A cost-effective urgent care policy to improve patient access in a dynamic scheduled clinic setting

Patient no-show in outpatient clinics has been a long recognized issue, which negatively impacts clinic operational efficiency in terms of costs and patient access to care. One way to reduce these negative impacts is to allow urgent walk-ins during a clinic day. Some clinics allow random walk-ins and some purposely leave open time slots to accommodate them. The objective of this paper is to develop a cost-effective urgent care policy that is added on top of a full schedule and takes into account scheduled patients’ no-show rates to improve patient access to care in a dynamic clinic environment. The findings indicate that the proposed approach outperforms the current random and urgent slot approaches. This paper demonstrates a dynamic approach for accommodating urgent patients into a patient scheduling system, based on the prediction of an individual patient's no-show probability and the maximum number of urgent patients allowed.     

Effective cancellation policy to reduce the negative impact of patient no-show

The problem of patient no-show in outpatient delivery systems has been a long recognized issue. The negative impacts include underutilized medical resources, increased healthcare costs, decreased access to care, and reduced clinic efficiency and provider productivity. Many clinics have cancellation policies of asking their patients to cancel 24 or 48?h in advance. However, there is no logical or mathematical basis for such a policy. The objective is to develop an effective cancellation policy that accounts for current no-show rates, the clinic's flow, and its fill rates to minimize the cost of patient wait time, physician idle time, and overtime. A simulation approach is presented to determine the hours required for patients to call in advance for cancelling appointments. The findings indicate that when fill rates are low and no-show probabilities are high, the time required for patients to cancel appointments needs to increase in order to achieve the goal of being cost-effective.     

Clinic scheduling models with overbooking for patients with heterogeneous no-show probabilities

Clinical overbooking is intended to reduce the negative impact of patient no-shows on clinic operations and performance. In this paper, we study the clinical scheduling problem with overbooking for heterogeneous patients, i.e. patients who have different no-show probabilities. We consider the objective of maximizing expected profit, which includes revenue from patients and costs associated with patient waiting times and physician overtime. We show that the objective function with homogeneous patients, i.e. patients with the same no-show probability, is multimodular. We also show that this property does not hold when patients are heterogeneous. We identify properties of an optimal schedule with heterogeneous patients and propose a local search algorithm to find local optimal schedules. Then, we extend our results to sequential scheduling and propose two sequential scheduling procedures. Finally, we perform a set of numerical experiments and provide managerial insights for health care practitioners.     

Outpatient appointment scheduling given individual day-dependent no-show predictions

This paper examines the combined use of predictive analytics, optimization, and overbooking to schedule outpatient appointments in the presence of no-shows. We tackle the problem of optimally overbooking appointments given no-show predictions that depend on the individual appointment characteristics and on the appointment day. The goal is maximizing the number of patients seen while minimizing waiting time and overtime. Our analysis leads to the definition of a near-optimal and simple heuristic which consists of giving same-day appointments to likely shows and future-day appointments to likely no-shows. We validate our findings by performing extensive simulation tests based on an empirical data set of nearly fifty thousand appointments from a real outpatient clinic. The results suggest that our heuristic can lead to a substantial increase in performance and that it should be preferred to open access under most parameter configurations. Our paper will be of great interest to practitioners who want to improve their clinic performance by using individual no-show predictions to guide appointment scheduling.     

A continuous-time seat control model for single-leg flights with no-shows and optimal overbooking upper bound

This article proposes a continuous-time model to combine seat control and overbooking policies for single-leg flights. We assume that demand is time-and-fare dependent and follows a Poisson process. No-show passengers receive refunds which depend on their fares. Overbooking penalty is a uniformly convex function of oversale. To maximize the expected revenue, airline managers seek optimal seat allocation among competing passengers. In the meantime, they need to determine an optimal aggregate overbooking upper bound, which balances the no-show refunds and oversale penalties. Our basic model shows (i) although the nested-fare structure does not hold for the face value of fares, its essence is preserved in the sense of net fares; i.e., the face value less the no-show refund; (ii) the optimal control policy is based on a set of pre-calculated time thresholds, which is easy to implement; and (iii) there exists an optimal overbooking upper bound, below which the value function strictly increases in the upper bound, and above which the value function stays constant. We further extend the basic model to consider fare-dependent no-show rates. Numerical examples are presented.     

A stochastic appointment scheduling system on multiple resources with dynamic call-in sequence and patient no-shows for an outpatient clinic

This research focuses on the stochastic assignment system motivated by outpatient clinics, especially the physical therapy in rehabilitation service. The aim of this research is to develop a stochastic overbooking model to enhance the service quality as well as to increase the utilization of multiple resources, like therapy equipment in a physical therapy room, with the consideration of patients’ call-in sequence. The schedule for a single-service period includes a fixed number of blocks of equal length. When patients call, they are assigned to an appointment time for that block, and an existing appointment is not allowed to be changed. In each visit, a patient might require more than one resource and a probability of no-show. Two estimation methods were proposed for the expected waiting and overtime cost with multiple resources: Convolution Estimation Method and Joint Cumulative Estimation Method for the upper and lower bound value; respectively. A numerical example based on a physical therapy room was used to show that this stochastic model was able to schedule patients for better profitability compared with traditional appointment systems based on four prioritization rules. The workload in each appointment slot was more balanced albeit more patients were assigned to the first slot to fill up the empty room.     

Analysis of seat allocation and overbooking decisions with hybrid information

We investigate a single-leg airline revenue management problem where an airline has limited demand information and uncensored no-show information. To use such hybrid information for simultaneous overbooking and booking control decisions, we combine expected overbooking cost with revenue. Then we take a robust optimization approach with a regret-based criterion. While the criterion is defined on a myriad of possible demand scenarios, we show that only a small number of them are necessary to compute the objective. We also prove that nested booking control policies are optimal among all deterministic ones. We further develop an effective computational method to find the optimal policy and compare our policy to others proposed in the literature.     

A hybrid data mining/simulation approach for modelling outpatient no-shows in clinic scheduling

This paper considers the outpatient no-show problem faced by a rural free clinic located in the south-eastern United States. Using data mining and simulation techniques, we develop sequencing schemes for patients, in order to optimize a combination of performance measures used at the clinic. We utilize association rule mining (ARM) to build a model for predicting patient no-shows; and then use a set covering optimization method to derive three manageable sets of rules for patient sequencing. Simulation is used to determine the optimal number of patients and to evaluate the models. The ARM technique presented here results in significant improvements over models that do not employ rules, supporting the conjecture that, when dealing with noisy data such as in an outpatient clinic, extracting partial patterns, as is done by ARM, can be of significant value for simulation modelling.     

基于收益管理理论的门诊预约存量控制研究

门诊预约机制能够帮助医疗服务系统实现合理的资源组织与顺畅的服务流程,目前是医疗系统管理中的热点问题。论文分析了收益管理的适用性条件,提出其在医院门诊预约调度问题中应用的可行性,然后构建了门诊预约存量控制的Littlewood基础模型,并考虑患者爽约的情况,建立了超订策略下的门诊预约存量控制模型,最终用实例验证了所提出方法的实用性和有效性。     

Application of discrete-event simulation in health care clinics: A survey

In recent decades, health care costs have dramatically increased, while health care organisations have been under severe pressure to provide improved quality health care for their patients. Several health care administrators have used discrete-event simulation as an effective tool for allocating scarce resources to improve patient flow, while minimising health care delivery costs and increasing patient satisfaction. The rapid growth in simulation software technology has created numerous new application opportunities, including more sophisticated implementations, as well as combining optimisation and simulation for complex integrated facilities. This paper surveys the application of discrete-event simulation modeling to health care clinics and systems of clinics (for example, hospitals, outpatient clinics, emergency departments, and pharmacies). Future directions of research and applications are also discussed.     

Matching daily healthcare provider capacity to demand in advanced access scheduling systems

Advanced access scheduling, introduced in the early 1990s, is reported to significantly improve the performance of outpatient clinics. The successful implementation of advanced access scheduling requires the match of daily healthcare provider capacity with patient demand. In this paper, for the first time a closed-form approach is presented to determine the optimal percentage of open-access appointments to match daily provider capacity to demand. This paper introduces the conditions for the optimal percentage of open-access appointments and the procedure to find the optimal percentage. Furthermore, the sensitivity of the optimal percentage of open-access appointments to provider capacity, no-show rates, and demand distribution is investigated. Our results demonstrate that the optimal percentage of open-access appointments mainly depends on the ratio of the average demand for open-access appointments to provider capacity and the ratio of the show-up rates for prescheduled and open-access appointments.     

可加号的门诊预约能力分配问题

预约服务可以有效优化医院门诊就诊流程,针对我国患者预约意识不强和预约患者爽约率高的特点,本文研究患者需求量较高时可以增加号源的条件下,考虑加号和拒绝患者成本,以门诊收益期望最大为目标,匹配预约患者和现场挂号患者需求量的能力分配问题。证明了门诊收益期望函数的单峰性,给出了最优解满足的条件。通过大量数值实验分析不同参数对门诊能力分配方案的影响,结果表明两类患者需求量对能力分配方案有较大影响,可加号情况下能力分配方案对患者爽约更敏感。     

Matching patient and physician preferences in designing a primary care facility network

This paper introduces an integer programming model for planning primary care facility networks, which accounts for the interests of different stakeholders while maximizing access to health care. Physician allocation to health-care facilities is explicitly modelled, which allows consideration of physician incentives in the planning phase. An illustrative case study in the Turkish primary care system is presented to show the implications of focusing on patient or physician preferences in the planning phase. A discussion of trade-offs between the different stakeholder preferences and some recommendations for modelling choices to match these preferences are provided. In the context of this case, we found that using an access measure that decays with distance, and incorporating nearest allocation constraints improves performance for all stakeholders. We also show that increasing the number of physicians may have adverse affects on access measures when physician preferences are addressed.     

Dynamic multi-priority,multi-class patient scheduling with stochastic service times

Efficient patient scheduling has significant operational, clinical and economical benefits on health care systems by not only increasing the timely access of patients to care but also reducing costs. However, patient scheduling is complex due to, among other aspects, the existence of multiple priority levels, the presence of multiple service requirements, and its stochastic nature. Patient appointment (allocation) scheduling refers to the assignment of specific appointment start times to a set of patients scheduled for a particular day while advance patient scheduling refers to the assignment of future appointment days to patients. These two problems have generally been addressed separately despite each being highly dependent on the form of the other. This paper develops a framework that incorporates stochastic service times into the advance scheduling problem as a first step towards bridging these two problems. In this way, we not only take into account the waiting time until the day of service but also the idle time/overtime of medical resources on the day of service. We first extend the current literature by providing theoretical and numerical results for the case with multi-class, multi-priority patients and deterministic service times. We then adapt the model to incorporate stochastic service times and perform a comprehensive numerical analysis on a number of scenarios, including a practical application. Results suggest that the advance scheduling policies based on deterministic service times cannot be easily improved upon by incorporating stochastic service times, a finding that has important implications for practice and future research on the combined problem.     

考虑存在取消预约情形的门诊预约能力分配策略

在现实的门诊预约问题中,已经预约的患者在接收医疗服务之前,有可能取消先前的预约,这会对医院的收益造成负面影响,如何在考虑患者存在取消预约的情形下,设计合理有效的能力分配策略来保证医院的收益,是一个值得研究的问题.本文针对具有提前预约和当天预约的门诊预约能力分配问题,在考虑提前预约患者可能存在取消预约行为的情形下,提出了一种提前预约患者和当天预约患者的最优能力分配策略。文中首先以医院的期望收益最大作为决策目标,建立了存在取消预约患者的医疗预约问题的马尔科夫过程模型,并给出了该模型的相关性质;基于所建立模型的特征,证明了对于任意的提前预约时段,存在提前预约患者的最佳数量,进而给出了提前预约患者和当天预约患者的最优能力分配策略以及确定该策略的精确算法;最后,通过数值试验说明了本文所提出的能力分配策略的适用性和有效性。     

Risk-averse decision making in overbooking problem

Traditional literature studying overbooking problems focuses on risk-neutral decision makers. In this paper, we propose a multi-period overbooking model incorporating risk-aversion and extend well-known structural results (the 3-region policy) under the risk-neutral case to the risk-averse one on the basis of an exponential utility function. We also show that the optimal policy for the risk-neutral decision maker can be obtained by letting the risk-aversion parameter approach to zero under the risk-averse case. Therefore, the extant results under the risk-neutral case can be interpreted as a special case of ours. We also investigate how the optimal policy changes with some cost parameters and the decision maker's degree of risk-aversion. Numerical results suggest that the optimal bounds in the 3-region policy may increase or decrease with the decision maker's degree of risk-aversion.     

A stochastic model for a visit to the doctor’s office

This paper presents a stochastic model of an individual patient’s experience during a visit to a doctor’s office. The stochastic model is based on tracking the visit of patients at a local family practice clinic. A rigorous, iterative procedure for model development allows the stochastic model to be constructed, evaluated, and validated to establish consistency with both the theoretical stochastic assumptions and the clinic’s actual operating environment. This model extends the use of stochastic models in health care in two important respects. First, the stochastic model represents an application of semi-Markov processes in outpatient health care settings. Second, through the use of the infinitesimal generator associated with the transition probability matrices governing patient flow, numerical predictions for first passage times are easily obtained.     

“酒店+OTA”双渠道供应链超订策略研究

为解决市场需求不确定环境下,酒店和在线旅行网站(Online Travel Agency,OTA)合作时的能力超订量与在线房间预留量的决策问题,建立了基于佣金合作模式的数学模型,给出了实现酒店整体期望收益最大化的在线房间预留量与能力超订量。借助数值分析,进一步研究了佣金率与需求不确定性对最优决策的影响。结果表明,当佣金率与门店需求不确定性较小时,酒店采取双渠道策略并且实施超订;当佣金率与门店需求不确定性很大时,酒店采取门店单渠道策略但不实施超订。另外,在线房间预留量随着佣金率、门店需求不确定性的增大而减小。     

A simulation study of scheduling clinic appointments in surgical care: individual surgeon <Emphasis Type="Italic">versus</Emphasis> pooled lists

The purpose of this paper is to compare two methods of scheduling outpatient clinic appointments in the setting where the availability of surgeons for appointments depends on other clinical activities. We used discrete-event simulation to evaluate the likely impact of the scheduling methods on the number of patients waiting for appointments, and the times to appointment and to surgery. The progression of individual patients in a surgical service was modelled as a series of updates in patient records in reaction to events generated by care delivery processes in an asynchronous fashion. We used the Statecharts visual formalism to define states and transitions within each care delivery process, based on detailed functional and behavioural specifications. Our results suggest that pooling referrals, so that clinic appointments are scheduled with the first available surgeon, has a differential impact on different segments of patient flow and across surgical priority groups.     

Two-dimensional cargo overbooking models

This paper introduces two-dimensional (weight and volume) overbooking problems arising mainly in the cargo revenue management, and compares them with one-dimensional problems. It considers capacity spoilage and cargo offloading costs, and minimizes their sum. For one-dimensional problems, it shows that the optimal overbooking limit does not change with the magnitude of the booking requests. In two-dimensional problems, the overbooking limit is replaced by a curve. The curve, along with the volume and weight axes, encircles the acceptance region. The booking requests are accepted if they fall within this region. We present Curve (Cab) and Rectangle (Rab) models. The boundary of the acceptance region in the Cab (resp. Rab) model is a curve (resp. rectangle). The optimal curve for the Cab model is shown to be unique and continuous. Moreover, it can be obtained by solving a series of simple equations. Finding the optimal rectangle for the Rab model is more challenging, so we propose an approximate rectangle. The approximate rectangle is a limiting solution in the sense that it converges to the optimal rectangle as the booking requests increase. The approximate rectangle is numerically shown to yield costs that are very close to the optimal costs.