272 ◾ Michael L. Washington
see how computer simulation could provide insight on the potential clinic ow of an STD clinic if
the clinic started a campaign to have more clients return for their second and third HBV vaccina-
tions. From the computer simulation, administrators wanted to answer the following questions:
1. Would the clinic have the capacity to serve more clients? If more clients returned for their
second and third doses, there would be more clinic visits than would normally occur, which
would be an increased burden on the sta.
2. Would campaigning for more clients to return for their second and third doses disrupt the
current client ow?
Six clinic employees were directly involved with clients. eir titles and responsibilities were
as follows:
◾ 1 Clerk: e clerk was responsible for greeting clients, distributing paperwork, and data entry.
◾ 2 Nurse Practitioners: Nurse practitioners provided clinical evaluations (e.g., histories and
exams) and education, and they prescribed treatment.
◾ 2 Registered Nurses (RNs): RNs administered vaccinations, drew blood and collected other
specimens, and provided education. Nonclient care duties performed by RNs were prepar-
ing and cleaning rooms, laboratory activities, paperwork, and obtaining supplies.
◾ 1 Counselor: For clients seeking consultation about HBV, HIV, and other STDs, a coun-
selor was available.
e clinic provided services to 30 to 70 clients per day, and was, at that time, oering HBV
vaccines to unvaccinated clients and return clients. Clients visiting for their second or third dose
of HBV vaccination were labeled “Return HBV” in the model. e clinic averaged a little more
than ve Return HBV clients a day. Six other client categories existed. More detailed information
about these client categories can be obtained from the author.
Arena® version 3.5 by Systems Modeling (now Rockwell Software) was the software used to
model patient ow. e layout of the clinic is shown in Figure32.2. e model was modied for
what-if scenarios concerning only the number of Return HBV clients visiting the clinic. Scenarios
included increasing the number of Return HBV clients incrementally to four times the current
level. e RNs were the sta of interest, since they administer vaccinations.
During preimplementation operations, the RN utilization rate was about 13% (Figure32.3).
is was low, and increasing the number of Return HBV clients was not expected to disrupt the
RNs’ daily routine. After quadrupling the current Return HBV level, the utilization rate increased
to about 22%. e utilization rate was still low, and almost 40% lower than the next lowest
resource utilization rate.
Personnel other than RNs were aected by the increase of Return HBV clients. When the
number of Return HBV clients increased, the clerk utilization rate increased from 58% to 70%.
e increase was due to the clerk retrieving or creating les for extra Return HBV clients. e
counselor and nurse practitioner utilization rates stayed about the same because the extra Return
HBV clients do not visit them.
Since extra Return HBV clients were occupying the RN’s and the clerk’s time, other clients
might have to wait to see the RN and clerk, thus increasing other clients’ average length of stay
(ALOS) in the clinic. Although the overall ALOS did not change much, the ALOS for the Return
HBV and Category 3 clients increased by more than ten minutes. Return HBV, Category 1, and
Category 3 clients’ ALOS showed a gradual linear increase as the number of Return HBV clients
Industrial Engineers in Public Health ◾ 273
increased. e ALOS for the Category 2 clients also increased by more than ten minutes; how-
ever, that statistic was not very reliable since an average of 0.75 Category 2 clients a day visited
the clinic.
If more HBV vaccinations are provided by the clinic to clients returning to complete their vacci-
nation series without any additional changes, the clinic should be able to handle four times as many
Return HBV clients as are currently served. Before this analysis, clinic administrators suspected
that RNs were underutilized. At the time of this study, administrators planned to assign RNs more
duties, such as additional client education. If more than four times the current level of Return HBV
clients arrive, the clinic administrators might consider hiring an extra part-time clerk.
Conclusion
Although industrial engineers have contributed to improving processes within the manufactur-
ing industry, a need to use more engineering tools exists in the public health arena. Although
this chapter only discussed three specic applications, researchers are using numerous analytical
methods and engineering tools to solve public health problems. Some past and potentially new
examples of industrial engineering tools used in public health include:
◾ mathematical modeling and simulation of disease processes;
◾ material handling, transportation, storage location, and storage techniques vaccines, medi-
cine and other medical supplies;
◾ a bar-coding system to monitor vaccine usage information, and to easily record the vaccine
information in medical records;
Categories of Clients
Time In Clinic (Minutes)
Clerk
Waiting room
Client
completing
paperwork
Counselor
room
Current Time (2:19PM)
Bathroom
Bathroom
Counselor
Nurses
Clerk
Nurse Practitioners
Everyone
Category 1
Category 3
Return HepB
New
Category
Category 4
Category 5
Client leaving
Client leaving
Utilization (%)
02:19:49
27
69
14
69
62
52
53
46
29
69
56
0
39
A Nurse Practitioner
waiting for a client to
return from the bathroom
A Registered Nurse with a client
Figure 32.2 Picture of the computer animation model of a California sexually transmitted dis-
ease clinic.
274 ◾ Michael L. Washington
◾ cost–benet analyses and Markov modeling to assess the continuation of routine vaccina-
tion of children;
◾ computer simulation to determine where and how much vaccines and medication to stock-
pile against a bioterrorist attack;
◾ decision theory to determine the best drug treatment for STD clients;
◾ facility layout to recommend physical changes to an existing or new clinic;
◾ statistical process control to identify disease outbreaks, medical errors, and potential bioter-
rorism attacks.
Number of Clients Using the Clinic Increases
Nurse = Registered Nurse (RN), NurseP = Nurse Practitioner
Multiples of HepB Clients
Rate
Current Twice Triple Quadruple
Clerk
Counselor
Nurse
Nurse P
80%
70%
60%
50%
40%
30%
20%
10%
0%
Figure 32.3 Results from the computer simulation model showing the personnel utilization
rate as the number of clients using the clinic increases.
Industrial Engineers in Public Health ◾ 275
Numerous opportunities for industrial engineers (and other disciplines like operations research
and economics) exist in public health and the pipeline for quality health services researchers can
become larger if public health ocials examine these disciplines for answers. Conversely, engi-
neering disciplines might need to look into the public health sector to apply their skills when one
considers the decline of jobs in the manufacturing sector.
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