Discretionary Task Ordering: Queue Management in Radiological Services

Maria  Ibanez; Jonathan R. Clark; Robert S. Huckman; Bradley R. Staats

Article | Management Science | September 2018

Discretionary Task Ordering: Queue Management in Radiological Services

by Maria Ibanez, Jonathan R. Clark, Robert S. Huckman and Bradley R. Staats

Abstract

Work-scheduling research typically prescribes task sequences implemented by managers. Yet employees often have discretion to deviate from their prescribed sequence. Using data from 2.4 million radiological diagnoses, we find that doctors prioritize similar tasks (batching) and those tasks they expect to complete faster (shortest expected processing time). Moreover, they exercise more discretion as they accumulate experience. Exploiting random assignment of tasks to doctors’ queues, instrumental variable models reveal that these deviations erode productivity. This productivity decline lessens as doctors learn from experience. Prioritizing the shortest tasks is particularly detrimental to productivity. Actively grouping similar tasks also reduces productivity, in stark contrast to productivity gains from exogenous grouping, indicating deviation costs outweigh benefits from repetition. By analyzing task completion times, our work highlights the tradeoffs between the time required to exercise discretion and the potential gains from doing so, which has implications for how discretion over scheduling should be delegated.

Keywords: discretion; scheduling; queue; healthcare; learning; experience; Decentralization; operations; service operations; service delivery; Performance; Performance Effectiveness; Performance Efficiency; Performance improvement; Performance Productivity; Decisions; time management; Cost vs Benefits; Health Industry; Operations; Service Operations; Service Delivery; Performance; Performance Effectiveness; Performance Efficiency; Performance Improvement; Performance Productivity; Decisions; Time Management; Cost vs Benefits; Health Industry;

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Citation:

Ibanez, Maria, Jonathan R. Clark, Robert S. Huckman, and Bradley R. Staats. "Discretionary Task Ordering: Queue Management in Radiological Services." Management Science 64, no. 9 (September 2018): 4389–4407. (Working paper available here. Winner of the 2017 Best Paper Competition of the POMS College of Healthcare Operations Management. Featured in Forbes, Quartz, and Inc.)

In 2015, the Department of Veterans Affairs (VA) ran the largest healthcare system in the United States, with over 1,700 sites of care that served nearly 9 million veterans. One year earlier, a scandal had erupted over a cover-up of the excessive wait times veterans faced to get medical appointments in some VA facilities. The fallout led to the resignation of the Secretary of Veterans Affairs, a criminal investigation by the Federal Bureau of Investigation, and the eventual replacement of 14 of VA’s top 17 leaders. This case documents the efforts of the new leadership team to improve access, regain trust, and transform the organization to address the broadening medical needs of the nation's growing veteran population.

Accuracy and consistency are critical for inspections to be an effective, fair, and useful tool for assessing risks, quality, and suppliers—and for making decisions based on those assessments. We examine how inspector schedules could introduce bias that erodes inspection quality by altering inspector stringency. Our analysis of thousands of food safety inspections reveals that inspectors are affected by the inspection outcomes at their prior inspected establishment (outcome effects), citing more violations after they inspect establishments that exhibited worse compliance levels or trends. Moreover, consistent with negativity bias, the effect is stronger after observing compliance deterioration than improvement. Inspection results are also affected by when the inspection occurs within an inspector’s day (daily schedule effects): inspectors cite fewer violations after spending more time conducting inspections throughout the day and when inspections risk prolonging their typical workday. Overall, our findings suggest that currently unreported violations would be cited if the outcome effects—which increase scrutiny—were triggered more often and if the daily schedule effects—which erode scrutiny—were reduced. For example, our estimates indicate that if outcome effects were doubled and daily schedule effects were fully mitigated, 11% more violations would be detected, enabling remedial actions that could substantially reduce foodborne illnesses and hospitalizations. Understanding and addressing these inspection biases can help managers and policymakers improve not only food safety but also process quality, environmental practices, occupational safety, working conditions, and infrastructure.

Article | Annals of Emergency Medicine

The Inpatient Discharge Lounge as a Potential Mechanism to Mitigate Emergency Department Boarding and Crowding

Brian Franklin, Sharif Vakili, Robert S. Huckman, Sarah Hosein, Nicholas Falk, Katherine Cheng, Maria Murray, Sheila Harris, Charles A. Morris and Eric Goralnick

Delayed access to inpatient beds for admitted patients contributes significantly to emergency department (ED) boarding and crowding, which have been associated with deleterious patient safety effects. To expedite inpatient bed availability, some hospitals have implemented discharge lounges, allowing discharged patients to depart their inpatient rooms while awaiting completion of the discharge process or transportation. This conceptual article synthesizes the evidence related to discharge lounge implementation practices and outcomes. Using a conceptual synthesis approach, we reviewed the medical and gray literature related to discharge lounges by querying PubMed, Google Scholar, and Google and undertaking backward reference searching. We screened for articles either providing detailed accounts of discharge lounge implementations or offering conceptual analysis on the subject. Most of the evidence we identified was in the gray literature, with only three peer-reviewed articles focusing on discharge lounge implementations. Articles generally encompassed single-site descriptive case studies or expert opinions. Significant heterogeneity exists in discharge lounge objectives, features, and apparent influence on patient flow. Although common barriers to discharge lounge performance have been documented, including underuse and care team objections, limited generalizable solutions are offered. Overall, discharge lounges are widely endorsed as a mechanism to accelerate access to inpatient beds, yet the limited available evidence indicates wide variation in design and performance. Further rigorous investigation is required to identify the circumstances under which discharge lounges should be deployed as well as how discharge lounges should be designed to maximize their effect on hospitalwide patient flow, ED boarding and crowding, and other targeted outcomes.

Keywords: health care delivery; emergency room; operations improvement; operations management; Health Care and Treatment; Service Delivery; Operations; Management; Performance Improvement; Service Operations;

Citation:

Franklin, Brian, Sharif Vakili, Robert S. Huckman, Sarah Hosein, Nicholas Falk, Katherine Cheng, Maria Murray, Sheila Harris, Charles A. Morris, and Eric Goralnick. "The Inpatient Discharge Lounge as a Potential Mechanism to Mitigate Emergency Department Boarding and Crowding." Annals of Emergency Medicine 75, no. 6 (June 2020): 704–714. View Details

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Discretionary Task Ordering: Queue Management in Radiological Services

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