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Chester Chambers
Maqbool Dada
Kayode Williams

Improving
Processes
for Health
Care Delivery
Lessons from Johns Hopkins Medicine
Improving Processes for Health Care Delivery
Chester Chambers • Maqbool Dada
Kayode Williams

Improving Processes
for Health Care Delivery
Lessons from Johns Hopkins Medicine
Chester Chambers Maqbool Dada
Carey Business School Carey Business School
Johns Hopkins University Johns Hopkins Hospital
Baltimore, MD, USA Baltimore, MD, USA

Kayode Williams
Anesthesiology & Critical Care Medicine
Johns Hopkins University, School of Medicine
Baltimore, MD, USA

ISBN 978-3-031-19042-1 ISBN 978-3-031-19043-8 (eBook)

https://doi.org/10.1007/978-3-031-19043-8

Mathematics Subject Classification (2020): 90B90, 90B22

© The Editor(s) (if applicable) and The Author(s), under exclusive license to Springer Nature Switzerland
AG 2022
This work is subject to copyright. All rights are solely and exclusively licensed by the Publisher, whether
the whole or part of the material is concerned, specifically the rights of translation, reprinting, reuse of
illustrations, recitation, broadcasting, reproduction on microfilms or in any other physical way, and
transmission or information storage and retrieval, electronic adaptation, computer software, or by similar
or dissimilar methodology now known or hereafter developed.
The use of general descriptive names, registered names, trademarks, service marks, etc. in this publication
does not imply, even in the absence of a specific statement, that such names are exempt from the relevant
protective laws and regulations and therefore free for general use.
The publisher, the authors, and the editors are safe to assume that the advice and information in this book
are believed to be true and accurate at the date of publication. Neither the publisher nor the authors or
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I have had many talents given to me and I
feel they are in trust. I shall not bury them but
give them to the lads who long for a wider
education.

Baltimore, MD Johns Hopkins

Foreword

Quality comes not from the inspection, but from improvement of the pro-
duction process.

William E. Deming

Dr.’s Chambers, Dada and Williams crafted a timely and excellent body of work pro-
viding real-time examples from a large, highly matrixed Academic Medical Center
of Johns Hopkins Medicine. Those of us buffeted by the winds of the current public
health crisis know all too well the collective challenge of caring for our patients in
health systems with high steady state bed utilization, emergency room wait times,
clinic visits delayed for months, and operating and recovery room holds. Our current
state was challenged by the crisis as we reconfigured care locations and provider
networks, and cancelled elective procedures to free up capacity, equipment, and
supplies to meet the increased and unpredictably fluctuating load of critically ill pa-
tients. With this in mind, innovation in hospital operational processes to improve
efficiencies of the system, while maintaining quality and outcome, would enhance
equitable access to care and better prepare for future public health crises.

Johns Hopkins University has a rich history as the first in the US to have a depart-
ment of Operations Research. The authors note the field of operations management
leverages work from industrial engineering, economics, and operations to provide
insight to how we think about a system and model the functions of hospital medical
operations— ultimately, improving efficiency and outcomes, reducing healthcare
waste and improving access.

Their work provides exemplars of health care practices in the inpatient and out-
patient settings. Our healthcare systems are complex, hence the application of sim-
ple methods to analyze and inform would not serve. They bring to light the nu-
ances of healthcare, taking into consideration the myriad, unique variables: multi-

vii
viii Foreword

ple care providers, varying geographics and disease prevalence, highly specialized
providers, patients with the complexity of chronic co-morbidities, multiple hand-
offs, and more. All are interrelated and affect throughput, requiring operational ef-
ficiencies to optimize utilization of system capacities. How do we predict the per-
formance of these complicated systems, patients, care providers, shared resources,
changes in payer and practices, and unanticipated strains on the system? Applica-
tions of the authors’ described foundational principles can provide insight to inform
strategy and tactics leading to improved efficiencies and predictability of perfor-
mance.

As the field moves forward, increased application of artificial intelligence tools

will engender a shared future where one could imagine every hospital’s operational
strategy based on a digital twin to inform ongoing decisions (Erol et al (2020)).
The creation of hospital digital twins could facilitate testing a system under varying
permutations of design and operations to better predict performance. Building on
the authors’ foundational principles, along with the further application of artificial
intelligence tools, will allow modeling of data in these complex systems, to better
position health systems to allow for planning and access to care at baseline and for
future public healthcare crises.

Gainesville, Florida, USA Coleen Koch, MD, MS, MBA

August 2022 Folke H. Peterson Dean’s Distinguished Professor
Dean, University of Florida College of Medicine
Preface

Its not a question if - just a question of when!

Regardless of current background, position, or demographic characteristics, a time

will come when you will be deeply concerned about the function of systems that
provide health care services. The person most directly involved may be you, but it
may be a parent, a child, a friend, or some other loved one. No life will escape the
need for a functioning system to deliver health related care. Thus, millions of hours
have been spent developing, managing, and working to improve the functioning of
such systems.

Early efforts to develop health care systems surely began before recorded history.
The desire to avoid or manage pain is instinctive to all sentient beings. The earli-
est writing that is commonly labeled as a medical text stems from six papyri from
ancient Egypt and date to between 2000 and 1500 BCE (Stiefel et al (1996), Cas-
tiglioni (2019)). These earliest recorded efforts include the use of herbs and practices
thought to be helpful based on series of recorded observations. The effectiveness of
such efforts was a mixed bag, but over time humans made more discoveries about
how different practices, and ingestion of various elements eased pain, or prolonged
life.

Much later, the enlightenment and the development of the scientific method
yielded more formal ways to experiment, test methods, and measure results in ef-
forts to identify better approaches. (Bernard (1957)) The need to co-locate varied
resources and newly discovered elements of care eventually led to the consolidation
of such efforts and the collection of resources in larger spaces that became formal
hospitals and clinics.

Beginning in the 19th century a various areas of engineering and applied math
were directed to the problem of building and managing the hospital and its housed

ix
x Preface

processes. The need to improve these systems was a primary driver of the first Amer-
ican universities that focused on research in addition to teaching. One of the earli-
est leaders in this regards was a small school in Baltimore, Maryland founded by
Johns Hopkins (French (1946)). This early medical school and associated collec-
tion of smaller schools was a leader in the creation of many practices still used
today including grand rounds, a system of interns and residents, and the formation
of specialties that focus on a subset of diseases or patients such as neurosurgery and
pediatrics (Long (1991)).

Efforts to make the hospital run better and serve a growing population quickly
included expertise from faculty with skills in engineering and mathematics. Con-
sequently, Johns Hopkins developed the first department in an American univer-
sity focused on what eventually become known as Operations Research in 1952
(Flagle (2002)). The tools developed in Operations Research departments included
such esoteric topics as Queueing theory, Discrete Event Simulation, and other forms
of mathematical modeling in which an abstract representation of an actual system
could be constructed and analyzed as part of the search for better ways to get things
done (Gass and Assad (2005)). Thus, the link between hospital operations and Op-
erations Research was institutionalized in the US. (Similar efforts took place simul-
taneously in the UK.)

The economic reality of the country evolved at the same time. In the early 1800’s
bartering for services was common because the typical worker had very limited abil-
ity to pay for health care delivery. At the same time, the skills and education needed
to deliver medical care grew rapidly as scientific approaches to care produced thou-
sands of new ideas, drugs, devices, and procedures. It quickly became very difficult
and time consuming for one to learn all that needed to be understood for the general
practice of medicine. The need for more devices, equipment, space, and training in-
evitably led to increases in both the quality of care and the cost to deliver it.

Social responses to increasing expenses included the rise of many benevolent so-
cieties, religious charities, insurance companies, and even government programs to
help individuals manage the cost of these essential services. Over time this industry
grew to become the largest single sector in the world’s largest economy and that
growth shows no sign of stopping in the foreseeable future. (CMS (2020), Loren-
zoni et al (2014)) Such growth has consequences not imagined in the 19th century.

Government efforts to deal with health care costs include ever expanding bodies
of regulations and a myriad of ways to restrict payments that are presented as efforts
to “manage” costs. The need for means to improve efficiency and manage costs are
readily apparent from consideration of a few simple facts. For full service hospitals
in the United States, the median profit per patient discharge is negative (-$82) (Bai
and Anderson (2016)). In other words, most hospitals lose money on the typical ad-
mitted patient. Administrators struggle not just to maximize patient satisfaction, but
to simply keep the doors open. Most rural areas have a shortage of care providers,
Preface xi

and almost every hospital administrator or clinic manager will report that the short-
ages of nurses (Lasater et al (2020)) and general practitioners (Majeed (2017)) show
no sign of relenting.

The high cost of inpatient care leads to increased demand for outpatient ser-
vices. The shortage and growing costs of providers for outpatient services drives the
search for increased throughput from fixed levels of resources. Consequently, the
role of engineers and mathematicians that was first seen in the early construction
of medical facilities emerges once again in a very different context. The engineers
needed to design the buildings and spaces must now be supplemented with those
needed to improve the processes that take place within those spaces.

This monograph is meant to be a small contribution to the body of knowledge

directed toward this endeavor. Over the past decade the authors have worked on
dozens of quality improvement projects, supervised many efforts to gather data on
system performance and quality, taught thousands of students from business and
medical disciplines, and constructed many models, cases, research publications, and
readings on this critical topic. All of this work has been carried out within the envi-
ronment of the world’s most famous hospital.

We make no claims to have all of the answers or even to fully understand all of
the many nuances of the problems. However, it does seem fair to say that the reader
may be aided by exposure to what we have witnessed, tested, and applied in this
setting.

Organization of Content

If we think about improving the operations function of a small to medium sized

service unit we can easily find recipes for the task as a series of simple steps. First,
define the processes in place to deliver the service and analyze them in terms of
resource usage, capacity, quality, and output. Assuming that pricing is exogenous
to the unit manager, (as is almost always the case in health care delivery) one then
focuses on the connections between the value delivered, and the cost incurred to de-
liver that value. Once this understanding is in hand we can compare the performance
of one unit to that of another as part of the mission to seek ways to improve one or
both parts of this performance metric.

Unfortunately, when we apply many common tools of this approach to the pro-
cesses of health care delivery, they often break down. This is not to say that the
inherent logic of process analysis, cost reduction, and performance measurement
do not apply in health care. Rather, we repeatedly find that special care and ad-
justments are needed in their application. For example, introductory approaches to
process analysis tend to focus on the identification of a bottleneck resource, and
a parallel search for sources of variability that can be eliminated. This approach
facilitates a matching of capacity to demand, and increases the efficiency and pre-
xii Preface

dictability of process performance. However, several distinctive characteristics of

health care services complicate this approach. These characteristics include patient
participation, simultaneity, perishability, intangibility, and heterogeneity (Fitzsim-
mons and Fitzsimmons (2006)).

To this list, we add two additional elements that we have found to be quite com-
mon. First, many resources are shared among an ever changing collection of jobs.
Resources float from room to room, or patient to patient with frequent interruptions,
repeating some tasks and splitting others into smaller parts that must be performed
by multiple specialized resources. The high division of labor in hospitals and the
hierarchical structures that result interfere with efforts to define, measure, and com-
pare performance. Therefore, improving these processes requires additional tools
and modified approaches are needed.

Second, the psychology and culture of health care providers is such that thinking
of cost reduction as a first priority is anathema to their nature. Few providers hold a
clear idea of what a process costs because their minds will not allow this consider-
ation to be their primary concern. Some providers simply refuse to speak in terms
of costs, because to do so feels like it is implicitly pricing human suffering. On the
other hand, administrators cannot escape the reality that most hospitals lose money
and that if no action is taken, they will cease to function. Costing is not widely un-
derstood in health care but the system will collapse if it is not addressed.

This complexity also affects the notions of quality of service and value of out-
comes. Health outcomes for the many must be balanced against attention to the
relative few who are on site right now in ways that effect health outcomes, costs,
waiting times, and many other elements of patient and provider experience. The fact
that outcomes lay along so many dimensions simultaneously makes simple metrics
such as profit and loss woefully inadequate. Again, this is not to imply that such
measurements are immaterial, but that their treatment must be managed in a style
that respects the context and culture of the industry.

After we do develop an understanding of process performance, quality, and costs

we can easily identify a set of issues to be addressed. With these issues in mind,
we will address new questions in the second phase of this text. How are we going
to make this system better? Can we identify an approach that can be replicated and
applied across systems with such complex issues and varying settings? It is clear
that managers need tools that are robust enough to be used in many settings, and yet
powerful enough to help get this job done.

This short book is a compendium of readings, examples, exercises, and case stud-
ies intended to help identify both areas in need of improvement, and some means
to bring that improvement about. In Chapter 1 we begin with a primer on basic el-
ements of Process Analysis with a special effort to place the terms, and approaches
within the context of Health Care Management. The reader will quickly realize that
Preface xiii

many complicating factors common in health care settings warrant additional tools
and adjustments to these generic approaches. Chapters 2 and 3 deal with tools to
help in this regard, and present examples to show why they are needed. More specif-
ically, Chapter 2 discusses simple tools including Gantt Charts and the Critical Path
Method as aids to presenting and understanding complex systems. Chapter 3 consid-
ers issues related to shared resources and schedules that can be repeated as cycles
throughout a session, or shift. Chapter 4 introduces Queueing theory as a way to
formalize the consideration of variability related to inter-arrival and activity times.
Chapter 5 wrestles with the question “how much will an episode of care cost?”
These 5 chapters constitute the first major section of the text.

With an understanding of this foundational material in hand, we turn to the ques-

tion of how to move from analysis to improvement. In Chapter 6 we lay out a frame-
work that has often helped us in this regard. A six step process is depicted to move
from process mapping to eventual process improvement. Technically speaking the
center piece of this methodology is the use of Discrete Event Simulation as a man-
agement tool. Consequently, Chapter 7 explores why this tool is needed, and what
types of insights it is likely to produce. Examples of implementations and issues un-
covered are interspersed in these chapters to highlight applications of the approach.
We conclude with a collection of case studies as Chapters 8 through 11 that relate
to major portions of the preceding chapters and help contextualize their application.

Readers are encouraged to work from start to finish. However, each chapter is
written with the idea that most people will pick and choose what is most relevant to
them at any point in time. Consequently, we have made an effort to allow each chap-
ter to serve as a stand alone reading on the relevant topic. This design results in a
bit of redundancy, but hopefully reinforces key messages without becoming tedious.

Background and Intended Audience

Over the past decade we have taught courses on Services Management, Health
Care Services, Fundamentals of Health Care Processes, Introductions to Process
Analysis, Business Analytics, and a host of Immersion courses focused on various
processes in the settings of clinics, hospitals, and insurers. In addition, we have
published a collection of works in various medical and business journals, and have
been involved in a host of quality improvement projects, business planning efforts,
and operational studies. Over the course of this work a guiding framework emerged
that can be taught and repeatedly applied in process improvement efforts (Dada and
Chambers (2019)). This framework and its associated readings, cases, assignments,
lectures, videos, and projects that we developed or led became the source content
for this text.

The primary audience for this text is students in courses similar to ours that may
be taught in schools of Business, Nursing, Medicine, and Public Health with a focus
on health care delivery processes. The first eight chapters easily map onto an 8 week
xiv Preface

course on the topic. We typically use one or more of the included case studies as an
end of course project or as part of a final exam. These cases fit most directly into
MBA, or MS programs on the topic. However, we strive to present the content in a
way that makes it accessible to undergraduate students in advanced electives as well.
A second audience includes administrators such as clinic managers, and department
heads working in this space.

The sequencing of the chapters is designed to fit within a course structure, but
each chapter stands on its own as a reference for anyone in need of one of the tools
discussed. While the work presents a variety of tools we note that the book is not
a substitute for more detailed training material on the most technical topics. The
primary example is the use of Discrete Event Simulation. Many other texts fill this
void. Our objective is to present the logic of the ideas and to explain their use.

We submit that any reader who has ever pondered questions like, “why is this
place so slow,” or “why is this charge so high” will benefit from exposure to this
material. We strongly suspect that this group includes anyone who has ever inter-
acted with this system at a stressful time, which is virtually everyone. Again, its not
a question of if you will ever be in that group - only one of when.

Finally, we wish to thank the hundreds of health care professionals involved in

our prior studies, projects, and publications that have led to this point. This includes
the technicians, nurses, doctors, administrators, and patients who allowed us to view
their activities and care. Thanks also goes to the dozens of readers, reviewers, and
presentation audience members who have added content, clarity, and focus.

Most importantly we thank our families who have suffered long hours as read-
ers, supporters, and sounding boards along the way. Chester Chambers particularly
thanks S, L, and C: the Queen of All, The Light of the World, and the Joyous Con-
tinuation respectively.

Maqbool Dada particularly thanks his wife Shamim and our children Natasha
and Myra for their love and support over many decades while tolerating innumer-
able long-winded discourses on all things academic.

Kayode Williams dedicates this work to his wife Oyinkansola without whose
love and support his career achievements would not be possible, their sons and
daughter-in-law, Olatunji and his wife Victoria, Oluwatomi, and their granddaugh-
ter, Rosie, all of whose enquiring minds have spurred his quest to acquire knowl-
edge.

Baltimore, MD, USA Chester Chambers

July 2022 Maqbool Dada
Kayode Williams
Prologue

As we seek to build intuition regarding the management of health care processes,

we must wrestle with the vastness of the system under study. For example, if one
looks into the breadth of the systems connected with Johns Hopkins medicine one
finds a vast array of outpatient clinics and surgical centers in the US that handle
almost a million patient visits per year, and hospitals that handle over 4 million vis-
its per year including more than 350,000 emergency department visits (Chambers
and Williams (2017b)). The system also includes hospital management and facili-
ties in China, Singapore, India, Japan, United Arab Emirates, Saudi Arabia, Turkey,
Lebanon, Pakistan, Chile, Peru, Mexico, Brazil, Panama, Columbia, and Canada. In
addition, the system adds insurance companies, and schools of medicine, nursing,
and public health.

In the consideration of such a large and complex network, it is imperative that we

focus on lessons and tools that are applicable across a plethora of settings. With this
in mind we will focus on smaller problems in proto-typical settings to help develop
insights that can be generalized and adjusted to fit whatever system you wish to im-
prove. It is instructive to focus on bite sized chunks of a care delivery system such
as a single clinic, emergency department (ED), operating room (OR) suite, hospital
ward, or hospital. Narrowing the focus facilitates calculations and allows for the ex-
ploration of small examples that can be created to convey key points.

Unfortunately, this approach flies in the face of the fact that health care is the
largest single industry in the world’s largest economy (for Economic Co-operation
and Development (2020)). As a result, it involves a vast network of facilities, staff,
physicians, and resources spread across almost every community. This vast land-
scape creates a multitude of hand-offs between units, and coordination among far-
flung agents. Any analysis of these parts suffers if connections to the rest of the
system are ignored. The simultaneous need to break large problems into manage-
able portions and to understand the nature of connections among system parts makes
the study of health care processes uniquely difficult and complex. With this in mind,
it is helpful to envision a virtual system that can serve as a microcosm of the larger

xv
xvi Prologue

reality. We will frequently refer to this mental model throughout the chapters that
follow.

Envision a large hospital located in a moderate sized city on the east coast of
the United States. Let us refer to this unit as Eastern University Hospital. We use
this construct as a literary device. While the bulk of our research and experience
has taken place within the Johns Hopkins system, Eastern is not intended to be a
replication of any particular clinic, ward, unit, or hospital. As a result, the problems
presented here are fully informed by our study of actual settings, but not meant to
be duplications of any singular unit. The data presented are a composite of sources
that we have gathered over the past 10 years.

Eastern happens to be a teaching hospital, meaning that many processes will in-
volve residents in addition to the nurses, clinical assistants, attending physicians,
and a host of technicians and other staff. We will consider patients entering Eastern
through at least 3 routes. Some patients will arrive at the ED. We will assume that
these patients arrive one at a time with random times between arrivals. We will also
assume that the ED has some fixed number of examination rooms, but we will treat
the waiting area as though it has infinite capacity. Most patients who enter via the
ED will later be discharged and sent home. However, some portion of these patients
will need to move to an OR suite. The OR suite will have a fixed number of rooms.
Most surgeries in this suite will be scheduled in advance (elective surgeries) whereas
those that stem from ED visits will not (emergency surgeries). After patients leave
the ED, they may travel to a ward such as medical, orthopedic, or neurology ward.
Other patients will be in critical condition and will be sent to an intensive care unit
(ICU). The ICU will have finite capacity as well.

Most patients who interact with Eastern will do so through the Eastern Hospital
Outpatient Clinic (E-HOC). This clinic deals with patients by appointment, and has
scheduled opening and closing times each working day. The vast majority of patients
that enter E-HOC will go home after their visit. However, it is possible that they
will need to move to an OR, ward, or very rarely the ICU. Managers at E-HOC
and other clinics routinely deal with the problem of developing, and fine-tuning an
appointment schedule. This schedule is designed to strike a balance between waiting
times and overtime operations for the clinic. Any patients still in the clinic at the
proposed closing time will be seen, meaning that the clinic does not really close
until all of the patients on the schedule have been treated.

0.1 A Patient’s Journey Through the Eastern University Hospital

System

Frank Caldwell resides in the same city as Eastern Hospital and is in generally
good health. Frank doesn’t think much about the health care system, even though
0.1 A Patient’s Journey Through the Eastern University Hospital System xvii

he recognizes it as the largest sector of the economy, and the largest employer in
his town. Frank has health insurance through his employer but hasn’t paid much
attention to its cost because he is young, he doesn’t use the system much, and his
co-pays are pretty low. One afternoon Frank suffers an injury to his right hand during
a pickup basketball game after work and decides to drive himself to the ED. This is
his entry point to the Eastern Hospital System.

0.1.1 Entry Through the ED

Frank has suffered an injury to his right hand during the pickup basketball game,
but has also had some pain in this hand before. He is pretty sure that this particular
injury is just a sprain, but the ED was close by and he wanted to be sure. Either
way, this is certainly not a life-threatening condition.1 As he enters the ED he sees
a line of 7 patients waiting in front of what looks like a Nurses’ station. Frank is
pretty sure that there are more than one of these stations but the others are around
the corner so he does not see exactly how many are in place. While he is waiting
he notices that patients are walking into the ED at a rate that he estimates to be
about 1 per minute. (actually 55 patients per hour.) During a short triage step that
takes roughly 4 minutes he is told that, typically 10% of the patients who enter the
ED are admitted to the hospital. The rest are released and go home; usually with a
prescription and some instructions about how to deal with the malady. Frank is told
that since his condition is not critical he will have a short wait before seeing the
doctor. He is also told that for patients who are admitted the time with the doctor
averages about 30 minutes, but for simpler cases like his it is likely to be around 10
minutes. Frank walks over to a waiting area and takes a seat. When he looks around
he counts 34 patients in the room with him. Frank is concerned that the wait will
be rather long, but is told that more than one doctor is in the ED that day; and that
the staff can process patients quickly enough to maintain a fairly stable number of
patients in the waiting room.

Frank also happens to be a fairly new student in an evening MBA program in

town, and recalls some readings about process management. He wonders if he can
figure out a few things about how this system is working. Like most patients he
is primarily worried about his health, but since he has a few minutes to think, he
wonders if he can determine how long the average patient spends in the ED, how
many doctors are working in the ED that day, and how many patients are in the ED
in total.

1 This vignette parallels a problem presented in Anupindi et al (1999) and will also be revisited in
the review material after Chapter 1.
xviii Prologue

0.1.2 Specialty Outpatient Clinic

It turns out that Frank has not broken any bones. However, the doctor recommends
that Frank visit Dr. Twofer, who is a specialist in sports medicine. This particular
specialist is renown for his use of arthroscopic procedures to remove floating bodies
in wrist and hand joints and the ED physician suspects that this issue is contributing
to Frank’s problems. However, before the procedure can be scheduled Frank will
have a visit to a clinic that this surgeon shares with several other physicians in the
Orthopedics department to determine whether the surgery is really necessary. Upon
arrival at the clinic, Frank checks in and is informed that, since this clinic is affil-
iated with a teaching hospital he will be seen by a resident first, before seeing Dr.
Twofer. Frank sees Dr. Twofer chatting on the phone in the hallway and wonders
why he has to wait. He is told that the doctor is on the phone getting information on
another case, and that Frank should not have to wait long because the resident and
the attending physician will work in parallel, at first, and then come back together
to complete Frank’s visit.

When Frank made this appointment several slots were available. Frank selected
the first appointment for the day hoping that this would minimize his waiting time.
He was surprised to find that another patient had the same appointment time that he
did, but the clinical assistant (CA) at the desk informed Frank that this was a normal
practice for this clinic. While standing at the desk Frank notices a template next to
the screen that the CA was viewing labeled “Appointment Schedule for Dr. Twofer”.
It looked something like this,

TABLE 1: A PPOINTMENT S CHEDULE FOR O RTHO C LINIC 1

Metric Average Value

New 1 8:00
Return 1 8:00
Return 2 8:30
New 2 8:50
Return 3 8:50
Return 4 9:30
New 3 10:10
Return 5 10:10
Return 6 11:30

As Frank looks over the scheduling template he thinks to himself, these people
make everything so complicated they can’t simply add two numbers together. Why
can’t they just have patients come in every half hour? They have 9 patients on the
schedule so they can easily finish at noon. It’s obvious to Frank that this would be a
0.1 A Patient’s Journey Through the Eastern University Hospital System xix

much simpler schedule and it would have to work better than the odd looking mess
posted here. 2

0.1.3 Procedure Capacity and Parallel Processing

At the end of the visit, Dr. Twofer schedules a simple arthroscopic procedure to
clean out some floating debris within Frank’s wrist. Dr Twofer is well known for
these procedures and has worked over the past 20 years to streamline his operating
process. In his consultation with the surgeon, Frank learns that the surgeon uses 2
rooms in a procedure suite at the same time. A patient is prepped, and positioned
in Room 1. This process, which takes 35 minutes involves one OR and the staff as-
signed to that case. Dr. Twofer then enters Room 1 and completes his portion of the
process over the next 25 minutes. After each case, it takes 15 minutes to clean the
room, but only 5 minutes for the surgeon to scrub and change gowns before moving
to Room 2 to work on the next patient, who is already prepped and ready by this
time. This cycle then repeats so that the surgeon can complete 3 surgeries in one
session. 3

Frank is curious about this odd process. It seems like a waste to assign 2 OR’s
to one surgeon who can only be in one place at a time. He once read that the OR
is among the most expensive resources in the hospital and thinks to himself, “no
wonder health care costs are so high”.

0.1.4 Patient Flows and Transfers Between Units

Frank’s time in the OR goes according to plan, but the effects of the anesthesia
linger much longer than is typical, and the surgeon believes that Frank should be
held overnight for observation. Dr. Twofer explains to Frank that this happens in
1 to 2% of his patients and is nothing to be alarmed about. Frank will wait in the
post-anesthesia care unit (PACU) until he is moved to a bed on one of the hospital
floors. Frank is still groggy but alert enough to ask how long it will be before he is
moved to a room. Dr. Twofer explains that it can take anywhere from a few minutes
to a few hours, and that the nursing staff will take care of him from here. The doctor
then moves on to the next case.

As Frank lies in wait in the PACU he gets a bit irritated thinking about the wait.
“This hospital has over 800 beds and I have to wait to find just one?” Frank vaguely
2 This schedule parallels that used in the clinic discussed in detail in Chapter 10, and is also
discussed in the review material after Chapter 3.
3 This vignette is inspired by that depicted in Bohmer et al (2007) and will be revisited in the

review material after Chapter 2.

xx Prologue

remembers that Eastern usually has an occupancy rate of around 70% (AHA (2017))
and wonders, “if 30% of 800 beds are empty, it doesn’t make any sense for me to be
waiting this long. There doesn’t seem to be any way to make sense of this mess.”

0.1.5 Billing and the Cost of Care

Frank is moved to a bed in the medical ward after a half hour or so and spends the
night. He is a little uncomfortable at first, but his medical symptoms dissipate over
the next 8 hours. By morning he is ready to go home and a nurse informs him that
he will be leaving soon. His surgeon comes by about 8 AM and tells Frank that he
is cleared to go. There are just a few administrative issues to work through and a
few forms to sign, but it shouldn’t take too long. For some reason that Frank doesn’t
understand his discharge is not completed until the middle of the afternoon.

About a week later Frank gets a statement from the hospital that shows costs
of $18,000. Stamped across the top of the statement is a note that reads, “THIS IS
NOT A BILL” but it sure looks like a bill to Frank. In the coming days Frank gets
a similar statement from the surgeon’s office and another from some anesthesiology
partnership. Frank is a little upset by these statements. When all of these charges are
totaled they are close to $30,000. Frank wonders if some of these “costs” occurred
because the hospital was so slow in moving him from the PACU to the bed, and then
not allowing him to go home as soon as he was ready. Eventually, Frank gets a bill
from his insurance provider. The bill shows the total charges of close to $30,000,
but it seems to indicate that the insurer pays roughly $12,000 and that Frank owes
about $600 of that amount. Frank doesn’t really understand what is going on here,
but he is so relieved that this $30,000 in charges translates to a $600 check from him
that he decides not to ask any questions. However, he does wonder how the hospital
can survive if the gap between its costs and revenues is that high.

0.2 Health Care Process Analytics

As we follow a patient’s journey through an episode of care we are struck by the

number of intersection points between the patient and the medical system. A sin-
gle event easily leads to interactions with an ED, a specialty clinic, a PACU, an
OR suite, a medical ward, and a billing system. This list omits the interactions with
pharmacies, counseling services, social workers, and government agencies that are
common when considering older patients who make up the bulk of the patient pop-
ulation.

In the coming pages we introduce a collection of tools, and observations used

to shed light on the myriad of questions that naturally arise through the patient’s
0.2 Health Care Process Analytics xxi

experience with this large, complex system. We will frequently refer to Frank’s story
to provide context to the discussion of a number of the analytical techniques that we
use. However, the larger issue is that these settings and problems are really mini-
laboratories in which we develop tools that can be applied generally to settings of
the reader’s interest.
Another random document with
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seemed crooked and out of shape. Other cottages were
scattered amongst the furnace débris, were built anywhere
and everywhere that a place could be found for them, on
different levels and in sundry nooks and corners of the hilly
waste.

Then she came to higher mounds still, and crossing

these she saw deep, black pools in their hollows, stretches
of dark, stagnant water, which never reflected anything that
was pretty or bright except the moon in God's pure heaven
above. Here and there some one, more thrifty than his
neighbours, had made a little garden in the waste; but what
could grow in such a smoky atmosphere and in such poor
and barren soil? A few struggling plants of the most hardy
kinds were all that the best garden in Daisy Bank could
produce.

Marjorie was glad to get back even to the dismal house

in which her lot was cast; it seemed almost cheerful to her
after the unkempt hideousness of its depressing
surroundings.

CHAPTER XII
BLACK COUNTRY ROSES

THAT first day at Daisy Bank was a fair sample of many

others which followed it. Bit by bit order was restored to the
once untidy and comfortless house. Mrs. Holtby's room was
made as sweet and cheerful as it was possible for any room
in such a neighbourhood to be; the floor was washed, the
carpet shaken, clean white curtains were hung in the
window, and fresh hangings on the bed; whilst upon the
table stood a vase, which was filled with spring flowers, a
constant supply of which was sent regularly by Phyllis from
the dear home garden.

Then Marjorie took another room in hand, and, with

Bessie's and Patty's help, worked the same reformation
there, and so by degrees the house looked more home-like
and far less dreary. But it was a hard life to which she had
come, and sometimes she felt inclined to despair.

Work as hard as she might, from early in the morning

till late at night, she could never keep pace with the darning
and patching, the clearing and dusting, which seemed
always waiting to be done. Her feet were weary with
running up and down stairs; her head ached with the noise
of the children, and at times she longed terribly for a single
day's holiday and rest; but of this she saw no prospect
whatever. Beyond a daily run over the pit mounds, she
never got out, and she saw no one in these walks to whom
she could speak. Her thoughts were her only companions,
and they were anxious ones at times.

The home letters sounded bright, as a rule, but now and

again some sentence in her mother's made her feel how
much she was missed there. Her own letters were as
cheerful as she could make them, although she wrote a
truthful account of the place to which she had come, for she
had promised her mother that she would do so.

As Marjorie wandered over the wilderness of ashes day

after day, she thought of them all and of her pretty home,
and a terrible yearning came over her to see them again,
and to look even for five minutes at the scenes she loved so
well. And then her thoughts would wander to Captain
Fortescue. She had kept her promise to him before leaving
home; she had written to tell him where she was going, but
she had never received an answer; sometimes she
wondered whether her letter had ever reached him. What
was he doing now? Had he left the army? Was he happy la
the new life upon which she supposed he must have
entered? She thought of his words to her mother,—

"I shall allow myself in no luxury until all is paid."

What a hard life that would mean, if he kept his word!

And she believed that he would keep his word; she felt that
he was a man to be trusted. Over and over again her busy
thoughts returned to this subject, and in her prayers for
those at home, his name was added. It could not be wrong
to pray for him, surely.

One day when spring weather was beginning, and when

even Daisy Bank looked a degree less dismal, Marjorie
found a friend. As she passed one of the tumble-down
cottages, she noticed an old man who was coming out of it
with a rose-tree in his arms, and then she saw that a row of
similar pots stood in the sunshine against the discoloured
wall of the house. The roses were just coming into leaf, and
she noticed that the old man was bending lovingly over
them, loosening the soil near their stems, and giving each
of them some water from a jug which was standing on the
doorstep. Marjorie felt that at last she had found something
in Daisy Bank at which it was pleasant to look. She went up
to the old man and admired his roses, and he showed them
to her with great pride, telling her the name and the colour
of each.

"Would you like to see my garden, miss?" he asked.

 He took her through the kitchen, which was quite clean,
although bare of paint and whitewash, and led her to the
back of his cottage. There he showed her his lawn, a tiny
strip of green about three feet long and two feet broad,
covered with grass. This he watered daily, to keep it from
being blackened by the smoke-laden atmosphere, and kept
it short by cutting it every evening with a pair of scissors.
He was intensely proud of it, however, and of a row of hardy
plants which were leading a struggling existence under the
wall of the house. London Pride was, perhaps, the only one
which did not appear to be depressed by its surroundings,
and which might justly have changed its name to Daisy
Bank Pride.

But the old man was proud of them all, and beamed
with delight when Marjorie stooped to examine them. That
tiny garden was the joy of his heart, as dear to him as the
lovely home garden had been to her, and quite as beautiful
in his eyes.

"It's a wonder that anything will grow here," she said.

"Ay, it's unlikely soil; but the Lord's plants do thrive

sometimes in that."

"Yes," said Marjorie, for she did not quite see what he
meant.

"There was old Dan'el in Babylon, and Obadiah, him as

lived in Jezebel's time, and there was saints in Nero's
household. They had bad soil, all of 'em, but they was
faithful 'trees of the Lord's planting,' that He might be
glorified."

And then Marjorie felt that she had found a friend. Old
Enoch would have been stamped as an ignorant man by
many, but he knew his Bible well, and could repeat much of
it by heart. It was his daily study, and he was taught by the
Spirit of God. Many and many a time, when things seemed
darker than usual, Marjorie would run in to see him, and
she always came away feeling brighter and better.

It was on the very day upon which she first made old
Enoch's acquaintance that, as she was going back to Colwyn
House, she had a great and most unexpected surprise.
Coming along the lane to meet her, and picking his way
amongst the pools which even the spring sunshine had not
dried up, she saw a well-known figure, and her heart
danced with joy at the sight, for it seemed to her like a bit
of home put down amongst the dreariness of Daisy Bank.

It was Louis Verner!

"Oh, Louis, how nice to see you!" she cried. "It is lovely
to see a home face!"

"I thought you would be pleased to see me, Marjorie.

I'm on my way home, and I thought I could tell them about
you."

"And you've come out of your way on purpose to see

me! How awfully good of you, Louis!"

"Not at all good; I wanted to come. Marjorie, you're

prettier than ever!"

"Don't talk such nonsense, Louis!" she said. "Tell me

about yourself. How have you been getting on?"

"Oh, fairly well, I think. We've had an awfully jolly term;

all sorts of things going on."

"And what are you going to be?"

 "Now, Marjorie, that's too bad! You said you would ask
me when you came home next."

"Very well, I won't scold you to-day, when you've been

so good as to come and see me. How long can you stay?"

"Only an hour."

"Will you come in?"

"I'd rather not," said Louis; "we can't talk if all those
people are there. Can't you come for a walk?"

"I'll ask Mrs. Holtby."

The permission was readily given; and Mrs. Holtby, who

was sitting up in her room, crept to the window, and peeped
through the blind with true feminine curiosity, to see who
was the friend from home with whom her much-valued
mother's help was so anxious to go out.

"A very particular friend, I should imagine," she said to

herself with a smile, as the two disappeared together over
the pit mounds.

"Marjorie," said Louis, as she joined him, "of all

detestable and hateful places on the face of this earth, I do
think Daisy Bank is the worst!"

"Don't be too hard on it, Louis! You should see it at

night, when the sky is lit up by the furnace lights. We have
constant illuminations here."

"I don't know what Mrs. Douglas will say when I tell
her."
 "Then you mustn't tell her, Louis. I shall be very angry if
you make it out blacker than it is."

"I couldn't do that," said Louis, laughing, "if I were to

try."

"Well, what does it matter, Louis? If I don't mind it, why

should anybody else?"

They came now to one of the large dark pools.

"What a ghastly hole!" he said. "Just the place to tempt

a fellow to commit suicide."

"Now, Louis! That is our best lake, the Derwentwater of

these parts."

"Derwentwater, indeed!" said Louis, scornfully. "Look

here, Marjorie! I don't like your being here at all."

"I assure you, Louis, there is no need to pity me."

Then Louis suddenly changed his tone.

"Marjorie."

"Yes, Louis."

"Why do you never write to me?"

"I haven't time, Louis; it's as much as I can do to write

home."

"But I do think you might write to me, because I am—

well, I really am awfully fond of you, Marjorie. Do you know
I like you better than any girl I know? Upon my word I do."
 "Thank you, Louis," said Marjorie, with a mock bow,
"that's a very pretty compliment."

"It isn't a compliment, Marjorie; at least I mean it's

quite a true one. Did you get the picture postcards I sent
you?"

"Yes, thank you, Louis; I asked mother, if she was

writing to you, to thank you for them."

"So she did; but I had rather have had a letter from
you, Marjorie."

They were walking towards the railway station when the

hour was over, and Louis's train was almost due, when he
said suddenly—

"Marjorie, I'm going away, and you haven't said

anything nice to me."

"Now that isn't a compliment!" she said, laughing again.

"Look, Louis! The signal is down; we must hurry."

They ran down the steps, and he had barely time to get
his ticket before the train came in.

As he jumped into the carriage, Marjorie could not help

wishing that she was going with him, or at any rate that she
was on her way to the same destination.

CHAPTER XIII
MOTHER HOTCHKISS
 As time went on, in spite of her hard work, Marjorie
began to feel not merely accustomed to the life at Colwyn
House, but really fond of the people with whom she lived.
Mrs. Holtby was very grateful for all that she had done for
them, and was willing to fall in with any suggestion that she
might make. Her health was gradually returning, and she
was able to come downstairs, and to relieve Marjorie of
several lighter duties.

As for Patty, she was Marjorie's firm ally and most

willing helper, and Marjorie rejoiced when she saw the look
of care departing from the child's face, as she realized that
the burden of the family no longer rested upon her
shoulders. The boys were at times exceedingly naughty and
troublesome, but the little ones were devoted to "Miss
Duggie" as they called her, and loved to sit on her knee
listening to Bible stories, or to children's hymns which she
sang to them. Their mother would often creep into the room
and listen too; she told Marjorie that it made her think of
her own mother, and of the lessons she had learnt long ago,
but which, alas she feared that she had forgotten.

On Sunday Marjorie took the elder ones to the church,

which stood on a hill overlooking the cindery waste, and
which could be seen from any part of its forlorn parish. Mr.
Holtby never went to any place of worship; both he and his
wife had fallen into careless ways, and had become
accustomed, after years of neglect, to regard Sunday as
little more than an excuse for a better dinner than usual,
and an opportunity for a certain amount of self-indulgence.

One day in the early summer, when the sun was shining
as brightly in Daisy Bank as in more favoured spots,
Marjorie was standing at old Enoch's door, once more
admiring his roses. They were actually coming into bud, and
the old man's excitement was great as he counted the
coming blossoms.

"The very first that comes out shall be for you, Miss
Douglas."

"Thank you, Enoch; I wonder which it will be."

"This Crimson Rambler, Miss, I believe. Look at it; you

can just see the colour coming in the bud."

"So I can!"

"Miss Douglas," the old man went on, "do you ever go
to see old Mother Hotchkiss?"

"What a name! No, I never heard of her."

"She lives in that old house down the lane; you must
have noticed it, surely; two big square windows, almost like
shop windows, and lots of nice plants in them."

"Oh yes, I know."

"Well, I wish you'd go and see her; I don't think she's

long for this world, and she's as ignorant as a heathen in
Africa."

"Poor old thing!"

"Ay! You may well say, 'Poor old thing!' Miss Douglas,
she knows nothing. She can neither read nor write, and as
for Scripture, why, a baby in yon schools over there knows
more about it."

"I'll go and see her, Enoch. Who looks after her?"

 "Nobody much; the neighbours go in a bit, and I do
what I can."

"Has she no one belonging to her?"

"She has a daughter, but she's married and away—a

pretty girl too. She went to this school, and she was a good
hand at learning, so I believe; they made her a pupil
teacher, and her mother wasn't half proud of her. But she
went to be a teacher up in the North-country somewhere,
and she got married there, and now I'm told that her and
her husband have gone abroad—and except Carrie, I don't
believe poor old Mother Hotchkiss has anybody else
belonging to her."

"It's a funny name," said Marjorie.

"You're right there, Miss; it's a gipsy name. There are a

lot of Hotchkisses about here; there's one street in
Wolverhampton full of them. This old body has gipsy blood
in her, if I'm not mistaken; she looks like it, anyhow."

The next day Marjorie fulfilled her promise to Enoch,

and knocked at the door of the house in the lane. The old
woman came to open it, with a red shawl over her head.

"Mrs. Hotchkiss," said Marjorie, "I've brought you a few

flowers that came this morning from my home in the
country."

"Are they for me?" said the old woman, stretching out
her hand eagerly for the moss rosebuds and mignonette.
"Come in, Miss. I've seen you pass; you're Holtby's girl,
arn't you?"

"Yes," said Marjorie, smiling to herself at her new name,

"and Enoch told me you were not well."
 "I'm very ill, Miss—awful bad, getting worse every day,
that's what I am."

Marjorie followed her through a large room with wooden

beams across the ceiling, and entered an inner room, larger
still.

"What a large house you have, Mrs. Hotchkiss!"

"Too large!" groaned the old woman. "It used to be a

farm."

"A farm here!" exclaimed Marjorie.

"Yes, long ago, in the old time when they hadn't found
the coal; it was all country here then."

"It looks like a very old house," said Marjorie, as she

noticed the overhanging chimney-piece with its long,
narrow shelf, on which stood a china tea-pot and various
other treasures. On either side of it was a deep recess or
chimney corner, in which were curious, ancient cupboards,
only about two feet in height, and having dark oaken doors.
Opening out of this large kitchen was a stone flight of steps,
leading down to an underground dairy, with three wide
shelves one above another. These, in the olden time, were
kept spotlessly clean, and were covered with large flat
bowls of milk and cream; but now they were thickly coated
with dirt, and were piled with all manner of rubbish.

The old woman could not talk for some time, for the
effort of going to the door had brought on a severe fit of
coughing, so, whilst she recovered her breath, Marjorie had
plenty of time to look round the room. It was frightfully
untidy and dirty, but that did not surprise her, for old Mrs.
Hotchkiss was too ill to do more than creep out of bed and
come downstairs to the fire, where she sat in an old
armchair with her feet on the fender.

"Have you been ill long?" she asked, when the old
woman was able to speak.

"Ever since Carrie went away. Not so bad as this,

though. I'm getting worse every day."

"May I come and see you sometimes?"

"Yes, my dear, do."

"Would you like me to read to you a little when I

come?"

"Ay, do; I can't read. There was none of this schooling

in my day, and it's lonesome sitting here and doing
nothing."

"Then I'll come to-morrow. I always get out about this

time, and I'll come as often as I can."

When Marjorie left old Mother Hotchkiss she looked at

her watch, and saw that it was time that she was going
home, as it was getting near teatime.

But, as soon as she opened the door of Colwyn House,

Bessie, who was cleaning the kitchen, left her work and
came to meet her. "There's a gentleman been here while
you were gone, Miss. He didn't look half sorry when I said
you was out. He said he would look if he could see you
about anywheres."

"Who was he?"

 "He didn't leave any name. He was an awful nice
gentleman, too!"

"Bessie, could you see that Mrs. Holtby gets her tea, if I
go to look for him?"

"Yes; I'll see to her."

Marjorie said to herself that Louis would be so

disappointed if he missed her, after again coming so far out
of his way to see her.

"Which way did he go, Bessie?"

"Well, I told him I thought you had gone Bradley way,

so I should think you'd find him somewhere over there. He
hasn't been gone long."

Marjorie hurried on over the muddy road, and then

climbed one of the highest mounds, that she might be able
to see in which direction Louis had gone. Yes, there he was,
crossing the opposite one, and coming to meet her.

But no; it was not Louis! Her heart heat quickly as she
saw who it was. It was Captain Fortescue!

"Miss Douglas! I've found you at last!"

"I am so sorry you have had such a hunt. Where have

you come from, Captain Fortescue?"

"Not Captain Fortescue," he said. "I have dropped that

title since I left the army. I am living in Birmingham now."

"Oh! So near as that? I mean I did not know you were

anywhere in this neighbourhood," she explained.
 "Yes; I have been in Birmingham a fortnight now. Thank
you for keeping your promise, Miss Douglas."

"Oh! Then you did get my letter?"

"Yes, I did. I meant to answer it when I could tell you

what I was going to do, and then I found that Birmingham
was to be my headquarters, so I thought I would come and
answer it by word of mouth."

"What are you doing in Birmingham?"

"I'm an agent for a large insurance company. I think I'm

very fortunate to get anything to do so soon—it's a pretty
good appointment, too. I hope each quarter to be able to
send a small instalment to Rosthwaite, Miss Douglas."

"It is very good of you," she answered; "but I do hope

you are not stinting yourself by doing so. It troubles me
very much when I think that you are."

He gave her a pleased, grateful look as she said this.

"Now, Miss Douglas, you are never to trouble about me

again. I have given up smoking, and one or two little things
that I am all the better without, but, beyond that, I assure
you I am not straitened in any way. How could I take a nice
holiday like this, if I were short of money?"

"I'm afraid it is not a very pleasant place for you to

come to for a holiday," she said, laughing.

"It doesn't quite come up to our last walk together."

"Where was that? Oh, I remember. Up to Seatoller and

Honister. How far away it all seems!"
 "How is old Mary? How does she get on without you?"

"Oh! Poor old thing. Mother goes to see her when she
can. I've just found an old woman here, Captain Fortescue."

"Have you? Is she like old Mary?"

"Oh dear no! A poor dirty old woman, half a gipsy, I

think; but I'm glad to have some one to go and see."

They were standing now beside one of the dismal

ponds, in which a number of ragged boys were wading.

"Miss Douglas," he said, "I am going to ask you a

question, and I want a truthful answer. I know you will give
me one."

"How awfully solemn it sounds!" she said, laughing.

"Nothing very dreadful, I hope?"

"No, not dreadful, but something I want very much to

know. Are you happy here?"

"Oh yes!" Marjorie said. "I think I can truthfully say that
I am. Of course it is a very busy life; but I'm getting fond of
the people, and it is far better than I expected it would be."

"Thank you," he said. "Now I wonder if you would mind

doing something else for me?"

"I will if I can, Captain Fortescue."

"Will you tell me exactly what your life here is? Take an
ordinary day, yesterday, for instance. Tell me what time you
got up and went to bed, and give me a sketch of the day."

She did as he asked her, in as lively and cheerful a way

as she could, making the best of everything, and dwelling
very little on the discomforts of her life, or on the hard work
which she had to do.

"Thank you," he said again, when she had finished. "I'm

afraid you will think me awfully inquisitive, but I had a
reason for wishing to know."

"A reason, did you say? What was it?"

He hesitated a little before answering her.

"Never mind," she said. "Don't tell me, if you had rather
not."

"Oh, I don't mind your knowing, if you don't mind my

telling you, Miss Douglas. You see, I sometimes—I often
think of you, and wonder what you are doing—and now I
shall be able to picture it out."

They walked on without speaking for a minute or two

after that, and then he looked at his watch and said he
must catch the next train at Deepfields, as that was the
best way to get back to Birmingham, and as the station was
some way off he would have to go in that direction.

"What a long way for you to go back!" he said suddenly.

"Don't come any farther."

"Do let me come," she said. "I so seldom have any one
to talk to."

They spoke of many things after that, and the time

seemed to fly all too quickly.

"I have enjoyed my holiday very much," he said, as

they stood on the platform waiting for the train. "May I give
you my card? That is my address in Birmingham. Now, you
made me a promise when we said good-bye last, and I
want you to make me another promise now."

"What is it?" she asked.

"It is this; that if you are in any difficulty or trouble, if

things don't go happily in any way, you will write to me or
come to me. Will you promise?"

"Yes, I will."

"Thank you. Good-bye."

He jumped into the train as he said this, and she stood

watching on the platform till it was out of sight.
 CHAPTER XIV
THE OLD OAK CUPBOARD

THE year was passing on; day after day, week after
week, month after month, following each other in quick
succession, and Marjorie was keeping a private calendar of
her own, and counting the days that must still pass before
Christmas came, when she was to go home for her first
holiday.

Daisy Bank did not alter much with the changing

seasons: there was very little to mark the progression of
spring, summer, and autumn. Barely a tree was in sight,
and the few that were to be found were so stunted,
blighted, and covered with smoke that the spring freshness
of their leaves lasted but a few days. Upon the mounds
grew a few coarse daisies—at least, the children called them
daisies; they were a kind of feverfew with a daisy-like
flower. Nothing else would grow there, which is perhaps why
the place got its name, a name which had at first appeared
to Marjorie to be utterly unsuitable.

During all the summer months and throughout the early

autumn, her life had been most uneventful and
monotonous. There was the daily routine of household
duties, "the common round, the daily task," but nothing
more. No one else came to see her, and from that day in
June, when he had stepped into the Birmingham train, she
had seen and heard nothing more of Captain Fortescue. She
always thought of him by his old name, even though she
knew that he had dropped the title.
 The arrival of the home letters was the great event of
Marjorie's week, and she read and re-read them until she
almost knew them by heart. They made her home-sick at
times, but she fought bravely against the feeling, and
looked on hopefully to Christmas.

All this time, old Mrs. Hotchkiss had been growing more
and more feeble, and as autumn advanced, she was quite
unable to leave her bed. A rough girl of sixteen, who lived
next door, waited upon her, and she seemed to have plenty
of money to pay her, and she was never behind-hand in her
rent. How she lived, Enoch did not know; he told Marjorie
that she used to be very badly off, and that he had often
seen her scraping up the cinders on the ash-heaps, but he
fancied that now Carrie must be sending her money, as she
seemed to have sufficient for all she wanted. Marjorie often
took her soup, and milk puddings, which Mrs. Holtby was
pleased that she should make for her, and she was always
grateful for these. She much enjoyed hearing Marjorie read,
and a feeble glimmer of light seemed to have penetrated to
her poor dark soul.

But one day, late in October, when Marjorie went to see

her, she found the old woman crying and evidently in great
trouble.

"What is it, Mother Hotchkiss?"

"The doctor has been," she said, "and he says as how I

won't be long now. I heard him tell Anna Maria when she let
him out."

"Well, don't cry," said Marjorie; "you know what I told

you when I was here last."

"Yes, I think of it all the time."