Improving operational effectiveness of tactical master plans for emergency and elective patients under stochastic demand and capacitated resources

This paper develops a two-stage planning procedure for master planning of elective and emergency patients while allocating at best the available hospital resources. Four types of resources are considered: operating theatre, beds in the medium and in the intensive care units, and nursing hours in the intensive care unit. A tactical plan is obtained by minimizing the deviations of the resources consumption to the target levels of resources utilization, following a goal programming approach. The MIP formulation to get this tactical plan is specifically designed to account for emergency care since it allows for the reservation of some capacity for emergency patients and possible capacity excess. To deal with the deviation between actually arriving elective patients and the average number of patients on which the tactical plan is based, we consider the possibility of planning a higher number of patients than the average to create operating slots in the tactical plan (slack planning). These operating slots are then filled in the operational plan following several flexibility rules. We consider three options for slack planning that lead to three different tactical plans on which we apply three flexibility rules to get finally nine alternative weekly schedules of elective patients. We then develop an algorithm to modify this schedule on a daily basis so as to account for emergency patients’ arrivals. Scheduled elective patients may be cancelled and emergency patients may be sent to other hospitals. Cancellation rules for both types of patients rely on the possibility to exceed the available capacities. Several performance indicators are defined to assess patient service and hospital efficiency. Simulation results show a trade-off between hospital efficiency and patient service.     

An integrated simulation-optimization framework for the operational planning of seaport container terminals

In this article the operational planning of seaport container terminals is considered by defining a suitable integrated framework in which simulation and optimization interact. The proposed tool is a simulation environment (implemented by using the Arena software) representing the dynamics of a container terminal. When the system faces some particular conditions (critical events), an optimization procedure integrated in the simulation tool is called. This means that the simulation is paused, an optimization problem is solved and the relative solution is an input for the simulation environment where some system parameters are modified (generally, the handling rates of some resources are changed). For this reason, in the present article we consider two modelling and planning levels about container terminals. The simulation framework, based on an appropriate discrete-event model, represents the dynamic behaviour of the terminal, thus it needs to be quite detailed and it is used as an operational planning tool. On the other hand, the optimization approach is devised in order to define some system parameters such as the resource handling rates; in this sense, it can be considered as a tool for tactical planning. The optimization procedure is based on an aggregate representation of the terminal where the dynamics is modelled by means of discrete-time equations.     

Simulation based analysis of patient arrival to health care systems and evaluation of an operations improvement scheme

Various demands of different patients over both medical resource and time domains in health care systems raise requests of strategies for balanced system capacity from an operations perspective. In this paper, a quantitative modeling technique with both patient arrival and associated treatment process integrated are used to characterize health care system performance and evaluate system efficiency. The patient arrival process is described as a dynamic random Poisson process and patient treatments are characterized as consumption processes of various health care resources over time with a view of the “product line” used. The waiting time of patients and usage of health care resources are proposed as system performance measures based on their means, variances, and confidence intervals. A simulation considering patients with several various diseases is given to find a mechanism of conflicting factors in decisions of balanced system capacity, and an operation scheme of “evenly balanced load for bottlenecks” is obtained based on analysis of simulation outputs. Simul8 provides the software environment for the simulation.     

Combining simulation and goal programming for healthcare planning in a medical assessment unit

This paper describes a detailed simulation model for healthcare planning in a medical assessment unit (MAU) of a general hospital belonging to the national health service (NHS), UK. The MAU is established to improve the quality of care given to acute medical patients on admission, and to provide the organisational means of rapid assessment and investigation in order to avoid unnecessary admissions. The simulation model enables different scenarios to be tested to eliminate bottlenecks in order to achieve optimal clinical workflow. The link between goal programming (GP) and simulation for efficient resource planning is explored. A GP model is developed for trade-off analysis of the results obtained from the simulation. The implications of MAU management preferences to various objectives are presented.     

The impact of managerial and organizational aspects on hospital wards’ efficiency: Evidence from a case study

In spite of its acknowledged relevance, the impact of managerial and organizational aspects on hospital wards’ efficiency has been so far overlooked by the literature. In order to explore this issue, this paper presents a model of the relations between the decision making process of a hospital ward and its technical efficiency. In order to test the model, a two-step approach has been adopted. In the first step the technical efficiency of wards belonging to a large Italian Hospital Enterprise has been calculated using DEA. In the second step, efficiency scores have been regressed on a set of variables capturing managerial goals and actions internal to the ward, as well as re-organizations imposed by the hospital central management. Responses to a questionnaire administered to the heads of ward were used to build the independent variables. Results show that both decisions internal to the ward and exogenous re-organizations affect the ward’s efficiency, and suggest that these variables are more significant in explaining efficiency than environmental ones.     

Fixed cost and resource allocation based on DEA cross-efficiency

In many managerial applications, situations frequently occur when a fixed cost is used in constructing the common platform of an organization, and needs to be shared by all related entities, or decision making units (DMUs). It is of vital importance to allocate such a cost across DMUs where there is competition for resources. Data envelopment analysis (DEA) has been successfully used in cost and resource allocation problems. Whether it is a cost or resource allocation issue, one needs to consider both the competitive and cooperative situation existing among DMUs in addition to maintaining or improving efficiency. The current paper uses the cross-efficiency concept in DEA to approach cost and resource allocation problems. Because DEA cross-efficiency uses the concept of peer appraisal, it is a very reasonable and appropriate mechanism for allocating a shared resource/cost. It is shown that our proposed iterative approach is always feasible, and ensures that all DMUs become efficient after the fixed cost is allocated as an additional input measure. The cross-efficiency DEA-based iterative method is further extended into a resource-allocation setting to achieve maximization in the aggregated output change by distributing available resources. Such allocations for fixed costs and resources are more acceptable to the players involved, because the allocation results are jointly determined by all DMUs rather than a specific one. The proposed approaches are demonstrated using an existing data set that has been applied in similar studies.     

Developing a platform for comparison of hospital admission systems: An illustration

There is an increasing need to develop a platform for comparing hospital admission planning systems due to a shift in the service paradigm in the health sector. The current service concept of hospital admission planning aims at optimising the use of scarce hospital resources without paying much attention to the level of service offered to patients. As patients nowadays do not accept long waiting times for hospital admission, it becomes necessary to consider alternative admission service concepts. Waiting lists have also become a political issue, and alternative concepts have been advocated such as giving all patients an appointment for admission. A simulation model was built to examine the impacts of extreme admission service concepts in a simplified hospital setting. The alternative concepts considered are based on the ‘zero waiting time’ principle (immediate treatment), and the ‘booked admissions’ principle (using an appointment for admission). The results of these admission service concepts are compared with the results of the current concept, based on the ‘maximising resource use’ principle. The paper deals with the development of a framework and tool that allows evaluating different, somehow conflicting, hospital admission planning concepts and the usefulness of such framework and tool for more refined/real-life approaches to hospital admission planning.     

Modelling the size and skill-mix of hospital nursing teams

Previously published work has described the development of a hospital capacity simulation tool, PROMPT. PROMPT has now been adopted by a number of hospitals in the UK and is used for both strategic and operational planning and management of key hospital resources. The work, as presented here, extends the PROMPT functionality to consider in more detail workforce issues. In particular, working with some of the current hospital users, the research has focussed on detailed planning for calculating the size and skill-mix of inpatient nursing teams. The chosen methodology utilizes both simulation and optimization. Outputs from the PROMPT three-phase discrete event simulation are fed into a stochastic programme which suggests the optimal number of nurses to employ (whole time equivalents) by skill-mix and the corresponding numbers by shift. A novel feature of the tool is the ability to predict and compare nursing needs based on different methods of capturing patient-to-nurse ratios as currently adopted across the UK National Health Service. Illustrative results from one hospital demonstrate that although the overall sizes of nursing teams on different wards are of an acceptable level and comparable to the outputs from the simulation phase of the work, often the number of nurses employed at different grades is not well matched to patient needs and the skill-mix should be reconsidered. Results from the optimization phase of the work suggest that it is cost beneficial to increase the number of permanently employed nurses to account for fluctuations in demand and corresponding high costs of temporary (agency) nurses. The scenario functionality of the tool permits for the study of changing size and skill-mix as a consequence of changes in patient volumes, patient case-mix, numbers of beds and length of stay.     

An evaluation of the applicability of system dynamics to patient flow modelling

The objective of this research is to determine whether Systems Dynamics (SD) is a beneficial method for modelling hospital patient flow from a strategic planning perspective. While discrete event simulation has frequently been used as a tool for analysing and improving patient flow in health care settings, the desire to assess and understand patient flow and resource demand from a more strategic, and therefore aggregate, perspective led to the use of SD. To evaluate the suitability of such an approach, a model was developed in collaboration with the General Campus at The Ottawa Hospital with particular attention paid to the delays experienced by patients in the emergency department. The modelling techniques used, model validation and scenarios tested with the model are discussed, accompanied by comments regarding the appropriateness of SD for such a model.     

Assessing the technical and allocative efficiency of hospital operations in Greece and its resource allocation implications

In this paper, we seek to develop a research framework concerning the assessment of the efficiency of public sector hospital operations. Public hospitals are increasingly under pressure to improve their operations both in terms of resources they use and also in terms of the quantity and quality of their outcomes. The assessment of efficiency entails both the notions of technical and allocative efficiency as they yield complementary information about the management effectiveness of individual hospitals. Technical efficiency has a diagnostic purpose as it yields comparative information about the effectiveness with which individual units convert their input resources into outputs. On the other hand allocative efficiency has a planning orientation since the objective of the assessment is to gauge efficiency improvements by means of resource reallocation. A linear programming based model is proposed for assessing allocative efficiency in the light of uncertainty about the prices of input factors. The empirical part of the paper is based on data from Greek public hospitals. Results and policy implications are discussed based on data from 98 general hospitals based on information from 1992. It was found that significant inefficiencies are present in the operations of Greek hospitals that account approximately for 100 MEcu in 1992 prices.     

Simulation optimization for an emergency department healthcare unit in Kuwait

This paper integrates simulation with optimization to design a decision support tool for the operation of an emergency department unit at a governmental hospital in Kuwait. The hospital provides a set of services for different categories of patients. We present a methodology that uses system simulation combined with optimization to determine the optimal number of doctors, lab technicians and nurses required to maximize patient throughput and to reduce patient time in the system subject to budget restrictions. The major objective of this decision supporting tool is to evaluate the impact of various staffing levels on service efficiency. Experimental results show that by using current hospital resources, the optimization simulation model generates optimal staffing allocation that would allow 28% increase in patient throughput and an average of 40% reduction in patients’ waiting time.     

Deterministic Mathematical Modelling for the Spatial Allocation of Multi-Categorical Resources: with an Application to Real Health Data

This paper presents some mathematical formulations of deterministic non-linear optimization models for planning the spatial distribution of public service facilities and their utilization. The modelling is performed as a function of multi-categorical resource types and the consumer's zone of residence over a large geographical domain. The mathematical solution to the deterministic model, its parameter estimation by log-linear regression, and some preliminary results of simulation for a Massachusetts hospital database are presented.     

Branch-and-price approach for the multi-skill project scheduling problem

This work introduces a procedure to solve the multi-skill project scheduling problem (MSPSP) (Néron and Baptista, International symposium on combinatorial, optimization (CO’2002), 2002). The MSPSP mixes both the classical resource constrained project scheduling problem and the multi-purpose machine model. The aim is to find a schedule that minimizes the completion time (makespan) of a project, composed of a set of activities. In addition, precedence relations and resources constraints are considered. In this problem, resources are staff members that master several skills. Thus, a given number of workers must be assigned to perform each skill required by an activity. Practical applications include the construction of buildings, as well as production and software development planning. We present a column generation approach embedded within a branch-and-price (B&P) procedure that considers a given activity and time-based decomposition approach. Obtained results show that the proposed B&P procedure is able to reach optimal solutions for several small and medium sized instances in an acceptable computational time. Furthermore, some previously open instances were optimally solved.     

Scheduling projects with heterogeneous resources to meet time and quality objectives

In service organizations, heterogeneity in workforce skills can lead to variation in end-product/service quality. The multi-mode, resource-constrained, project scheduling problem (MRCPSP), which assumes similar skills among resources in a given resource pool, accounts for differences in quality levels of individuals by assigning different activity durations depending on the skill level used. This approach is often inadequate to model the problem type investigated here. Using typical projects from the customer training division of a large telecommunications company (which motivated this research), a labor assignment problem using a successive work–time concept is formulated and solved using integer programming optimization procedures. The setting represents a multiple-project environment where projects are separate and independent, but require the same renewable resource mix for their completion. The paper demonstrates how the output of the model can be used to identify bottlenecks (or critical resource skills), and also demonstrates how cross-training the appropriately skilled groups or individuals can increase throughput. The approach guides decision-making concerning which workers to cross-train in order to extract the greatest benefits from worker-flexibility.     

Dimensioning hospital wards using the Erlang loss model

How many beds must be allocated to a specific clinical ward to meet production targets? When budgets get tight, what are the effects of downsizing a nursing unit? These questions are often discussed by medical professionals, hospital consultants, and managers. In these discussions the occupancy rate is of great importance and often used as an input parameter. Most hospitals use the same target occupancy rate for all wards, often 85%. Sometimes an exception is made for critical care and intensive care units. In this paper we demonstrate that this equity assumption is unrealistic and that it might result in an excessive number of refused admissions, particularly for smaller units. Queuing theory is used to quantify this impact. We developed a decision support system, based on the Erlang loss model, which can be used to evaluate the current size of nursing units. We validated this model with hospital data over the years 2004–2006. Finally, we demonstrate the efficiency of merging departments.     

Multi-objectives Tabu Search based algorithm for progressive resource allocation

Military course of action planning involves time and space synchronization as well as resource and asset allocation. A mission could be seen as a defined set of logical ordered tasks with time and space constraints. The resources to task rules require that available assets should be allocated to each task. A combination of assets might be required to execute a given task. The couple (task, resources) constitutes an action. This problem is formulated as a multi-objectives scheduling and resource allocation problem. Any solution is assessed based on a number of conflicting and heterogeneous objectives. In fact, military planning officers should keep perfecting the plan based on the Commander’s criteria for success. The scheduling problem and resource allocation problem are considered as NP-Hard Problems [A. Guitouni, B. Urli, J.-M. Martel, Course of action planning: A project based modelling, Working Paper, Faculté des sciences de l’ administration, Université Laval, Québec, 2005]. This paper is concerned with the multi-objectives resource allocation problem. Our objective is to find adequate resource allocation for given courses of action schedule. To optimize this problem, this paper investigates non-exact solution methods, like meta-heuristic methods for finding potential efficient solutions. A progressive resource allocation methodology is proposed based on Tabu Search and multi-objectives concepts. This technique explores the search space so as to find a set of potential efficient solutions without aggregating the objectives into a single objective function. It is guided by the principle of maximizing the usage of any resource before considering a replacement resource. Thus, a given resource is allocated to the maximum number of tasks for a given courses of action schedule. A good allocation is a potential efficient solution. These solutions are retained by applying a combination of a dominance rule and a multi-criteria filtering method. The performance of the proposed Pareto-based approach is compared to two aggregation approaches: weighted-sum and the lexicographic techniques. The result shows that a Pareto-based approach is providing better solutions and allowing more flexibility to the decision-maker.     

Estimation of resource requirements in optimization problems of network planning

It is well known that optimization problems of network planning concerned with non-depositable resources are as a rule non-convex. The extreme difficulties of solving non-convex optimization problems make any pre-solution analysis of such problems highly welcome. This paper is devoted to an important tool for such analysis of our class of problems. The main ideas of the paper are as follows.Jointly with a given non-convex problem Ξ we consider an adjoint convex problem Θ, which is obtained from Ξ by lifting all resource constraints. Feasible schedules of the problem Θ are called Θ-feasible for the problem Ξ. By estimation of resource requirements we understand construction of such estimates which are valied for every Θ-feasible schedule. Two kinds of estimates are considered: pointwise (i.e. for single time units) and interval (for longer time spans) ones.Much attention is paid to numerical aspects of estimation. That is why a hierarchy of upper estimates is built ranging from a rough but easily computed one to the best estimate, requiring much more sophisticated computations. Amazingly enough such hierarchy does not exist for lower estimates, the simplest of them, next in roughness to the total zero only, being the best.     

Modelling the flow of congestive heart failure patients through a hospital system

The number of hospital admissions in England due to heart failure is projected to increase by over 50% during the next 25 years. This will incur greater pressures on hospital managers to allocate resources in an effective manner. A reliable indicator for measuring the quantity of resources consumed by hospital patients is their length of stay (LOS) in care. This paper proposes modelling the length of time heart failure patients spend in hospital using a special type of Markov model, where the flow of patients through hospital can be thought of as consisting of three stages of care—short-, medium- and longer-term care. If it is assumed that new admissions into the ward are replacements for discharges, such a model may be used to investigate the case-mix of patients in hospital and the expected patient turnover during some specified period of time. An example is illustrated by considering hospital admissions to a Belfast hospital in Northern Ireland, between 2000 and 2004.     

A simulation optimization approach for a two-echelon inventory system with service level constraints

In this paper, we present a simulation optimization algorithm for solving the two-echelon constrained inventory problem. The goal is to determine the optimal setting of stocking levels to minimize the total inventory investment costs while satisfying the expected response time targets for each field depot. The proposed algorithm is more adaptive than ordinary optimization algorithms, and can be applied to any multi-item multi-echelon inventory system, where the cost structure and service level function resemble what we assume. Empirical studies are performed to compare the efficiency of the proposed algorithms with other existing simulation algorithms.