Optimal patient and personnel scheduling policies for care-at-home service facilities

In this paper we study the problem of personnel planning in care-at-home facilities. We model the system as a Markov decision process, which leads to a high-dimensional control problem. We study monotonicity properties of the system and derive structural results for the optimal policy. Based on these insights, we propose a trunk reservation heuristic to control the system. We provide numerical evidence that the heuristic yields close to optimal performance, and scales well for large problem instances.     

Facilitated modelling with discrete-event simulation: Reality or myth?

Is it possible for discrete-event simulation to be used in a facilitated workshop environment? Over the last decade there have been various attempts to use simulation in this way, but we argue here that none have been successful in achieving a fully facilitated mode where the model is both developed and used in the workshop. We attempt to use a discrete-event simulation in a facilitated mode as part of a lean improvement workshop in a hospital setting. The model was successfully developed and used within the 3 day period of the workshop. Although the intervention was successful, we still had to build the model in the ‘back-office’, meaning that a fully facilitated mode was not achieved. The paper concludes by discussing how fully facilitated modelling with discrete-event simulation might be made possible; the answer is more about changing mind-sets than about technological challenge.     

A branch-and-price approach for integrating nurse and surgery scheduling

A common problem at hospitals is the extreme variation in daily (even hourly) workload pressure for nurses. The operating room is considered to be the main engine and hence the main generator of variance in the hospital. The purpose of this paper is threefold. First of all, we present a concrete model that integrates both the nurse and the operating room scheduling process. Second, we show how the column generation technique approach, one of the most employed exact methods for solving nurse scheduling problems, can easily cope with this model extension. Third, by means of a large number of computational experiments we provide an idea of the cost saving opportunities and required solution times.     

Robust surgery loading

We consider the robust surgery loading problem for a hospital’s operating theatre department, which concerns assigning surgeries and sufficient planned slack to operating room days. The objective is to maximize capacity utilization and minimize the risk of overtime, and thus cancelled patients. This research was performed in collaboration with the Erasmus MC, a large academic hospital in the Netherlands, which has also provided historical data for the experiments. We propose various constructive heuristics and local search methods that use statistical information on surgery durations to exploit the portfolio effect, and thereby to minimize the required slack. We demonstrate that our approach frees a lot of operating room capacity, which may be used to perform additional surgeries. Furthermore, we show that by combining advanced optimization techniques with extensive historical statistical records on surgery durations can significantly improve the operating room department utilization.     

Uncertainty and value of information when allocating resources within and between healthcare programmes

A two-stage stochastic mathematical programming formulation has been developed to optimally allocate resources within and between healthcare programmes when there is an exogenous budget and the parameters of the healthcare models are variable and uncertain. This formulation solves the optimal resource allocation problem and calculates the expected value of acquiring additional information to resolve the uncertainties within the allocation. It is shown that the proposed formulation has several advantages over the chance constrained and robust mathematical programming methods.     

Simulation modelling for contracting hospital emergency services at the regional level

Hospital emergency services are closely connected to demographic issues and population changes. The methodology presented here helps to assess the effects of the forecasted demand changes on the next-year emergency unit workloads. The objective of the study is to estimate the expected volume of emergency hospital services, as measured by the number and costs of medical procedures provided to patients, to be contracted by the Polish National Health Fund (NFZ) branch at the regional level to cover the forecasted demand. A discrete-event simulation model was developed to elaborate the credible forecasts of the function components, the fundamental elements of the contract values granted by the NFZ for emergency departments for the following year. Emergency department-level data were drawn from the NFZ regional branch registry to perform a statistical analysis of emergency services provided to patients in 17 admission units and emergency wards in 2010. The model results indicate that the predicted increase in two age groups, i.e., the youngest children and the older population, will have different effects on the number and value of hospital emergency services to be considered in the contracting policy. There is potential for a discrete-event simulation to support strategic health policy decision making at the regional level. The value of this approach lies in providing estimates for the what-if scenarios related to the prognosis of changing acute demand.     

Selfish routing in public services

It is well observed that individual behaviour can have an effect on the efficiency of queueing systems. The impact of this behaviour on the economic efficiency of public services is considered in this paper where we present results concerning the congestion related implications of decisions made by individuals when choosing between facilities. The work presented has important managerial implications at a public policy level when considering the effect of allowing individuals to choose between providers. We show that in general the introduction of choice in an already inefficient system will not have a negative effect. Introducing choice in a system that copes with demand will have a negative effect.     

Staff optimization for time-dependent acute patient flow

The emergency department is a key element of acute patient flow, but due to high demand and an alternating rate of arriving patients, the department is often challenged by insufficient capacity. Proper allocation of resources to match demand is, therefore, a vital task for many emergency departments.Constrained by targets on patient waiting time, we consider the problem of minimizing the total amount of staff-resources allocated to an emergency department. We test a matheuristic approach to this problem, accounting for both patient flow and staff scheduling restrictions. Using a continuous-time Markov chain, patient flow is modeled as a time-dependent queueing network where inhomogeneous behavior is evaluated using the uniformization method. Based on this modeling approach, we recursively evaluate and allocate staff to the system using integer linear programming until the waiting time targets are respected in all queues of the network. By comparing to discrete-event simulations of the associated system, we show that this approach is adequate for both modeling and optimizing the patient flow. In addition, we demonstrate robustness to the service time distribution and the associated system with multiple classes of patients.     

OR in healthcare: A European perspective

The European Working Group “Operational Research Applied to Health Services” (ORAHS) is one of the domain specific EURO Working Groups organized by EURO - the European Association of Operational Research Societies. In this paper we report on the development of ORAHS as a platform for OR in health, and analyse the papers presented at meetings over the 35 years of its existence. We propose a two-way framework for analysis, where one dimension is the nine stages of the product life cycle: identifying consumer requirements, designing a new service to meet these requirements, forecasting demand for such a service, securing resources for it, allocating these resources, developing Programs & Plans to use these resources for delivering the service, establishing criteria for service delivery, managing the performance of the service, and finally, evaluating its performance. The other dimension is a three-level classification into broad application areas referring to processes at different levels in healthcare: Patients & Providers, Units & Hospitals, and Regional & National. We use this framework to carry out a quantitative analysis of all the papers presented during the meetings of ORAHS since its inception in 1975. We then describe developments over this period in applying OR approaches and techniques to healthcare, and present an overview of the main application areas and challenges.     

Discrete Conditional Phase-type models utilising classification trees: Application to modelling health service capacities

Discrete Conditional Phase-type models (DC-Ph) consist of a process component (survival distribution) preceded by a set of related conditional discrete variables. This paper introduces a DC-Ph model where the conditional component is a classification tree. The approach is utilised for modelling health service capacities by better predicting service times, as captured by Coxian phase-type distributions, interfaced with results from a classification tree algorithm. To illustrate the approach, a case-study within the healthcare delivery domain is given, namely that of maternity services. The classification analysis is shown to give good predictors for complications during childbirth. Based on the classification tree predictions, the duration of childbirth on the labour ward is then modelled as either a two or three-phase Coxian distribution. The resulting DC-Ph model is used to calculate the number of patients and associated bed occupancies, patient turnover, and to model the consequences of changes to risk status.     

Developing a market-based approach to managing the US strategic petroleum reserve

The Strategic Petroleum Reserve has not been used effectively to manage the consequences of oil shocks in the United States. The main reason is that political decision makers tend to hoard the reserves during crises and bureaucratic processes delay the sale of the reserves. Also, the enabling legislation focused on ameliorating shortages whereas disruptions result price spikes rather than shortages. We develop a Markov game of the buildup and drawdown of the reserve in which a public player aims to maximize consumer welfare at the same time private holders of inventory maximize their profit. The methodological contribution in this paper is the development of financial options to implement the public player’s optimal policy. We use the solution of this game to calculate the number and value of options necessary for the private marketplace to trigger the optimal buildup and drawdown of the reserve.     

Long-term integrated surgery room optimization and recovery ward planning,with a case study in the Brazilian National Institute of Traumatology and Orthopedics (INTO)

This paper proposes an integrated approach for the long-term planning and surgery allocation problem with downstream constraints. It is motivated by a case study in the Brazilian National Institute of Traumatology and Orthopedics, which provides elective high complexity surgeries for patients from the Brazilian public health system. We introduce an optimization problem that designs a periodic surgery allocation schedule as well as a recovery ward utilization plan, with a view at balancing patient arrivals and releases in the long term, in such a way that all surgeries are performed in a timely manner.     

Combining discrete-event simulation and system dynamics in a healthcare setting: A composite model for Chlamydia infection

This paper presents a composite model in which two simulation approaches, discrete-event simulation (DES) and system dynamics (SD), are used together to address a major healthcare problem, the sexually transmitted infection Chlamydia. The paper continues an on-going discussion in the literature about the potential benefits of linking DES and SD. Previous researchers have argued that DES and SD are complementary approaches and many real-world problems would benefit from combining both methods. In this paper, a DES model of the hospital outpatient clinic which treats Chlamydia patients is combined with an SD model of the infection process in the community. These two models were developed in commercial software and linked in an automated fashion via an Excel interface. To our knowledge this is the first time such a composite model has been used in a healthcare setting. The model shows how the prevalence of Chlamydia at a community level affects (and is affected by) operational level decisions made in the hospital outpatient department. We discuss the additional benefits provided by the composite model over and above the benefits gained from the two individual models.     

Locating specialized service capacity in a multi-hospital network

Multi-hospital systems have become very common in today’s healthcare environment. However, there has been limited published research examining the opportunities and challenges of pooling specialized services to a subset of hospitals in the network. Therefore, this paper considers how hospital networks with multiple locations can leverage pooling benefits when deciding where to position specialized services, such as magnetic resonance imaging (MRI), transplants, or neonatal intensive care. Specifically, we develop an optimization model to determine how many and which of a hospital network’s hospitals should be set up to deliver a specialized service. Importantly, this model takes into account both financial considerations and patient service levels. Computational results illustrate the value of optimally pooling resources across a subset of hospitals in the network versus two alternate approaches: (1) delivering the service at all locations and requiring each site to handle its own demand, or (2) locating the service at one hospital that handles all network demand.     

Time-indexed formulations for scheduling chains on a single machine: An application to airborne radars

Airborne radars are widely used to perform a large variety of tasks in an aircraft (searching, tracking, identifying targets, etc.) Such tasks play a crucial role for the aircraft and they are repeated in a “more or less” cyclic fashion. This defines a scheduling problem that impacts a lot on the quality of the radar output and on the overall safety of the aircraft.     

SimLean: Utilising simulation in the implementation of lean in healthcare

Discrete-event simulation (DES) and lean are approaches that have a similar motivation: improvement of processes and service delivery. Both are being used to help improve the delivery of healthcare, but rarely are they used together. This paper explores from a theoretical and an empirical perspective the potential complementary roles of DES and lean in healthcare. The aim is to increase the impact of both approaches in the improvement of healthcare systems. Out of this exploration, the ‘SimLean’ approach is developed in which three roles for DES with lean are identified: education, facilitation and evaluation. These roles are demonstrated through three examples of DES in action with lean. The work demonstrates how the fusion of DES with lean can improve both stakeholder engagement with DES and the impact of lean.     

Joint-optimization of inventory policies on a multi-product multi-echelon pharmaceutical system with batching and ordering constraints

This paper presents a methodology to find near-optimal joint inventory control policies for the real case of a one-warehouse, n-retailer distribution system of infusion solutions at a University Medical Center in France. We consider stochastic demand, batching and order-up-to level policies as well as aspects particular to the healthcare setting such as emergency deliveries, required service level rates and a new constraint on the ordering policy that fits best the hospital’s interests instead of abstract ordering costs. The system is modeled as a Markov chain with an objective to minimize the stock-on-hand value for the overall system. We provide the analytical structure of the model to show that the optimal reorder point of the policy at both echelons is easily derived from a simple probability calculation. We also show that the optimal policy at the care units is to set the order-up-to level one unit higher than the reorder point. We further demonstrate that optimizing the care units in isolation is optimal for the joint multi-echelon, n-retailer problem. A heuristic algorithm is presented to find the near-optimal order-up-to level of the policy of each product at the central pharmacy; all other policy parameters are guaranteed optimal via the structure provided by the model. Comparison of our methodology versus that currently in place at the hospital showed a reduction of approximately 45% in the stock-on-hand value while still respecting the service level requirements.     

Oligopoly models for market price of electricity under demand uncertainty and unit reliability

Several oligopoly models have been proposed for representing strategic behavior in electricity markets, which include Bertrand, Cournot, and Supply Function Equilibrium (SFE). For the most part, these models are deterministic, with the exception of the SFE originally developed by Klemperer and Meyer. However, their model does not include supply side uncertainties. In this paper, we consider both load and supply side uncertainties (resulting from generator availabilities). We obtain Nash equilibrium solutions for Cournot and SFE models, in which asymmetric firms (whose generating units have different costs and capacities) submit their bids so that each firm’s expected profit is maximized.     

A column generation approach for solving the patient admission scheduling problem

This paper addresses the Patient Admission Scheduling (PAS) problem. The PAS problem entails assigning elective patients to beds, while satisfying a number of hard constraints and as many soft constraints as is possible, and arises at all planning levels for hospital management. There exist a few, different variants of this problem. In this paper we consider one such variant and propose an optimization-based heuristic building on branch-and-bound, column generation, and dynamic constraint aggregation to solve it. We achieve tighter lower bounds than previously reported in the literature and, in addition, we are able to produce new best known solutions for five out of twelve instances from a publicly available repository.