Using simulation in out-patient queues: a case study
Fenghueih Huarng
Overwork and overcrowding in
some periods was an impor-
tant issue for the out-patient
department of a local hospital
in Chia-Yi in Taiwan. The
hospital administrators
wanted to manage the patient
flow effectively. Describes a
study which focused on the
utilization of doctors and staff
in the out-patient depart-
ment, the time spent in the
hospital by an out-patient,
and the length of the out-
patient queue. Explains how a
computer simulation model
was developed to study how
changes in the appointment
system, staffing policies and
service units would affect the
observed bottleneck. The
results show that the waiting
time was greatly reduced and
the workload of the doctor
was also reduced to a reason-
able rate in the overwork and
overcrowding periods.
International Journal of
Health Care Quality
Assurance
9/6 [1996] 21–25
© MCB University Press
[ISSN 0952-6862]
National Chung Cheng University, Chia-Yi, Taiwan
Mong Hou Lee
National Chung Cheng University, Chia-Yi, Taiwan
Introduction
As a result of the rapid growth of the econ-
omy and the availability of education for all
in Taiwan, the people of Taiwan have started
to demand more efficient health care at a
reasonable cost, and with better quality of
service. The new insurance policy for every-
one in Taiwan, the evaluation system
imposed on all hospitals by the Department of
Health, and increasing severe competition
within the industry, are some of the issues
forcing Taiwan’s hospitals to improve their
quality of service and operational effective-
ness. As hospitals raise their technical qual-
ity, patients will lay more emphasis on qual-
ity assurance. In order to survive, most of
Taiwan’s hospitals are making efforts to
improve their service quality to satisfy their
patients.
There are many indicators of quality assur-
ance. In the out-patient department, the main
indicator of quality assurance for patients is
“waiting” itself; patients should be attended
to within an acceptable time. In Taiwan most
hospitals do not give their patients timed
appointments, but instead issue a sequencing
number. Therefore, most patients suffer a
long wait.
In this case history, the utilization of doc-
tors and staff in the out-patients department,
the time spent in the hospital by the out-
patient, and the length of the out-patient
queue is studied for a small local hospital at
Chia-yi in Taiwan. Using the simulation
technique, some suggestions for improve-
ment are presented to help the hospital
adjust their operations to reduce the waiting
time and improve quality assurance in the
out-patient department.
Literature review
The waiting problem is listed as one of the
indicators of quality assurance for the health
care system in several papers[1-3]. Jackson[4]
proposes two main principles for scheduling
patients in out-patient departments. First, the
scheduled time slot between two patients
depends on the average consultation time of
each physician. The best ratio of average
consultation time to scheduled time slot
between two patients is from 0.85 to 0.95. Sec-
ond, it is better for the time point to be in
multiples of five minutes. Welch[5] considers
punctuality and consultation time as two
main factors affecting the scheduling system
for an out-patient department. Because many
patients are unsure about the time of their
appointment, they tend to arrive earlier than
they should; hence, their waiting times
increase. In addition, because many physi-
cians are late, patients’ waiting times
increase even more. Rising et al.[6] proposed
a new scheduling system. First, allocate the
consultation time to patients who turn up
without an appointment. Then, the remain-
ing time slots are scheduled to patients by
appointment so that the out-patients’ waiting
time is reduced and the physicians’ over-
running time is reduced too.
Allessandra et al.[7] study the efficiency of a
family planning clinic and propose several
alternatives for improvement to reduce the
length of the queues and increase the utiliza-
tion of physicians. Vassilacopoulos[8]
allocates doctors to several shifts according
to the patients’ arrival rate in an accident and
emergency department. Babes and Sarma[9]
study the out-patient queues of Ibn-Rochd
Health Centre and compare the advantages
and disadvantages of using queuing models
and simulation techniques.
For other hospital operation problems,
see [10-18].
The out-patient service
before improvements
The various functions of the out-patient
department of the case hospital include regis-
tration, general practice medicine, a cash
desk (patients are charged on-site for treat-
ment), pharmacy (the drugstore is inside in
the hospital in Taiwan), immunology, and lab.
The manager of the case hospital told us the
most serious problem in the out-patient
department is overcrowding in the dermatol-
ogy clinic. The patients’ waiting time in der-
matology is so long that the waiting area is
not large enough to accommodate the queue.
Staff in dermatology feel tired when they are
[ 21 ]
Fenghueih Huarng and
Mong Hou Lee
Using simulation in out-
patient queues: a case study
International Journal of
Health Care Quality
Assurance
9/6 [1996] 21–25
[ 22 ]
under pressure, but in other sections there
are fewer patients and staff are not very busy.
In order to have real data instead of per-
sonal, subjective impressions, the average
number of patients at each session was col-
lected and categorized according to different
sessions and different allocations of physi-
cians and staff. Six models, including differ-
ent sessions, different numbers of physicians,
different numbers of cashiers, and the aver-
age number of patients are listed in Table I.
Table I shows that dermatology is the bottle-
neck, but the average number of patients per
hour in models III, V and VI is smaller (82/8 =
10.25, 80/8 = 10, and 104/12 = 8.7 respectively).
In other words, apart from model IV, there are
fewer patients in the afternoon.
Because it was difficult to record every
patient’s waiting time at each function (the
waiting time for consulting a physician, the
waiting time for paying for treatment, etc.),
we collected only the service times and
patients’ inter-arrival times for simulation,
and the waiting time at each function could
be estimated from the results of the simula-
tion. In this case study, the service time for
each function was recorded for 30 days during
December 1992 to January 1993. The arrival
time of each patient was set to be the end of
his/her registration time, as it was hard to
verify and collect the exact time of the
patient’s arrival at the case hospital, and both
the registration time and the queue length
are quite short in the case hospital. Hence, in
this case study, the registration function is
excluded from the out-patient system.
When the data were collected, the mean
inter-arrival times on the Wednesday after-
noon and on the Saturday afternoon were
suspected to be different. First, each
Table I
The average number of patients in each model
Model Session Programme
I Mon. Wed. Sat. GM, GS,
(Morning) Skeletology
II Tues. Thurs. Fri. GM, GS,
(Morning)
III Mon. Tues. Fri. GM, GS,
(Afternoon)
IV Wed. Sat. GM, GS,
(Afternoon) Dermatology
V Thurs. GM, GS,
(Afternoon) Skeletology
VI Sun. GM, GS,
Notes:
Morning: 8.00 a.m.-12 noon; afternoon: 2.00 p.m.-10 p.m.
GM = general medicine; GS = general surgery
inter-arrival time was matched against the
exponential distribution. Since the sample size
was about 200, a Z-test was conducted to check
the difference between two means. The Z value
is 0.696 which is less than Z0.95 (= 1.645), hence,
the inter-arrival times for Wednesday after-
noon and Saturday afternoon are combined to
be exponentially distributed with 2.28 min-
utes of average inter-arrival time for model
IV. There are another 125 patients who
registered on each Wednesday and Saturday
morning for dermatology (the patients
registered in advance represent only about
5 per cent for the other programme). The
service time is matched against an appropri-
ate distribution and listed in Table II.
In order to study the out-patient flow for
model IV, the number of simulations run on
the SLAM system[19] is 1,000 using the above
data on arrival and service processes. In
model IV, there are two physicians – one is
responsible for both general medicine and
general surgery, the other treats the patients
in dermatology – one nurse responsible for
immunizations, one pharmacist, and four
pathologists responsible for different jobs in
the lab. The results of the simulation are
listed in Table III. To validate the simulation
model, the results shown in Table III are con-
sistent with the views of managers and staff
of the out-patient department, and the aver-
age number of patients served in simulation,
333, compares with the actual average num-
ber of patients, 335; the error rate is 0.6 per
cent.
From Table III, it is shown that the queuing
problem is acceptable, since the time spent in
the system for those patients in general medi-
cine and general surgery is 20.1 minutes (only
17.6 per cent of patients had to wait above half
Number of Number of Average number
physicians cashiers of patients
2 2 90
2 2 67
1 1 82
2 2 335
(225 for
dermatology)
2 1 80
1 1 104
Fenghueih Huarng and Table II
Mong Hou Lee Distributions of service time and their associated parameters
Using simulation in out-
patient queues: a case study Service Sample size Distribution Parameters
International Journal of General medicine 212 Exponential MAR = 0.3597
Health Care Quality General surgery 49 Exponential MAR = 0.3546
Assurance Skeletology 48 Exponential MAR = 0.3571
9/6 [1996] 21–25
Dermatology 129 Exponential MAR = 0.5495
Cash desk 413 Lognormal Mean = 1.10
SD = 1.20
Laboratory 63 Normal Mean = 13.30
SD = 2.80
Pharmacy 501 Exponential MAR = 0.8475
Immunology 294 Exponential MAR = 0.2703
Notes:
MAR = mean arrival rate (patient served per hour)
SD = standard deviation

an hour). However, the waiting time for those

patients in dermatology is 30.59 minutes, the
time in the system being 37.9 minutes (13.0
per cent of patients had to wait above 1.5
hours). The average consulting time for each
patient in dermatology is quite short (only
1.82 minutes). Most of the time, patients in
dermatology do not need the services of the
lab and immunology, and it takes only 1.10
minutes and 1.18 minutes for the average
service time spent at the cash desk and in the
pharmacy. Hence, most of the time spent in
the system for patients in dermatology is for
waiting. This is not a good indicator for qual-
ity assurance. Moreover, the utilization rate
of physicians in dermatology is 0.96 per cent,
which is quite high. The maximum busy time
could be as long as eight hours. Usually, for an
eight-hour period of work, there is at least a
half-hour break. Hence, the working load is
too high for a physician. Currently the wait-
ing area available is designed for 20 people,
but the simulation results show that the max-
imum queue is 36, which is much larger than
the capacity. Therefore, model IV does need
some action to improve the current condi-
tions.
Suggestions for improvement
There are two main ways to change the queu-
ing problems. One is to change the arrival
process, the other is to change the service
process[20]. In this study, we propose two
alternatives. First, change the arrival
process, that is, increase the number of
patients who make an appointment. Accord-
ing to Jackson’s[4] suggestion, the ratio of
consulting time between two consecutive
patients to time slot between two consecutive
appointments is set to be 0.95. When all the
patients are scheduled by appointment and
all patients are assumed to arrive on time,
patients in general medicine and general
surgery are influenced to some extent; time
in the system is decreased from 20.1 minutes
to 16.61 minutes, and the time in system for
patients in dermatology is reduced to only
17.42 minutes, along with a large reduction in
the maximum queue (the new queue is 14
patients). Moreover, the average number of
patients served is 242, which is only ten fewer
than the original model IV. Although it is
impossible to limit the number of patients
without appointments and those who do not
arrive in time for their appointments[6], it is

Table III
The results of simulation for model IV
Departmental performance GM and GS Dermatology Cash desk Laboratory Pharmacy Immunology
Average waiting time (minutes) 2.42 30.59 0.24 0.0 2.58 2.57
Average queue (number of parients) 0.42 13.91 0.14 0.0 2.02 0.33
Max. queue (number of parients) 6 36 5 0.0 12 5
Average utilization 0.47 0.96 0.76 0.30 0.75 0.48
Average No. of patients served 81 252 338 11 369 60
Max. idle time (minutes) 66.94 28.61 – – 15.81 113.11
Max. busy time (minutes) 198.45 480.0 – – 353.16 211.04
Notes:
Average time in system for patients in GM and GS 20.1 minutes
Average time in system for patients in dermatology 37.9 minutes

[ 23 ]
Fenghueih Huarng and
Mong Hou Lee
Using simulation in out-
patient queues: a case study
International Journal of
Health Care Quality
Assurance
9/6 [1996] 21–25
Table IV
The results of simulation for model IV (assume 20 per cent of increase)
Departmental performance
Average waiting time (minutes)
Average queue (number of patients)
Max. queue (number of patients)
Average utilization
Average no. of patients served
Max. idle time (minutes)
Max. busy time (minutes)
Notes:
Average time in system for patients in GM and GS 19.3 minutes
Average time in system for patients in dermatology 19.9 minutes
[ 24 ]
almost certain that the overall waiting time is
reduced when the ratio of appointment to
non-appointment patients is large. The imple-
mentation of the appointment system
requires the agreement of staff in the depart-
ment of medical records. Unfortunately, the
staff in this department are not willing to
make more effort to implement the appoint-
ment system.
The second approach is to change the ser-
vice process. There are two options to making
this change. One is to bring in one new physi-
cian with specialty in dermatology on
Wednesday afternoons or Saturday after-
noons. The other is to find another session to
have the current physician practising in
dermatology. The first option is not appropri-
ate because of the following two reasons.
First, recruiting could be a big problem; sec-
ond, there would be more patients on the
Wednesday afternoon or Saturday afternoon
to increase the workload of the pharmacy
whose current utilization rate is already 76
per cent. Incidentally, the high workload of
the physician in dermatology implies that the
physician is popular with the patients and
therefore they would prefer to be referred to
this same physician. Therefore, the second
option is better. There are only two consult-
ing rooms available. It is better not to add a
physician into a session which currently has
two physicians, and Sunday is not a normal
working day for the physician. Hence, the
best option is to extend the current physician
in dermatology to one afternoon of model III.
According to Worthington’s[21] empirical
study, it is shown that, as the supply
increases, the demand increases. This is
called “feedback”. In other words, as supply
increases, the demand does not increase until
the queuing reaches the level before the
increase of supply. However, in this study, we
think the above feedback could be reached
only if the supply is highly insufficient. It is
assumed that the patients in dermatology
will increase about 20 per cent if the case
hospital extends the current physician in
GM and GS Dermatology Cash desk
2.29 8.4 0.15
0.54 3.78 0.09
6 13 4 0.0
0.48 0.78 0.66
83 206 296
58.22 50.04 – –
243.78 455.62 – –
dermatology to one afternoon of model III.
Therefore, there are 255 × 2 = 510 patients in
every week; after the increase of 20 per cent,
the average number of patients in dermatol-
ogy per week becomes 612. It is assumed that
the 612 is divided into three afternoons. There
are 204 patients in each afternoon in derma-
tology. Also, it is assumed that there are
125/255 = 49 per cent of patients who register
in the same morning to be first in the queue
to see a doctor. Then the average inter-arrival
time becomes 2.61 minutes. The simulation
results are shown in Table IV.
From Table IV, the average time in the sys-
tem for patients in dermatology is reduced
from 37.9 minutes to 19.9 minutes (only 3 per
cent of patients whose time in system is
greater than 1.5 hours, 17.6 per cent of
patients whose time in the system is above
half an hour). The improvement in waiting
time is evident. The maximum queue length
is reduced from 36 to 13 (the average queue
length is reduced from 13.91 to 3.78) such that
waiting space is not a problem any more. The
utilization rate of physicians in dermatology
is reduced to 78 per cent such that the physi-
cian is at less risk of making erroneous diag-
noses due to fatigue and is able to concentrate
on providing quality consultation time to
each patient in turn. The satisfaction of
physicians in dermatology could be higher
with his/her workload reduced to a reason-
able rate. Since the decrease of the number of
patients in dermatology will not increase the
workload of the other services in the out-
patient department, the case hospital added
an extra session for dermatology patients on
Monday afternoons at the end of 1993. The
total number of patients in dermatology
every month from March 1994 to May 1994
(the average number of patients per week is
shown in parentheses) is listed in Table V.
From Table V, it is shown that patients gradu-
ally shift to the new section (Monday after-
noon). The managers and staff of the out-
patient department of the case hospital have
all shown their satisfaction with the changes.
Laboratory Pharmacy Immunology
0.0 1.96 2.94
0.0 1.29 0.6
10 5
0.30 0.67 0.48
11 334 65
28.0 106.80
300.16 247.45
Fenghueih Huarng and
Mong Hou Lee
Using simulation in out-
patient queues: a case study
International Journal of
Health Care Quality
Assurance
9/6 [1996] 21–25
Table V
Outpatient number in dermatology
Monday Wednesday Saturday
March 450(112) 459(115) 691(138)
April 771(154) 718(180) 619(155)
May 716(179) 1013(203) 880(220)
Notes:
( ) indicates the average out-patient number in each
afternoon
Conclusion
In this case study, the out-patient department
was analysed, and the most overcrowded
sessions (model IV) were simulated to study
the patients’ queue and service utilization of
staff. It is obvious that, before the improve-
ment, the high workload of the physician in
dermatology should be changed by increas-
ing the available consultation time of the
physician. The simulation was used to solve
the remaining problems of how much the
consultation time should be increased and
how the change would affect the current
system. A few alternatives were proposed to
improve the queuing problem in model IV
with the simulation results. The case hospital
chose the option of adding an extra session of
dermatology on Monday afternoons. The
results show that the total number of patients
increased, which is consistent with
Worthington’s[21] “feedback” theory. The
queue length was reduced considerably and
the patients’ average waiting time was
reduced by 18 minutes in dermatology.
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[ 25 ]