Journal of Simulation

ISSN: 1747-7778 (Print) 1747-7786 (Online) Journal homepage: http://www.tandfonline.com/loi/tjsm20

Appointment scheduling of inpatients and

outpatients in a multistage integrated surgical
suite: Application to a Tunisian ophthalmology
surgery department

Safa Chabouh, Sondes Hammami, Eric Marcon & Hanen Bouchriha

To cite this article: Safa Chabouh, Sondes Hammami, Eric Marcon & Hanen Bouchriha (2018)
Appointment scheduling of inpatients and outpatients in a multistage integrated surgical suite:
Application to a Tunisian ophthalmology surgery department, Journal of Simulation, 12:1, 67-75,
DOI: 10.1080/17477778.2017.1398288

To link to this article: https://doi.org/10.1080/17477778.2017.1398288

Published online: 14 Nov 2017.

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Journal of Simulation, 2018
VOL. 12, NO. 1, 67–75
https://doi.org/10.1080/17477778.2017.1398288

Appointment scheduling of inpatients and outpatients in a multistage

integrated surgical suite: Application to a Tunisian ophthalmology surgery
department
Safa Chabouha, Sondes Hammamia,b, Eric Marconc and Hanen Bouchrihaa
a
Université de Tunis El Manar, Ecole Nationale d’Ingénieurs de Tunis, LR-11-ES20 Laboratoire d’Analyse Conception et Commande des
Systèmes, Tunis, Tunisia; bUniversité de Carthage, Ecole Nationale d’Ingénieurs de Carthage, Tunis, Tunisia; cUniversité de Lyon INSA-LYON,
Université Jean Monnet Saint-Etienne, DISP, EA 4570, Villeurbanne, France

ABSTRACT ARTICLE HISTORY

This article addresses the challenges of appointment scheduling of inpatients and outpatients Received 19 October 2016
with stochastic service times in a multistage integrated surgical suite. It takes into account Accepted 24 October 2017
the availability and compatibility of resources, with the presence of a variety of patient types.
KEYWORDS
Twelve  appointment heuristics are proposed and evaluated by means of a discrete event Discrete-event simulation;
simulation model, in terms of expected patient waiting time and expected surgical suite optimisation; appointment
completion time. These heuristics are further compared with a lower bound obtained by a mixed scheduling; integrated
integer program. The computational experiments are based on real data of a hospital-integrated surgical suite; inpatient/
facility within an ophthalmology surgery department in a Tunisian hospital. outpatient flows

1. Introduction reasons, the resource compatibility in this problem plays

an important role as a constraint for patient scheduling.
In this paper, we address the appointment scheduling
Defining appointment and service start times in such an
(AS) of inpatients and outpatients with stochastic service
environment seems to be a more challenging task than
times in a particular type of outpatient surgery facil-
in dedicated surgical suites. In this paper, we focus only
ity: a hospital-integrated facility. A hospital-integrated
on elective patients; urgent patients are not considered.
facility is an integrated surgical suite (ISS), where the
Our second goal is to consider different stages of the
surgical outpatients and inpatients, are treated simulta-
ISS: pre-operation, surgery, and recovery. AS in this
neously and share some resources, especially operating
context is a complicated task due to the dependencies
rooms and related human resources (Castoro, Bertinato,
between these activities, the uncertainty in processing
Baccaglini, Drace, & McKee, 2007). Unlike inpatients,
times, and the need to ensure the simultaneous availa-
outpatients are not hospitalised prior to and after surgery.
bility of a variety of service providers/resources in order
AS is a scheduling method used for managing arrival
to deliver the desired services.
times of patients at the facility. Its objective lies at the
Dealing with AS in ISS has been considered by some
intersection of efficiency and timely access to health
studies (Ewen & Mönch, 2014; Pham & Klinkert, 2008).
services, to meet the requirements of all stakeholders,
This research differs from earlier studies in respect not
including patients (through reducing waiting times) and
only of the approach but also of the objective. In this
health care providers (through minimising makespan or
paper, we address the AS problem of in- and outpatients
completion time) (Gupta & Denton, 2008). Given that
in an ISS, considering different stages and assuming sto-
inpatients are already in the hospital ward, the appoint-
chastic service times. We aim to develop an effective
ment schedule implementation requires the scheduler to
and easy-to-implement appointment decision tool for
identify, in each slot, arrival times at the surgical suite for
hospital management. For ease of implementation, we
outpatients and start times of procedures for inpatients.
develop appointment heuristics based on the use of sev-
The main goal of this study is to consider the two
eral sequencing rules. These heuristics are evaluated by
types of patient when designing an AS. In fact, at the
means of a discrete event simulation (DES) model that
ISS each type of patient has a distinct pathway, dedicated
assumes stochastic service times. Their comparison is
and shared resources, and different types of surgery
based on their performance in terms of waiting time
performed by their specific type of surgeon. For these

CONTACT  Safa Chabouh  safa.chabbouh.gi@gmail.com

© Operational Research Society 2018
68   S. CHABOUH ET AL.
(WT), completion time (CT), and the proportion of out-
patients discharged after a certain time (PAH). In order
to return home safely the same day, outpatients have to
leave the ISS before a certain time. To study the effec-
tiveness of the appointment heuristics, we compare them
to a lower bound. This latter is the optimal appointment
schedule delivered by a mixed integer program (MIP)
developed for the same problem.
The remainder of the paper is organised as follows: the
next section discusses the relevant literature on surgery
AS problems. We then define the problem by describing
the case study. In the following section, we discuss the
methodologies we have applied. Before concluding, we
present the experimental results. Finally, we summarise
the most significant managerial insights.
2.  Literature review
Various modelling approaches have been devoted to the
study of surgical AS problems. In our review, the focus
will be on papers that tackle AS problems of elective
surgeries in the short term, and particularly decisions
about patient sequences and the setting of their arrival
times while taking into account randomness in surgical
process durations. Three approaches have been used for
AS under uncertainty: optimisation, simulation, and the
combination of optimisation and simulation methods.
Within the optimisation category, queuing theory has
been widely used to solve clinic AS problems but not in
surgical facilities. It has assumed steady-state behaviour
for the system, which is hardly achievable in healthcare
environments (Cayirli & Veral, 2003). In addition to the
queuing theory, researchers have used stochastic pro-
gramming to tackle the AS problem of a single server
(i.e., the operating room) considering uncertainty in
surgery durations for inpatient facilities (Denton &
Gupta, 2003; Denton, Viapiano, & Vogl, 2007) and in
patient attendance for dedicated outpatient facilities
(Berg, Denton, Erdogan, Rohleder, & Huschka, 2014).
Other analytical methods, developed by Begen and
Queyranne (2011), Begen, Levi, and Queyranne (2012),
Ge, Wan, Wang, and Zhang (2013), and Mak, Rong, and
Zhang (2014), also considered single-stage systems and
addressed randomness by making assumptions on data
for surgery durations in inpatient facilities. The afore-
mentioned papers considered only single-stage systems
due to the complexity of the methods used. In contrast
to analytical methods, simulation has the flexibility
to model large and complex systems (e.g., multistage
systems).
Simulation methods, especially DES, have been used
extensively in modelling health care systems (Günal &
Pidd, 2010). In the case of outpatient clinics, they are
used for designing and/or testing several appointment
schedules while focusing on WT between patients’
arrival and the effective beginning of their treatment.
Huschka, Denton, Gül, and Fowler (2007) developed
a simulation model to evaluate an outpatient surgical
centre’s performance in terms of patient WT and over-
time. Authors defined appointment heuristics based on
surgery duration data and sequencing rules. Regarding
inpatient facilities, many studies Marcon and Dexter
(2006), Testi, Tanfani, and Torre (2007), Arnaout and
Sevag (2008), Azari-Rad, Yontef, Aleman, and Urbach
(2014) developed DES models to evaluate the impact of
applying sequencing heuristics to the performance of
the surgical suite in terms of CT. As patient arrival times
at the surgical suite have not been considered in these
studies, the waiting time has not either been considered.
In summary, simulation methods were used only to
compare different appointment schedules, thus do not
deliver a competitive optimisation strategy. To fill this
gap, recent studies Gul, Denton, Fowler, and Huschka
(2011), Saremi, Jula, ElMekkawy, and Wang (2013), Ewen
and Mönch (2014), Saremi, Jula, ElMekkawy, and Wang
(2015) developed simulation-based optimisation meth-
ods to address the AS of patients in outpatient surgery
settings. The DES models developed were integrated
into the optimisation part to evaluate the selected crite-
ria (WT and overtime or makespan) while taking into
account the randomness in process durations. The DES
models are used also to compare easy-to-implement heu-
ristics with the proposed approaches (for an outpatient
surgical centre (Gul et al., 2011; Saremi et al., 2013)).
The literature review shows that there are few papers
that treat the AS problem in an ISS. The majority of these
studies addressed the AS problem for only one type of
elective surgery or focus on a single stage. Our work
differs from the aforementioned papers in the follow-
ing ways. First, we address the daily stochastic AS prob-
lem of elective in- and outpatients in a multistage ISS.
Second, we consider several constraints simultaneously
such as the availability of resources at the ISS, compati-
bility constraints, and specific constraints related to out-
patients. Third, we aim to offer hospital management a
scheduling rule that is easy to implement and effective
in terms of WT and CT.
3.  The case study
Surgical services in integrated hospital facilities are
offered to both in-and outpatients. Outpatients are
admitted, have their surgery, and leave the hospital the
same day, while inpatients are hospitalised one or more
days before and after surgery. We studied patient flow
in an ophthalmology ISS of a public Tunisian hospital,
illustrated in Figure 1. During surgery, in- and outpa-
tient flows go through three stages: the pre-operative, the
operative, and the post-operative stage. The pre-opera-
tive phase for outpatients (whom we refer to as p = 1), is
done in the Preoperative Holding Unit (PHU) (respec-
tively, hospitalisation ward for inpatients). The operative
phase is performed in operating rooms for all patient
types. The post-operative phase is completed whether

Figure 1. In- and outpatient’s flows in the Tunisian ISS.
in the recovery room (PACU) or hospitalisation ward,
depending on the patient’s type and their anaesthesia
type. Only outpatients and inpatients undergoing gen-
eral anaesthesia (whom we refer to as p = 2) are routed
to the PACU. Inpatients undergoing local anaesthesia
(whom we refer to as p = 3) are transferred directly to
their bed in the hospitalisation ward. As depicted in
Figure 1, there are three types of patients p = 1, 2, and
3. Our field of study is limited to the ISS and does not
consider the hospitalisation ward. Hence, preparation
and recovery resources in for inpatients are assumed
to be unlimited. The limited resources in each stage are
presented in Table 1.
We notice that for each type of patient, different types
of surgery are considered. Each type of surgery is per-
formed by a specific type of surgeon. Three major types
of ophthalmologic surgery are performed in this facil-
ity. The first two types are related to cataract surgery:
Phacoemulsification (which we refer to as n = 1 with a rel-
ative frequency of 45%) and Extracapsular (which we refer
to as n = 2 with a relative frequency of 40%). Theses sur-
geries can be done both on an outpatient and an inpatient
basis. They are performed, respectively, by surgeon type
s = 1 and type s = 2. The third type, Strabismus surgery
and others (which we refer to as n = 3 with a relative fre-
quency of 15%), are performed by surgeon type s = 3. This
surgery type is only done on an inpatient basis and can
be performed both under local and general anaesthesia.
The ISS operates a 12-h day from 8 am to 8 pm, with
all patients arriving at the beginning of the day.
4. Methodology
This paper addresses the daily AS of in- and out-
patients in an integrated hospital facility. We first
develop appointment heuristics based on the use of
Table 1. Limited resources per stage in the ISS.
Stage Limited resources Specification
Preoperative stage Preparation beds Dedicated to p = 1
Nurses Shared by all patient types
Surgery stage ORs and Surgeons
Recovery stage Recovery beds A predefined quota on the number of beds dedicated to patients of type p = 1 and type p = 2
JOURNAL OF SIMULATION   69
easy-to-implement sequencing rules. We then build a
DES model that describes patient flow in the facility and
takes into account uncertainty in service durations. It is
used to evaluate the appointment heuristics on the basis
of three performance indicators: WT, CT, and PAH. The
results for the appointment heuristics are compared to
a lower bound delivered by the MIP which solves the
deterministic version of the problem.
The WT measures the patient’s satisfaction. It includes
a WT between the patient’s arrival and his effective entry
into the ISS and a WT before surgery.
The CT (or makespan) refers to the time at which
the last patient leaves the surgical suite. To compare the
CT of an appointment schedule (i) (CT(schedule i)) and
the lower bound for the CT (CT*), we calculate the gap
(Gap(CT)schedule i) given by the Equation (1):
CT(schedule i) − CT∗
Gap(CT)schedule i = (1)
CT∗
The last indicator PAH studies the feasibility of an
appointment schedule according to specific constraints
related to outpatients. In fact, the outpatients must leave
the facility before a predetermined time H to ensure that
they return home safely. For each appointment schedule
(i), PAH is calculated using the Equation (2). This con-
straint will be taken into account only in the MIP. Thus,
all outpatients in the lower bound leave the ISS before
the chosen hour H.
(Number of outpatients discharged after H)schedule i
PAHschedule i =
Total number of outpatients discharged
(2)
We first discuss our MIP. Second, we describe the
appointment heuristics. Finally, we present the simu-
lation model.
70   S. CHABOUH ET AL.

4.1.  The lower bound q5,t,3,n = I5,3,n − X5,t,3,n + X3,(t−d ),3,n

3,3,n
∀t, n (12)

The lower bound is given by the MIP which solves the Resource (13)
∑ ∑
X2,t,1,n − X2,(t−d ),1,n ≤ R2 ∀t
2,1,n
availability n n
deterministic version of the problem. The notations and constraints
the optimisation model are presented as follows: (14)
∑ ∑
X2,t,1,n − X2,(t−d ≤ B2 ∀t, n
2,1,n ),1,n
n n
The indexes
(15)
� �
≤ ls,n ∀t, s, n
∑
𝜎pn 𝛽ns X3,t,p,n − X3,(t−d
3,p,n ),p,n
t = 1, …, T discrete time index, where T is the number of time slots in p
each day
p = 1, 2, 3 ∑∑� (16)
�
patient type index (defined in the case study section) X3,t,p,n − X3,(t−d ≤ Ot ∀t
3,p,n ),p,n
j = 1, …, 5 stage index, where j = 1 and 2 refer to the pre-operation p n
stage for inpatients and outpatients, respectively; j = 3
(17)
∑ ∑
refers to the surgery for all patient types; j = 4 refers (X4,t,p,n − X4,(t−d
4,p,n ),p,n
) ≤ KR4 ∀t
to recovery stage of p = 1 and 2, and j = 5 refers to the p=1,2 n

hospitalisation of p = 3 and 2 ∑

(X4,t,p,n − X4,(t−d ) ≤ BRp ∀t∀p = 1, 2 (18)
s = 1, ..., S surgeon type index, where S is the number of surgeon n
2 ,p,n),p,n

types
n = 1, ..., N surgery type index, where N is the number of surgery types The number of 4
∑ ∀n, p = 1, 2 (19)
patients that X4,(T −d = 𝛼pj Ij,p,n
4,p,n ),p,n
The parameters have to be
j=1

served:
R2 number of nurses for pre-operation 3 ∀n, p = 3 (20)
B2
∑
number of beds in PHU (j = 2) X3,(T −d
3,p,n ),p,n
= 𝛼pj Ij,p,n
Ot number of operating rooms at time t j=1

ls,n number of surgeons of type s performing surgery of type n The CT indicator

∑
∀t, p = 1, 2 (21)
Mypt ≥ x4,(t−d
R4 number of nurses for the recovery constraints n
4.p,n ),p,n

BRp number of beds in PACU (j = 4) per patient type p

mp ≥ typt ∀t, p = 1, 2 (22)
We note that a nurse for pre-operation prepares one
(23)
∑
My3t ≥ x3,(t−d ∀t
patient at a time and a nurse for recovery can supervise n
3.p,n ),p,n

K patients at a time. m3 ≥ ty3t ∀t (24)

dj,p,n service duration of patient type p in stage j who is having m1 ≤ H (25)
surgery type n.
Ij,p initial number of patients of type p in the line, waiting to be m ≥ mp ∀p (26)
served at stage j, including patients who have appointments
in the first stage (we assume that at t = 1, the lines are empty
for surgery and recovery stages)
xj,t,p,n , qj,t,p,n are positive integers ∀j, t, p, n
H maximum completion time for outpatients
M an arbitrarily large number The MIP is developed in detail by Chabouh, Hammami,
γp penalty coefficient of waiting in a single time slot for a patient Bouchriha, and Marcon (2016). Given a day of length T
of type p
β penalty coefficient of operating the clinic per time slot
and a number of patients who need to be scheduled dur-
αpj One if a patient of type p goes through stage j, zero otherwise ing this day, we divide T into equal time slots. We have to
σpn One if a patient of type p has surgery of type n, zero otherwise determine the number of patients who should be asked to
βns One if surgery of type n is performed by surgeon of type s, zero
otherwise arrive at the beginning of each time slot. We assume that
Decision variables patients are punctual, do not baulk, and receive service in
a First-In–First-Out manner. The MIP is inspired by the
xj,t,p,n number of patients of type p who are having surgery of type n integer program proposed by Saremi et al. (2013). We have
at stage j to start being processed at time t
qj,t,p,n number of patients of type p having surgery of type n who are extended their model to different types of patient flows in
waiting to be served at stage j at time t an ISS. In addition, we have considered other compatibil-
Xj,t,p,n cumulative number of patients of type p having surgery of
type n at stage j whose treatment started at time t ity requirements i.e., surgeon–surgery-type compatibility
m last time block, in which all patients have been discharged (CT) and patient–surgery-type compatibility. The MIP model
mp CT of patient’s type p
ypt One if some patient of type p is discharged from the ISS at time uses the mean processing times in each stage, which are
t; zero otherwise calculated based on data presented in Section 4.3.
The MIP The AS in the ISS can be identified as a three-stage
hybrid flow-shop scheduling problem. Knowing that the
The objective (3)
∑∑∑
Minimize 𝛾p q3,t,p,n + 𝛽m
function t p n two-stage flow-shop scheduling problem is NP-complete
The cumulative ∑t
∀j, t, p, n (4) (Linn & Zhang,1999), the AS in the multistage ISS can
variable Xj,t,p,n = xj,𝜏,p,n
constraints
𝜏=1 be considered as NP-complete.
Compatibility (5)
∑∑
xj,t,p,n ≤ M𝛼 pj ∀j, p
requirements t n
∑ ∑
xj,t,p,n ≤ M𝜎 pn ∀n, p (6)
4.2.  Appointment heuristics
t j
The heuristics include two stages. The first stage determines
Queue balance q1,t,p,n = I1,p,n − X1,t,p,n ∀t, n, p = 2, 3 (7)
constraints the order in which patient types are assigned to blocks based
q2,t,1,n = I2,1,n − X2,t,1,n ∀t, n (8) on a sequencing rule. In the second stage, appointment
(9) times are defined using an appointment rule which specifies
∑
q3,t,p,n = I3,p,n − X3,t,p,n + Xj,(t−d
j,p,n ),p,n
∀t, n, p
j=1,2
q4,t,p,n = I4,p,n − X4,t,p,n + X3,(t−d
3,p,n ),p,n
= 0 ∀t, n, p = 1, 2 (10) the number of patients scheduled to each appointment slot.
q5,t,2,n = I5,2,n − X5,t,2,n + X4,(t−d ∀t, n (11) This study tests 6 sequencing rules and two appointment
4,2,n ),2,n
rules, which results in a total of 12 appointment heuristics.

4.2.1.  Sequencing rules
Some sequencing rules were widely applied to surgery
scheduling problems, namely Longest Processing Time
(LPT), Shortest Processing Time (SPT), and Dome
Shape rule (DSR), which are based on mean surgery
duration. SPT was recommended by Gul et al. (2011).
Robinson and Chen (2003) recommended DSR for the
AS of an outpatient clinic based on patients’ service time.
In our study, and to the best of our knowledge, we are
the first to apply rules based on the mean service dura-
tions of the three stages of the surgical suite such as the
Generalised Johnson Rule (GJR) and the Shortest Total
Operating Time rule (STOTR) (Stevenson, Benedetti, &
Bourenane, 2006). They are applied mainly to minimise
the completion time of three-stage processes in manu-
facturing. In summary, we sort patient types according
to the following sequencing rules:
• SPT: Increasing mean of surgery time;
• LPT: Decreasing mean of surgery time;
• DSR: First decreasingly sorts the patient types
based on their mean surgery times. Then, it starts
generating the patient types’ sequence by placing
the type with the largest surgery time in the middle
of the sequence, and putting types with less surgery
time before and after it, alternatively;
• InvDSR: Inversed Dome-Shape Rule
• GJR: For each patient type, we create two fictive
processes. The first one’s duration (D1) is equal to
the sum of preparation and operating times. The
second one’s duration (D2) is equal to the sum of
surgery and recovery times. Then, we sort patient
types by increasing order of the ratio D1/D2.
STOTR: For each patient type, we calculate the total
• 
service time (dtot), and we sort then by increasing order
of dtot. For the first type in the sequence, if preparation
time is less than recovery time, it will be placed at the
beginning of the sequence. Otherwise, it will be placed
at the end of the sequence. For the remaining types, we
repeat the latter step until all of them are scheduled.
4.2.2.  Appointment rules
Given a specific sequence of patient types, we have to
determine the arrivals of patients per batch. The first
appointment is set at the beginning of the day. The
number of patients who should be called to arrive at
the first appointment is determined in two ways: Basic
way (all patients of the first type classified in sequence
arrive simultaneously and so on) and Enhanced way
(the number of patients, who arrive simultaneously is
equal to the number of operating rooms). Subsequent
appointments are set to the prior appointment time plus
(1) the mean time for the previous patient type’s surgery
for SPT, LPT, DSR, and InvDSR, or (2) the mean time for
the previous patient type’s preparation for the remaining
rules. In summary, we define 12 appointment heuris-
tics named as follows: Basic SPT, Basic LPT, Basic DSR,
JOURNAL OF SIMULATION   71
Basic InvDSR, Basic GJR, and Basic STOTR for sched-
uling rules, where patients arrive according to the Basic
appointment rule; and Enhanced SPT, Enhanced LPT,
Enhanced DSR, Enhanced InvDSR, Enhanced GJR, and
Enhanced STOTR for scheduling rules, where patients
arrive according to the Enhanced appointment rule.
4.3.  Simulation model
To build the DES model, several steps were followed
(Kelton, Sadowski, & Sadowski, 2000). We established
a conceptual representation of the system (illustrated
in Figure 2). The structure of the model followed the
patient flow which is illustrated in Figure 1. The model’s
entities are patients. Our model is a terminating simula-
tion (Banks, Carson, Nelson, & Nicol, 2005). Extensions
such as tardiness and no-shows are straightforward with
our model; however, they are uncommon in the ISS we
studied, and for simplicity we do not include them in
our analysis. Hence, we assume arrivals are on time and
all patients show up for their scheduled procedure. We
assume also that the surgeries are considered independ-
ent from one another; operating rooms are identical and
parallel, and all the patients are scheduled before the
day begins.
The data needed for the DES model consisted mainly
of the patient/surgery-type partitions (presented in
Section 3), the number of resources and process times at
each stage (illustrated in Figure 2). The relevant data were
collected over a two-month period. A total of 70 patients
were observed and tracked. We established auto- and
cross-correlation analysis between service times, which
revealed the absence of correlations. Then, distributions
were fit for all stages of a patient’s movement through
the ISS using the chi-square and Kolmogorov–Smirnov
tests by means of the Arena Input analyser tool.
The DES model was tested to make sure that it rep-
resented the real data collected. The difference between
average observed CT and simulated CT, for two days and
different numbers of patients, is less than 5% showing
that the model is validated.
5.  Experiments and results
The numerical experiments were carried out on an
Intel@Corei-7 processor 2.1  GHz and 8  GB Memory
RAM. The appointment heuristics, DES, and MIP mod-
els were implemented, respectively, in MS Visual C++,
Rockwell Arena TM software, and ILOG CPLEX 12.3
optimization library.
Preliminary experiments were performed in which
the number of simulation replications was varied show-
ing that 40 runs were needed to obtain a satisfactory
half width of the generated 95% confidence intervals
(0.95CIs) for the selected simulation outputs (e.g., CT).
We conduct two studies to evaluate the performance of
our methods. First, we compare the performance of the
MIP model with the appointment heuristics on the basis
72   S. CHABOUH ET AL.
Figure 2. The conceptual representation of the simulation model.
of several criteria described in Section 4. We considered
the test problem with 32 patients and 50% of ambulatory
surgery proportion AP. Second, we conduct a sensitivity
analysis by varying the AP in order to investigate the
robustness of the appointment heuristics.
5.1.  Appointment heuristics comparison
We compare the 12 appointment heuristics with the
particular procedure practice at the Tunisian ISS
named “Current practice” and with the simulated lower
bound named “Simulated LB”. In our experiments, we
used a 10-min time slot for the MIP. The length of day
T = 12 h = 72 time slots. For our test problem, the MIP
delivers the appointment schedule with CT* = 460 min,
WT* = 0 min, and PAH* = 0%, in 14 s.
The comparison results for Gap(CT), WT, and PAH
are illustrated in Figure 3. We presented the average val-
ues and box plots for performance indicators per arrival
scenario. The boxes show 0.95CI for each metric and
whiskers show the best and worst cases or each heuristic.
Figure 3 shows that the Simulated LB outperforms
the other rules. Regarding the heuristics, some rules that
deliver good CT values result in long WT and vice versa
(Enhanced DSR/InvDSR). This is consistent with the
finding of Saremi et al. (2013), that DSR offered shorter
WT but longer CT. Moreover, the Current Practice
tends to satisfy only health care providers by reducing
CT while dissatisfying patients through WTs and PAH.
On the other hand, heuristics that are based on surgery
durations only outperformed those based on all stage
durations for all performance measures. In addition, the
Enhanced appointment rules outperform the Basic ones.
In particular, the Enhanced SPT presents a compromise
between all proposed performance measures. This is
consistent with the finding of Gul et al. (2011), which
stipulates that SPT yields the best schedules in terms of
overtime and WT for an outpatient surgery centre.
5.2.  Sensitivity analysis of ambulatory surgery
proportion’s variation
The comparison of the appointment heuristics showed
that, for each criterion, some sequencing rules are bet-
ter than others. We conducted a sensitivity analysis to
investigate the behaviour of these heuristics according
to each indicator when we vary the AP within a range of
±10% from the current one (50%). In this analysis, we
study the robustness of SPT, LPT, and DSR rules for all
the criteria, and we exclude InvDSR, STOTR, and GJR
since they presented the worst performance for almost
all the criteria. Figure 4 shows the impact of the AP var-
iation on Gap(CT),WT, and PAH.
Our findings suggest that WT and PAH are not sensi-
tive to the variation of AP. Hence, for the same sequenc-
ing rule, the Enhanced appointment rules outperform
the Basic ones. Particularly, Enhanced SPT remains the
best heuristic in terms of WT and PAH. Conversely, CT is
very sensitive to the variation of AP. This variation results
in a new distribution of patient types for each range of
AP. Given that ambulatory cases are generally shorter
than inpatient cases (Pham & Klinkert, 2008), total pro-
cessing times will vary with AP, and the makespan will
in turn be affected. Furthermore, the effective appoint-
ment heuristic depends on the AP and follows only the
performance of Gap(CT). Table 2 summarises the results
of the sensitivity analysis. We conclude that there is no
best appointment heuristic; instead, it must be chosen
depending on the type of surgery facility considered
(whether it is dedicated or integrated).
 JOURNAL OF SIMULATION   73

Figure 3. Gap(CT), WT, and PAH (H = 15:00) per arrival scenario.

Figure 4. The impact of AP variation on Gap(CT), WT, and PAH per appointment heuristic.
74   S. CHABOUH ET AL.
Table 2. The best appointment heuristic(s) per AP’s range.
Ambulatory proportion [10%,40%]
Performance indicator CT Basic/Enhanced DSR
CT + WT + PAH Enhanced DSR
6. Conclusion
In this article, we addressed the AS of in- and outpatients
in a multistage ISS with stochastic service time durations,
where patients have shared and dedicated resources,
depending on their type, while considering specific con-
straints related to outpatients. Twelve appointment heuris-
tics are proposed and evaluated by means of a DES model,
in terms of WT, CT, and PAH. These heuristics are further
compared with a lower bound obtained by the MIP. The
computational experiments are based on real data of a
Tunisian ophthalmology hospital-integrated facility.
The experiments showed that the choice of the best
rule, which presents a trade-off between health care
provider satisfaction and patient’s satisfaction, while
respecting specific constraints related to outpatients,
depends on the AP, in other words, on the type of out-
patient surgery facility.
Several directions for future research are apparent
from this study such as taking into account other uncer-
tainties related to patient arrival and applying alternative
easy-to-implement approaches (e.g., lean approaches).
Acknowledgments
We are grateful to two industrial engineering students:
Maher Amara and Firas Ktari who carried out data collec-
tion and modelling. We are also grateful to the staff members
of the Tunisian ophthalmology surgical department at Habib
Thamer Hospital, who were very helpful in supplying both
our students and ourselves with information for our model.
Disclosure statement
No potential conflict of interest was reported by the authors.
Statement of contribution
We focus on the application of OR methods such as: dis-
crete event simulation (DES), mathematical programming,
and heuristics, in performance modelling and evaluation in
a particular type of health care facility: the outpatient sur-
gery hospital-integrated facility known as the integrated
surgical suite (ISS). We address the appointment scheduling
(AS) of Inpatients and Outpatients in the ISS. We consider
a real case of a Tunisian ISS: a multistage system serving a
variety of patient types and assuming stochastic service times
at each stage. We define patient types considering the sur-
gery delivery system (Inpatient vs. Outpatient), anaesthesia
types, and surgery/surgeon types. The resource availability
and compatibility play an important role as constraints for
AS, since each type of patients has separated pathway, ded-
icated and shared resources, and different types of acts per-
formed by specific surgeon types. The study of literature in
[40%;60%] >60%
Enhanced SPT/LPT Basic DSR/ Enhanced LPT
LPT
Enhanced SPT Enhanced LPT
this domain reveals the paucity of papers that handle the AS
of ISSs considering multistage systems under uncertainty. We
target this gap by developing an effective and easy-to-imple-
ment appointment decision tool. The approach is composed
of two steps: appointment schedules’ generation on the basis
of easy-to-implement sequencing rules used in practice and
the evaluation of the generated arrival scenarios via a DES
model. To study the effectiveness of the tool, we evaluate
the performance of arrival scenarios and compare them to
a lower bound. This latter is obtained by the resolution of
a mixed integer program which addresses the determinis-
tic version of the problem. Finally, we conduct a sensitivity
analysis by varying the Ambulatory surgery Rate in order to
investigate the robustness of the appointment heuristics.
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