital,
the clerks or service providers will give them the queuing number.
Second, the patients wait for calling names as their queues for receiving the first treatment
from nurses or practitioner nurses. In this procedure, the patients may have taken the first
examined, such as checking blood pressure, examining the visual eyes etc. However, in some
situations the patients are not accepted the treatment as their queuing number and not first in
first out. As these reasons, because the service discipline of the clinic is not real first in first
out. These can make the patients feel unsatisfied with the service providers. Therefore, the
queuing system should be transparent. The installation of monitor displaying in the clinic for
calling patients’ name is necessity, along with the calling by nurses or service providers.

Third, after passing the first examination, the patients must wait for the physicians with the
long time. In this stage, each patient may get the different queue because they want to meet
the different physicians as their individual needs. However, their queue number should be
already allocated at the registration desk. This stage is the critical point of this procedure
because it takes a long waiting time of patients. This stage is the bottle neck process, because
of lacking a number of physicians. For solving this problem, the processing time of each
patient should be investigated. And then, allocating the adequate number of physicians or
service providers should be taken. In addition to these concepts, we further consider the
queuing discipline. Most of health care services adopt the FIFO (First in first out) discipline
in its process. As the research of Fomundam and Hermann [13], they have reviewed about the
other disciplines, i.e. models for preemptive and non-preemptive discipline, a priority
discipline for different categories of patients. As these disciplines, the preemptive discipline
may be accepted in case of the serious symptom of patients, such as in an emergency
department. Moreover, the priority discipline may be accepted in the case of patients who are
personals of a hospital, but the time of servicing them should be after the queuing patients
who have an appointment.

3.2.2 Lean Thinking for Eliminating Wastes

546
As mentioned in the sub section 2.2, we focus on the elimination of the non-value-added
action in the value stream. The two points for eliminating wastes are adopted into this model.
First, reducing patients’ waiting time can be achieved by allocation the number of physicians
for sufficiently serving patients. Second, when lacking a number of physicians is becoming
the bottle neck problem, the nurses or practitioner nurses in the primary examination stage
conversely have idle time. Therefore, reduction the number of them should be considered and
the excess numbers can be assigned to work in the other clinics. Besides these, the reduction
of waiting time can be performed by managing the appointment process with allocating the
number of physicians and service providers for matching with the number of patients.

3.2.3 Social Cognitive Approach and Lean Thinking

In this approach, we adopt the self-efficacy into the proposed model. It means respecting
people that is one of the principle approaches of lean thinking. In this situation,
communication and cooperation among patients and service providers are the key points of
this concept. The politeness of service providers’ dealing with patients should be conveyed.
When the patients have any problems or the suspect point, the service providers should
communicate them with the good manner and willingly response with them. In addition, the
physicians can also take action in this process, such as during the diagnosis process, they
should inform the patients about their symptoms. As this action, not only make patients
satisfied with physicians, but also raise the value of physicians. We believe that the
self-efficacy belief in social cognitive approach is feasible and can be accommodated into the
work systems of health care services in order to increase patients’ satisfaction and get more
understanding among patients and service providers.
3.3 Outcomes
Patients’ satisfaction and waiting time reduction are the interesting outcomes of this model.
When inputs and management process in the organizations are well prepared and allocated
with the appropriate approach, it can increase the patients’ satisfaction and reduce the waiting
time. However, the evaluation process should be constructed such as investigation treatment
time of each patient, patients’ waiting time on each stage of the flow process, throughput time
of patients in process before out of the clinic, and the effects of loss of healthcare
organization by patients’ refusing to wait and go elsewhere. When we know about this
information, the solving techniques can be implemented. Reduction the unproductive time or
waiting time can reduce costs and improve quality of care. In addition, patients’ satisfaction
can be evaluated by constructing the appraisal documents; the persons who assess these are
the patients. The more satisfaction of patients, the less of production costs in health care
services can be achieved. Moreover, feedback from outcomes is also necessary. Particularly,
if outcomes are not satisfactory, then correction on input and process should be performed.

547
 4. Conclusion and Discussion
This work has attempted to reduce waiting time and provided sufficient information to
analysts who are interested in using queuing theory for improving the quality of healthcare
services. In the proposed model, we focus on queuing system management, patients’ waiting
time, and the social cognitive approach in the health care system of out-patients clinic of
public hospitals. With this situation, we expect to reduce waiting time of patients and increase
the satisfaction of patients. Although, the public hospitals are not aim at profit achievement of
the patient service, the satisfactions of patients are the key point of operating organization.
The competition among the public hospitals is becoming the essential episode of their quality
of care. Furthermore, reduction of wastes in operating process and resources can be converted
to saving costs. This means that it can save the budget of Thai government for serving health
care to Thai people. The challenge in the future is to introduce this proposed model into an
actual hospital situation. However, the report from the Institute of Information Technology
and Communication [12] has illustrated that the ratio of the number of Thai population
comparing with the number of physicians is so high, 2,893. For this reason, the policy of
producing more physicians or service providers in Thailand should be recognized. Moreover,
the ethics of professional careers should be combined in the syllabus course of teaching
medical care students for decreasing rate of medical care personnel’s leaving to work aboard
or in the private hospitals instead.

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