Patient flow modelling and performance analysis of healthcare delivery processes in hospitals: A review and reflections

Modelling patient flows, important for performance improvement of hospital processes.Existing approaches for patient flow modelling in hospital systems are classified.Recent literature on patient flow modelling and performance analysis is reviewed.A generic framework for such modelling and analysis of hospital systems is provided.The framework may serve as a guide to improve healthcare delivery. Analysis of hospital processes is essential for development of improved methods, policies and decision tools for overall performance improvement of the hospital system. Amidst the current scenario of continuously increasing healthcare costs and scarcity of resources, optimal utilization of resources without hampering the quality of care has gained importance in any country. Modelling, analysis and management of patient flows, in this context, plays a key role in performance analysis and improvement of hospital processes as appropriate modelling of patient flows may help healthcare managers make decisions related to capacity planning, resource allocation and scheduling, appointment scheduling and for making necessary changes in the process of care. The concept of patient flow and its modelling has gained much attention in healthcare management literature over past few decades. In this paper, the existing approaches pertaining to modelling of patient flows in hospital systems have been classified and critically appraised focussing on the recent advancements in order to identify future research avenues. A generic framework for patient flow modelling and performance analysis of hospital systems that may serve as a guide for the practitioners dealing with similar kinds of problems to improve healthcare delivery has also been provided.

[1]  Abdur Rais,et al.  Operations Research in Healthcare: a survey , 2011, Int. Trans. Oper. Res..

[2]  Daiki Min,et al.  A simulation study of appointment scheduling in outpatient clinics: Open access and overbooking , 2013, Simul..

[3]  Fredrik A. Dahl,et al.  Simulating the influence of a 45% increase in patient volume on the emergency department of Akershus University Hospital , 2010, Proceedings of the 2010 Winter Simulation Conference.

[4]  A. H. Marshall,et al.  Modelling the flow of congestive heart failure patients through a hospital system , 2007, J. Oper. Res. Soc..

[5]  Marc Lambrecht,et al.  An advanced queueing model to analyze appointment-driven service systems , 2009, Comput. Oper. Res..

[6]  Elia El-Darzi,et al.  Length of Stay-Based Patient Flow Models: Recent Developments and Future Directions , 2005, Health care management science.

[7]  Refael Hassin,et al.  Scheduling Arrivals to Queues: A Single-Server Model with No-Shows , 2008, Manag. Sci..

[8]  Michael Pidd,et al.  Discrete event simulation for performance modelling in health care: a review of the literature , 2010, J. Simulation.

[9]  Thierry J. Chaussalet,et al.  A Semi-open Queueing Network Approach to the Analysis of Patient Flow in Healthcare Systems , 2007, Twentieth IEEE International Symposium on Computer-Based Medical Systems (CBMS'07).

[10]  James R. Wilson,et al.  Modeling patient arrivals in community clinics , 2008 .

[11]  Osman Balci,et al.  Modeling and analyzing a physician clinic environment using discrete-event (visual) simulation , 2001, Comput. Oper. Res..

[12]  Ray J. Paul,et al.  Simulation modelling in healthcare: reviewing legacies and investigating futures , 2007, J. Oper. Res. Soc..

[13]  Sally C. Brailsford,et al.  OR in healthcare: A European perspective , 2011, Eur. J. Oper. Res..

[14]  L Mayhew,et al.  Using queuing theory to analyse the Government’s 4-h completion time target in Accident and Emergency departments , 2008, Health care management science.

[15]  Sally McClean,et al.  A non-homogeneous discrete time Markov model for admission scheduling and resource planning in a cost or capacity constrained healthcare system , 2010, Health care management science.

[16]  W. C. Benton,et al.  Performance measurement criteria in health care organizations: Review and future research directions , 1996 .

[17]  P H Millard,et al.  A three compartment model of the patient flows in a geriatric department: a decision support approach , 1998, Health care management science.

[18]  G Christodoulou,et al.  Using a continuous time hidden Markov process, with covariates, to model bed occupancy of people aged over 65 years , 2001, Health care management science.

[19]  Richard J. Boucherie,et al.  Planning and scheduling of semi-urgent surgeries , 2010, Health care management science.

[20]  P. H. Millard,et al.  A simulation modelling approach to evaluating length of stay, occupancy, emptiness and bed blocking in a hospital geriatric department , 1998, Health care management science.

[21]  Thierry J. Chaussalet,et al.  Random effects models for operational patient pathways , 2010 .

[22]  D. Scott Sink,et al.  Productivity management : planning, measurement and evaluation, control, and improvement , 1985 .

[23]  David J. Worthington,et al.  Reflections on queue modelling from the last 50 years , 2009, J. Oper. Res. Soc..

[24]  Sally McClean,et al.  Using a Markov reward model to estimate spend-down costs for a geriatric department , 1998, J. Oper. Res. Soc..

[25]  George Miller,et al.  Using Models and Data to Support Optimization of the Military Health System: A Case Study in an Intensive Care Unit , 2004, Health care management science.

[26]  Sally McClean,et al.  Costing hospital resources for stroke patients using phase-type models , 2011, Health care management science.

[27]  Martha A. Centeno,et al.  A simulation study to increase throughput in an endoscopy center , 2010, Proceedings of the 2010 Winter Simulation Conference.

[28]  Rainer Kolisch,et al.  Providing radiology health care services to stochastic demand of different customer classes , 2008, OR Spectr..

[29]  P. Harper.  A Framework for Operational Modelling of Hospital Resources , 2002, Health care management science.

[30]  John R. Olson,et al.  Healthcare Operations Management , 2008 .

[31]  Linda V. Green,et al.  Queueing Analysis in Health Care , 2013 .

[32]  Alexander Kolker,et al.  Process Modeling of Emergency Department Patient Flow: Effect of Patient Length of Stay on ED Diversion , 2008, Journal of Medical Systems.

[33]  Nicola J. Robertson,et al.  A loss network model with overflow for capacity planning of a neonatal unit , 2010, Ann. Oper. Res..

[34]  N. Koizumi,et al.  Modeling Patient Flows Using a Queuing Network with Blocking , 2005, Health Care Management Science.

[35]  Soemon Takakuwa,et al.  Simulation Analysis of an Outpatient Department of Internal Medicine in a University Hospital , 2006, Proceedings of the 2006 Winter Simulation Conference.

[36]  Taesik Lee,et al.  Outpatients appointment scheduling with multi-doctor sharing resources , 2010, Proceedings of the 2010 Winter Simulation Conference.

[37]  Julie C. Lowery.  Introduction to simulation in health care , 1996, Winter Simulation Conference.

[38]  Ger Koole,et al.  Dimensioning hospital wards using the Erlang loss model , 2010, Ann. Oper. Res..

[39]  Peter J. H. Hulshof,et al.  Taxonomic classification of planning decisions in health care: a structured review of the state of the art in OR/MS , 2012 .

[40]  P. Kuo,et al.  Optimization of operating room allocation using linear programming techniques. , 2003, Journal of the American College of Surgeons.

[41]  J. Cochran,et al.  Stochastic bed balancing of an obstetrics hospital , 2006, Health care management science.

[42]  Thierry J. Chaussalet,et al.  Models for Extracting Information on Patient Pathways , 2009 .

[43]  Giovanni Felici,et al.  Integrating simulation and optimisation in health care centre management , 2003, Eur. J. Oper. Res..

[44]  Emre A. Veral,et al.  Assessment of patient classification in appointment system design , 2008 .

[45]  Talal M. Alkhamis,et al.  Simulation optimization for an emergency department healthcare unit in Kuwait , 2009, Eur. J. Oper. Res..

[46]  David J. Worthington,et al.  Setting staffing requirements for time dependent queueing networks: The case of accident and emergency departments , 2012, Eur. J. Oper. Res..

[47]  Fabrice Labeau,et al.  Estimating the waiting time of multi-priority emergency patients with downstream blocking , 2014, Health care management science.

[48]  Peter H. Millard,et al.  Markov model-based clustering for efficient patient care , 2005, 18th IEEE Symposium on Computer-Based Medical Systems (CBMS'05).

[49]  Marie E. Matta,et al.  Evaluating multiple performance measures across several dimensions at a multi-facility outpatient center , 2007, Health care management science.

[50]  William E. Stein,et al.  A stochastic model for a visit to the doctor's office , 2007, Math. Comput. Model..

[51]  G. M. Koole,et al.  Modeling the emergency cardiac in-patient flow: an application of queuing theory , 2007, Health care management science.

[52]  G. Bevan,et al.  "Systematic" , 1966, Comput. J..

[53]  Peter H. Millard,et al.  A Model-Based Approach to the Analysis of Patterns of Length of Stay in Institutional Long-Term Care , 2006, IEEE Transactions on Information Technology in Biomedicine.

[54]  John T. Blake,et al.  A comprehensive simulation for wait time reduction and capacity planning applied in general surgery , 2007, Health care management science.

[55]  Peter H. Millard,et al.  Clustering patient length of stay using mixtures of Gaussian models and phase type distributions , 2009, 2009 22nd IEEE International Symposium on Computer-Based Medical Systems.

[56]  Karolina J. Glowacka,et al.  A hybrid data mining/simulation approach for modelling outpatient no-shows in clinic scheduling , 2009, J. Oper. Res. Soc..

[57]  Emre A. Veral,et al.  OUTPATIENT SCHEDULING IN HEALTH CARE: A REVIEW OF LITERATURE , 2003 .

[58]  Thierry J. Chaussalet,et al.  Nonproportional random effects modelling of a neonatal unit operational patient pathways , 2011, Stat. Methods Appl..

[59]  Murray J. Côté,et al.  Patient flow and resource utilization in an outpatient clinic , 1999 .

[60]  Jeffery K. Cochran,et al.  A multi-class queuing network analysis methodology for improving hospital emergency department performance , 2009, Comput. Oper. Res..

[61]  Kenneth J. Klassen,et al.  Improving Performance in Outpatient Appointment Services with a Simulation Optimization Approach , 2009 .

[62]  Pinar Keskinocak,et al.  Improving patient flow in an obstetric unit , 2011, Health Care Management Science.

[63]  M. Mackay,et al.  Modelling Variability in Hospital Bed Occupancy , 2005, Health care management science.

[64]  Thierry J. Chaussalet,et al.  A Random Effects Sensitivity Analysis for Patient Pathways Model , 2008, 2008 21st IEEE International Symposium on Computer-Based Medical Systems.

[65]  G. Harrison.  Implications of mixed exponential occupancy distributions and patient flow models for health care planning , 2001, Health care management science.

[66]  Ronald E Giachetti,et al.  A queueing network model to analyze the impact of parallelization of care on patient cycle time , 2008, Health care management science.

[67]  Michel Bierlaire,et al.  An analytic finite capacity queueing network model capturing the propagation of congestion and blocking , 2009, Eur. J. Oper. Res..

[68]  A. K. Shahani,et al.  Capacity planning for intensive care units , 1998, Eur. J. Oper. Res..

[69]  Sheldon Howard Jacobson,et al.  Application of discrete-event simulation in health care clinics: A survey , 1999, J. Oper. Res. Soc..

[70]  Paul R. Harper,et al.  Reduced outpatient waiting times with improved appointment scheduling: a simulation modelling approach , 2003, OR Spectr..

[71]  Gabriel J Escobar,et al.  Length of stay and imminent discharge probability distributions from multistage models: variation by diagnosis, severity of illness, and hospital , 2010, Health care management science.

[72]  Mark Fackrell,et al.  Modelling healthcare systems with phase-type distributions , 2009, Health care management science.

[73]  Alexander Komashie,et al.  Modeling emergency departments using discrete event simulation techniques , 2005, Proceedings of the Winter Simulation Conference, 2005..

[74]  Richard J. Boucherie,et al.  Queuing Networks in Healthcare Systems , 2012 .

[75]  Kurt M. Bretthauer,et al.  Blocking in Healthcare Operations: A New Heuristic and an Application , 2011 .

[76]  Alexander Kolker,et al.  Process Modeling of ICU Patient Flow: Effect of Daily Load Leveling of Elective Surgeries on ICU Diversion , 2009, Journal of Medical Systems.

[77]  Michael Pidd,et al.  Interconnected des models of emergency, outpatient, and inpatient departments of a hospital , 2007, 2007 Winter Simulation Conference.

[78]  Peter H. Millard,et al.  Using a Queueing Model to Help Plan Bed Allocation in a Department of Geriatric Medicine , 2002, Health care management science.

[79]  Martin L. Puterman,et al.  Reducing patient wait times and improving resource utilization at British Columbia Cancer Agency’s ambulatory care unit through simulation , 2009, Health care management science.

[80]  Kenneth J. Klassen,et al.  Appointment system design with interruptions and physician lateness , 2013 .

[81]  William E. Spangler,et al.  Estimating Procedure Times for Surgeries by Determining Location Parameters for the Lognormal Model , 2004, Health care management science.

[82]  Adele H Marshall,et al.  Using Coxian Phase-Type Distributions to Identify Patient Characteristics for Duration of Stay in Hospital , 2004, Health care management science.

[83]  Martin Pitt,et al.  An analysis of the academic literature on simulation and modelling in health care , 2009, J. Simulation.

[84]  Paul Robert Harper,et al.  Modelling for the planning and management of bed capacities in hospitals , 2002, J. Oper. Res. Soc..

[85]  E. El-Darzi,et al.  A simulation study of the winter bed crisis , 2001, Health care management science.

[86]  S I McClean,et al.  Markov Chain Modelling for Geriatric Patient Care , 2005, Methods of Information in Medicine.

[87]  Emre A. Veral,et al.  Designing appointment scheduling systems for ambulatory care services , 2006, Health care management science.

[88]  P. E. Joustra,et al.  Reducing access times for an endoscopy department by an iterative combination of computer simulation and Linear Programming , 2009, Health care management science.

[89]  Ira Horowitz,et al.  Analysis of capacity management of the intensive care unit in a hospital , 1999, Eur. J. Oper. Res..

[90]  N. Bailey.  A Study of Queues and Appointment Systems in Hospital Out‐Patient Departments, with Special Reference to Waiting‐Times , 1952 .

[91]  Paul Intrevado,et al.  Effects of clinical characteristics on successful open access scheduling , 2007, Health care management science.

[92]  Randolph W. Hall,et al.  Modeling Patient Flows Through the Health care System , 2013 .

[93]  Sheldon M. Ross,et al.  Stochastic Processes , 2018, Gauge Integral Structures for Stochastic Calculus and Quantum Electrodynamics.

[94]  Jaejin Jang,et al.  Simulation-based patient flow analysis in an endoscopy unit , 2010, 2010 IEEE Workshop on Health Care Management (WHCM).

[95]  Thomas R Rohleder,et al.  Using simulation modeling to improve patient flow at an outpatient orthopedic clinic , 2011, Health care management science.

[96]  Vidyadhar G. Kulkarni,et al.  Appointment Scheduling Under Patient No-Shows and Service Interruptions , 2012, Manuf. Serv. Oper. Manag..

[97]  Sally McClean,et al.  A queueing model for bed-occupancy management and planning of hospitals , 2002, J. Oper. Res. Soc..

[98]  R. Hall.  Patient flow : reducing delay in healthcare delivery , 2006 .

[99]  B. Zhang,et al.  A mixed integer programming approach for allocating operating room capacity , 2009, J. Oper. Res. Soc..

[100]  Martin L. Puterman,et al.  Improving resource utilization for diagnostic services through flexible inpatient scheduling: A method for improving resource utilization , 2007, J. Oper. Res. Soc..

[101]  Archis Ghate,et al.  A Markov decision process approach to multi-category patient scheduling in a diagnostic facility , 2011, Artif. Intell. Medicine.

[102]  F. Hank Grant,et al.  An application of discrete-event simulation to an outpatient healthcare clinic with batch arrivals , 2011, Proceedings of the 2011 Winter Simulation Conference (WSC).

[103]  Leo Breiman,et al.  Classification and Regression Trees , 1984 .

[104]  Erik Demeulemeester,et al.  Operating room planning and scheduling: A literature review , 2010, Eur. J. Oper. Res..

[105]  Peter H. Millard,et al.  A continuous time Markov model for the length of stay of elderly people in institutional long‐term care , 2005 .

[106]  Jeffery K. Cochran,et al.  A queuing-based decision support methodology to estimate hospital inpatient bed demand , 2008, J. Oper. Res. Soc..

[107]  Yariv N. Marmor,et al.  Emergency department operations: The basis for developing a simulation tool , 2005 .

[108]  R. Boucherie,et al.  Redesign of a University Hospital Preanesthesia Evaluation Clinic Using a Queuing Theory Approach , 2009, Anesthesia and analgesia.

[109]  A. Agresti,et al.  Multinomial logit random effects models , 2001 .

[110]  Mehrdad Tamiz,et al.  An integrated queuing and multi-objective bed allocation model with application to a hospital in China , 2009, J. Oper. Res. Soc..

[111]  M. Gunal.  A guide for building hospital simulation models , 2012 .

[112]  Bernt Lie,et al.  Modeling and Simulation of Patient Flow in Hospitals for Resource Utilization , 2010, Simul. Notes Eur..

[113]  Herbert Moskowitz,et al.  Improving patient flow at an outpatient clinic: study of sources of variability and improvement factors , 2009, Health care management science.

[114]  M. Brahimi,et al.  Queueing Models for Out-Patient Appointment Systems — a Case Study , 1991 .

[115]  Qinan Wang,et al.  Modeling and analysis of high risk patient queues , 2004, Eur. J. Oper. Res..

[116]  Yu-Li Huang,et al.  Radiology scheduling with consideration of patient characteristics to improve patient access to care and medical resource utilization , 2013 .

[117]  Hichem Kamoun,et al.  Multiobjective study to implement outpatient appointment system at Hedi Chaker Hospital , 2011, Simul. Model. Pract. Theory.

[118]  Marc Lambrecht,et al.  Modeling a hospital queueing network , 2011 .

[119]  Florin Gorunescu,et al.  Continuous-time Markov model for geriatric patients behavior. Optimization of the bed occupancy and computer simulation , 2002 .

[120]  Mehrdad Tamiz,et al.  Combining simulation and goal programming for healthcare planning in a medical assessment unit , 2009, Eur. J. Oper. Res..

[121]  Paul R. Harper,et al.  Modelling the size and skill-mix of hospital nursing teams , 2010, J. Oper. Res. Soc..

[122]  L. Green,et al.  Strategies for cutting hospital beds: the impact on patient service. , 2001, Health services research.

[123]  Carl M. Harris,et al.  Fundamentals of queueing theory , 1975 .

[124]  Elena Tanfani,et al.  A three-phase approach for operating theatre schedules , 2007, Health care management science.

[125]  Marie Jeanette Persson,et al.  Analysing management policies for operating room planning using simulation , 2010, Health care management science.

[126]  M. Brandeau,et al.  Operations research and health care : a handbook of methods and applications , 2004 .

[127]  Navonil Mustafee,et al.  Applications of simulation within the healthcare context , 2010, J. Oper. Res. Soc..

[128]  T J Chaussalet,et al.  A closed queueing network approach to the analysis of patient flow in health care systems. , 2006, Methods of information in medicine.

[129]  Lorne L Holland,et al.  Reducing laboratory turnaround time outliers can reduce emergency department patient length of stay: an 11-hospital study. , 2005, American journal of clinical pathology.

[130]  Jaakko Kujala,et al.  Cardiac surgery productivity and throughput improvements. , 2007, International journal of health care quality assurance.

[131]  Chengbin Chu,et al.  A planning and scheduling problem for an operating theatre using an open scheduling strategy , 2010, Comput. Ind. Eng..

[132]  Michael Pidd,et al.  Understanding Accident and Emergency Department Performance using Simulation , 2006, Proceedings of the 2006 Winter Simulation Conference.

[133]  Ger Koole,et al.  Optimal outpatient appointment scheduling , 2007, Health care management science.

[134]  Elena Tanfani,et al.  A simulation-based modeling framework to deal with Clinical Pathways , 2011, Proceedings of the 2011 Winter Simulation Conference (WSC).