Time and Patient$

UNIVERSITY PARK, Pa. -- The "bad guys" in Jonathan Clark's video game are not gun-wielding guerillas, fire-breathing dragons or flesh-eating zombies. Instead, the "antagonists" are wasted time, lost customers and reduced profits.

In the summer of 2013, Clark -- assistant professor of health policy and administration and executive director of the Master of Health Administration (M.H.A.) program -- piloted a video game in his online M.H.A. class HPA 897A, Healthcare Operations Management. He is using the game again this semester as part of his resident M.H.A. version of the class. The setting of the game is a walk-in physician clinic; the goal is to optimize the clinic's operations to ensure patient satisfaction and maximize profits.

Clark developed the game -- called Time and Patient$ -- in collaboration with Chris Stubbs and Zac Zidik of Penn State's Educational Gaming Commons office and Wendy Mahan, senior instructional designer in the College of Health and Human Development. The services of the Educational Gaming Commons office are available to any faculty member, staff member, or student who is interested in developing unique learning tools.

"Time and Patient$ allows students to apply the principles they learn in two areas in my course," said Clark. "The first is general process analysis, which provides basic tools for evaluating and analyzing processes to identify problems and guide process-improvement efforts. The second is queuing theory, which provides a framework for understanding, evaluating, and managing the patient experience in the context of waiting in line.

According to Clark, the students' assignment was to play the video game as much as desired and then to write a reflection on the experience.

For the fun of It

For players, the video game begins when the clinic opens its doors on Monday morning. Patients begin to trickle in. Some are seen by doctors or nurse practitioners right away; others sit patiently in the waiting room. As time passes, the clinic becomes busier and busier. Patients with simple problems are dealt with in a few minutes; those with complicated problems demand more attention. A few patients grow weary of waiting, so they get up and leave. Two nurses take breaks. A new doctor begins her shift. By closing time, the clinic has met its profit goal, but not its patient satisfaction goal. On the whole, at the beginning of the game the clinic is not performing well. The student’s challenge is to change that.

The simulation, which covers 10 shifts over five "days," is designed so that players can control all of the clinic's operations, from the number of doctors and nurses on staff, to the time it takes for each patient to be seen. Players even can decide whether or not the waiting room will have an aquarium or coffee service, which might make waiting more pleasant. A "leader board" enables players to compare their performance with one another.

"I got very wrapped up in the game," said Meredith Mills, an online M.H.A. student living in Hershey, Pa. "I might have gotten a little overly competitive. I spent over five hours straight one day just perfecting my options, until I was the most profitable."

Another online M.H.A. student Kevin Lynch, of Falmouth, Mass., said the Yammer discussions the students had about the game became charged with friendly competition. For example, take this Yammer excerpt posted by student Jeanine Fadeley, an online M.H.A. student from Syracuse, N.Y., and directed at Lynch:

Okay, I concede to your victory. I cannot get Friday PM to be profitable. I am $148 off and I have taken away options and it effects the high volume days, which impacts my revenue and satisfaction at a greater extent. I fired the analyst since I got what I needed from it and it did get me a bit closer but still not in the green. I cannot lower the exam rooms or decrease any other amenities because again, the trade off is too high on higher volume days. My satisfaction scores are very high and, therefore, although you are making a higher profit, I'm poised for growth. (So, I still win.) Just kidding.

Lynch's response, directed at the whole class:

Does anyone know a good audiologist? I can't seem to hear Jeanine talking trash anymore!

"Allowing the students to communicate with one another on Yammer while playing the simulation increased their enjoyment," said Wendy Mahan, an instructional designer for the college. "The students shared strategies and questions, and occasionally some good-natured ribbing. In reading through their posts on Yammer, it was clear that they were having a good time."

Mills noted that the obsession she developed with the game was a reminder to her about why she avoids video games in general. "At least this was educational and also very applicable to real-life operational management situations," she said.

"Real-World" Experience

According to Chris Stubbs, a project manager for the Educational Gaming Commons office, part of the goal of Penn State's M.H.A. program is to prepare students for a world in which they are going to have to think on their feet and respond to unexpected challenges.

"As we worked with Jonathan [Clark] and several other faculty members within the program, it was clear that they were looking for ways to push their students to think critically, but creatively, about the ways they approach and solve problems of practice," he said. "Time and Patient$ is important because, as an educational tool, it allows students to engage in the kinds of active thinking and analysis that are so important to successful practitioners, and are at the core of the program itself."

Stubbs noted that video games are good learning tools because they let players experiment, fail, and try again in a safe environment. "Often in education we reward 'the right answer' and we penalize everything else," he said. "But when you remove the penalties for being wrong, you encourage people to take what they've learned and experiment—to apply their learning in unique ways. That kind of synthesis and problem solving is what we ultimately want to see in our graduates because that will lead to success in a world that often does not simply have one right or wrong answer."

Since the video game is set up from the viewpoint of an operations manager, it provides opportunities for students to make multiple decisions and to see how their choices can have a far-reaching impact.

"The simulations that we work on, in general, encourage active learning in an environment that represents the 'real world,'" said Mahan. "The problems are relevant to the students' current positions or to the positions they hope to obtain with their degree."

Clark noted that one of the main lessons his students learned from playing Time and Patient$ was how difficult and complex managing a clinic can be. "Players control the schedules of workers; they hire and fire people; and they even apply the principles of the psychology of waiting by changing the appearance and amenities available in the waiting room," he said. "Then they observe the effects of those decisions on performance, and respond accordingly."

Mills said she appreciated the flexibility the game provided. "I liked that you could pull different 'levers' to affect the patient outcome, and that I didn't always know which levers would affect the patient in a positive or negative way."

Next Steps

Stubbs said that a challenge in developing the game was that it was set up around the freedom to choose. "The freedom to choose is a double-edged sword in games," he said. "It can be wonderful and motivating for the player, but it is also very tricky to design. The more choices you offer the player, the more likely it is that someone will do something you would never have anticipated. It requires a lot of testing and balancing to make sure you create a game that is challenging for the player, but open enough to allow you to succeed using multiple different strategies."

Despite these and other challenges, Clark said the video game has provided his students with everything he had hoped it would and more; however, he sees some areas where the game can be expanded to include additional lessons.

"Ultimately, the vision is to go beyond just one walk-in clinic to include an entire health system with other clinics, hospitals, and outpatient centers," he said. "We may even include multiple competitor health systems, which would allow students to apply competitive analysis and marketing techniques."

Stubbs added that another idea the team has discussed is the possibility of adding more social elements to the game; for example two classmates might run separate clinics in the same fictional place, competing for a finite supply of patients.

But, as it stands, the game succeeds at challenging students to think through the various types of scenarios that occur in the real world.

"In today's health care environment one of the biggest challenges is how to respond to the external downward pressure on revenues while maintaining employee engagement and patient satisfaction," said Lynch. "We were given an opportunity to develop our strategic thinking skills and to 'see' the results we could expect based on our ability to request, analyze, and interpret data. But, most importantly, the game reinforced to me that we must approach health care delivery as a team and that each member of the staff, from the receptionist to the biller, brings value."

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Assistant Professor
Health Policy Administration

Last Updated March 18, 2014