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ABSTRACT
SMITH III, RAYMOND LESTER. Whole Hospital Capacity Dynamics: Modeling and
Exploration. (Under the direction of Stephen Dean Roberts).
Modern medicine has achieved great progress in treating individual patients. This
progress is based mainly on advances in the life sciences and development of medical
devices and imaging technology. Advancements in health care delivery, however, have not
occurred at a similar rate. Improvements to health care delivery are mostly driven by
performance and process improvement (PPI) initiatives, such as six-sigma initiatives. These
tend to have a narrow scope oriented toward improving a specific issue. While PPI
initiatives do yield improvements, their impact often falls short of expectations and may
result in circulating a bottleneck around the hospital. Hospital-wide improvements should
utilize simulation modeling as a resource to examine strategic unit capacity concerns which
may lead to improved efficiency. When compared to the PPI approach, simulation modeling
would help mitigate risks, improve results, and reduce deployment time. In this dissertation,
we explore hospital-wide capacity dynamics under normal and severe operating conditions in
order to provide hospital administrators with strategic planning insights. To do this, we first
construct a generalized whole hospital simulation model representative of a medium size
semi-urban community hospital. To make this model produce a faithful representation of a
whole hospital we carefully reviewed and validated the model with a group of subject matter
experts. We then used the whole hospital model to explore four different questions related to
strategic unit capacity. The first question addressed focuses on the unit capacity allocation
required to maintain and improve patient flow and key performance measures. A
fundamental analysis approach, using the whole hospital model to simulate varied levels of
unit capacity, is proposed as a simple way to develop insight into the relationship between
the various unit capacities. The second question addressed focuses on the unit capacity
allocation required hospital-wide to satisfy a set of multiple objective criteria and constraints.
A goal seeking approach, treating the whole hospital model as a black box function, is
proposed as an efficient way to render a capacity determination satisfying the criteria. The
third question addressed focuses on the identification of capacity related factors found
hospital-wide that most significantly affect emergency department operations. A sensitivity
analysis for the whole hospital model is proposed where a factor screening design is first
performed to identify the important factors and subsequently a regression analysis is
performed to identify the significant factors. To do this, we develop the response variable
based on modifications to the Overall Equipment Efficiency (OEE) hierarchical metric for
the emergency department. Sensitivity analysis indicates that the number of emergency
department treatment rooms and standard acute care medical beds are the most significant
factors in achieving performance objectives. The fourth question addressed focuses on
hospital resilience and recovery when a patient demand surge caused by a natural disaster is
encountered. A Monte Carlo experimentation, using the whole hospital model, is proposed
as an efficient way to examine the recovery times for several defined strategies. Experiment
results suggest that strategies utilizing a broad set of adaptive capacity features realize better
patient flow and recovery times. To explore these questions variations of the whole hospital
model were used.

© Copyright 2016 Raymond Lester Smith III
All Rights Reserved

Whole Hospital Capacity Dynamics: Modeling and Exploration
by
Raymond Lester Smith III
A dissertation submitted to the Graduate Faculty of

North Carolina State University
in partial fulfillment of the
requirements for the degree of
Doctor of Philosophy
Industrial Engineering
Raleigh, North Carolina
2016
APPROVED BY:
_______________________________ _______________________________
Stephen Dean Roberts Kristen Hassmiller Lich
Committee Chair
_______________________________ _______________________________
Reha Uzsoy Jeffrey A. Joines
DEDICATION
I dedicate this dissertation to my loving wife, Margaret, who has been steadfast in her
support and encouragement during the years required to complete this endeavor. I sincerely
appreciate her personal sacrifice and dedication to accommodate my various academic
pursuits.
I also dedicate this dissertation to my loving parents, Raymond and Sandra. They
have always encouraged and supported my educational interests and personal achievements.
ii
BIOGRAPHY
Raymond Lester Smith III was born in Endicott, New York, raised and lived the
better part of his life in Raleigh, North Carolina. He attended Needham B. Broughton High
School in Raleigh. Raymond attended North Carolina State University and graduated with a
Bachelor of Science in Industrial Engineering in May 1992 and a Master of Science in
Industrial Engineering and Operations Research (co-degrees) in May 1999. In 1995,
Raymond started his professional career with the IBM Corporation in Research Triangle
Park, North Carolina, in the Personal Systems Division. During his career, he has held a
number of technical and leadership roles including positions as senior engineer, advisory
engineer, project manager, business architect, solution architect, and senior manager.
Leading a portfolio of increasingly challenging software and technology integration projects,
Raymond recognized the growing importance of systems engineering principles. While
working at the IBM Corporation and later Lenovo Incorporated, he completed a Master of
Science in Systems Architecting and Engineering at the University of Southern California in
August 2009. That same year, Raymond decided the time was right to pursue a Ph.D. in
Industrial and Systems Engineering at North Carolina State University. Upon his return,
interest was found in a variety of topics that included health care systems, medical decision
making, economic systems, information technology, operations management, system
dynamics and business strategy. Along the journey, Raymond earned a Master of Economics
degree and attended the University of North Carolina at Chapel Hill as an interinstitutional
student. His research and professional interests include systems analysis and design,
simulation modeling and analysis, optimization, systems dynamics, and systems thinking.
iii
ACKNOWLEDGEMENTS
I wish to acknowledge my committee members who were generous with their

expertise and time.
I would like to express my deep appreciation to Professor Stephen D. Roberts in his
role as advisor and committee chair. Professor Roberts encouraged my interest in the field of
industrial engineering and, in particular, the applications of simulation modeling and
analysis, and health care. I sincerely appreciate his kind support and thoughtful guidance
provided throughout the process of completing this dissertation. I would also like to express
my sincere appreciation to Professor Kristen Hassmiller Lich at the University of North
Carolina at Chapel Hill for her ongoing support, guidance and encouragement as I worked
through many challenges in the dissertation. I am very grateful to her for the time spent
serving as a mentor while I developed my skills and knowledge with system dynamics.
Special thanks go to Professor Reha Uzsoy who provided valuable feedback, insights, ideas
and challenges that helped shape this work into a better dissertation. Finally, special thanks
go to Professor Jeffrey Joines for his role in being a mentor and strong supporter.
I also want to acknowledge people that helped me complete the dissertation research.
Special thanks go to Jeffrey Strickler, DHA, RN, MA, at UNC Health Care for his ongoing
support and interest in this research. His knowledge and experience regarding hospital
operations contributed greatly to the development of this research. Thanks also go to Jackie
Ring, MA, RN, at Johnston Health for her introduction and guidance to hospital operations
and health systems. I also would like to thank Professor Scott Rockart at the University of
North Carolina at Chapel Hill for introducing me to the system dynamics field and research
community.
Finally, I would like to thank my loving wife, Margaret, for being patient and
supportive as I worked to complete this dissertation.
iv
TABLE OF CONTENTS
LIST OF TABLES ............................................................................................................................... xii

LIST OF FIGURES ............................................................................................................................. xiv
Chapter 1 Introduction ...................................................................................................................... 1
1.1 Introduction and Motivation .................................................................................................... 1
1.2 Description of Research ........................................................................................................... 2
Chapter 2 A Description of the Whole Hospital Model .................................................................... 8

2.1 Introduction .............................................................................................................................. 8
2.1.1 Health System Collaboration ................................................................................. 8
2.1.2 System Dynamics ................................................................................................. 10
2.1.3 Previous Related Work ........................................................................................ 11
2.1.4 Chapter Organization ........................................................................................... 11
2.2 Model Conceptualization and Development .......................................................................... 12
2.2.1 Community Hospital Acute Care Patient Flow .................................................... 13
2.2.1.1 The Emergency Department.............................................................................. 15
2.2.1.2 The Surgical Unit .............................................................................................. 16
2.2.1.3 The Medical/Surgical Inpatient Wards ............................................................. 18
2.2.2 Model Boundaries ................................................................................................ 19
2.2.3 Model Formulation............................................................................................... 21
2.2.3.1 The Dynamic Hypothesis .................................................................................. 21
2.2.3.2 The Structural Formulation ............................................................................... 24
2.2.4 Model Assumptions ............................................................................................. 27
2.2.5 Model Inputs ........................................................................................................ 29
2.3 A Detailed Model Description ............................................................................................... 29
v
2.3.1 Emergency Department ........................................................................................ 30
2.3.1.1 Model Boundaries ............................................................................................. 30
2.3.1.3 Model Structural Formulation ........................................................................... 36
2.3.1.4 Model Inputs ..................................................................................................... 39
2.3.1.5 Dynamic System Behavior ................................................................................ 40
2.3.2 Surgical Department............................................................................................. 41
2.3.2.4 Model Inputs ..................................................................................................... 49
2.3.2.5 The Dynamic Behavior ..................................................................................... 49
2.3.3 Medical-Surgical Inpatient Wards ....................................................................... 55
2.3.3.3 The Structural Formation .................................................................................. 62
2.3.3.4 Model Inputs ..................................................................................................... 64
2.3.3.5 Observed Model Behavior ................................................................................ 64
2.3.4 Radiology and Medical Imaging Diagnostics ...................................................... 66
2.3.5 Laboratory Diagnostics ........................................................................................ 80
vi
2.3.5.4 Model Inputs ..................................................................................................... 87
2.4 Model Calibration and Validation.......................................................................................... 90
2.4.1 Model Calibration ................................................................................................ 90
2.4.2 Model Validation ................................................................................................. 92
2.5 Model Limitations.................................................................................................................. 93
2.6 Conclusions ............................................................................................................................ 94
Chapter 3 Insights from a Fundamental Analysis ........................................................................... 95

3.1 Introduction ............................................................................................................................ 95
3.2 Terminology........................................................................................................................... 96
3.3 The Emergency Department and Medical Inpatient Wards ................................................. 100
3.3.1 A Fundamental Analysis .................................................................................... 100
3.3.1.1 Medical Intensive Care Unit Capacity ............................................................ 102
3.3.1.2 Medical Progressive Care Unit Capacity ........................................................ 107
3.3.1.3 Medical Acute Care Unit Capacity ................................................................. 112
3.3.1.4 Capacity Recommendations ............................................................................ 118
3.3.2 Sensitivity to Adjustments in Patient Demand ................................................... 120
3.3.2.1 An Enhanced Set of Capacity Recommendations ........................................... 121
3.3.2.2 Change in the Emergency Department Patient Demand ................................. 123
3.3.2.3 Sensitivity Analysis Results for Emergency Department Patient Demand ..... 124
3.3.3 Observations and Conclusions ........................................................................... 132
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3.4 The Surgical Unit and Surgical Inpatient Wards ................................................................. 133
3.4.1 A Fundamental Analysis .................................................................................... 134
3.4.1.1 Surgical Intensive Care Unit Capacity ............................................................ 135
3.4.1.2 Surgical Progressive Care Unit Capacity ........................................................ 142
3.4.1.3 Surgical Acute Care Unit Capacity ................................................................. 149
3.4.1.4 Capacity Recommendations ............................................................................ 155
3.4.2 Sensitivity to Adjustments in Patient Demand ................................................... 157
3.4.2.1 An Enhanced Set of Capacity Recommendations ........................................... 158
3.4.2.2 Change in Scheduled Elective Surgical Patient Demand ................................ 160
3.4.2.3 Sensitivity Analysis for Scheduled Surgical Patient Demand ......................... 161
3.4.3 Observations and Conclusion ............................................................................. 169
Chapter 4 Capacity Determination: A Goal Seeking Approach .................................................... 171

4.1 Introduction .......................................................................................................................... 171
4.2 Methodology ........................................................................................................................ 173
4.3 Capacity Determination: Emergency Department and Medical Wards ............................... 175
4.3.1 Problem Formulation ......................................................................................... 177
4.3.2 Model Results..................................................................................................... 181
4.3.3 Observations and Findings ................................................................................. 190
4.4 Capacity Determination: Surgical Unit and Surgical Wards ............................................... 193
4.4.1 Problem Formulation ......................................................................................... 194
4.4.2 Model Results..................................................................................................... 198
4.4.3 Observations and Findings ................................................................................. 208
4.5 Conclusions and Future Work.............................................................................................. 212
Chapter 5 Sensitivity Analysis Using the Overall Capacity Efficiency Metric ............................ 214
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5.1 Introduction .......................................................................................................................... 214
5.2 Proceedings of the 2014 Winter Simulation Conference ..................................................... 218
5.2.1 Proceedings Paper .............................................................................................. 218
5.2.2 Supplemental Analysis ....................................................................................... 231
5.3 Extensions and Limitations .................................................................................................. 236
5.3.1 Extensions .......................................................................................................... 236
5.3.2 Limitations ......................................................................................................... 237
5.4 Conclusions .......................................................................................................................... 238
Chapter 6 Exploring Hospital Resilience to Demand Surge ......................................................... 240

6.1 Introduction .......................................................................................................................... 240
6.2 Literature Review................................................................................................................. 241
6.3 Problem Framework............................................................................................................. 245
6.3.1.1 Hillsborough Hospital ..................................................................................... 247
6.3.2 Hospital Capacity Adaptation ............................................................................ 250
6.3.3 Model Modifications .......................................................................................... 251
6.3.3.1 Split Patient Flows .......................................................................................... 252
6.3.3.2 Operational States ........................................................................................... 254
6.3.3.3 Congestion States ............................................................................................ 254
6.3.3.4 Adaptive Features............................................................................................ 256
6.3.4 Adaptive Features Illustrated ............................................................................. 261
6.4 Methodology ........................................................................................................................ 264
6.4.1 Surge Event Characteristics ............................................................................... 264
6.4.2 Surge Demand Response.................................................................................... 266
6.4.3 Strategy Definition ............................................................................................. 267
ix
6.4.4 Experimentation ................................................................................................. 273
6.5 Observations ........................................................................................................................ 274
6.5.1 The Monte Carlo Experiment............................................................................. 274
6.5.1.1 Summary Observations ................................................................................... 275
6.5.1.2 ED Patient Flow Recovery Time .................................................................... 279
6.5.1.3 ED Patients Leaving-Without-Being-Seen ..................................................... 282
6.5.1.4 Surgical Unit Patient Flow Recovery Time .................................................... 287
6.5.1.5 Medical and Surgical Inpatient Ward Flow Recovery Time ........................... 291
6.5.2 Observations for Recovery Time with Varied Demand Surge Volume ............. 294
6.5.2.1 Contingency Operational State........................................................................ 295
6.5.2.2 ED Patient Flow Recovery Time .................................................................... 296
6.5.2.3 Surgical Unit Patient Flow Recovery Time .................................................... 299
6.5.2.4 Medical-Surgical Inpatient Wards Patient Flow Recovery Time .................... 303
6.5.3 Observations for Varied Demand Surge Volume Over Time ............................ 306
6.5.3.1 Contingency State Activation.......................................................................... 307
6.5.3.2 Ambulance Diversion State Activation ........................................................... 308
6.5.3.3 ED Waiting Area and Treatment Room Occupancy ....................................... 309
6.5.3.4 Patient Early Discharge Recovered Bed Days ................................................ 311
6.5.3.5 Scheduled Inpatient Surgery Cancellation ...................................................... 312
6.5.3.6 Medical-Surgical Inpatient Ward Occupancy ................................................. 313
6.6 Conclusions and Future Work.............................................................................................. 315
Chapter 7 Conclusion .................................................................................................................... 319

7.1 Contributions of Dissertation ............................................................................................... 319
7.2 Future Work ......................................................................................................................... 322
x
7.3 Applicability to the Broader Research Community ............................................................. 323
LIST OF REFERENCES ................................................................................................................... 325

APPENDICES .................................................................................................................................... 336
APPENDIX A. SIPOC DIAGRAMS BY UNIT ................................................................................ 337
APPENDIX B. WHOLE HOSPITAL MODEL PARAMETER VALUES ....................................... 340
APPENDIX C. EMERGENCY SEVERITY INDEX TRIAGE ALGORITHM ................................ 342
APPENDIX D. EMERGENCY DEPARTMENT SPLIT PATIENT FLOW .................................... 343
APPENDIX E. SURGE CAPACITY OPERATIONAL STATES .................................................... 344
APPENDIX F. ISERC 2014 PROCEEDINGS PAPER ..................................................................... 345
xi
LIST OF TABLES
Table 2-1: Patient arrival source, daily arrival rate and coefficient of variation .................................. 40
Table 2-2: Patient arrival source, daily arrival rate, and coefficient of variation ................................. 49
Table 2-3: Schedule of unit bed type length-of-stay durations............................................................. 64
Table 2-4: Radiology and medical imaging order request origination ................................................. 70
Table 2-5: Radiology and medical imaging equipment, cycle time and capacity ................................ 71
Table 2-6: Radiology and medical imaging target turnaround delay times .......................................... 71
Table 2-7: Equipment specification: analyzer capacity and cycle time ............................................... 87
Table 3-1: Resource and capacity terminology .................................................................................... 97
Table 3-2: Inpatient ward operations terminology ............................................................................... 98
Table 3-3: Emergency department operations terminology ................................................................. 98
Table 3-4: Surgical unit operations terminology .................................................................................. 99
Table 3-5: Unit capacity allocation for ED and medical ward units .................................................. 101
Table 3-6: Capacity recommendations and utilization results against targets .................................... 118
Table 3-7: ED performance metric results and targets ....................................................................... 119
Table 3-8: Medical ward performance metric results and targets ...................................................... 120
Table 3-9: Capacity recommendations and utilization results against targets .................................... 122
Table 3-10: Standard set ED performance metric results and targets ................................................ 122
Table 3-11: Standard set medical inpatient wards performance metric results and targets ................ 123
Table 3-12: Mean ED arrival rates and the corresponding percentage change .................................. 124
Table 3-13: Unit capacity allocation by surgical unit and wards ....................................................... 134
Table 3-14: Capacity recommendations and utilization against targets ............................................. 155
Table 3-15: Surgical unit performance metric results and targets ...................................................... 156
Table 3-16: Surgical ward performance metric results and targets .................................................... 157
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Table 3-17: Standard set capacity recommendations and utilization results against targets .............. 159
Table 3-18: Baseline surgical unit (SU) performance metrics and targets ......................................... 159
Table 3-19: Baseline surgical inpatient wards performance metric results and targets...................... 160
Table 3-20: Mean SU arrival rates and model inputs as patients per day (ppd) values...................... 161
Table 4-1: Objective function equation (4-1) member parameters: ................................................... 180
Table 4-5: Multiobjective optimization results for the decision variables ......................................... 182
Table 4-6: Objective function equation (4-10) member parameters: ................................................. 197
Table 4-10: Multiobjective results for the decision variables ............................................................ 199
Table 6-1: Hillsborough hospital unit capacity allocation adaptation schedule ................................. 251
Table 6-2: Description of operational states ....................................................................................... 255
Table 6-3: Description for congestion states ...................................................................................... 255
Table 6-4: Description for ED adaptive features ................................................................................ 256
Table 6-5: Description for hospital adaptive features ........................................................................ 257
Table 6-6: Description of strategy objectives ..................................................................................... 270
Table 6-7: Adaptive capacity feature selection and parameterization by strategy ............................. 272
Table 6-8: Adaptive capacity feature specification and parameterization description ....................... 272
Table 6-9: Variable distribution parameterization.............................................................................. 273
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LIST OF FIGURES
Figure 2-1: A generalized community hospital acute care patient flow ............................................... 15
Figure 2-2: Model boundaries for the whole hospital model ............................................................... 20
Figure 2-3: The whole hospital model patient flow causal loop diagram ............................................ 22
Figure 2-4: The whole hospital model stock and flow diagram ........................................................... 26
Figure 2-5: Model boundaries for the emergency department ............................................................. 31
Figure 2-6: Emergency department causal loop diagram ..................................................................... 37
Figure 2-7: Emergency department stock and flow diagram ............................................................... 38
Figure 2-8: Emergency patient arrivals by hour of day, and day of week............................................ 39
Figure 2-9: Dynamic ED behavior for a baseline run of model ........................................................... 41
Figure 2-10: Model boundaries for the surgical department ................................................................ 42
Figure 2-11: Surgical unit causal loop diagram.................................................................................... 47
Figure 2-12: Surgical unit stock and flow diagram .............................................................................. 48
Figure 2-13: Cumulative patient groups arriving to the surgical unit .................................................. 51
Figure 2-14: Surgical unit utilization by operative care unit ................................................................ 52
Figure 2-15: Surgical unit patient completion by origination type....................................................... 53
Figure 2-16: Surgical inpatient transfer from post-operative care to surgical ward ............................. 54
Figure 2-17: Surgical ward patient flow and occupancy ...................................................................... 55
Figure 2-18: Model boundaries for the inpatient wards ....................................................................... 57
Figure 2-19: Medical and surgical inpatient ward causal loop diagram ............................................... 61
Figure 2-20: Inpatient ward stock and flow diagram ........................................................................... 63
Figure 2-21: Observed dynamic behavior for medical inpatient wards ............................................... 65
Figure 2-22: Observed dynamic behavior for surgical inpatient wards ............................................... 66
Figure 2-23: Model boundaries for radiology and medical imaging services ...................................... 68
xiv
Figure 2-24: Radiology and medical imaging order flow causal loop diagram ................................... 74
Figure 2-25: Radiology and medical imaging stock and flow diagram................................................ 76
Figure 2-26: Radiology and medical imaging requests per hour.......................................................... 78
Figure 2-27: Radiology and medical imaging services utilization ....................................................... 79
Figure 2-28: Radiology and medical imaging services turnaround time (TAT) .................................. 79
Figure 2-29: Model boundaries for the laboratory diagnostic services ................................................ 81
Figure 2-30: Laboratory specimen processing causal loop diagram .................................................... 85
Figure 2-31: Laboratory specimen processing stock and flow diagram ............................................... 86
Figure 2-32: Arriving laboratory requests by priority type .................................................................. 89
Figure 2-33: Laboratory turnaround time and utilization ..................................................................... 90
Figure 3-1: Utilization with respect to MICU capacity ...................................................................... 103
Figure 3-2: LWBS with respect to MICU capacity ............................................................................ 103
Figure 3-3: Waiting time with respect to MICU capacity .................................................................. 104
Figure 3-4: Waiting time exceeding threshold limit ........................................................................... 104
Figure 3-5: Discharged LOS with respect to MICU capacity ............................................................ 104
Figure 3-6: Admitted LOS with respect to MICU capacity ............................................................... 104
Figure 3-7: Admitted patient boarding time exceeding threshold limit ............................................. 105
Figure 3-8: MICU capacity utilization ............................................................................................... 106
Figure 3-9: Transfer time exceeding threshold limit .......................................................................... 106
Figure 3-10: MICU bed census at midnight ....................................................................................... 106
Figure 3-11: MICU bed census at midday.......................................................................................... 106
Figure 3-12: Utilization with respect to MPCU capacity ................................................................... 108
Figure 3-13: LWBS with respect to MPCU capacity ......................................................................... 108
Figure 3-14: Waiting time with respect to MPCU capacity ............................................................... 109
xv
Figure 3-15: Waiting time exceeding threshold limit ......................................................................... 109
Figure 3-16: Discharged LOS with respect to MPCU capacity ......................................................... 109
Figure 3-17: Admitted LOS with respect to MPCU capacity ............................................................ 109
Figure 3-18: Admitted bed placement delay exceeding threshold ..................................................... 110
Figure 3-19: Capacity utilization with respect to ED capacity ........................................................... 111
Figure 3-20: Admitted transfer times exceeding threshold ................................................................ 111
Figure 3-21: Medical PCU midnight bed census................................................................................ 111
Figure 3-22: Medical PCU midday bed census .................................................................................. 111
Figure 3-23: Capacity utilization with respect to MACU capacity .................................................... 113
Figure 3-24: LWBS with respect to MACU capacity ........................................................................ 113
Figure 3-25: Waiting time with respect to MACU capacity .............................................................. 115
Figure 3-26: Waiting time exceeding threshold limit ......................................................................... 115
Figure 3-27: Discharged LOS with respect to MACU capacity ......................................................... 115
Figure 3-28: Admitted LOS with respect to MACU capacity ............................................................ 115
Figure 3-29: Admitted patient bed placement delay exceeding threshold ......................................... 116
Figure 3-30: Capacity utilization with respect to ED capacity ........................................................... 117
Figure 3-31: Patient transfer times exceeding threshold limit ............................................................ 117
Figure 3-32: Medical ACU midnight bed census ............................................................................... 117
Figure 3-33: Medical ACU midday bed census ................................................................................. 117
Figure 3-34: Utilization and LWBS rates with respect to the mean ED arrival rate .......................... 125
Figure 3-35: Wait time and threshold exceeded with respect to the mean ED arrival rate ................ 126
Figure 3-36: Discharged and admitted LOS with respect to the mean ED arrival rate ...................... 127
Figure 3-37: Patient transfers exceeding threshold with respect to mean ED arrival rate.................. 128
Figure 3-38: MICU utilization and patient census with respect to mean ED arrival rate ................... 129
xvi
Figure 3-39: MPCU utilization and patient census with respect to mean ED arrival rate .................. 131
Figure 3-40: MACU utilization and patient census with respect to mean ED arrival rate ................. 131
Figure 3-41: Utilization with respect to SICU capacity ..................................................................... 137
Figure 3-42: Inpatient elective surgery cancellation .......................................................................... 137
Figure 3-43: Outpatient elective surgery rescheduled ........................................................................ 137
Figure 3-44: Inpatient elective surgery rescheduled........................................................................... 137
Figure 3-45: Surgery intake waiting time delay ................................................................................. 139
Figure 3-46: Patient bed placement exceeding threshold limit .......................................................... 139
Figure 3-47: Outpatient surgery LOS time duration .......................................................................... 139
Figure 3-48: Inpatient surgery LOS time duration ............................................................................. 139
Figure 3-49: Inpatient bed placement delay exceeding threshold limit .............................................. 140
Figure 3-50: Utilization with respect to operating room capacity ...................................................... 141
Figure 3-51: Patient transfer times exceeding threshold limit ............................................................ 141
Figure 3-52: Midnight bed census with respect to operating room capacity ...................................... 141
Figure 3-53: Midday bed census with respect to operating room capacity ........................................ 141
Figure 3-54: Utilization with respect to SPCU capacity .................................................................... 144
Figure 3-55: Inpatient elective surgery patient cancellation............................................................... 144
Figure 3-56: Outpatient elective surgery patients rescheduled........................................................... 144
Figure 3-57: Inpatient elective surgery patients rescheduled ............................................................. 144
Figure 3-58: Elective surgery patient intake waiting time delay ........................................................ 145
xvii
Figure 3-63: Utilization with respect to operating room capacity ...................................................... 148
Figure 3-64: Transfer time delay exceeding threshold limit .............................................................. 148
Figure 3-65: Midnight bed census with respect to operating room capacity ...................................... 148
Figure 3-66: Midday bed census with respect to operating room capacity ........................................ 148
Figure 3-67: Utilization with respect to SACU capacity .................................................................... 150
Figure 3-68: Inpatient elective surgery patients cancelled ................................................................. 150
Figure 3-69: Outpatient elective surgery patients rescheduled........................................................... 150
Figure 3-70: Inpatient elective surgery patients rescheduled ............................................................. 150
Figure 3-71: Elective surgery patient intake waiting delay ................................................................ 152
Figure 3-76: SACU utilization with respect to operating room capacity ........................................... 154
Figure 3-77: Transfer time delay exceeding threshold limit .............................................................. 154
Figure 3-78: SACU midnight bed census ........................................................................................... 154
Figure 3-79: SACU midday bed census ............................................................................................. 154
Figure 3-80: Utilization and intake delay with respect to the mean SU arrival rate........................... 162
Figure 3-81: Cancellation and rescheduling rates with respect to the mean SU arrival rate .............. 163
Figure 3-82: Patient length-of-stay with respect to the mean SU arrival rate .................................... 164
Figure 3-83: Inpatient LOS by destination ward with respect to the mean SU arrival rate................ 165
Figure 3-84: Inpatient transfer delay exceeding threshold limit by destination ward ........................ 165
Figure 3-85: Attractive surgery ward patient transfers exceeding threshold ...................................... 167
Figure 3-86: SICU ward occupancy rate and census with respect to mean SU arrival rate ............... 167
xviii
Figure 3-87: SPCU occupancy rate and census with respect to the mean SU arrival rate ................. 168
Figure 3-88: SACU occupancy rate and census with respect to the mean SU arrival rate ................. 168
Figure 4-1: Diagram of inputs and outputs for hospital operations .................................................... 177
Figure 4-2: Objective function indexed value results (0%: 1 = -3,964,293) ...................................... 183
Figure 4-3: ED volume of annual cases arriving and by disposition ................................................. 183
Figure 4-4: Emergency department treatment room unit capacity and utilization ............................. 185
Figure 4-5: ED waiting time, delay exceeding threshold, and percent LWBS................................... 185
Figure 4-6: ED LOS times and targets for discharged and admitted patients .................................... 186
Figure 4-7: Medical patient volume and patient transfer delay exceeding target ............................... 188
Figure 4-8: MICU unit capacity, utilization, and patient placement delay exceeding targets ............ 188
Figure 4-9: MPCU unit capacity, utilization, and patient placement delay exceeding targets ........... 189
Figure 4-10: MACU unit capacity, utilization, and patient placement delay exceeding targets ........ 189
Figure 4-11: Objective function indexed value results ....................................................................... 191
Figure 4-12: ED treatment room unit capacity and utilization ........................................................... 192
Figure 4-13: ED waiting time, waiting time delay exceeding target, and LWBS percentage ............ 192
Figure 4-14: Diagram of inputs and outputs for hospital operation ................................................... 194
Figure 4-16: Annual surgical unit demand volume by origination source ......................................... 201
Figure 4-17: Surgical unit capacity, utilization, and utilization target ............................................... 203
Figure 4-18: Surgical unit cancellation rate, rescheduling rate, and patients held overnight ............. 203
Figure 4-19: Surgical unit length-of-stay time by patient destination ................................................ 204
Figure 4-20: Surgical ward discharges and transfers, and transfer delay exceeding target ................ 206
Figure 4-21: SICU unit capacity, utilization rate, and placement delay exceeding target ................. 206
Figure 4-22: SPCU unit capacity, utilization rate, and placement delay exceeding target................. 207
xix
Figure 4-23: SACU unit capacity, utilization rate, and placement delay exceeding target ................ 207
Figure 4-25: Surgical unit capacity, utilization, and utilization target ............................................... 210
Figure 4-26: Surgical pre-operative and post-operative care unit capacity utilization ....................... 211
Figure 4-27: Surgical cancellation rate, rescheduling rate, and patients held overnight .................... 211
Figure 5-1: OCE composite metric responding to percentage change ............................................... 233
Figure 5-2: OCE availability component metric responding to percentage change ........................... 234
Figure 5-3: OCE performance component metric responding to percentage change ......................... 234
Figure 5-4: OCE quality component metric responding to percentage change .................................. 235
Figure 5-5: LWBS rate measure responding to percentage change ................................................... 236
Figure 6-1: A disruptive event impact and recovery timeline (Sheffi and Rice, 2005) ...................... 247
Figure 6-2: Architectural rendering of UNC Health Care Hillsborough campus ............................... 248
Figure 6-3: Causal loop diagram for the ED and inpatient ward........................................................ 258
Figure 6-4: Causal loop diagram for surgical unit and inpatient ward ............................................... 259
Figure 6-5: Causal loop diagram for bed capacity management ........................................................ 260
Figure 6-6: Scenario 1 time-series plots for adaptive feature activation ............................................ 262
Figure 6-7: Scenario 2 time-series plots for adaptive feature activation ............................................ 263
Figure 6-8: Surge event patient arrivals by demand surge volume .................................................... 265
Figure 6-9: Emergency department tradeoff dimensions ................................................................... 268
Figure 6-10: Hospital tradeoff dimensions ........................................................................................ 269
Figure 6-11: Contingency state and crisis state activation hours ....................................................... 276
Figure 6-12: Ambulance diversion state activation and ED waiting delay time ................................ 278
Figure 6-13: Scheduled surgery cancellation state activation and quantity cancelled ....................... 278
Figure 6-14: Patient flow recovery times for discharge patients versus admission patients .............. 281
xx
Figure 6-15: Patient flow recovery times for discharge and admission patients ................................ 281
Figure 6-16: ED LWBS patient flow recovery times versus rate of departure................................... 286
Figure 6-17: ED LWBS patient flow recovery times and rate of departure ....................................... 286
Figure 6-18: Surgical unit outpatient flow versus inpatient flow recovery times .............................. 289
Figure 6-19: Surgical unit outpatient flow and inpatient flow recovery times .................................. 289
Figure 6-20: Medical versus surgical inpatient ward patient flow recovery times ............................. 292
Figure 6-21: Medical ward and surgical ward patient flow recovery times ....................................... 292
Figure 6-22: Contingency state activation time by demand surge volume ........................................ 295
Figure 6-23: ED admission patient flow recovery time by demand surge volume ............................ 298
Figure 6-24: ED discharge patient flow recovery time by demand surge volume ............................. 299
Figure 6-25: Surgical unit inpatient flow recovery time by demand surge volume ........................... 302
Figure 6-26: Surgical unit outpatient flow recovery time by demand surge volume ......................... 302
Figure 6-27: Surgical inpatient ward flow recovery time by demand surge volume ......................... 305
Figure 6-28: Medical inpatient ward flow recovery time by demand surge volume .......................... 306
Figure 6-29: Contingency state activation over time by demand surge volume ................................ 308
Figure 6-30: Ambulance diversion state activation over time by demand surge volume ................... 309
Figure 6-31: ED waiting area patient occupancy ............................................................................... 309
Figure 6-32: ED treatment room patient occupancy .......................................................................... 310
Figure 6-33: ED treatment room patient occupancy with a patient admission hold........................... 311
Figure 6-34: Inpatient hospital ward early discharge bed days recovered ......................................... 312
Figure 6-35: Scheduled inpatient surgery cancellation ...................................................................... 313
Figure 6-36: Surgical inpatient ward floor bed patient occupancy..................................................... 314
Figure 6-37: Medical inpatient ward floor bed patient occupancy ..................................................... 315
xxi
CHAPTER 1 INTRODUCTION
1.1 Introduction and Motivation
Modern medicine has achieved great progress in treating individual patients. This
progress is based mainly on advances in the life sciences and development of medical
devices and imaging technology. However, relatively few resources have been invested
to the proper functioning of health care delivery as an integrated system in which access
to efficient care is delivered to many thousands of patients in an economically sustainable
way. At present, the majority of improvements to health care delivery are achieved
through performance and process improvement (PPI) initiatives structured under Lean
Six Sigma programs. These initiatives haven been traditionally focused on individual
departments, such as the emergency department (ED) or the surgical department, or
specific processes such as registration or discharge. Although PPI initiatives may
demonstrate some positive gains, at the hospital-wide, or system level, the impact of
these initiatives often result in the shift of bottlenecks around the hospital from location
to location, while failing to realize improvement in the entire system’s performance.
Rather than focus on the improvement of specific department or processes, studies
need to consider a hospital-system of interdependent elements, or subsystems, that form a
complex whole and behave in ways that these elements acting alone would not.
Improvements at the hospital-system level through the alignment of available capacity
and resources with demand, either through design of robust control policy or through
optimization, should result in better hospital-wide performance, reduced capacity cost, or
1
improved patient outcomes. The policies being enacted through health care reform under
the Affordable Care Act (ACA) will likely leave the health care supply side, such as
hospitals, facing lower reimbursement rates and reduced revenues, lower pay for
physicians, much tighter access to capital, and significantly smaller budgets. On the
demand side, a population with increased and more secure health insurance coverage is
more likely seek to exercise the benefits provided under this coverage. Therefore, it will
be increasingly important that health care systems realize improvements at the hospital-
system level in order to address both financial challenges and demand for better health
outcomes. The anticipated tightening between the demand and supply side will require
healthcare systems and hospitals to strategically manage their capacity holdings in order
to remain financially viable.
1.2 Description of Research
This dissertation seeks to rigorously explore the effects of capacity dynamics on
patient flow throughout the interdependent and interrelated departments of a whole
hospital. Unit capacity imbalances in select areas of the hospital can have a
tremendously adverse impact on the mission of providing timely treatment and services
for acute care patients. In this context, unit capacity would be considered the constraint
in a complex system that contributes to the presence of an endogenous behavior
influencing hospital-wide patient flow. In complex systems, such as a medium sized
hospital, many units are managed and controlled independently. Weak integration or
coordination of interdependent activities may result in a natural or induced system
2
behavior, where heavy oscillations contribute to system instability and poor performance.
While this work clearly touches upon matters that are of operational and tactical concern,
it focuses specifically on the strategic interests related to hospital management, planning
and control.
The question explored in this dissertation considers the whole hospital as a
complex system: “how do we strategically plan and allocate unit capacity in a whole
hospital environment to promote timely patient flow for acute care treatment and
services?” To answer this question, we: (1) develop and describe a whole hospital model
which incorporates the interdependent departments for a representative hospital; (2)
perform a fundamental analysis to develop insights regarding strategic unit capacity
allocation; (3) perform a capacity determination where multiple criteria are used in the
unit capacity allocation; (4) present a measure used to evaluate emergency department
performance which considers the influence of hospital-wide capacity; and (5) explore
hospital resilience and recovery under conditions of a severe patient demand surge.
Details of these accomplishments are briefly outlined and further described below.
Chapter 2 presents a detailed description of the development of the whole hospital
model that establishes the strategic platform for exploring hospital-wide capacity
dynamics. The whole hospital model in Chapter 2 was developed through a partnership
and collaboration with subject matter experts at UNC Johnston Health located in
Smithfield and Clayton, UNC Medical Center located in Chapel Hill, and UNC
Hillsborough located in Hillsborough. This collaboration led to the development of the
generalized hospital framework structure for the model representative of a community
3
hospital. The model incorporates national data representative of a medium sized
community hospital. Additionally, the model is parameterized such that it can be
reconfigured to match a variety of community hospitals. The model has been reviewed
and validated by subject matter experts to ensure consistent and representative system
behavior.
Chapter 3 presents the insights of a fundamental analysis conducted to explore
how changes in unit capacity in particular areas of the hospital affect overall system
behavior and performance. The purpose is to better understand unit capacity allocation
impacts on relationships and interdependencies between the clinical and ancillary units
and their respective performance measures. The analysis is organized into two parts.
First, the chapter considers unit capacity allocation between the emergency department
and the medical inpatient ward units. Second, the chapter considers unit capacity
allocation between the surgical unit and the surgical inpatient ward units. Sensitivity
analysis is also used to explore the effects of unit capacity allocation.
Chapter 4 presents the capacity determination for a whole hospital where a goal
seeking approach is used to satisfy multiple objectives. The purpose of this approach is
to advance beyond the simple one-factor-at-a-time capacity analysis and incorporate
multiple criteria of interest to a hospital administrator engaged in strategic capacity
planning. The chapter is organized into three sections. The first briefly introduces the
methodology used in conjunction with the whole hospital simulation model. The second
describes the capacity determination for the emergency department and medical ward
4
units. The third describes the capacity determination for the surgical unit and surgical
ward units.
Chapter 5 presents a sensitivity analysis for the emergency department using a
modification of the established Overall Equipment Efficiency (OEE) hierarchy of metrics
as a key performance indicator. The purpose of the sensitivity analysis is to identify the
unit capacity related factors in the whole hospital model that contribute to poor
performance. The modified OEE hierarchy of metrics is first used to complete a set of
group factor screening analyses to identify the important factors of interest, and then used
to complete a sensitivity analysis, using regression methods, to identify the significant
factors of interest. The results of the sensitivity analysis indicate that emergency
department performance may depend significantly on the unit capacity and patient flow
in clinical and ancillary departments hospital-wide.
Chapter 6 presents the exploration of hospital resilience and recovery in response
to severe patient demand surge caused by a disruptive event, such as a nature disaster.
The purpose of the exploration is to examine the robustness of strategies that utilize
various combinations of adaptive capacity features and capacity dynamic allocation in
their response to patient demand surge. Outcomes from these strategies demonstrate
important differences in the patient flow recovery times required to return to the baseline
patient flow absent the demand surge. Although patient flow recovery time is a primary
measure of performance considered in this study, other measures of impact, such as the
leaving-without-being-seen rates over time or the number surgical cancellations, are
important to completing an assessment. The exploration provides beneficial insight for a
5
hospital administrator planning a response strategy in preparation for a future demand
surge event.
This dissertation contributes to the industrial and systems engineering literature in
four significant ways. First, the research describes and develops a generalized whole
hospital model based on system dynamics that is representative of a medium size, semi-
urban, community hospital which is both scalable and configurable. This model has been
reviewed by subject matter experts and carefully validated. The work contributes a
modeling resource useful for the purpose of studying how unit capacity affects system
behavior and performance where hospital-wide interdependencies between units exist.
Second, capacity determination using a goal seeking approach attempts to allocate
unit capacity hospital-wide such that multiple objectives of interest to a hospital
administrator might be satisfied. Results from this work reveal that the goal seeking
approach is useful in hospital-wide capacity determination and offers an improvement
over the simple one-at-a-time approach. This is the first known example where unit
capacity levels are determined hospital-wide using an optimization method. This work
provides contributions to areas of strategic hospital capacity planning and health care
performance improvement.
Third, use of the modified OEE hierarchy of metrics as a key performance
indicator enables the search for significant capacity factors hospital-wide using both
factor screening design and regression based sensitivity analysis. Results from this work
revealed that unit capacity allocation hospital-wide can have a significant effect on the
emergency department performance. This work provides contributions to many areas
6
which include: (1) an example of a factor screening design use in system dynamics; (2)
insights to improve hospital management and productivity; and (3) the application of an
innovative, modified structured hierarchy of metrics for a whole hospital and a service
based industry.
Finally, the exploration of hospital resilience and recovery under the conditions of
a severe patient demand surge uniquely integrates capacity adaptation and compares
strategies. Insight from this work is useful to a hospital administrator planning a
response strategy in preparation for a future demand surge event. This work contributes
insights for capacity dynamics and strategic response considerations to the literature
related to disaster preparedness, planning and management, which is currently dominated
by static planning models, management organizational tools, and preparation checklists.
7
CHAPTER 2 A DESCRIPTION OF THE WHOLE HOSPITAL MODEL
2.1 Introduction
This chapter describes the whole hospital simulation model used in the research
presented throughout the dissertation. A significant contribution of this work is a
generalized framework that incorporates hospital-wide department interdependencies
which can be used to evaluate the strategic allocation of structural resources and
information. The framework is representative of a medium sized semi-urban, community
hospital, which includes an emergency department, surgical services, and outpatient and
inpatient services. Additionally, this framework represents a community hospital with
bed capacity between 50 and 450 beds distributed among intensive care, progressive care,
and standard care unit wards.
The remainder of this section briefly introduces the background leading to the
development and construction of the whole hospital model. First, the collaboration with
a health system discussed. Second, the selection of a modeling paradigm methodology is
examined. Third, the relevant work previously published by the author is referenced.
Finally, the organization of the chapter is presented.
2.1.1 Health System Collaboration
UNC Health Care, a not-for-profit medical system owned by the State of North
Carolina and based in Chapel Hill at the University of North Carolina at Chapel Hill,
served as the collaboration partner during the development and construction of the whole
hospital model. UNC Health Care affiliate Johnston Health System based in Smithfield,
8
North Carolina assisted in the foundational work necessary to document the core
processes and inner workings of a community hospital. This work focused on the two
hospitals operated by Johnston Health: the Johnston Medical Center located in
Smithfield, a 199 bed community general hospital, and the Johnston Medical Center
located in Clayton, a 50 bed community general hospital. The Clayton location recently
expanded from a free-standing emergency department and outpatient surgery facility to
include additional clinical and surgical operations and a 50 bed inpatient facility.
Discussions regarding concerns over capacity planning and resource allocation amidst an
uncertain future demand specific to this hospital helped shape the perspective of this
research.
UNC Medical Center, formerly known as UNC Hospitals, located at the
University of North Carolina at Chapel Hill, provided invaluable insight into general
hospital operation and administration through a number of experienced subject-matter-
experts. These experts helped improve and review the model implementation in the areas
of the emergency department operations, the surgical unit operations, the diagnostic
radiology and medical imaging, and the diagnostic laboratory operations. Additionally,
the new construction UNC Health Care Hillsborough, a 68 bed hospital located in nearby
Hillsborough, is referenced within the research in a study of capacity planning and surge
resiliency.
9
2.1.2 System Dynamics
The generalized framework for the whole hospital model is based on the insights
obtained through collaboration and interviews with subject-matter-experts regarding
hospital operations and administration. During these ongoing engagements the presence
of multiple feedback structures emerged with interdependences and mutual interactions in
various processes throughout the hospital. Additionally, general hospital operations
provide information feedback flows that may result in circular causality leading to
hospital congestion. The term dynamic complexity best describes this hospital-wide
behavior, which experiences long delays between causes and effects with conflicting
goals (Sterman, 2000).
The challenges of dynamic complexity hospital-wide may be effectively
addressed with the systems modeling methodology of system dynamics (SD). The
methodology involves development of causal diagrams and policy-oriented computer
simulation models well suited to represent the flow of patients, the allocation of capacity
resources and the flow of information for hospital operations. The approach was
developed by computer pioneer Jay W. Forrester in the mid-1950s and first described in
his book Industrial Dynamics (Forrester, 1961), with some additional principles
presented in later work (Forrester, 1969, 1971, 1980; Senge and Forrester, 1980). The
methodology recognizes that the structure of any system, as defined by many circular,
interlocking and time delayed relationships among its components, is often just as
important in determining the system behavior as the individual components. Pidd (1996)
thoughtfully describes the delineation between qualitative and quantitative approaches
10
made in the application of system dynamics. This research decidedly adopts a
quantitative approach that is strongly influenced by the earlier works of Coyle (1996) and
Wolstenholme (1990).
2.1.3 Previous Related Work
While this chapter provides a complete description of the whole hospital model,
an earlier reference to this work in the concise form of a conference proceedings paper is
available. This paper was submitted and accepted into the Proceeding of the 2014
Industrial and Systems Engineering Research Conference held in Montreal Quebec
Canada. The 2014 ISERC conference proceedings paper entitled “A Simulation
Approach to Exploring Whole Hospital Operational Performance and Efficiencies” by
Raymond Smith and Stephen Roberts (Smith III and Roberts, 2014) is available in
Appendix F. The proceedings paper describes the departments and their
interdependencies regarding the flow of patients, materials, and information, although
with less detail than presented here. This chapter presents in detail the causal loop
diagrams and the stock and flow diagrams, which could not be accommodated in the
space restricted proceedings paper. Additionally, the conference proceedings paper
introduces and presents the early use of a factor screening design and analysis method, a
topic further discussed in Chapter 5.
2.1.4 Chapter Organization
The remainder of this chapter is organized into five specific sections. First, the
whole hospital model is conceptualized with regard to the scope, boundaries, and
11
assumptions, specifying the development considerations for external input. Second, the
detailed model description is presented with respect to the individual units and their
interdependencies. Third, the model calibration, analysis, and validation methods used to
ensure a faithful representation of hospital operations are described. Fourth, the model
limitations are outlined. Finally, the conclusions and discoveries from the whole hospital
model development and operation are discussed.
2.2 Model Conceptualization and Development
The model conceptualization and development for the whole hospital model
identifies the scope of the hospital processes, patient flows, department interdependencies
and operational boundaries to be considered. The presentation of this information is
organized into five sections. First, an overview of the community hospital is presented,
describing hospital processes and generalized patient flow. Second, the model
boundaries specific to hospital departments and processes are described. Third, a model
formulation is introduced that describes at the conceptual level the model dynamic
hypothesis and structural formulation. Fourth, the general assumptions regarding features
included and excluded from the model are enumerated. Finally, considerations for data
input sources to the model are generally described.
Throughout this section numerous sources of information were used to
conceptualize and develop the model. A substantial portion of this information came
through discovery and discussion in working with subject-matter-experts to understand
and capture their processes. Many references in the literature on health care and hospital
12
operations management helped provide the background necessary to conceptualize the
model (Brandeau et al., 2004; Griffin, 2011; Hopp and Lovejoy, 2012; Langabeer II and
Helton, 2015; McLaughlin and Olson, 2012; Shiver and Eitel, 2009; Vissers and Beech,
2005). Additionally, current concerns over the emerging role of the emergency
department (Morganti, 2013), the increase in acuity for admitted patients (Mullins et al.,
2013), and the impact of hospital occupancy on admission delay (Forster et al., 2003), are
considered. Knowledge and insight gained from these sources is applied throughout the
remainder of this chapter and the advancing evolution of the whole hospital model.
2.2.1 Community Hospital Acute Care Patient Flow
In the United States the term community hospital is used frequently to describe a
broad range of health care facilities. Herein, the term community hospital is used to
describe a nonfederal, short-term general, non-specialty hospital generally accessible by
the public. Academic medical centers, teaching hospitals, and facilities providing highly
specialized and quaternary levels of care are excluded. In 2014, nearly 90% of the 4,999
registered community hospitals located in the United States would satisfy this criteria. In
contrast, specialty hospitals tend to focus in areas such as obstetrics and gynecology,
otolaryngology, orthopedics, or rehabilitation. This study focuses on delivery of health
care delivery for acute care within the community hospital. Acute care is a branch of
secondary health care where patients receive active but short-term treatment for a severe
injury or episode of illness, an urgent medical condition, or during recovery from surgery.
This is delivered by teams of health care professionals that may include a range of
medical and surgical specialties. Patients undergoing acute care treatment may require a
13
stay at a hospital, emergency department, ambulatory surgery center, urgent care center
or other short-term stay facility, along with the assistance of diagnostic services, surgery,
or follow-up outpatient care in the community. Hospital-based acute inpatient care
typically has the goal of discharging patients as soon as they are deemed healthy and
stable. Within an acute care hospital-based setting, this study explores hospital
operations behavior and patient flow.
An illustration of the generalized acute care patient flow between departments in a
community hospital is presented in Figure 2-1 below. This patient flow illustrates the
most frequented pathways, and does not preclude the existence of more varied patient
flows. Not illustrated are the requests and processing for diagnostics, the flow of
materials, or the flow of information. The three significant areas depicted in the
illustration include the emergency department, the surgical unit, and inpatient wards, each
which is further described below.
14
Figure 2-1: A generalized community hospital acute care patient flow
2.2.1.1 The Emergency Department
Patients arrive to the emergency department as either walk-in arrivals or
ambulance arrivals. Initially, patients are registered and triaged, and then placed in a
waiting area depending on emergency room workload and patient acuity. Over time
some patients decide to leave-without-being-seen (LWBS) by a physician because of the
waiting time delay or perceived congestion encountered. Patients who enter the
15
emergency room examination and treatment area may encounter a variety of procedures
dependent on their health condition. These procedures generally consist of progressive
stages that include patient evaluation, diagnosis, treatment, and deposition. During the
diagnosis stage patients may likely provide specimen samples to be processed by the
diagnostic laboratory unit and/or be sent to the diagnostic radiology and medical imaging
unit. The diagnostic results may require consultation and review by a specialist which,
depending on the patient medical condition, will likely result in further diagnostic testing.
The treatment stage begins when the diagnosis step is complete and a plan has been
determined. Approximately 78% of the patients that arrive are treated and medically
stabilized with the disposition being discharge to home, where subsequent follow-up is
directed to a primary care physician or clinic. The remaining patients are treated and
stabilized in the emergency department with the deposition being admission to the
hospital to receive ongoing treatment, or surgical intervention. These patients are routed
as appropriate either to an inpatient ward or surgical unit for emergency surgery.
2.2.1.2 The Surgical Unit
Scheduled surgery patient arrivals to the surgical unit generally receive either
elective or semi-elective procedures. An elective procedure may be performed to
improve health or well-being for a medical condition, whereas a semi-elective procedure
is necessary to preserve the patient’s life although it does not to be performed
immediately. Patients may be admitted to the hospital for subsequent inpatient treatment
and recovery, or discharged as an outpatient following brief post-surgery recovery. By
contrast, patients that originate through the emergency department requiring surgery are
16
considered to be urgent; that is, where the patient can wait until they are medically stable
within a few hours up until the next day, or an emergency surgery, where surgery must be
performed immediately without delay in order to avoid the risk of permanent disability or
death. Emergency surgery is performed as demanded and urgent surgery is often
performed as an add-on to the surgical schedule.
Excluding preoperative planning and diagnostic activities for scheduled patients,
Figure 2-1 illustrates the sequential patient flow where patients first entering the pre-
operative care area to be prepared for surgery. Although infrequent, diagnostic tests can
be ordered while a patient is held in the pre-operative care area to further evaluate a
medical condition before proceeding with surgery. When the patient is prepared, the
surgical team ready, and operating theater suite available, the patient is moved into the
intra-operative care area, which also known as the operating room theatre. When the
surgical procedure has been completed the patient advances to the post-operative care
area, often known as the post-anesthesia care unit (PACU). This is an area designed to
provide care for patients recovering from general, regional, or local anesthesia.
Following patient recovery, patients are either transferred to a surgical inpatient ward for
ongoing care and recovery, or discharged home as an outpatient with follow-up
instructions and guidance. Congestion in the post-operative care unit may be caused by
patient complications or the inability to transfer patients in a timely manner to an
inpatient ward. This congestion may disrupt the surgical schedule resulting in delay,
reschedules, or cancellations.
17
2.2.1.3 The Medical/Surgical Inpatient Wards
Admitted hospital patients arrive to the inpatient wards through one of three
originating sources: the emergency department, the surgical unit, or as a direct medical
admission. Emergency department admitted patients are held in a boarding status until an
available bed in an appropriate medical inpatient ward is available. Surgical ward
admitted patients are held in the surgical unit post-operative care area and transported to
an available bed in the appropriate surgical inpatient ward. Direct medical admission
patients that originate through an affiliated physician or clinic with hospital privileges are
placed into an available bed in the appropriate medical inpatient ward.
Inpatient wards are designated as either medical wards or surgical wards, largely
to organize nursing skills and align procedures, as well as to prevent the risk of patient
cross contamination. Inpatient wards of both designations are further organized
according to patient acuity levels and nursing skill specialization. In general, the three
levels of care in this organization include: (1) an intensive care unit (ICU), also known as
the critical care unit; (2) a progressive care unit (PCU), sometimes known as a step-down
unit; (3) an acute care unit (ACU), where a standard level of is provided. As a patient’s
health status improves or deteriorates, the patient may be upgraded or downgraded
through these levels of care.
High occupancy levels in the inpatient wards may have severe negative
consequences on surgical and emergency department operations. In the surgical unit,
scheduled surgeries may be rescheduled or suffer cancellation if forecasts indicate
insufficient inpatient bed capacity is available for post-surgery patient recovery. This can
18
be partially mitigated by using the post-operative care areas to hold a limited number of
surgical patients overnight until beds become available.
In the emergency department, patients waiting to complete the hospital
admissions boarding process may be delayed for an extended period of time. This is
detrimental to emergency department productive first by blocking the use of the treatment
area causing other patients to wait longer, and second by overburdening medical staff
required to provide ongoing care. Extreme cases of congestion in emergency department
where medical staff can no longer adequately treat, monitor or board patients may result
in a decision to post an ambulance diversion status. Activating an ambulance diversion
status signals first responders to transport patients to another hospital, if possible, due to
the current backlog and wait time. Ambulance diversion usage is well-studied and the
downside issues enumerated (Pham et al., 2006). Physicians are mostly responsible for
the timely discharge of patients which affects the hospital ward occupancy levels.
2.2.2 Model Boundaries
Model boundaries identify the scope of the model and determine which dynamic
behaviors are driven exogenously or emerge endogenously. A “bull’s eye” diagram is
useful during the conceptual stage to communicate whether features are excluded,
determined exogenously, or determined endogenously. Excluded features generally have
no representation in the model. Exogenous inputs provide information from external
sources, but receive no feedback regarding the changing state of the system model.
Endogenous behaviors are determined by the exogenous inputs and the model structure.
The model boundaries for the whole hospital model are illustrated in Figure 2-2.
19
Figure 2-2: Model boundaries for the whole hospital model
As shown in Figure 2-2, some excluded features include the scheduling of
medical and diagnostic staff, the physician task performance, the patient acuity levels, the
patient case mix, diagnostic complexity, and provisions for interruption due to equipment
maintenance or repair. The exogenous inputs consist of patient arrival detail, patient flow
and distribution detail, unit capacity specification, and a response function for patients
leaving-without-being-seen (LWBS). Details of the endogenous behaviors are further
described in the next section that presents a description of the model. Appendix A
includes a series of detailed supplier, inputs, process, outputs and customers (SIPOC)
process flows used to guide the development of the model boundaries (ASQ, 2016).
20
2.2.3 Model Formulation
This section first introduces the dynamic hypothesis representative of the dynamic
behavior within the generalized community hospital, and then presents a corresponding
structural formulation used to construct the whole hospital model. In this section, the
dynamic hypothesis and structural formulation are presented at a conceptual level of
detail for the community hospital. A more detailed series of dynamic hypotheses and
structural formulations are presented in section 2.2.3.1 and section 2.2.3.2, respectively.
2.2.3.1 The Dynamic Hypothesis
The dynamic hypothesis describes the dynamic behavior and interactions believed
to be responsible for the observable state of the system over time. The dynamic
hypothesis is often described visually using a causal loop diagram as a reference. For the
whole hospital model, the causal loop diagram helps visualize the interaction between
departments and explain the system behavior related to patient flow through the use of
feedback loops. Feedback loops in the whole hospital model mainly consist of balancing
loops, which tend to restrict flow due to limitations imposed by capacity or resource
limitations. Figure 2-3 presents the causal diagram loop describing the patient flow
between the emergency department, the surgical unit, and the medical and surgical
inpatient wards.
21
S
Departing Emergency S Discharging Emergency Arriving Direct Medical
Patients Patients to Home Admission Patients
S
Rate of Patients Rate of ED Patients
Leaving-Without-Being-Seen O Rate of Direct Medical
Discharge Home
(LWBS) Patient Admission
S O (Physician Referred)
S
Emergency Emergency Care O Medical Patient Medical Patient
Discharged Medical Ward Bed
Arriving Emergency Department LOS Discharge Capacity LOS
Patient Time Capacity
Patients Capacity B1b B1c B2b
Spent in ED
S S S SS S S
S O O S O
Rate of Emergency Patients O Rate of Medical Wards
S Patients Occupying B2a Patients Occupying B2c
Arriving (Walk-in & B1a B1d Rate of ED Patient Medical Inpatient Patient Discharge
Emergency
Ambulance) Department (ED) Medical Admission Wards (MIPW)
O O O O S
O
Medical Patient Time Discharging Medical
S Spent in
S Patient Time O Patients to Home
Surgical Spent in ED S Medical Wards O
Patient Time B1e
Spent in ED S Discharging Surgical
O Outpatients to Home
S
Rate of ED Patient Rate of Surgical O
Surgical Admission Outpatients Discharge
Home
O
S O Surgical Care
Surgical Patient Surgical Patient
LOS Surgical Ward Bed
Arriving Surgical Surgical Unit Outpatient Time Discharge Capacity LOS
Patients B3b B3c Spent in SU Capacity
Capacity
S S S S
S S S
S SS O O Patients Occupying O
Rate of Elective Surgical Rate of Surgical Ward
Patients Occupying Rate of Surgical B4a Surgical Inpatient B4b
Patients Arriving (Outpatient B3a B3d Patient Discharge
& Inpatient) Surgical Unit (SU) Inpatient Admission Wards (SIPW)
O O S
O O
Discharging Surgical
Patient Time Patients to Home
Inpatient Time Spent in
S O O
Spent in SU S Surgical Wards
Figure 2-3: The whole hospital model patient flow causal loop diagram
22
Emergency Department: The emergency department (ED) occupancy is affected
by members of the B1 loop structure as described: loop B1a manages the inflow of
arriving emergency patients; loop B1b manages the outflow of departing emergency
patients who leave-without-being-seen (LWBS); loop B1c manages the outflow of
discharge patients that have been treated and require no further attendance; loop B1d
manages the outflow of admitted patients to the medical inpatient ward; and, loop B1e
manages the outflow of emergency patients that require immediate surgery. Emergency
department room capacity is the limiting resource that impacts the inflow of waiting
emergency patients.
Medical Inpatient Wards: The medical inpatient wards (MIPW) occupancy is
affected by members of the B2 loop structure as described: loop B2a manages the inflow
of admitting patients originating from the emergency department; loop B2b manages the
inflow of arriving as direct medical admission patients ordered through a hospital
affiliated physician; loop B2c manages the outflow of medical patient discharge once
they have fulfilled their treatment length-of-stay and sufficient capacity to discharge them
is available. Medical inpatient ward bed capacity is the limiting resource that impacts the
inflow of medical patient admissions.
Surgical Unit: The surgical unit (SU) occupancy of the operative areas is affected
by members of the B3 loop structure as described: loop B3a manages the inflow of
scheduled elective surgical patients arriving both as outpatients and inpatients; loop B3b
manages the inflow of emergency surgery patients originating from the emergency
23
department; loop B3c manages the outflow of surgical outpatient discharge once they
have fulfilled their procedure and post-operative recovery length-of-stay; loop B3d
manages the outflow of surgical patients admitted to the surgical inpatient wards once
they have fulfilled their procedure and post-operative recovery length-of-stay. Surgical
unit capacities in the pre-operative, intra-operative, and post-operative areas are the
limiting resources that impact the inflow and processing of surgical patients.
Surgical Inpatient Wards: The surgical inpatient wards (SIPW) occupancy is
affected by members of the B4 loop structure as described: loop B4a manages the inflow
of admitting patients originating from the surgical unit; loop B4b manages the outflow of
surgical patient discharge once they have fulfilled their treatment length-of-stay and
sufficient capacity to discharge them is available. Surgical inpatient ward bed capacity
is the limiting resource that impacts the inflow of surgical patient admissions.
Ancillary Services: Diagnostic radiology and medical imaging and laboratory
services are not shown in Figure 2-3. The flow of order requests, specimen transfers, and
completed diagnostic results would impose additional layers of feedback loops. Delay in
diagnostic services due to high workload demand or capacity limitations may contribute
to delays, lengthening stays and increasing occupancy levels.
2.2.3.2 The Structural Formulation
The structural formulation used to construct the whole hospital model corresponds
to the dynamic hypothesis presented. The structural formulation translates the causal
loop diagram description into a visual presentation using a stock and flow diagram.
With regard to patient flow, stocks represent areas occupied by patients where procedures
24
are performed, treatment is received, or recovery occurs, and where delays in progress are
encountered. Flow represents the movement, transition or transformation of a patient
from one area of the hospital to another.
A stock and flow diagram for the whole hospital model is illustrated in Figure
2-4. The diagram illustrates the dwelling places occupied by patients as stocks, such as
the emergency department, the surgical unit, the medical inpatient wards, and the surgical
inpatient wards. The diagram further illustrates the rate of movement between various
stocks as flows. Flow as a rate of movement between the stocks contributes to the system
behavior observed. Rates of movement may be determined by the available capacity, as
well as the expected time delay, such as a length-of-stay or a procedure treatment time.
Figure 2-4 illustrates the inflow of patient arrivals occupying the emergency
department and the outflow of patient departures, either as leaving-without-being-seen by
physician, discharged after treatment, or admitted to the hospital. The figure illustrates
the inflow of emergency admission and direct admission patients occupying the medical
inpatient wards and the outflow of patient departures when discharged. The figure also
illustrates the inflow of scheduled surgery and emergency surgery patients occupying the
surgical unit and the outflow of patient departures either discharged or admitted to the
surgical ward. Lastly, the figure illustrates the inflow of surgical admission patients
occupying the surgical inpatient wards and the outflow of patient departures when
discharged.
25
Medical Ward Bed
Capacity Arriving Direct Medical
Rate of Patients Admit Patients
Leaving-Without-Being-Seen
Arriving Emergency (LWBS)
Patients Medical Ward Bed Rate of Direct Medical
Emergency Care Availability Patient Admission
LOS
Patients Occupying
Emergency Medical Patient
Rate of Emergency Patients Department (ED) Rate of ED LOS Discharging Medical
Arriving (Walk-in & Ambulance) Patient Medical Patients to Home
Admission
Patients Occupying
Rate of ED Patient Medical Inpatient Wards
Discharge Home Rate of ED Patient (MIPW) Rate of Medical Wards
Surgical Admission Patient Discharge
Surgical Ward Bed Medical Patient

Capacity Discharge Capacity
Arriving Surgical
Patients Surgical Ward Bed
Availability
Patients Occupying
Surgical Unit (SU) Surgical Patient
Rate of Elective Surgical Rate of Surgical LOS
Patients Arriving (Outpatient Inpatient Admission Discharging Surgical
& Inpatient) Patients to Home
Rate of Surgical
Patients Occupying
Outpatient Discharge
Home Surgical Inpatient Wards Rate of Surgical Wards
(SIPW) Patient Discharge
Surgical Care
LOS
Surgical Patient
Discharge Capacity
Figure 2-4: The whole hospital model stock and flow diagram
26
2.2.4 Model Assumptions
In addition to the model boundaries defining the model scope, this section
provides additional explanation and background to foundational assumptions. These
assumptions, which influence both the model construction and implementation, are
described below.
1. Acute care delivery – Adult acute care is the focus of the study since it constitutes the
majority of the health care delivered the community hospital setting. Pediatric acute
care, women’s acute care, and obstetrics are not included in the model scope since
these areas often function independently as a hospital within a hospital. Additionally,
while mental health patients may impact the delivery of acute care they are not
included in this model scope because of the numerous dependencies residing outside
the community hospital.
2. Individual patient detail – Individual patient detail and attributes, such as patient
acuity levels and contribution to a Case Mix Index (CMI) calculation, exceed the
level of detail captured in the whole hospital model. The focus of study is at a higher
level of detail such as examining the dynamic behavior with the accumulation and
flow of patients throughout the whole hospital.
3. Catheterization laboratory – Catheterization laboratories are examination rooms used
to visualize arteries and chambers of the heart to treat abnormalities. In a community
hospital setting, the majority of the procedures performed are scheduled as a clinic
operation with limited hours. Less than 2% of the arriving emergency patients
require immediate access to a catheterization laboratory. An emergent patient is
27
transferred from the community hospital to a medical center, where a skilled surgical
team is available on demand. Therefore, catheterization laboratories are not included.
4. Observation status – Patients may be placed in observation status when their health
condition warrants monitoring or short treatment, beyond an emergency room visit,
for up to 48 hours. Physician orders may be updated, and made retroactive, for either
hospital admission or observation status; thus, making tractability difficult. This
status exists mainly for the purpose of determining financial reimbursement and
directly depends on the individual patient’s medical condition. Therefore, the
observation status is not included model.
5. Patient readmissions – Patient readmissions are of concern because reimbursement
rates are increasingly determined by patient outcomes. Readmissions may occur due
to a number of reasons that may include risk due to premature patient discharge, poor
self-care instructions or adherence, failure to correctly administer prescriptions, or
complete follow-up appointments. This wide range of contributing causes for patient
readmission is not within the scope of the model.
6. Ambulance diversion status – Ambulance diversions are often used in some parts of
the country to reduce patient arrival volumes during periods where a hospital may
encounter high levels of congestion. Recent research has explored the detrimental
cycle perpetuated through over use and defensive strategies enabled ambulance
diversions. Hospital operations experts contend that with appropriate planning and
capacity alignment ambulance diversion is unwarranted. The collaborating subject-
matter-experts requested that this feature not be exercised in the model.
28
2.2.5 Model Inputs
Model inputs align specifically with the exogenous inputs previously cited in
section 2.2.2 on model boundaries. The values and defined functions used to represent
these model inputs are obtained from a broad range of data sources reported in the public
domain, shared through collaborative partners, and provided by subject-matter-experts.
The details of these sources are presented in the next section, A Detailed Model
Description, with the further identification of lower level exogenous inputs.
While numerous factors contribute to the dynamic behavior of the whole hospital
model, three patient arrival sources act as the principal drivers of system behavior. These
include the emergency department patient arrival rates, the direct admission patient
arrival rates, and the scheduled surgery patient arrival rates. These patient arrival rates
can vary dramatically over the hour of day, and the day of week; however, the patterns of
these arrivals are fairly consistent, as reported through several hospital studies.
2.3 A Detailed Model Description
The Model Conceptualization and Development section 2.2 presents the scope of
the whole hospital model. This section presents a detailed model description of the
interdependencies between the individual hospital departments and units, all which
contribute to a dynamic behavior within the whole hospital. This presentation and
discussion is organized by department or unit, which includes the emergency department,
surgical unit, medical inpatient wards, surgical inpatient wards, and the ancillary
diagnostic areas for radiology and medical imaging, and the laboratory.
29
2.3.1 Emergency Department
Patients may navigate a multitude of pathways through the emergency department
before reaching a final disposition of being held for observation, admitted to the hospital,
or discharged home. Arriving patients are initially registered and triaged, and then wait
for an available room assignment to be evaluated by a physician. Physician staffing may
vary throughout the day. Once examined, patients may simply receive treatment and be
immediately discharged, or require further diagnostic evaluation, as performed through
laboratory and medical imaging tests, to determine a diagnosis, treatment and disposition.
Difficult cases may require consultation with a specialty physician, and may require an
iterative series of diagnostic evaluations before a treatment or disposition is rendered.
2.3.1.1 Model Boundaries
Model boundaries for the emergency department are illustrated in Figure 2-5,
which visually organizes into groups the excluded features, exogenous inputs, and
endogenous behaviors in the model. The exogenous inputs, which act as model inputs,
are further divided into internally or externally emergency department controlled factors.
External factors include the rate of emergency arrivals, the laboratory turnaround
times, the radiology and medical turnaround times, and lastly, the rate of patient
admissions. Additionally, the response to schedule pressures, and leaving-without-being
seen (LWBS) rates are predetermined functions. These external factors affect patient
flow throughout the emergency department; however, under normal operating conditions
the emergency department does not control these factors. Internal factors include the
30
number of emergency rooms, the examination capacity, the treatment capacity, and the
discharge capacity, as well as the process targets for turnaround times.
Figure 2-5: Model boundaries for the emergency department
Endogenous behaviors are the combined result of the exogenous inputs and model
structure. Endogenous behaviors include capacity utilization, patient waiting times,
patient waiting backlogs, schedule pressure, and turnaround times for the various
processes. Endogenous behaviors are the observable dynamic behavior that renders
beneficial insight into the hospital operations of study.
31
The emergency department represents perhaps one of the most complex
departments located on hospital property. Although the emergency department operates
rather autonomously there are a substantial number of interdependencies with other areas
of the hospital that can impact its performance and patient flow. This section attempts to
describe these interlinkages both within and outside the emergency department that
contribute to an observable system behavior. Due to the complex relationships, a causal
loop diagram is used to visually depict the dynamic complexity. While emergency
patients may demand a varied order of services depending on their health concerns, most
will follow a sequence that can be abstracted to include: (1) wait post registration and
triage; (2) emergency room assignment and examination; (3) laboratory diagnostics; (4)
radiology or medical imaging diagnostics; (5) treatment; (6) case disposition, and
discharge. Figure 2-6 illustrates this sequence of events using a causal loop diagram and
a description for each area that explains the interactions follows below:
Waiting Area: Patient arrivals occupying the emergency department waiting
room, once they have been triaged, are affected by members of the B1 loop structure, as
described: Loop B1a manages the outflow of waiting patients in the form of departing
left-without-being-seen (LWBS) patients, which is influenced by the wait time and
congestion a waiting patient encounters; and, Loop B1b manages the outflow of waiting
patients as they are assigned an available emergency room location in order to be
examined and evaluated by a physician. When emergency room capacity is greatly
constrained, patient throughput is reduced causing an increase in wait time and
32
congestion in the waiting room area. This results in an increase in the number of
departing LWBS patients. Ideally, emergency room capacity would satisfy the demand
and the rate of departing LWBS patients would be minimal.
Examination Area: Patients occupying the emergency room location to be
examined and evaluated by a physician are affected by members of the B2 loop structure:
Loop B2a manages the inflow of waiting patients based on the availability of an
emergency room location for placement; Loop B2b manages the outflow of examination
patients based on an examination capacity production rate, which is subject to influence
by schedule pressure dependent resulting from overall emergency room utilization and
the ability to meet examination target delay times (processing times). In essence, as the
emergency room occupancy increases achieving examination processing target delays
times becomes difficult, increasing schedule pressure on the staff to perform at a higher
rate to address the patient backlog.
Once an examination is completed a course of action is determined by the
physician where patients may proceed forward along one of four care pathways: (1) no
further immediate medical assistance is required in the emergency department and the
patient is directed toward a disposition phase (Loop B6); (2) immediate treatment is
provided where medical issue is diagnosed or evident, such as wound care (Loop B4); (3)
additional information in the form of radiology or medical imaging (Loop B3) is required
in order to make a diagnosis, and assign a treatment plan; and (4) additional information
in the form of bodily fluid analysis results performed by a laboratory (Loop B5) is
required to make a diagnosis, and assign a treatment plan. As illustrated in Figure 2-6,
33
the patient flow may circulate among diagnostic processes (Loops B3 and B5) until the
physician diagnosis is reached and a treatment plan is determined.
Radiology and Medical Imaging Diagnostics: Patients occupying the diagnostics
area to complete radiology and medical imaging, while the emergency room location is
still retained, are affected by members of the B3 loop structure, as described: Loop B3a
manages the inflow of patients entering radiology and medical imaging department; and
Loop B3b manages the outflow of patients exiting the radiology and medical imaging
department, subject to the time delay imposed by the radiology and imaging turnaround
time (TAT) which is a function of demand and activities within the department. Thus, as
demand peaks in specific areas of the radiology and medical imaging diagnostics
department, the turnaround time will increase subject to the staffed production capacity.
Radiology and medical imaging diagnostic results completion may result in the patient
either providing a diagnostic laboratory specimen for analysis, entering treatment,
reentering medical imaging, or entering disposition.
Receiving Treatment: Patients occupying the emergency room location to receive
treatment are affected by members of the B4 loop structure, as described: Loop B4a
manages the inflow of patients entering treatment; and Loop B4b manages the outflow of
patients exiting treatment, subject to the treatment cycle time. Outflowing patients enter
disposition.
Laboratory Diagnostics: Patients occupying the emergency room provide bodily
fluid specimens for analysis by the diagnostic laboratory are affected by members of the
B5 loop structure, as described: Loop B5a manages the inflow of diagnostic laboratory
34
specimens to be analyzed; and Loop B5b the outflow of diagnostic laboratory specimens,
subject to the diagnostic laboratory turnaround time (TAT) which is a function of demand
and activities within the department. Thus, as demand workload increases in the
diagnostic laboratory area, the turnaround time may increase based on the production rate
of the analyzer equipment and staff work rate. Diagnostic laboratory results completion
may either result in the patient entering radiology and medical imaging, entering
treatment, reentering laboratory diagnostics or entering disposition.
Disposition and Discharge: Patients in the disposition stage, still occupying an
emergency room, are affected by members of the B6 loop structure: Loop B6a manages
the inflow of patients entering the disposition stage in preparation for patient discharge
home or admission to the hospital; and Loop B6b the outflow of patients exiting the
disposition stage, subject to disposition capacity production rate which is subject to
influence by schedule pressure resulting from emergency room utilization and the ability
to meet disposition processing target delay times.
35
2.3.1.3 Model Structural Formulation
The causal loop diagram previously presented in Figure 2-6 serves as the basis for
the model structural formulation for the emergency department. The model structural
formulation can be visualized as a stock and flow diagram, as illustrated in Figure 2-7.
The diagram illustrates the dwelling places occupied by patients, specimens, and orders
in stocks, such as the waiting room area, examination, imaging, laboratory, treatment and
disposition. The diagram further illustrates the rate of movement as flows that occur
between the various stocks. The flow rates between stocks influences the observed
system behavior. The rates of movement may be determined by the available capacity in
an area, as well as the expected time delay, such as a length-of-stay, associated with a
process, such as a procedure or treatment.
36
Radiology &
Medical Imaging
TAT
S O
S
Patient Entering Patients in Patients Exiting
Emergency Room Emergency Room Radiology & B3b Radiology & Medical
Radiology & Medical B3a
Occupancy Capacity Imaging
Imaging Medical Imaging
SS O O
O S
O
Emergency Room O Emergency
Room
Arriving Availability Utilization
Emergency Treatment
Patients Cycle Time
S S S S
S S S S O S S
Patients Entering Patients in B2b Patients Exiting Patients Entering
Patients in Emergency B1b B2a Patients Entering B4a Patients in B4b Patients Exiting
Emergency Room Examination Examination Disposition
Waiting Room Treatment Treatment Treatment
S O
O O S S S
O O O
O
Exam Capacity
S O S O Production Rate B6a
Diagnostic
Patient S
B1a Exam Schedule Laboratory TAT
Waiting Time
Pressure S
O B2 S O Patients in
B1 S
S S Disposition
S Patient Specimen Patient Specimen Departing
S Exam Capacity Patients Providing B5b Diagnostics O
B5a in Diagnostic Patients to
Departing Patients Patient LWBS S Utilization Diagnostic Laboratory Completion
Exam Processing Laboratory Home
LWBS Rate Likelihood Specimen B6b
S Target Delay S O O
S S
S S
S Disposition Patients Exiting
S Exam Schedule Disposition
LWBS Schedule Pressure
Departing Likelihood Pressure Lookup <Emergency Room O SS
Table Utilization> O B6
Emergency Lookup Table
Patients S Admitting
Disposition Disposition
Patients to
Processing Target Capacity Hospital
Delay Production Rate
S
Disposition
Capacity Utilization
S
Disposition Schedule
Pressure Lookup Table
Figure 2-6: Emergency department causal loop diagram
37
pEXM2RAD pRAD2DSP
ED Radiology &
Emergency Room Medical Imaging
Emergency Room
Capacity Process
Occupancy
Rate of Examination Ordered Rate of Diagnostic Imaging Complete
Diagnostic Imaging Patients Moved to Disposition
Rate of Diagnostic Imaging Complete
Patients Moved to Treatment
Emergency pRAD2TRT
Emergency Room
Room Rate of Treatment Ordered
Availability Utilization Diagnostic Imaging
pEXM2TRT pTRT2DSP
pTRT2RAD
Patient ED Patient
Waiting Time Treatment Process
Rate of Examination Complete Rate of Treatment Complete ED Patient Awaiting
Patients Moved to Treatment Patients Moved to Disposition Admission to
Rate of ED Patient Hospital Rate of ED Patient
ED Patient pEXM2DSP Admission to Hospital Admitted to Hospital
ED Patient
ED Waiting Room Examination Disposition
Rate of ED Process Process
Rate of ED Room
Patients Arriving Rate of Examination Complete Rate of Treatment Patients Rate of ED Patient
Assignments
Patients Moved to Disposition Issued Diagnostic Lab Orders Discharge to Home
Rate of ED Patients pTRT2LAB Rate of Diagnostic Lab Orders
Departing as LWBS Exam Capacity Completed to Treatment
Deposition Capacity
Production Rate
pEXM2LAB pLAB2TRT Production Rate
ED Laboratory pLAB2DSP
Patient LWBS
Likelihood Rate Diagnostics
Process Disposition Disposition Capacity
Rate of Examination Complete Rate of Diagnostic Lab Orders
Exam Schedule Patients with Diagnostics Order Complete Moved to Disposition Schedule Pressure Utilization
LWBS Likelihood
Lookup Table Pressure
<Emergency Room
Utilization> Disposition
Exam Capacity Schedule Pressure
Exam Processing Utilization Disposition Processing Lookup Table
Target Delay Target Delay
Figure 2-7: Emergency department stock and flow diagram
38
2.3.1.4 Model Inputs
Emergency department patient arrivals are a principle driver of the dynamic
behavior in the whole hospital model. Although the patient arrival rate may vary
dramatically over the hours of a day, and the days of a week, these patterns tend to be
relatively consistent and predictable over time (Morzuch and Allen, 2006). Figure 2-8
below illustrates a well-recognized pattern of emergency department arrivals as a time-
series by day of the week. The whole hospital model utilizes time-series data, combined
with some randomization to introduce typical variation, to provide an ongoing patient
arrival source.
12
10
Patient Arrivals per Hour
8 Sun
Mon
6 Tue
Wed
4 Thu
Fri
Sat
2
Mean
0
0:00 6:00 12:00 18:00 24:00
Hour of Day
Figure 2-8: Emergency patient arrivals by hour of day, and day of week
The whole hospital model baseline, cited in examples for the dynamic behavior,
uses the daily arrival rate and corresponding coefficient of variation in Table 2-1.
39
Table 2-1: Patient arrival source, daily arrival rate and coefficient of variation
Arrival Source Type Daily Arrival Rate Coefficient of Variation
Emergency Arrivals 168.2 0.167
2.3.1.5 Dynamic System Behavior
The dynamic behavior observed within the emergency department for a
representative weekday 24 hour period is illustrated in Figure 2-9. The figure presents:
(1) the varied rate of emergency patient arrivals; (2) the rate of patients departing leaving-
without-being-seen (LWBS); (3) the rate of decision to admit emergency patients to the
hospital; (4) the rate of patients completing treatment in the emergency department being
discharged home; and (5) the utilization of the emergency room capacity. Emergency
room utilization reflects the fluctuation in aggregate for stock levels where patients may
be waiting for an examination, waiting for diagnostic test results, receiving treatment, or
waiting on the availability of a bed in an appropriate ward. As the arrival rate fluctuates
the utilization rate typically follows with a time delay. Additionally, Figure 2-9
illustrates periods where an increase in the LWBS rate typically corresponds to periods
where a sustained high utilization exists.
40
15 patients/hr
100 percent
7.5 patients/hr
50 percent
0 patients/hr
0 percent
864 870 876 882 888
Time (Hour)
ED Arrival Rate patients/hr
ED LWBS patients/hr
ED Decision to Admit patients/hr
ED Discharge Home patients/hr
ED Treatment Utilization percent
Figure 2-9: Dynamic ED behavior for a baseline run of model
2.3.2 Surgical Department
Patients requiring surgery arrive either as a scheduled elective surgery patient or
through the ED. The scheduled elective surgery patients receive pre-operative and post-
operative care planning, which includes diagnostics, prior to the day of surgery. Patients
that arrive in the ED requiring emergency surgery require diagnostics and preparation
before surgery. The surgical department consists of pre-operative care where patients are
prepared for surgery, intra-operative care where patients undergo surgery, and post-
operative care where patients are overseen in a post anesthesia care unit (PACU). Each
area may restrict the patient flow and influence delay times. Patients remain in the
PACU until they are ready to be moved into an available bed in the surgical ward.
41
The model boundaries for the surgical department are illustrated using the “bull’s
eye” diagram presented in Figure 2-10. Factors relevant to the model of the surgical
department have been organized into excluded considerations, exogenous inputs, and
endogenous behaviors. A few of the excluded factors will be discussed later in the
assumptions section. The central concern here is the exogenous inputs, which are further
organized into internal and external factors under the surgical department scope of
control.
Figure 2-10: Model boundaries for the surgical department
External factors include the rate of emergency surgery arrivals that must be
worked into the surgical schedule, the rate of scheduled surgery cancellations caused by
42
insufficient inpatient bed availability, the transfer delay time encountered when the
surgical inpatients wards are congested, and the demand distribution for surgical inpatient
ward beds. These factors can have a significant impact on the scheduled surgical case
completion throughput and general patient flow. Internal factors related to capacity
include the number of pre-operative beds, intra-operative rooms (operating rooms), and
post-operative beds (PACU). In addition, the volume and mix of inpatient and outpatient
schedule surgeries can have distinctively different effects on both patient flow and
throughput. Lastly, management of the operating theatres revolves around reference
turnaround time targets for surgical preparation and readiness, which can be subject to
schedule pressure and influence capacity utilization.
The surgical department performs a central role within the hospital structure and
maintaining its efficiency is critical to hospital profitability. Interdependencies with other
units within the hospital affect the surgical department’s performance and patient flow.
Under adverse conditions this may lead to scheduled surgeries being rescheduled when
insufficient time remains in the schedule or cancelled when insufficient bed space exist in
the surgical inpatient wards. This section attempts to describe the interdependencies both
within and outside the surgical department that contribute to an observable system
behavior in the model.
Due to the complex relationships, a causal loop diagram is used to visually depict
and explain these interactions. The dynamic hypothesis is illustrated in Figure 2-11.
Patient flow within the surgical department follows a rather generic sequence of events,
43
as follows: (1) scheduled patients arrive at a surgery registration and intake waiting area;
(2) patients are bought into the pre-operative care area where they are prepared for
surgery; (3) late stage required laboratory, or radiology and medical imaging diagnostics
are completed; (4) prepared patients are moved into the intra-operative area into an
operating room theatre to perform surgical procedures; (5) completed patients are moved
into the post-operative care area, also known as the PACU; and finally (6) patients are
either discharged home, or transferred into a nursing unit to receive inpatient care. The
interactions present for each step of this event sequence relevant to the model are
described in the sections that follow.
Waiting Area: Patients occupying the surgical unit intake waiting area are
affected by a complex organization of members in the B1 loop structure, as described:
Loop B1a manages the inflow of scheduled surgery patients expected to enter the surgical
intake waiting area subject to forecasted bed availability, and initiates schedule
cancellations when insufficient availability is anticipated; Loop B1b the inflow of surgery
patients to the intake waiting area; Loop B1c the outflow of surgery patients departing
from the intake waiting area after being rescheduled, which is subject to the surgical time
availability remaining in the day; and Loop B1d the outflow of surgery patients from the
intake waiting area to entering the pre-operative care area.
Pre-operative Area: Patients occupying the surgical unit pre-operative area are
affected by members of the B2 loop structure: Loop B2a manages the inflow of surgical
patients to the surgical unit pre-operative care unit, subject to pre-operative care bed
availability; and Loop B2b the outflow of surgical patients from the pre-operative
44
surgical unit to the intra-operative care area, subject to the pre-operative care cycle time
and intra-operative care bed availability.
Unique to the pre-operative care process is the circumstance where additional
diagnostic information from radiology and medical imaging and/or laboratory is
necessary in order for the surgery to proceed. Loop B5 illustrates the request and patient
progression through radiology and medical imaging, and the request completion with
reported results. Loop B6 illustrates the progression of providing a patient specimen to
the diagnostic laboratory, the processing of the patient specimen, and diagnostic
laboratory results completion with reported results available.
Intra-operative Area: Patients occupying the surgical unit intra-operative care
area are affected by members of the B3 loop structure, as described: Loop B3a manages
the inflow of surgical patients to the intra-operative care unit, subject to intra-operative
care operating room availability; and Loop B3b the outflow of surgical patients from the
intra-operative care unit to the post-operative care unit (PACU), subject to the intra-
operative care cycle time (surgical procedure cycle time) and post-operative care bed
availability. In essence, the intra-operative care area functions around the management of
the operating theatres and the cycle time required to complete surgical procedures.
Post-operative Area: Patients occupying the surgical unit post-operative care area
are affected by members of the B4 loop structure as described: Loop B4a manages the
inflow of surgical patients to the post-operative care unit, subject to post-operative bed
availability; and Loop B4b the outflow of surgical patients from the post-operative care
unit to being discharged to home or transferred to a surgical ward, subject to the post-
45
operative care cycle time (patient recovery and preparation time) and surgical ward bed
availability. High surgical ward bed occupancy may result in delayed transfers, which
would increase congestion in the post-operative care unit, and in extreme cases require
overnight accommodation of surgical patients.
The causal loop diagram previously presented in Figure 2-11 visually depicts the
interactions and relationships that exist within the surgical department and between other
hospital units. The model structural formulation can be developed directly from this
causal loop diagram and similarly visualized as a stock and flow diagram, as illustrated in
Figure 2-12. The stock and flow diagram illustrates stocks as dwelling places occupied
by patients that include patients in the intake waiting area, in the pre-operative care area,
undergoing radiology and medical imaging diagnostics, awaiting laboratory diagnostics,
completing procedures in the intra-operative care area, and recovering in the post-
operative care area. The diagram illustrates the rates of flow between these patient
dwelling places, or stocks. Feedback structures previously discussed under the dynamic
hypothesis are included to illustrate how the rates of flow between stocks influence the
observed system behavior. Rates of flow may be determined by the available capacity, as
well as time delays, such as cycle times and expected length-of-stays, as defined in the
process.
46
Departing
Cancelled Forecast Ward PreOp Bed IntraOp OR
Patients in PostOp Bed
Surgery Patients Bed Availability Utilization Diagnostic Utilization
S Radiology & Utilization
S Imaging TAT
O S Medical Imaging
O O S O S
PreOp Bed PreOp Bed O IntraOp OR IntraOp OR PostOp Bed PostOp Bed
Cancelled Occupancy
Capacity Occupancy S Capacity Capacity Occupancy
Surgery
S O O O S O S S
Patients S Patients Requiring Patients Requiring S O
Arriving S PreOp Bed Diagnostic Imaging
B5 Diagnostic Imaging IntraOp OR PostOp Bed
Surgery Requested Discharge Patients
Patients Availability O Complete Availability Availability to Home
B1a B2 S B3 B4 S
S S S O S S S S S S S
O S S
S Patients in SU Patients Enter SU Patients in SU Patients Exit SU
Patients Enter SU Patients in SU Patients Enter SU Patients in SU Patients Enter SU B4b
B1b B1d B2a B2b B3a B3b PostOp Area B4a PostOp Area
Waiting Area Waiting Area PreOp Area PreOp Area O IntraOp Area IntraOp Area PostOp Area
O O O O O O O
O O O O S O O
S PreOp IntraOp PostOp S

Departing Surgery B1c S O Transfer Patients
Patient O Cycle Time Cycle Time Cycle Time
Patients Patients Providing Patient Specimen to Ward
Rescheduled Waiting Time Diagnostic Laboratory B6 Diagnostic Laboratory
S Specimen Results Complete
S O
Reschedule O
S
Waiting Surgery Intake
B1 O
Patients Cycle Time
O S Diagnostic
Patient Specimen
S Laboratory TAT
S in Diagnostic
Patient Reschedule Laboratory
Available
Surgical Time Likelihood
Remaining S
Reschedule Likelihood
Lookup Table
Figure 2-11: Surgical unit causal loop diagram
47
PreOp Bed IntraOp OR PostOp Bed
Utilization Utilization Utilization
PreOp Bed PreOp Bed IntraOp OR IntraOp OR PostOp Bed PostOp Bed
Capacity Occupancy Capacity Occupancy Capacity Occupancy
SU PreOp Area
Diagnostic
PreOp Bed Imaging IntraOp OR PostOp Bed
Availability Availability Availability
Rate of Diagnostic
Patient Imaging Completion
Waiting Time Discharge Patients
Arriving Surgery Rate of Diagnostic Diagnostic
Patients Imaging Requests to Home
Imaging TAT
SU Patients in SU Patients in SU Patients in SU Patients in

Rate of SU Patients Waiting Area PreOp Area IntraOp Area PostOp Area Rate of SU Patients
Rate of SU PreOp Rate of SU IntraOp Rate of SU PostOp
Arriving Bed Assignment OR Assignment Bed Assignment Departing
Departing Surgery Rate of Diagnostic

Intake Laboratory Requests PreOp IntraOp PostOp
Patients Rescheduled Rate of SU Patients
Cycle Time Cycle Time Cycle Time Cycle Time Transfer Patients
Rescheduling
Rate of Diagnostic to Ward
Laboratory Completion
Available Surgical
Patient Reschedule
Time Remaining SU PreOp Area
Likelihood Rate Diagnostic
Diagnostics Laboratory TAT
Laboratory
Reschedule Likelihood
Lookup Table
Figure 2-12: Surgical unit stock and flow diagram
48
Surgical unit patient arrivals are a principal driver of the dynamic behavior of the
surgical wards. Surgical schedules are planned in advance and exhibit the highest
workloads during the weekdays from Mondays through Thursdays, typically diminishing
in volume as the week progresses. Patients requiring emergency surgery arrive
unexpectedly at various times of the day. A small number of these patients may require
an immediate life-saving surgical procedure; however, the remaining emergency patients,
although considered urgent, may be added to the next day’s surgical schedule. Table 2-2
presents the patient arrival source to the surgical unit, and the corresponding average
daily arrival rates and corresponding coefficients of variation. The model utilizes time-
series data to determine the arrivals of the scheduled surgical patients. The emergency
surgery patients originate from the emergency department.
Table 2-2: Patient arrival source, daily arrival rate, and coefficient of variation
Patient Arrival Source Daily Arrival Rates Coefficient of

Variation
Scheduled Inpatients 30.0 -
Scheduled Outpatients 20.0 -
Emergency Patients 7.6 0.167
2.3.2.5 The Dynamic Behavior
The surgical unit and surgery ward are largely influenced by the quantity of the
scheduled outpatient and inpatient surgeries, as well as emergency surgeries. Outpatient
49
scheduled surgeries require less coordination of resources but place a burden on the
surgical unit with respect to throughput. Inpatient scheduled surgeries require more
coordination of resources as follow-on ward space will be required for ongoing patient
recovery and care. Resource contention or coordination conflict may result in delay of
transfer to the appropriate surgical ward, which may increase congestion in the post-
operative care unit, and potentially impact the surgical operating schedule. Emergency
surgery patients arrive in a more varied fashion. Given their unexpected arrival they may
encounter substantial delay either for surgical staff to become available at odd hours or
they may be placed as an “add-on” to the schedule. The output of the base case
simulation was used to analyze the functioning of the surgical unit and surgical wards in
detail, as described below.
Figure 2-13 illustrates the base case for surgical unit patient arrivals for
emergency surgery, scheduled inpatient surgery, and scheduled outpatient surgery during
the course of one week. Emergency patients arrive from the emergency department over
the course of a 24 hour day. In comparison, patients scheduled for inpatient or outpatient
surgery arrive during the primary surgical unit operating hours, typically between 6am
and 4pm during the week. Consistent with hospital operations, surgical volumes are
generally higher for the first three days of the week. Scheduled surgery patients are
managed using an external schedule in Microsoft Excel which communicates with
Vensim. In this example, the ratio of outpatient to inpatient surgical procedures is
roughly 4:5. In addition, arriving inpatient surgeries have a slightly higher prioritization
for allocation of surgical unit resources.
50
10
3
patients/hr
6
3 3
3 2 3
4 2
2 3
2 2
2 2
0 1 2 3 1 2 3 1 2 3 1 2 1 2 3 1 2 3 1 2 3 1 1 3 1 2 3 1 1 2 3 1 2 3 1 1 2 3 1 2 3 1 2 3 1 2 3
1 1
840 864 888 912 936 960 984

Time (Hour)
Emergency Surgery 1 1 1 1 1 Scheduled Outp atient 3 3 3 3 3
Scheduled Inp atient 2 2 2 2 2
Figure 2-13: Cumulative patient groups arriving to the surgical unit
Figure 2-14 illustrates the base case for surgical unit utilization by pre-operative,
operative, and post-operative care unit. Specifically, days with heavy scheduled surgical
volume, typically Monday, Tuesday and Wednesday, frequently see pre-operative bed
utilization near 100% due to insufficient bed quantity or caused by congestion and delay
in the operative or post-operative care units. Delays may also be encountered in the pre-
operative care unit when cases arise where additional diagnostics are deemed necessary
and the results are required before surgery. This can erode pre-operative surgical unit
throughput. Days with lighter scheduled surgical volume, typically Thursday and Friday,
require less pre- and post- operative care resources, as illustrated in the figure.
51
1 1 1 1
0.8
2 3 2 2
3 3 3
3
0.6
Utilization
3
3
0.4 2
1 1
2 1 2
0.2
2
3 3
2 3 3 3 1 3
3 3 3 3 3 2
2 3 2 2 2 2 2
0 1 1 2 1 1 2 1 2 1 1 1 1 1 1 2 1 2 1
840 864 888 912 936 960 984

Time (Hour)
Pre-Op Bed Utilization 1 1 1 1 Post-Op Bed Utilization 3 3 3 3 3
Operating Theater Utilization2 2 2 2
Figure 2-14: Surgical unit utilization by operative care unit
Figure 2-15 illustrates patient-flow out of the surgical unit, by source of origin,
for scheduled inpatient, scheduled outpatient, and emergency patients. Emergency
patients are handled with priority based on necessity and appended to the daily surgical
schedule as allowable. The patient-flow also illustrates a higher priority in the schedule
for inpatient surgeries over outpatient surgeries. Surgical unit congestion caused by
scheduled inpatients delayed in completing a transfer to a surgical ward affects the
throughput for scheduled outpatients.
52
6 hours
10 patients/hr
1
1 1 1 1
3 hours 1 1
1 1
1 1 1
5 patients/hr 1
1
3 3
2 3
0 hours 2
2
0 patients/hr 4 4 4 4 4 2
4 4 4 4 4 4 2 3 4 4 4
2 3 2 3 2 3 2 3 2 3 2 3 2 3 2 3 2 3
840 864 888 912 936 960 984
Time (Hour)
Time in Surgical Unit 1 1 1 1 1 1 1 1 1 1 1 1 hours
Outp atient Discharge 2 2 2 2 2 2 2 2 2 2 2 patients/hr
Inp atient Admission 3 3 3 3 3 3 3 3 3 3 patients/hr
Emergency Disp osition 4 4 4 4 4 4 4 4 4 4 patients/hr
Figure 2-15: Surgical unit patient completion by origination type
Figure 2-16 illustrates the surgical patient transfer from post-operative care to the
appropriate surgical ward for ongoing treatment and recovery. These surgical wards
include the intensive care unit (ICU), progressive care unit (PCU), and acute care unit
(ACU). Although patient transfers appear similar in shape, they are distinctively
governed by the availability of the appropriate bed by unit, and the resource capacity
required to complete the transfer. Patients with higher acuities receive prioritization for
transfer when the ward capacity is available.
53
3
2
patients/hr
2
3
2 3
2 3 2 2
1
3 2
3
3
1 1 3
1 2 1 2
3 1
2 3 2 3 2 2 3 2 3 1 3 2 2 3 3 2 3 2
0 1 1
2 3
1 1
1
1 1 1 1 1 1 2 3 1
1
840 864 888 912 936 960 984
Time (Hour)
ICU Patient Transfer 1 1 1 1 1 ACU Patient Transfer 3 3 3 3
PCU Patient Transfer 2 2 2 2
Figure 2-16: Surgical inpatient transfer from post-operative care to surgical ward
Figure 2-17 illustrates system behavior for the surgical ward patient flow and
occupancy for the base case run of the model, which represents the Monday on week six.
As the week progresses occupancy in the ward will accumulate and capacity will become
increasingly constrained. Observed is (1) the arrival of emergency surgery admissions
which consists of a nominal volume; (2) the scheduled surgery inpatient admissions
which arrive following surgery and recovery in the post-operative care unit; (3) the
surgical ward discharge orders coinciding with the completion of morning physician
rounds; (4) the orders for patient transference to a lower or higher level of care as
required; (5) the occupancy level associated with the progressive care unit (PCU); and (6)
the occupancy level associated with the acute care unit (ACU).
54
8 patients/hr
100 percent
6 6 6 6 6 6
6 6 6
3
4 patients/hr
5 5
50 percent 2 2 5
2 5
3 5 2
5 5 5 5
4 5
2
3
0 patients/hr 2
12 12 1 2 2 1 4 1 4 1 1
0 percent 1 1 4 1 4
3 4 34 34 3 3 3 4 3 4
864 870 876 882 888
Time (Hour)
Emergency Surgery Admissions 1 1 1 1 1 1 1 patients/hr
Scheduled Surgery Admissions 2 2 2 2 2 2 2 2 patients/hr
Surgical Ward Discharge Ordered 3 3 3 3 3 3 3 3 patients/hr
Surgical Ward B ed Transfer 4 4 4 4 4 4 4 4 patients/hr
Surgical Ward Occupancy (PCU) 5 5 5 5 5 5 5 5 percent
Surgical Ward Occupancy (ACU) 6 6 6 6 6 6 6 6 percent
Figure 2-17: Surgical ward patient flow and occupancy
2.3.3 Medical-Surgical Inpatient Wards
Patients admitted to the hospital will be assigned to either a medical ward or a
surgical ward determined by the nature of their admission. Medical admission arrivals
are sourced through the ED or through the direct medical admission (DMA) process by a
hospital affiliated physician. Surgical admissions are sourced through the ED or
primarily through the scheduled surgery process by a hospital affiliated surgeon. Wards
are organized into three principal types: (1) a Critical Care Unit (CCU) which provides
the highest level of care (also referred to as an intensive care unit); (2) a Progressive Care
Unit (PCU) provides a “step-down” level of care (intermediate care); and, (3) Acute Care
Unit (ACU) provides a standard level of care. Patients may transition from the highest
level of care to the lowest level of care prior to being discharged. Although infrequent,
patients at a higher level of care may in rare circumstances be directly discharged.
55
The model boundaries for the medical-surgical inpatient wards are illustrated
using the “bull’s eye” diagram presented in Figure 2-18. Factors relevant to the model of
the medical-surgical inpatient wards have been organized into excluded considerations,
exogenous inputs, and endogenous behaviors. A few of the excluded factors will be
discussed later in the assumptions section. The central concern here is the exogenous
inputs, which are further organized into factors internal and external under the inpatient
wards scope of control.
External factors include the rate of patient arrivals, the patient length-of-stay both
until ward transfer occurs and hospital discharge occurs, physician rounding, laboratory
diagnostics turnaround time (TAT), radiology and medical imaging diagnostic turnaround
time (TAT), and finally the discharge cycle time. These factors can have a significant
impact on the overall efficiency of the inpatients wards with regard to patient flow and
throughput. Internal factors include the bed capacity within each ward, the management
of patient and bed transfers due to changes in required nursing skill, and the
responsiveness in making preparations for patients identified as ready-for-discharge. The
responsiveness to patients identified as being ready-for-discharge is evaluated against
turnaround target measures which determine the level of schedule pressure on the
capacity which will influence the capacity utilization. Lastly, bed management is subject
to the ability housekeeping can clean and prepare ward beds that have been vacated by
patients either discharged or transferred. Failure in this timeliness will diminish overall
bed availability and utilization for the treatment and recovery of patients.
56
Figure 2-18: Model boundaries for the inpatient wards
The medical-surgical inpatient wards perform an important role in the ongoing
treatment and recovery of patients who must remain in the hospital under nursing care. It
is important that the inpatient wards are efficiently managed to maximize throughput of a
limited number of ward beds, while remaining responsive to patients being admitted
through the emergency department, the surgical department and direct medical
admission. Excessive demand or poor responsiveness will result in increased congestion
and reduced patient flow in many areas outside the inpatient wards.
Due to the complex relationships, a causal loop diagram is used to visually depict
and explain these interactions. The dynamic hypothesis is visually illustrated in Figure
57
2-19. Patient flow within the medical-surgical inpatient wards follow a rather generic
sequence of events, as follows: (1) patients begin receiving treatment upon entering a
ward bed; (2) patients receiving treatment may require radiology and medical imaging
diagnostics to evaluate health condition; (3) patients may transfer wards to a more
appropriate level of nursing care as health condition improves or worsens; (4) patients
receiving treatment may experiment health improvement as expected with length-of-stay
and be identified as being ready-for-discharge; and (5) patients that were identified as
being ready-for-discharge have completed discharge preparations and formally entered
the discharge process. The major interactions presented in this event sequence relevant to
the model have been illustrated in Figure 2-19 and described in the sections that follow.
Receiving Treatment: Patients occupying an inpatient ward are affected by
members in the B1 loop structure, as described: Loop B1a manages the inflow of
arriving patients to the inpatient ward that may originate from the emergency department,
direct medical admissions, ward transfers and surgical unit transfers, all which are subject
to the availability of ward beds; and Loop B1b the outflow patients from a state of patient
treatment in the inpatient ward to a state of patient readiness to be discharged, based on
the treatment length-of-stay (LOS).
While receiving treatment patients will routinely provide laboratory specimens to
evaluate their condition, possibly require diagnostic imaging to evaluate response, and
most likely will be transferred to a lower skilled nursing unit as their condition improves.
Laboratory specimen occurs throughout the inpatient ward and restricts the movement
58
flow of patients while awaiting laboratory report results. Diagnostic imaging and patient
transfers are discussed in further detail below.
Patient Bed Transfers: Patients occupying an inpatient ward undergoing treatment
may experience improvements or deterioration in health conditions necessitating their
movement to a nursing ward with a more appropriate level of care. Inpatient transfers
among the wards are affected by members in the B2 loop structure, as described: Loop
B2a manages the outflow of treatment patients from a specific ward that are ready-to-
transfer to another ward as their health condition has changed, subject to a step down (or
step up) length-of-stay (LOS) time; Loop B2b manages the inflow of these identified
ready-to-transfer treatment patients into the waiting to transfer state; and, Loop B2c
manages the outflow of these waiting to transfer treatment patients into a new destination
ward, subject to the utilization of wards beds, the available ward beds, and the permitted
hours for patient transfers to occur.
Radiology and Medical Imaging Procedures: Patients occupying an inpatient ward
undergoing treatment may require radiology and medical imaging diagnostics to assess
their treatment progress. Loop B5 illustrates the request and patient progression through
radiology and medical imaging, and the request completion with reported results. A
treatment patient with a radiology and medical imaging order may not be eligible for
transfer or discharge while a request is pending or being processed.
Treatment Completion: Patients occupying an inpatient ward having completed
their course of treatment and ready to initiate discharge are affected by members in the
B4a loop structure, as described: Loop B4a manages the inflow of patient’s ready-for-
59
discharge; and Loop B4b manages the outflow of patient’s ready-for-discharge subject to
a capacitated production process, where preparations are made in order prepare the
patient for discharge, dependent on the processing target delay time, the current
utilization of ward beds. As the utilization of ward beds increases the schedule pressure
to facilitate discharge preparations will increase.
Ready-for-Discharge: Patients in the discharge process are affected by members
of the B5 loop structure as described: Loop B5a manages the inflow of ready-for-
discharge patients into the discharge process; and, Loop B5b manages the outflow of
patients from the discharge process having been completed and ready to be discharged
home, subject to the discharge cycle time. The ward bed they had occupied is released
when the patient exits the discharge process.
Bed Management: Bed management involves the management of bed capacity as
it moves among the states of being available, occupied, and uncleaned. Beds in these
states are affected by members of the B6 loop structure. Loops B6a and B6b transition
bed capacity from an available state to an occupied state according to the rates of patients
entering into and transferring between wards; Loops B6c and B6d transition bed capacity
from an occupied state to an uncleaned state as a result of the rates of patients exiting
from and transferring between wards; and Loops B6e and B6f transition bed capacity
from an uncleaned state to an available state, subject to housekeeping cleaning cycle time
and production rate. Housekeeping’s ability in turning vacated, unclean beds into
available beds can contribute substantially to overall patient throughput.
60
<Utilization
Ward Beds> O
Rate of IP Patient
Transfers to New
Wards
S
B2c
O
Patients in IP Wards
Waiting Transfer
S
Step Down LOS

B2b
O
O
Rate of IP Patients
Ready to Transfer Treatment LOS
Wards
Arriving Patients S Discharge Patients
to Wards to Home
B2a S
S S S O S S S S
S O
Rate of IP Patients in IP Rate of IP Patients in IP Rate of IP Patients Patients in Rate of Patients
Patients Entering B1a B1b B1c Wards Ready B1d Entering Discharge B1e Discharge B1f Exiting Discharge
Wards Receiving Patients Exiting
Wards Treatment Treatment for Discharge Process Process Process
S S
O O O O S O O O
O
Discharge Capacity
<Available Ward
Production Rate
Beds> S
O Rate of Patients O Discharge
Rate of Patients S B4
Completing Diagnostic Cycle Time
Requiring Diagnostic B3 Discharge Schedule
Imaging Imaging Pressure
O O O Discharge Capacity
S S Utilization
S S
O Diagnostic Discharge
Imaging TAT Processing Target Discharge
S Delay Schedule Pressure
Patients in Radiology Lookup Table
& Medical Imaging
<Rate of IP
Patients Entering <Rate of IP Utilitization
Wards> Patient Transfers Ward Beds
to New Wards> S
O
S S
S S
Wards Bed
Available Rate of Occupied Capacity
B5a Occupying B5b Ward Beds
Ward Beds
Ward Beds O
S O O
B5f B5 B5c
O S S S S
Rate of Rate of
Cleaning B5e Uncleaned B5d Vacating
Ward Beds Ward Beds Ward Beds
O O
O S
<Rate of Patients
Cleaning Exiting Discharge
Cycle Time Process>
Figure 2-19: Medical and surgical inpatient ward causal loop diagram
61
2.3.3.3 The Structural Formation
The causal loop diagram previously presented in Figure 2-19 visually describes
the relationships that exist within both the medical and surgical inpatient wards. This
will be used as the basis for the model structural formulation for the inpatient wards. The
model structure formulation can be visualized as a stock and flow diagram, as illustrated
in Figure 2-20. The diagram illustrates as stocks the dwelling places occupied by patients
that include patients receiving treatment, undergoing radiology and medical imaging,
waiting to be transferred, ready for discharge, and being discharge processed. The
diagram further illustrates as flows the rate of movement that occurs between these
dwelling places, or stocks. Feedback structures previously discussed in the causal loop
diagram also appear in order to illustrate how the rates of flow between stock influences
observed system behavior. The rates of flow may be determined by the available
capacity, as well as time delays, such as cycle times and length-of-stay, defined in the
process.
62
<Utilization Ward
Beds>
Rate of IP Patient Transfers
to New Wards
Patients in IP
Wards Waiting
Ward Transfer
Step Down LOS
Rate of IP Patients
Ready to Transfer Wards Treatment
Arriving Patients to LOS
Wards
Patients in IP Patients in IP
Wards Receiving Wards Ready for Patients in
Rate of IP Patients Treatment Rate of IP Patients Discharge Rate of IP Patients Discharge Process
Rate of IP Patients
Entering Wards Exiting Treatment Entering Discharge Exiting Discharge
Process Process
Rate of Patients Requiring
Diagnostic Imaging
<Available Ward Discharge Capacity
Beds> Rate of Patients Completing Production Rate Discharge
Diagnostic Imaging Cycle Time
Discharge Schedule
Patients in Pressure Discharge Capacity
Radiology & Diagnostic Utilization
Medical Imaging Imaging TAT
Discharge Process Discharge Schedule
Target Delay Pressure Lookup Table
Utilization
Ward Beds
<Rate of IP Patients
<Rate of IP Patient
Entering Wards>
Transfers to New Wards
Ward Bed
Capacity
Available Ward Occupied Ward
Beds Beds
Rate of Occupying
Ward Beds
Cleaning
Cycle Time
Uncleaned Ward
Rate of Cleaning Beds
Rate of Vacating
Ward Beds Ward Beds
<Rate of IP Patients
Exiting Discharge
Process>
Figure 2-20: Inpatient ward stock and flow diagram
63
Model inputs for the medical and surgical inpatient wards include the patient
length-of-stay, and patient discharge values. Table 2-3 presents the schedule for the
length-of-stay durations by wards and bed type. These values may vary dramatically
from hospital to hospital based on the patient demographics and services marketed.
Table 2-3: Schedule of unit bed type length-of-stay durations
Unit Bed Type Medical Surgical

Length-of-stay (h) Length-of-stay (h)
Intensive Care (ICU) 23.5 22.3
Progressive Care (PCU) 33.1 27.5
Standard Care (ACU) 92.3 84.6
The patient discharge values consist of a discharging processing target delay,
which is specified to be 4.5 hours from the time at decision to discharge is been made,
and a discharge cycle time, which is specified to be 2.7 hours per patient. Schedule
pressure is then determined based on the pending discharge orders, the processing target
delay and discharge cycle time, using an external table.
2.3.3.5 Observed Model Behavior
The dynamic behavior observed in the medical and surgical inpatient wards
representative of a 24 hour weekday period are illustrated in Figure 2-21 and Figure 2-22,
respectively. Figure 2-21 illustrates: (1) the rate of admissions originating from the
emergency department; (2) the rate of admissions originating from direct medical
64
admissions; (3) the backlog of medical patients in the wards identified as being ready for
discharge; (4) the backlog of patient bed transfer requests pending within the wards; (5)
the medical PCU ward percentage occupancy; and lastly, (6) the medical ACU ward
percentage occupancy.
Figure 2-22 illustrates: (1) the rate of surgery arrivals originating from the
emergency department; (2) the rate of scheduled surgery arrivals from the surgical
department; (3) the backlog of surgical patients in the wards identified as being ready to
discharge; (4) the backlog of patient bed transfer requests pending within the wards; (5)
the surgical PCU ward percentage occupancy; and lastly, (6) surgical ACU ward
percentage occupancy.
15 patients/hr
100 percent
7.5 patients/hr
50 percent
0 patients/hr
0 percent
864 870 876 882 888
Time (Hour)
ED Medical Admissions patients/hr
Direct Medical Admissions patients/hr
Medical Ward Discharge Order patients/hr
Medical Ward Bed Transfer patients/hr
Medical Ward Occupancy (PCU) percent
Medical Ward Occupancy (ACU) percent
Figure 2-21: Observed dynamic behavior for medical inpatient wards
65
9 patients/hr
100 percent
4.5 patients/hr
50 percent
0 patients/hr
0 percent
864 870 876 882 888
Time (Hour)
ED Surgery Admissions patients/hr
Scheduled Surgery Admissions patients/hr
Surgical Ward Discharge Home patients/hr
Surgical Ward Bed Transfer patients/hr
Surgical Ward Occupancy percent
Surgical Ward Occupancy percent
Figure 2-22: Observed dynamic behavior for surgical inpatient wards
2.3.4 Radiology and Medical Imaging Diagnostics
Physicians frequently order diagnostic testing for patients that arrive to the ED,
the surgical department, and patients being treated in the medical and surgical wards.
Demand fluctuations and urgent requests may place considerable workload on these
services throughout the day, which may result in further delay and patient blocking
situations. This subsection specifically explores the unit interactions and operations for
radiology and medical imaging to examine underlying physical human structure.
Radiology and medical imaging generally requires that the patient be transported to a
fixed piece of equipment to complete the imaging processed. Common types of medical
imaging considered in this study include Magnetic Resonance Imaging (MRI) scanner,
66
Computer Tomography (CT) scanner, X-radiation (X-ray), and Ultrasound (US). While
recent technology advancements have introduced portable imaging diagnostic equipment
for both x-ray and ultrasound, it has not displaced traditional fixed equipment. In a high
demand environment radiology and medical imaging resources may impose a significant
constraint on patient flow in units requiring diagnostics for diagnosis and treatment.
Radiology and medical imaging activities in the model are presented using the
bull’s eye diagram to conceptualize which factors are excluded from the model, serve as
exogenous inputs, or are determined endogenously through model dynamics. Exogenous
factors serve as inputs specifically in the department. A description of the factors found
in both the exogenous and endogenous categories are presented in Figure 2-23 below.
Factors in the excluded category are addressed under model assumptions.
Input features identified as exogenous include the arrival of orders received from
various requesting units, the specifications for diagnostic equipment cycle time, the
scheduling and variation of diagnostic equipment capacity, the specification of an
expected turnaround time (TAT), and the appropriate response to variations in schedule
pressure. These inputs in certain cases, such as order requests, are influenced by the
endogenous operations of other department units which make such requests.
67
Figure 2-23: Model boundaries for radiology and medical imaging services
Order Request Origination and Prioritization
Radiology and medical imaging order requests originate from the surgical
department, emergency department, surgical wards and medical wards, which
corresponds to the order of prioritization. Although infrequent, surgical requests usually
occur during the pre-operative stage during the day of surgery. The rate of occurrence
differs for emergency, inpatient, and outpatient surgical patients. Surgical patient
requests receive the highest prioritization in order to minimize surgical schedule
disruption.
Emergency department order requests vary with the patient arrival volume once a
patient has been initially been seen and determined that diagnostics need to be performed.
68
Emergency department requests generally receive the second highest prioritization for the
allocation of radiology and medical imaging resources. These patients generally retain an
emergency room bed before, during, and after processing which may contribute to
department congestion when long delays occur.
Finally, surgery and medical inpatient wards generally post radiology and medical
imaging requests as the result of early morning physician rounds. These requests are
generally worked into the schedule space permitting, except for those of an urgent nature.
In addition to the department requests, order request demand occurs in the form of a
scheduled and referral demand from clinics and physician referrals. Detail for the
origination of order requests is presented in Table 2-4 below.
Diagnostic Equipment Cycle Time and Capacity
This study considers radiology and medical imaging diagnostic equipment that
include MRI scanners, CT scanners, X-ray machines, and ultrasound machines.
Although additional specialized imaging diagnostic equipment do exist, these core
diagnostic equipment types address the majority of the radiology and medical imaging
volume, especially where order requests may result in interdepartmental patient delays.
Time delay and processing for radiology and medical imaging is based on the scheduled
capacity of available equipment and the approximate processing cycle time. Throughout
the base-case scenario it is assumed that all diagnostic equipment capacity is fully
scheduled.
69
Table 2-4: Radiology and medical imaging order request origination
Radiology & Medical Imaging Request Distribution

Request Origination Source Impacted (%) MRI scan CT scan X-ray Ultrasound
Surgical Department (7:00 AM to 6:00 PM)

ED 4.8% 15.8% 26.3% 57.9% 0.0%
Inpatient 11.1% 15.8% 26.3% 57.9% 0.0%
Outpatient 5.1% 15.8% 26.3% 57.9% 0.0%
Emergency Department (24 hours)

Emergency patients 48.8% 9.4% 26.7% 60.0% 3.9%
Surgical Inpatient Wards (Orders at 8:00 AM)

SICU Patients 76.0% 5.0% 21.0% 69.0% 5.0%
SPCU Patients 76.0% 10.0% 23.0% 63.0% 4.0%
SACU Patients 76.0% 6.0% 24.0% 67.0% 3.0%
Medical Inpatient Wards (Orders at 8:30 AM)

MICU Patients 56.9% 5.0% 21.0% 69.0% 5.0%
MPCU Patients 56.9% 10.0% 23.0% 63.0% 4.0%
MACU Patients 56.9% 6.0% 24.0% 67.0% 3.0%
Outpatient, clinic, and referrals 11.0% 19.0% 55.0% 15.0%
Target Turnaround Times and Schedule Pressure
As previously noted, several areas of the hospital where tasks are performed may
be subject to schedule pressure when achieving a target turnaround time is threatened. A
result may be a temporary increase in productivity as the staff respond to the workload.
The radiology and medical imaging unit experiences this phenomenon. This has been
accommodated in the model using a capacitated delay structure (Sterman, 2000).
Accordingly, schedule pressure is determined by a function that has been normalized
based on capacity, such that:
Schedule Pressure = (Backlog / Target Turnaround Delay Time) / Unit Capacity
70
Table 2-5 provides the unit capacity values and Table 2-6 the target turnaround
delay time values. Backlog is endogenously determined. Schedule pressure is then used
to determine an adjustment to productivity according to an external lookup table. As a
result, this structure regulates productivity and the turnaround times (TAT).
Table 2-5: Radiology and medical imaging equipment, cycle time and capacity
Diagnostic Unit Equipment Cycle Time Unit Capacity

Equipment Count (h/patient) (patients/h)
MRI 1 0.75 1.33
CT 2 0.50 4.00
X-ray 3 0.25 12.00
Ultrasound 2 0.50 4.00
Table 2-6: Radiology and medical imaging target turnaround delay times
Diagnostic Target Turnaround

Equipment Delay Time (h)
MRI 1.5
CT 0.5
X-ray 1.0
Ultrasound 0.5
Radiology and medical imaging diagnostics provide an important, time sensitive
service to many clinical areas of the hospital. Operational inefficiency, service
disruption, or demand overload that results in missed turnaround times for reporting
results will reduce patient flow and throughput in many of these clinical areas.
71
Figure 2-24 illustrates the interrelationship of activities within and outside the
radiology and medical imaging process using a causal loop diagram to explain the
dynamic hypothesis. Prioritization of diagnostic order requests is largely determined by
the clinical area order request originator. From highest to lowest priority, these request
originators include the surgical department, the emergency department, the general
clinics and the medical-surgical inpatient wards. The radiology and medical imaging
process follows a simple sequence of events, as described: (1) diagnostic order requests
are dispatched from clinical areas of the hospital; (2) radiology and medical imaging
receive, log, and queue order requests; (3) imaging diagnostic procedures are performed
on patients; (4) image processing and reading is performed; and, finally (5) diagnostic
order requests receive returned report with final disposition. This sequence of events and
associated interactions are explained below in further detail as illustrated by the causal
loop diagram in Figure 2-24.
Waiting order requests for patient radiology and medical imaging are affected by
a capacitated production structure defined by members within the B1 loop structure, as
described: Loop B1a manages the inflow of patients with orders requesting a radiology
or medical imaging procedure to be performed, subject to the imaging capacity
equipment, general procedure cycle time and influenced by schedule pressure based on a
pending backlog of requests; and Loop B1b manages the outflow of patients with
completed procedures into a waiting for report status, subject to the capacity production
rate and capacity utilization determined by schedule pressure. In conjunction with the B1
loop structure, Loop B2a manages the outflow of patients in a waiting for report status
72
into a final order request disposition status, subject a time-dependent radiology and
medical imaging reading and report time.
73
Surgery Unit
Orders to RAD
Emergency O
Orders to RAD Radiology Turn-
Radiology Image
S Around-Time S
General/Clinic Reading and Report
Orders to RAD Time
Med/Surg Ward
Orders to RAD S S SS
O
Patients with S RAD Procedure S Patients Waiting S S RAD Report to
Order Requesting B2 RAD Disposition Surgery Unit
B1a Completion Rate B1b RAD Processing and
RAD Procedure O O Reporting Rate
O O S
S S RAD Report to
Emergency
S
RAD Report to
RAD Capacity
Units B1 S General/Clinic
RAD Capacity
RAD Report to
Cycle Time
RAD Capacity S SRAD Capacity O Med/Surg Ward
Schedule Production Rate
S
O RAD Capacity
RAD Schedule Utilization
Pressure S S
O
RAD Processing RAD Schedule

Target Delay Pressure Lookup Table
Figure 2-24: Radiology and medical imaging order flow causal loop diagram
74
The causal loop diagram previously presented in Figure 2-25 provides the basis
for the model’s structural formulation for the radiology and medical imaging department.
The model’s structural formulation can be visualized in a stock and flow diagram,
illustrated in Figure 2-25 below. The diagram illustrates the accumulation, in a stock, of
waiting radiology and medical imaging request orders that originated from throughout the
hospital. These waiting orders are processed by a capacitated production system whose
processing rate is influenced by the schedule pressure created by the number of pending
request orders held in backlog. Once the patient has been processed, the images must be
read by a radiologist or medical specialist, a report generated and the results made
available to the requesting physician for review in order to determine a treatment plan.
The rate at which these awaiting radiology images are completed is determined by a time
dependent reading and report cycle time. With completion, the imaging request order is
fulfilled and a notification of the report made to the originator.
75
Unit Orders to
Radiology Imaging
Radiology Imaging Order Fulfillment by
Report to Unit
Radiology Imaging Radiology Imaging

Waiting Request Department Processing
Rate of Radiology Orders Rate of Radiology and Reporting Rate of Radiology
Imaging Orders Imaging Order Imaging Order
Arriving Processing Completion
Capacity Units
Capacity Schedule Radiology Imaging
Capacity Capacity Cycle Reading and Report
Production Rate Time Cycle Time
Radiology Imaging
Radiology Imaging
Schedule Pressure Capacity Utilization
Processing Target Schedule Pressure

Delay Lookup Table
Figure 2-25: Radiology and medical imaging stock and flow diagram
The radiology and medical imaging department responds to physician orders
originating from four primary sources represented in the model, which include, in order
of priority, the surgical unit, emergency department, hospital clinic, and the medical-
surgical wards. The surgical unit and emergency department place the greatest on-
demand volume with urgent turnaround times on the department. High volumes from
these areas can have substantial ramifications for the wait times for both medical-surgical
wards requests, and patients from a clinic, especially where the capacity is undersized.
Under extreme circumstances, low priority patients may experience lengthy delays which
might result in their being scheduled for a future day.
76
Evidence of this system behavior is illustrated through the figures that follow.
Figure 2-26 illustrates the base case for radiology and medical imaging requests per hour
received over the period of one week, where the week begins on a Sunday. As with most
weekend days a lighter volume is observed on both Saturday and Sunday. Every
morning of the week between the hours of 7 and 9 AM a noticeable spike is observed due
to the requests received as physicians complete their morning rounds in the wards and
submits their orders. Throughout the remainder of the day, the volumes from each of the
sources vary according to workload and operating hours.
Figure 2-27 illustrates the base case for radiology and medical imaging services
utilization over the same period. The utilization rises dramatically between 8 AM and 4
PM corresponding with hospital demand and operational activities. It is important to note
that in the base case two MRI machines were operated between the hours of 8 AM to 6
PM, which corresponded to peak workload, and only one MRI machine during the off
hours. This change in capacity explains the appearance of the sharp rebounding curves
with respect to utilization. Similarly, the capacity for X-ray is varied by one-third. No
capacity change occurs for CT or ultra-sound.
Figure 2-28 illustrates the varying average turnaround time (TAT) by request type
from the time a request is placed until completed. Since requests are prioritized by their
originating source, it is expected that emergency department requests would see a shorter
TAT than the inpatient wards. The lowest TAT occurs on Sunday which typically
coincides with reduced hospital occupancy, specifically in the surgical wards, and
diminished volume from outside referring practices and clinic. The behavior observed
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throughout the week reveals that the TAT for all types increases during the overnight
hours. This is partly due to the reduced capacity but also a function of the extended time
incurred to complete an imaging reading. The spike observed daily between 8 and 9 AM
reflects the request surge originating from the medical-surgical inpatient wards following
rounds, which is combined with the delayed effect of increases in scheduled capacity.
20
15
requests/hr
10
0
840 864 888 912 936 960 984 1008
Time (hours)
MRI requests Xray requests
CT requests US requests
Figure 2-26: Radiology and medical imaging requests per hour
78
1
utilization .75
.5
.25
0
840 864 888 912 936 960 984 1008
Time (hours)
MRI utilization Xray utilization
CT utilization US utilization
Figure 2-27: Radiology and medical imaging services utilization
10
7.5
hours
2.5
0
840 864 888 912 936 960 984 1008
Time (hours)
MRI request TAT Xray request TAT
CT request TAT US request TAT
Figure 2-28: Radiology and medical imaging services turnaround time (TAT)
79
2.3.5 Laboratory Diagnostics
Laboratory service requests originate with a specimen obtained from the patient
which is then submitted to the laboratory for analysis. Specimens are processed and
results are returned to the point of request for physician evaluation. In most medium
sized community hospitals laboratory services are centralized. Larger, urban medical
centers may have unit specific laboratories.
The model boundaries for the laboratory diagnostic services are presented using
the “bull’s eye” diagram in Figure 2-29. Factors relevant to the model of the laboratory
diagnostic services have been organized into excluded considerations, exogenous inputs,
and endogenous behaviors. A few excluded considerations will be addressed later in the
assumptions section. Exogenous inputs are further categorized as factors either external
to the laboratory, such as order request demand, or internal, such as analyzer equipment
parameters.
External factors include the rate of laboratory order requests received and the
distribution of order request priorities received. As long as the analyzer system capacity
is well matched to the peak demand volume of order requests received the laboratory
diagnostic services will perform relatively well. Aside from being prioritized in the
analyzer loading, priority order requests will be processed at the same rate as routine
order requests on the analyzer system. Internal factors specific to capacity include the
capacity of the analyzer system, the rate of analyzer system loading, and the analyzer
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specimen processing cycle time. Additional internal factors include the responsiveness to
standardized turnaround time targets in providing laboratory results, which can result in
schedule pressure to increase overall productivity in response to demand.
Figure 2-29: Model boundaries for the laboratory diagnostic services
The laboratory diagnostic provides an important, time sensitive service to all
clinical areas of the hospital. Operational inefficiency or disruption resulting in missed
turnaround times for laboratory results will result in reduced patient flow and throughput
in these clinical areas.
81
Figure 2-30 illustrates the interrelationship of activities within and outside the
laboratory process using a causal loop diagram to explain the dynamic hypothesis. The
laboratory process for both priority and routine order requests for specimen analysis
follows a simple sequence of events, as described: (1) order requests and specimens are
dispatched from clinical areas of the hospital; (2) laboratory arriving order requests with
specimens are logged, priority batched, and wait to be loaded into the analyzer; (3)
specimens enter the analyzer system as capacity becomes available; (4) specimens are
processed by the analyzer system according to the estimated procedure cycle time; (5)
analyzer completes specimen processing and analysis results are reported; and, finally (6)
specimen analysis report exceptions are reviewed and acted upon by laboratory staff.
These interactions are explained in greater detail referencing the causal loop diagram
presented in Figure 2-30. Explanation is provided primarily from the perspective of the
routine order requests and specimens (secondarily, the priority order requests and
specimens), in order to avoid redundancy, and the interactions between priority and
routine requests are specifically cited.
Specimens arriving to the laboratory follow a sequential procedure in order to
complete their processing. For routine specimens (alternatively, STAT specimens) the
sequential procedure is defined by members of within the B1 loop structure (B2 loop
structure), as described: Loop B1a (Loop B2a) manages the inflow of routine lab
specimens arriving to the laboratory where they are held waiting to be processed on the
analyzer system; Loop B1b (Loop B2b) the outflow of routine lab specimens from
waiting to be processed to loading or entering the analyzer system, subject to the analyzer
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system capacity availability, less capacity already allocated to STAT lab specimens, and
the maximum loading rate allowable for routine lab specimens; Loop B1c (Loop B2c)
the inflow of routine lab specimens that enter to be processed on the analyzer system; and
Loop B1d (Loop B2d) the outflow of routine lab specimens that have finished being
processed on the analyzer system, subject to the analyzer system cycle time, and ready to
have results reviewed and reported.
Finally, it is important to note the interaction between the Loop B1 and Loop B2
structures that occurs in the management of capacity allocated between the two specimen
types. Specifically, in Loop B1e and Loop B2e the total number of specimens being
allocated in the analyzer system and the analyzer system cycle time determine the
analyzer system capacity available. Available capacity will be prioritized first to waiting
STAT lab specimens to determine a loading rate, subject to the maximum loading rate,
and second to waiting routine lab specimens to determine a loading rate, subject to the
maximum loading rate.
The causal loop diagram presented in Figure 2-30, accompanied with explanation,
describes the relationships that exist within and outside the laboratory diagnostic services.
Using this information, the model structural formulation can be visualized as a stock and
flow diagram, as illustrated in Figure 2-31. The diagram illustrates as stocks the dwelling
places occupied by order requests and specimens as they proceed through the laboratory
process. The diagram further illustrates as flows the rate of movement and process
transformation for the order requests and specimen analysis. The stock and flow
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diagram also illustrates the allocation logic of analysis system capacity to between
priority and routine order requests and specimens, which forms a weak balancing loop
feedback structure. Rate of flow are determined by available analyzer system capacity,
maximum analyzer system loading rates and the analyzer system cycle time. The stock
and flow diagram also illustrates the structures for the estimated turnaround time of
priority and routine order requests.
84
Max Loading Rate for Reporting Routine
Arriving Routine Lab Routine Lab Specimens
Specimens Lab Results
S
S S S
S S
S Rate of Routine Lab Routine Lab Rate of Routine Lab
Rate of Routine Lab Routine Lab Specimens B1c Specimens Being
B1b B1d Specimens Completing
Specimens Arriving to B1a Specimens Waiting Processed in Analyzer
Loading/Entering into System on Analyzer System
Laboratory to be Processed Analyzer System
O O O O O
O S
B1e
Analyzer System
Capacity S
Analyzer System
O Capacity in Use
Analyzer System
S S
O Analyzer System Cycle Time
Analyzer System Capacity Available
Utilization O
O Reporting STAT
Arriving STAT Lab Lab Results
Specimens B2e
S
S S S S S O
S STAT Lab Specimens Rate of STAT Lab STAT Lab Specimens Rate of STAT Lab
Rate of STAT Lab Specimens B2c B2d
Specimens Arriving to B2a Waiting to be B2b Being Processed in Specimens Completing on
Loading/Entering into
Laboratory Processed Analyzer System Analyzer System Analyzer System
O O S O O
Max Loading Rate for

STAT Lab Specimens
Figure 2-30: Laboratory specimen processing causal loop diagram
85
Arriving Routine Lab Arriving STAT Lab
Specimens Specimens
Rate of Routine Lab Rate of STAT Lab
Specimens Arriving to Specimens Arriving to
Laboratory Laboratory
Max Loading Rate

for Routine Lab Max Loading Rate
Routine Lab Specimens for STAT Lab
STAT Lab Specimens
Specimens Waiting Specimens Waiting
Rate of Routine Lab Rate of STAT Lab

Specimens Loading into Specimens Loading into
Analyzer Analyzer
Analyzer
System
Utilization
Analyzer System Analyzer System

Capacity Capacity Available
STAT Lab
Routine Lab Specimens in
Specimens in Rate of STAT Lab Analyzer System Rate of STAT Lab
Rate of Routine Lab Analyzer System Rate of Routine Lab Specimens Entering into Specimens Completing on
Specimens Entering into Specimens Completing on Analyzer Analyzer
Analyzer Analyzer
Analyzer System Analyzer System

Capacity in Use Cycle Time Departing STAT
Departing Routine Lab Results
Lab Results
<Routine Lab <STAT Lab

Specimens Waiting> Specimens Waiting>
STAT Specimen
Routine Specimen Average Process
Average Process TAT
<Routine Lab Specimens TAT <STAT Lab Specimens STAT
in Analyzer System> Routine
in Analyzer System> Specimen
Specimen
Present
Present
STAT Lab Specimen
Routine Lab Specimen
Cumulative Time in
Cumulative Time in Rate of STAT Specimen
Rate of STAT Laboratory
Rate of Routine Laboratory Rate of Routine Specimen Average Time in
Specimen Time in
Specimen Time in Average Time in Laboratory Departing
Laboratory
Laboratory Laboratory Departing
<Rate of Routine Lab <Rate of STAT Lab

Specimens Completing on Specimens Completing on
Analyzer> Analyzer>
Figure 2-31: Laboratory specimen processing stock and flow diagram
86
Model inputs for the laboratory include the analyzer system capacity, the analyzer
system cycle time, and the maximum specimen loading rate. Analyzer systems are
usually modularly configured with expansion capability. Therefore, these values may be
specific to a particular implementation. Table 2-7 presents the equipment specification
for the analyzer capacity, cycle time, and maximum load rate. The system cycle time
does not include transport, recording, or reporting. The equipment specifications are
based on data shared by UNC Hospitals, and UNC Johnston Health.
Table 2-7: Equipment specification: analyzer capacity and cycle time
Analyzer Equipment STAT Routine

Specification Specimens Specimens
System capacity (specimens) 120 120
System cycle-time (h/specimen) 0.56 0.56
Max. load rate (specimens/h) 100 200
The laboratory receives and responds to requests to process laboratory specimens
originating from multiple sources that include the surgical unit, the emergency
department, the medical-surgical inpatient wards, as well as external sources such as
associated clinics and offsite practices. Although demand volumes vary, a substantial
portion of the demand can be anticipated as a function of the weekly, daily, and hourly
schedule. Laboratory requests consist of routine requests and priority requests,
87
commonly referred to as STAT requests. A majority of laboratory requests are received
as routine requests, which typically originate from the medical-surgical inpatient wards in
large batches on a schedule and as demanded. Priority requests originate principally from
the surgical unit, the emergency department, and the medical-surgical ICU wards, when
an urgent diagnosis is needed.
Figure 2-32 illustrates the base case for arriving laboratory diagnostic requests per
hour by routine and priority order types over the period of one week. Routine requests
are observed to arrive with greater frequency, with demand peaking at numerous points
throughout the day. Priority requests are observed to arrive in fewer number, but with
greater variation, and requests continue to arrive overnight consistent with activities of
the emergency department. Arriving requests on Sunday are lower for both order types,
which reflects lower inpatient ward occupancy, especially within the surgical ICU ward.
88
100
75
requests/hour
50
25
0
840 864 888 912 936 960 984 1008
Time (hours)
Routine Requests Priority Requests
Figure 2-32: Arriving laboratory requests by priority type
Figure 2-33 illustrates the base case for laboratory diagnostic analyzer utilization
of capacity and the turnaround time by order type over the period of one week.
Turnaround times for routine requests, an average of 1.08 hours, are consistently higher
than those for priority requests, an average of 0.75 hours. While the analyzer processing
cycle time is consistent irrespective of the order type, the specimen handling, specimen
backlog, load prioritization, and report prioritization contribute to this difference in
turnaround times. Analyzer utilization is observed to fluctuate throughout the day with
many instances that approach full utilization. Under periods of high utilization, routine
and priority request turnaround times will deteriorate.
89
2 hours
1 fraction
1 hours
.5 fraction
0 hours
0 fraction
840 864 888 912 936 960 984 1008
Time (hours)
Routine Requests hours
Priority Requests hours
Analyzer Utilization fraction
Figure 2-33: Laboratory turnaround time and utilization
2.4 Model Calibration and Validation
This section reviews the model calibration and validation methods used to ensure
the whole hospital model will produce dynamic behaviors consistent for the conditions
presented in a community hospital.
2.4.1 Model Calibration
Model calibration for a system dynamics model is used to approximate the values
for important, but uncertain, variables that contribute to a broader system behavior, for
which there is well documented historical data to serve as a reference mode. Examples of
the use of model calibration are demonstrated in studies of natural systems, disease
90
transmission, and climate concerns. Model calibration for the whole hospital model is
approached differently since a well-defined detailed historical record for community
hospital inputs and outputs is difficult to obtain. Instead, model calibration is used to
carefully evaluate the time series data for patient arrivals, the various response functions,
and the expected time durations.
Model calibration for patient arrival rates is determined based on historical time
series data obtained through comparison with several hospitals based in the United States.
This estimated patient arrival rate time series data is used to generate arrivals unique by
hour of day, and day of the week. In the example baseline case, 168 patients per day
arrive to the emergency department and 16 patients per day arrive as direct medical
admissions to the medical wards.
Model calibration for response functions, otherwise known as lookup functions,
require understanding how states and conditions of the community hospital impacts the
behavior of patients and performance of processes. Two examples for the whole hospital
model are cited. First, reacting to wait times and waiting area congestion patients may
leave-without-being-seen (LWBS) by a physician. This behavior is modeled through a
response function since an analytical equivalent does not exist. Second, physicians,
nurses, and staff are known to respond to the presence high workload demands by
increasing their work rate. This behavior is included throughout the model using a set of
response functions to adjust work rates in response to schedule pressure based on
expected turnaround times and demand. Although it is difficult to recreate the responses
exactly, these response functions improve the overall behavior the whole hospital model.
91
Lastly, model calibration is applied to patient length-of-stay durations, process
turnaround times and procedural cycle times. Inpatient hospital length-of-stay durations
are based on historical data reported by United States based hospitals. For the model,
these best fit lognormal distributions; however, Erlang distributions are then used as an
approximation because of their support in the system dynamics software used. Process
turnaround times and procedural cycle times reflect the capability of the process and
corresponding targets established as hospital policy or an objective. Interviews with
several subject-matter-experts and hospital operations literature determined the
calibration for these values.
2.4.2 Model Validation
Model validation for system dynamics modeling addresses two primary concerns:
Whether the model structure is correctly implemented, and whether the simulated
dynamic behavior is accurately achieved.
Structured-based model validation tests are concerned with the model formulation
and ensure that the model is suitable for the intended purpose and consistent with the real
world system. For the whole hospital model, effort was made to carefully map the major
processes and to seek ongoing collaboration with subject-matter-experts regarding the
implementation of functions within the model. This was an iterative process as the model
developed. Additionally, efforts were made to evaluate the suitability of the model
through careful examination of internal matters, which include checking for dimensional
consistency and range testing formulations for the proper handling of extreme values.
92
Behavior-based model validation tests are concerned with exploring the validity
of the model construction in the simulated dynamic behavior. Conducting behavior-
based model validation tests for the whole hospital model is especially challenging
because of the difficulties in obtaining representative historical data for the many aspects
of model behavior. The lack of this historical data required use of extended methods that
included: judging the behavior subjectively, qualitative analysis of time series, and
objective examination of quantitative summary data. In these cases, subject-matter-
expert review of the resulting simulated dynamic behaviors provided the strongest
validation.
2.5 Model Limitations
Three types of limitations related to the model may affect the outcome results
from this work. First, the ambitious effort to model a whole hospital environment often
resulted in situations where the data required to describe select portions of the model was
not readily available. This often led to the use of hospital industry reported data or data
from select journals and publications where available. More often, subject matter expert
guidance was used to overcome data insufficiency. Second, the choice of system
dynamics as the modeling methodology limits both the performance measures and
fidelity that can be obtained. While the model can render very valuable insights to the
dynamics within the hospital, in some cases a hospital administrator desire more detailed
information that can be extracted from the model. Finally, the cohort oriented approach
of the system dynamics methodology often limits the obtainable information specific to a
93
patient experience. The absence of such information is particularly impactful when
considering more operational natured concerns in areas such as surgical unit scheduling.
2.6 Conclusions
The whole hospital model presented in this chapter provides a strategic platform
to explore a multitude of interests related to hospital-wide capacity dynamics. In the
hospital industry today the application of productivity improvement initiatives, which
typically target individual units, results in modest gains rather than the transformative
improvements sought by health care leaders. Additionally, these initiatives generally
require lengthy time durations to determine whether an improvement was successful or if
further adjustment is required. In contrast, the whole hospital model can be used to
quickly experiment with a proposed scenario to evaluate its effect.
The background and knowledge required to construct a whole hospital model is
quite extensive. The information presented and amassed in this chapter is a testament to
that fact. While this information may not be of interest to all readers, perhaps it will
provide some guidance to the few that would consider a similar endeavor. Success in
constructing a whole hospital model depends on formulating a strong and solid
partnership with a hospital system and the generosity of the subject matter experts that
will be encountered both with their time and willingness to share information. The
administrators and staff at UNC Medical Center, UNC Hillsborough Campus, and UNC
Johnston Health have been excellent partners to work with.
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CHAPTER 3 INSIGHTS FROM A FUNDAMENTAL ANALYSIS
3.1 Introduction
This chapter considers the multi-decade long dilemma regarding how many
hospital beds are needed and where they should be located within the hospital in order to
maximize service and occupancy levels. This concern originated during the 1980’s when
excessive hospital bed capacity resulted in extremely low bed occupancy, which led to
underperforming hospitals. Later this situation has shifted to the present day problem
where insufficient hospital bed capacity has resulted in extremely high bed occupancy,
which may cause poorly performing health systems.
Green (2002) articulates the complexity involved in the hospital bed capacity
allocation problem and suggests many fundamental factors must be considered in
planning the number of beds that a specific hospital or hospital service should have.
Rather than embracing standardized bed occupancy targets by schedule to adjust hospital
bed capacity, Green demonstrated that queuing delay was a more meaningful measure
given hospital size, services, and demand can differ dramatically. Hospital bed capacity
planning has remained an area that many researchers have sought to demonstrate
improved understanding and methods over many years. Queuing theory methods,
deterministic methods, linear programming methods, and stochastic programming
methods have all been well demonstrated. However, all these methods have key
assumptions that must be accepted for their approximations. More importantly, most of
these models are restrictive and fail to accommodate department interdependencies
95
common in a hospital. It is believed that a whole hospital simulation offers tremendous
benefit to study these types of issues.
In this chapter the whole hospital model is used to perform a fundamental analysis
to examine how changes in unit capacity in select areas across the hospital affect system
behavior and performance. While it is often the objective of a capacity analysis to
determine the maximum performance obtainable given a set of inputs, our analysis
focuses more on understanding the relationship and interdependencies that unit capacity
allocation has between select hospital units. This study considers more than simply the
number of hospital beds but also includes the concern for capacity management hospital-
wide (Proudlove et al., 2003; Smith-Daniels et al., 1988).
We organize this chapter into two major parts. First, we examine the allocation of
unit capacity between the emergency department and medical inpatient wards and then
explore the sensitivity to adjustments in the emergency patient demand. Second, we
examine the allocation of unit capacity between the surgical unit and the surgical
inpatient wards and then explore the sensitivity to adjustments in the scheduled elective
surgery patient demand.
3.2 Terminology
Wherever possible the terminology common in hospital operations and familiar to
hospital administrators is utilized. However, within the limitations of a modeling
environment related meanings can be altered and new references to matters of importance
introduced. In this section we introduce the explicit definitions of several terms used to
96
describe both behavior and performance measures. First, we introduce terminology that
may be common regarding the status of resources and equipment, as presented in Table
3-1. Second, we introduce and describe the terminology specific to both the medical and
surgical inpatient wards, as presented in Table 3-2. Third, we introduce and describe the
terminology specific to the emergency department operations, as presented in Table 3-3.
Finally, we introduce and describe the terminology specific to the surgical department
operations, as presented in Table 3-4.
Table 3-1: Resource and capacity terminology
Term Description
Availability The proportion of a resource, such as a bed, room or operating

room theatre, that is committable to a patient, activity or task
Occupancy The proportion of a resource, such as a bed, room or operating
room theatre, occupied by a patient or in use performing an activity
or task
Unavailability The proportion of a resource, such as a bed, room or operating
room theatre, that has been vacated but is not yet committable due
to cleaning and preparation
Utilization The proportion of the available time a resource is in use, either
occupied by a patient or unavailable due to cleaning and
preparation
97
Table 3-2: Inpatient ward operations terminology
Term Description
Bed utilization The proportion of the available time a bed in a specific ward is
either occupied by a patient or unavailable
Midday census The total number of patients admitted to the hospital at midday, in a
specific medical-surgical ward (ICU, PCU or ACU)
Midnight census The total number of patients admitted to the hospital at midnight, in
a specific medical-surgical ward (ICU, PCU or ACU)
Attractive inpatient The condition where the transfer of a patient due to a change in
transfer health standing may improve general bed availability; however,
such transfers subject to bed availability.
Table 3-3: Emergency department operations terminology
Term Description
ED utilization The proportion of the available time treatment rooms are either
occupied by a patient or unavailable
Leaving-without-being- A patient encounter that ended with the patient leaving the
seen (LWBS) emergency department before the patient could be seen by a
physician, usually as a result of waiting time or congestion
Triage-to-room time The time a patient spends waiting from an initial medical screening
conducted at registration until the patient is placed in a room to be
examined by a physician
Discharged length-of- The time duration a patient spends in the emergency department
stay (LOS) from initial triage until being discharged home
Admitted length-of-stay The time duration a patient spends in the emergency department
(LOS) from initial triage until being admitted into the hospital
Bed placement time The time duration from when a decision is made to admit a patient
(boarding time) to the hospital until when the patient is boarded into the appropriate
nursing unit (ward); also known as boarding time
98
Table 3-4: Surgical unit operations terminology
Term Description
OR utilization The proportion of operating room theatre usage for patient surgical
procedures and general turnover and preparation
Intake delay time The nonvalue added time that a schedule surgical patient must wait
following registration complete until being brought into the surgical
unit preoperative care area
Inpatient surgery Elective surgeries cancelled generally within one day’s notice due
cancellation to a forecasted insufficient hospital resources to perform the
procedure or provide post-surgical care and recovery
Inpatient surgery Elective surgeries rescheduled on the day of surgery due to
reschedule (or delay) insufficient surgical time remaining to perform the procedure,
generally caused by excessive schedule delay or congestion
Outpatient surgery Elective surgeries rescheduled on the day of surgery due to
reschedule (or delay) insufficient surgical time remaining to perform the procedure,
generally caused by excessive schedule delay or congestion
Outpatient discharged The time duration a patient spends in the surgical unit from
length-of-stay (LOS) registration until being discharged home
Inpatient admitted The time duration a patient spends in the surgical unit from
length-of-stay (LOS) registration until transferred to a nursing unit ward
PACU overnight The average number of patients held in the PACU overnight due to
patients insufficient bed availability in a surgical inpatient ward, or higher
level of care
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3.3 The Emergency Department and Medical Inpatient Wards
The analyses presented in this section for the emergency department and medical
inpatient wards are organized into two parts. First, a fundamental analysis is performed
to evaluate the combined effect of emergency department treatment room capacity and
medical inpatient ward bed capacities on select performance measures. Second, a
sensitivity analysis is performed to evaluate the effect of adjusted emergency department
patient demand on a well-balanced system on select performance measures. Both these
analyses employ a one-factor-at-a-time approach using visual inspection to evaluate
results.
3.3.1 A Fundamental Analysis
We conduct a fundamental analysis where unit capacity is allocated to the
emergency department in the number of treatment rooms and the medical inpatient wards
in the number of medical intensive care unit (MICU), progressive care unit (MPCU), and
the acute care unit (MACU) beds. The purpose is to examine the effect these unit
capacity changes may have on select, representative performance measures in the whole
hospital model. We expect some performance measures will be more responsive than
others to unit capacity changes.
We present a framework in Table 3-5 that defines the unit capacity ranges and
increment sizes for each unit category input factor included in the fundamental analysis.
Using a one-factor-at-a-time approach, these input factors will be varied across the
specified range at intervals determined by the increment size. The illustrations presented
100
and discussed throughout the remainder of this section will frequently characterize the
relationship between two varying capacities.
Table 3-5: Unit capacity allocation for ED and medical ward units
Unit Category Range Minimum Range Maximum Increment Size
ED rooms 20 40 2
Medical ICU beds 1 8 1
Medical PCU beds 10 40 5
Medical ACU beds 100 200 10
Throughout the study, the emergency department patient arrival rate, 168.1
patients per day, and direct medical admission patient arrival rate, 16.0 patients per day,
remain constant although subject to hour-of-day and day-of-week time variations. To
reduce the unwanted ill-effects of select capacity restrictive processes unrelated to the
study focus certain areas in the model were over-provisioned. The results obtained from
the whole hospital model represent 52 weeks of simulated time which followed an
extensive conditioning period. Due to the unit capacity relationships, we organize the
presentation and discussion of these results by the medical inpatient ward categories.
Using these results, we present a consolidated set of unit capacity recommendations
deduced through visual inspection, and review the corresponding performance
measurement results.
101
3.3.1.1 Medical Intensive Care Unit Capacity
The allocation of unit capacity to the emergency department in the number of
rooms and the medical intensive care unit in the number of beds has a significant impact
on a number of operational performance metrics. This section seeks to explore the
consequences due to systematically varying allocated unit capacity levels.
Notably, ED capacity utilization is influenced by the number of ED room capacity
allocated and the number of medical intensive care unit (MICU) beds capacity allocated.
In this section, ED capacity is varied from 20 to 40 rooms and MICU capacity is varied
from 1 to 5 beds. It can be observed in Figure 3-1 that when only one or two MICU beds
are allocated, regardless of the ED capacity allocated, utilization will be exceedingly high
(>98%). The insufficient MICU bed capacity inhibits the timely admission of critical
patients, causing them to be held in the ED blocking treatment rooms. Figure 3-2
illustrates another impact of insufficient capacity allocation on the percentage of patients
leaving-without-being-seen (LWBS) due to emergency waiting room congestion and long
wait times. LWBS percentages are notably high, 66.7% and 33.4%, where MICU bed
capacity allocation is only 1 or 2, respectively. Both the ED capacity utilization and
LWBS percentage decline when three or more MICU beds are allocated and the ED
capacity increases.
Figure 3-3 through Figure 3-7 illustrate the effect of varied capacity allocations
for ED and MICU on the performance metrics. Collectively, these metrics suggest
improved operational performance may be obtained where ED room capacity is 34, or
greater, and MICU bed capacity is 4, or greater. These capacities result in a triage-to-
102
exam room waiting time of approximately 23 minutes, with a 2 hour threshold limit
exceeded less than 3% of the time.
ED Capacity Utilization
1
0.9
Utilization
0.8 micu=1
micu=2
0.7 micu=3
micu=4
0.6
micu=5
0.5
20 24 28 32 36 40
ED Capacity
Figure 3-1: Utilization with respect to MICU capacity
Leaving-Without-Being-Seen (LWBS)
Percentage
1
0.9
0.8
0.7
Percentage
0.6 micu=1
0.5 micu=2
0.4
micu=3
0.3
0.2 micu=4
0.1
micu=5
0
20 24 28 32 36 40
ED Capacity
Figure 3-2: LWBS with respect to MICU capacity
103
ED Triage-to-Room Wait Time ED Triage-to-Room Wait Time
Percentage Exceeding 2 Hour Threshold
9
8 1
7
0.8
6 micu=1
Percent age
Hours
5 micu=1
0.6
4 micu=2
micu=2
3 micu=3 0.4
micu=3
2 micu=4 0.2
1 micu=4
micu=5
0 0 micu=5
20 24 28 32 36 40 20 24 28 32 36 40
ED Capacity ED Capacity
Figure 3-3: Waiting time with respect to Figure 3-4: Waiting time exceeding
MICU capacity threshold limit
ED Discharged Patient Estimated ED Admitted Patient Estimated Length-

Length-of-Stay of-Stay
8 100
6 80
micu=1 micu=1
60
Hours
Hours
4 micu=2 micu=2
40
micu=3 micu=3
2
micu=4 20 micu=4
0 micu=5 0 micu=5
20 24 28 32 36 40 20 24 28 32 36 40
Figure 3-5: Discharged LOS with respect Figure 3-6: Admitted LOS with respect to
to MICU capacity MICU capacity
104
Figure 3-7 illustrates the relationship between ED and MICU capacity allocation
on ED admitted patient boarding time as measured by the fraction of time where a 12
hour threshold limit is exceeded. Ideally no delay in patient boarding time is preferred.
ED Admitted Patient Boarding Time

Exceeding a 12 Hour Threshold
1.0
0.8
Percent age
0.6 micu=1
micu=2
0.4
micu=3
0.2 micu=4
micu=5
0.0
20 24 28 32 36 40
ED Capacity
Figure 3-7: Admitted patient boarding time exceeding threshold limit
The remaining figures in this subsection specifically address the utilization of the
MICU capacity with respect to ED capacity range. In Figure 3-8 the MICU capacity
utilization is illustrated which suggests that at least 4 MICU beds be maintained in order
to keep utilization below 70%. Figure 3-10 describes the midnight bed census and Figure
3-11 the midday bed census levels. It is observed that that the midnight census is slightly
higher than the midday census; however, at a MICU capacity of 3 there is a distinct
increase in bed occupancy not seen elsewhere. Correspondingly, Figure 3-9 reveals a
similar, although subtle, anomaly at a MICU capacity of 3 suggesting that MICU
105
capacity at increased patient volume unduly restricts the transfer of medical patients
between wards, causing increased delay.
MICU Capacity Utilization Fraction of Attractive Medical Patient

Transfers Delayed More Than 12 Hours
1.0
ed=20 0.03
0.8 ed=22 ed=20
Utilization
ed=24 ed=22
0.6 0.02
Fraction
ed=26 ed=24
0.4 ed=26
ed=28
0.01
0.2 ed=30 ed=28
ed=32 ed=30
0.0 0
ed=34 ed=32
1 2 3 4 5 6 7 8 1 2 3 4 5 6 7 8
MICU Capacity ed=36 ed=34
MICU Capacity
Figure 3-8: MICU capacity utilization Figure 3-9: Transfer time exceeding
threshold limit
MICU Census at Midnight MICU Census at Midday

3 3
ed=20 ed=20
ed=22 ed=22
Beds Occupied
Beds Occupied
2 ed=24
2 ed=24
ed=26 ed=26
1 ed=28 1 ed=28
ed=30 ed=30
ed=32 ed=32
0 0
ed=34 ed=34
1 2 3 4 5 6 7 8 1 2 3 4 5 6 7 8
ed=36 MICU Capacity ed=36
MICU Capacity
Figure 3-10: MICU bed census at midnight Figure 3-11: MICU bed census at midday
106
3.3.1.2 Medical Progressive Care Unit Capacity
The allocation of capacity to the ED in the number of rooms and the medical
progressive care unit (MPCU) in the number of beds also has a significant impact on a
number of operational performance metrics. This section seeks to explore the
consequences due to systematically varying allocated capacity levels.
ED capacity utilization is influenced by the number room capacity allocated and
the number of medical beds capacity allocated. ED capacity is varied over a range of 20
to 40 rooms and MPCU capacity over a range of 10 to 40 beds. In Figure 3-12 it is
observed that when less than 25 beds are allocated, regardless of the ED room capacity
allocated, the utilization will remain exceedingly high (above 98% utilization). This is
largely attributed to the inadequate capacity needed to admit patients holding in the ED in
a timely manner, thus blocking emergency patient flow. Meaningful reduction in ED
utilization (below 80%) only occurs when allocated capacity is above 34 ED rooms and
the number of MPCU bed capacity above 30 beds.
Figure 3-13 also illustrates the case where inadequate capacity exists with less
than 25 MPCU beds regardless of the ED capacity allocated. In such cases, constrained
MPCU capacity contributes to a high percentage of patients leaving-without-being-seen
(LWBS) from the ED waiting room (78.7% (mpcu=10), 52.6% (15) and 26.9% (20),
respectively). Both utilization and LWBS percentage are observed to decline only when
30, or more, MPCU beds have been allocated capacity, and 34, or more, ED rooms are
maintained. Figure 3-14 through Figure 3-18 illustrate the effect of varying capacity
allocation for ED and MPCU on selected performance metrics. Collectively, these
107
metrics suggest that improved operational performance may be obtained where ED room
capacity is above 34, and MPCU bed capacity is above 30. At these levels the estimated
triage-to-exam room delay is 23 minutes and the 2 hour threshold is exceeded only 3%.
ED Capacity
Utilization
1.0
0.9 mpcu=10
Utilization
0.8 mpcu=15
mpcu=20
0.7
mpcu=25
0.6 mpcu=30
0.5 mpcu=35
20 24 28 32 36 40 mpcu=40
ED Capacity
Figure 3-12: Utilization with respect to MPCU capacity
Left-Without-Being-Seen (LWBS)
Percentage
1.0
0.8 mpcu=10
Percentage
0.6 mpcu=15
mpcu=20
0.4
mpcu=25
0.2 mpcu=30
mpcu=35
0.0
20 24 28 32 36 40 mpcu=40
ED Capacity
Figure 3-13: LWBS with respect to MPCU capacity
108
12 1.0
mpcu=10
10 0.8 mpcu=10
Percent age
mpcu=15
8 mpcu=15
mpcu=20
0.6
Hours
mpcu=20
6 0.4
mpcu=25
mpcu=25
4 mpcu=30 0.2 mpcu=30
2 mpcu=35
0.0 mpcu=35
0 mpcu=40
20 24 28 32 36 40 mpcu=40
20 24 28 32 36 40
ED Capacity
ED Capacity
MPCU capacity threshold limit
ED Discharged Patient Estimated ED Admitted Patient Estimated

Length-of-Stay Length-of-Stay
8 200
mpcu=10 mpcu=10
6 150
mpcu=15 mpcu=15
Hours
Hours
4 mpcu=20 100 mpcu=20

mpcu=25 mpcu=25
2 50
mpcu=30 mpcu=30
0 mpcu=35 0 mpcu=35
20 24 28 32 36 40 mpcu=40 20 24 28 32 36 40 mpcu=40
Figure 3-16: Discharged LOS with respect Figure 3-17: Admitted LOS with respect to
to MPCU capacity MPCU capacity
109
Figure 3-18 illustrates the relationship between ED and MPCU capacity allocation
on ED admitted patient boarding time as measured by the fraction of time where a 12
hour threshold limit is exceeded. Ideally, encountering no delay in patient boarding time
is preferred. A MPCU bed capacity of at least 25 is observed to provide better results.
The remaining figures in this subsection specifically address the utilization of the MPCU
capacity with respect to ED capacity range. In Figure 3-19 the MPCU capacity
utilization is illustrated which suggests that at least 30 MPCU beds be maintained in
order to keep utilization below 70%. In Figure 3-20, when MPCU bed capacity is less
than 25 beds, along with increased patient volume, the ability to transfer medical patients
between wards is increasingly restricted, resulting in increased delay for approximately
5% of transferring patients.

1.0
0.8
mpcu=10
Percent age
0.6 mpcu=15
mpcu=20
0.4 mpcu=25
0.2 mpcu=30
mpcu=35
0.0 mpcu=40
20 24 28 32 36 40
ED Capacity
Figure 3-18: Admitted bed placement delay exceeding threshold
110
The midnight census in Figure 3-21 is slightly higher than the midday bed census
in Figure 3-22 due to the mid-morning transfers and early evening patient arrivals.
MPCU Capacity Utilization Fraction of Attractive Medical Patient

Transfers Delayed More Than 12 Hours
1.0
ed=20
0.08
0.8 ed=22 ed=20
0.06
Utilization
ed=24 ed=22
0.6
Fraction
ed=26 ed=24
0.4 0.04
ed=28 ed=26
0.2 ed=30 0.02 ed=28
ed=32 ed=30
0.0 0.00
10 20 30 40 ed=34 10 20 30 40 ed=32
MPCU Capacity ed=36 MPCU Capacity ed=34
Figure 3-19: Capacity utilization with Figure 3-20: Admitted transfer times
respect to ED capacity exceeding threshold
MPCU Census at Midnight MPCU Census at Midday

25 ed=20 25 ed=20
20 ed=22 20 ed=22
Occupied Beds
Occupied Beds
ed=24 ed=24
15 15
ed=26 ed=26
10 10
ed=28 ed=28
5 ed=30 5 ed=30
0 ed=32 0 ed=32
10 20 30 40 ed=34 10 20 30 40 ed=34
MPCU Capacity ed=36 MPCU Capacity ed=36
Figure 3-21: Medical PCU midnight bed Figure 3-22: Medical PCU midday bed
census census
111
The figures presented in this section illustrate a representation of the relationship
between capacity allocation between the ED and the MPCU as quantified by several
operational performance metrics. In general, the operational performance is best where
above 34 ED rooms and above 30 MPCU beds are maintained.
3.3.1.3 Medical Acute Care Unit Capacity
The allocation of capacity to the ED in the number of rooms and the medical
acute care unit (MACU) in the number of beds also has a significant impact a number of
operational performance metrics. This section seeks to explore the consequences due to
systematically varying allocated capacity levels.
ED capacity utilization is influenced by the number room capacity allocated and
the number of medical beds capacity allocated. ED capacity is varied within a range of
20 to 40 rooms and MACU capacity is varied within a range of 100 to 200 beds. In
Figure 3-23 it is observed that when less than 170 beds are allocated that regardless of the
ED room capacity allocated the utilization will remain exceedingly high (above 95%
utilization). This is largely attributed to the inadequate capacity needed to timely admit
patients holding in the ED, thus blocking emergency patient flow. Meaningful reduction
in ED utilization (utilization below 85%) occurs when ED capacity is 34 rooms, or
higher, and the number of MACU capacity is at 170 beds, or more.
Figure 3-24 also illustrates the case where inadequate capacity exists with less
than 150 MACU beds regardless of the ED capacity allocated. In such cases, constrained
MACU capacity contributes to a high percentage of patients leaving-without-being-seen
(LWBS) from the ED waiting room (52.4% (macu=100), 43.8% (110), 35.5% (120),
112
26.9% (130) and 18.7% (140), respectively). Both utilization and LWBS percentage are
observed to decline only when 160, or more, MACU beds have been allocated capacity,
and 34, or more, ED rooms are maintained.
ED Capacity Utilization
1.0
macu=100
0.8
macu=110
Utilization
0.6 macu=120
0.4 macu=130
macu=140
0.2
macu=150
0.0 macu=160
20 24 28 32 36 40 macu=170
ED Capacity
Figure 3-23: Capacity utilization with respect to MACU capacity
Left-Without-Being-Seen (LWBS)
Percentage
1.0
macu=100
0.8
macu=110
Percentage
0.6 macu=120
0.4 macu=130
macu=140
0.2
macu=150
0.0
macu=160
20 24 28 32 36 40
macu=170
ED Capacity
Figure 3-24: LWBS with respect to MACU capacity
113
Figure 3-25 through Figure 3-29 illustrate the effects of varying ED and MACU
capacity allocations on select performance metrics. Collectively, these metrics suggest
that improved performance operations may be obtained where ED capacity is 34, or
greater, and MACU capacity is 170, or greater. At these capacity allocation levels the
estimated triage-to-exam room waiting time is 23 minutes, with a 2 hour threshold time
limit exceeded only 2.7% of the time.
Figure 3-29 illustrates the relationship between ED and MACU capacity
allocation on ED admitted patient boarding time as measured by the fraction of time
where a 12 hour threshold limit is exceeded. Ideally no delay in patient boarding time
would be preferred. It is observed that a MACU bed capacity of at least 160, or more,
will provide improved results.
114
8 macu=100 1.0
macu=100
6 macu=110 0.8 macu=110
Percentage
macu=120 0.6
Hours
macu=120
4 macu=130
0.4 macu=130
2 macu=140
0.2 macu=140
macu=150
macu=150
0 0.0
macu=160
20 24 28 32 36 40 20 24 28 32 36 40 macu=160
macu=170
ED Capacity ED Capacity macu=170
MACU capacity threshold limit
ED Discharged Patient Estimated ED Admitted Patient Estimated

Length-of-Stay Length-of-Stay
8 60
macu=100 macu=100
6 macu=110
48 macu=110
36
Hours
Hours
macu=120 macu=120
4
macu=130 24 macu=130
2 macu=140 12 macu=140
0 macu=150 macu=150
0
20 24 28 32 36 40 macu=160 20 24 28 32 36 40 macu=160
ED Capacity macu=170 ED Capacity macu=170
Figure 3-27: Discharged LOS with Figure 3-28: Admitted LOS with respect to
respect to MACU capacity MACU capacity
115
1.0
macu=100
0.8
macu=110
Percentage
0.6 macu=120
0.4 macu=130
macu=140
0.2
macu=150
0.0 macu=160
20 24 28 32 36 40 macu=170
ED Capacity
Figure 3-29: Admitted patient bed placement delay exceeding threshold
The remaining figures in this subsection specifically address MACU capacity
utilization with respect to ED capacity range. In Figure 3-30 the MACU capacity
utilization is illustrated which suggests that at least 180 MACU beds be maintained in
order to keep utilization near 80%. In Figure 3-31 it is observed that maintaining a
MACU bed capacity with fewer than 170 beds, in combination with the maximum ED
capacity allocated, will result in nearly 20% of patients being transferred across all wards
to incur a delay greater than 12 hours. The observed midnight census illustrated in Figure
3-32 is slightly less than the midday bed census illustrated in Figure 3-33, a reversal of
previously observed conditions with the MICU and MPCU. The higher midday census is
not, however, unexpected given the majority of patients leaving the MACU are usually
discharged home by midafternoon once all needed discharge activities have been
116
fulfilled. A small fraction of patients may be transferred from MACU to the MICU or
MPCU wards due to deterioration in medical status.
MACU Capacity Utilization Fraction of Attractive Patient Transfers

Delayed More Than 12 Hours
1.0 ed=20
0.25 ed=20
0.8 ed=22
0.20 ed=22
Utilization
0.6 ed=24 ed=24
Fraction
0.15 ed=26
ed=26
0.4 0.10 ed=28
ed=28
ed=30
0.2 0.05
ed=30 ed=32
0.0 ed=32 0.00 ed=34
100
120
140
160
180
200
100
120
140
160
180
200
ed=36
ed=34
ed=38
MACU Capacity ed=36 MACU Capacity ed=40
Figure 3-30: Capacity utilization with Figure 3-31: Patient transfer times
respect to ED capacity exceeding threshold limit
MACU Census at Midnight MACU Census at Midday

180 ed=20 180 ed=20
160 ed=22 160 ed=22
Occupied Beds
Occupied Beds
140 ed=24 140 ed=24

120 ed=26 120 ed=26
100 ed=28 100 ed=28
80 ed=30 80 ed=30
60 ed=32 60 ed=32
100
120
140
160
180
200
100
120
140
160
180
200
ed=34 ed=34
MACU Capacity ed=36 MACU Capacity ed=36
Figure 3-32: Medical ACU midnight bed Figure 3-33: Medical ACU midday bed
census census
117
The figures presented in this section illustrate a representation of the relationship
between capacity allocation between the ED and the MACU as quantified by several
performance metrics. In general, the operational performance improves where ED room
capacity exceeds 34 and MACU bed capacity exceeds 170. Additional sensitivity analysis
regarding the emergency department patient arrival rate is performed in the next
subsection.
3.3.1.4 Capacity Recommendations
Based on results from the fundamental analysis, we present in Table 3-6 a
consolidated set of unit capacity recommendations deduced through visual inspection.
Performance metric results for this set are tabulated in Table 3-7 for the emergency
department and Table 3-8 for the medical inpatient wards.
Table 3-6: Capacity recommendations and utilization results against targets
Capacity Capacity Capacity Target

Type Recommended Utilization Utilization
ED 35 81.6 % 80.0 %
MICU 5 57.4 % 70.0 %
MPCU 30 78.4 % 85.0 %
MACU 170 93.2 % 90.0 %
118
In Table 3-7, we observe that nearly all the performance metrics conform to their
threshold limits. However, in Table 3-8 the utilization rates for the MICU and MPCU,
57.4% and 78.4%, are well below their utilization targets of 70% and 85%, respectively.
This provides a sizable hedge against demand fluctuations impacting performance
metrics. In addition, the utilization rate for the MACU at 93.2% is higher than the
desired utilization target of 90%. This provides less of a buffer to guard against demand
fluctuations.
Table 3-7: ED performance metric results and targets
Performance Metric Metric Result Metric Target
ED utilization (%) 81.6 % 80.0 %
ED LWBS (%) 0.6 % < 2.0 %
ED triage-to-room wait time (hours) 0.33 hours minimize
ED triage-to-room wait time exceeding a 2.1 % < 5.0 %

2 hour threshold limit (%)
ED discharged length-of-stay (hours) 4.43 hours minimize
ED admitted length-of-stay (hours) 5.46 hours minimize
119
Table 3-8: Medical ward performance metric results and targets
MICU Utilization (%) 57.4 % 70.0 %
MPCU Utilization (%) 78.4 % 85.0 %
MACU Utilization (%) 93.2 % 90.0 %
MICU boarding time exceeding a 12 hour 0.0 % < 5.0 %

threshold time limit (%)
MPCU boarding time exceeding a 12 hour 0.0 % < 5.0 %
MACU boarding time exceeding a 12 0.0 % < 5.0 %
hour threshold time limit (%)
Fraction of attractive medical inpatient 1.3 % < 3.0 %
transfers delayed more than 12 hours
Although the threshold limits were not violated, instances are observed where the
realized capacity utilizations did not meet their intended targets. In the next section on
sensitivity to adjustment in patient demand, we will enhance this consolidated set to
better align with the capacity utilization targets. The enhanced consolidated set will then
be used as a standard to examine adjustments in emergency department patient demand.
3.3.2 Sensitivity to Adjustments in Patient Demand
We perform a sensitivity analysis in this section to examine what effect
adjustments in emergency department patient demand will have on select, representative
performance measures in the whole hospital model. First, we establish an enhanced
consolidated set of capacity recommendations that will be used as a standard throughout
120
this study. Second, we introduce the reference used to describe the adjustments in patient
demand and the corresponding patients per day values used as input in the whole hospital
model. Third, we present and discuss the output from the whole hospital model for the
performance measures specific to the emergency department and the medical inpatient
wards.
3.3.2.1 An Enhanced Set of Capacity Recommendations
An enhanced set of capacity recommendations are obtained by using the results
from the fundamental analysis as a guide to reduce the range search space and increase
the number of simulation experiments. A simple heuristic is used to eliminate
nonconforming results and identify the best candidate sets that minimize allocated unit
capacity. The selected set of capacity recommendations, which are summarized in Table
3-9 below, will be used as the standard set of capacity recommendations throughout this
study for experimentation purposes.
In comparison to the capacity recommendations from the fundamental analysis,
the standard set increases ED capacity by 1 treatment room, decreases MICU capacity by
1 bed, decreases MPCU capacity by 2 beds, and increases MACU capacity by 10 beds.
Table 3-10 and Table 3-11 present the performance metric results from the
simulation experiments and the accompanying targets for the emergency department and
medical inpatient wards, respectively. We observe that not only are the utilization results
well aligned with their targets, but also performance metrics are consistent with threshold
limits. These results indicate this standard set is a well-balanced combination of capacity
recommendations upon which to perform the sensitivity analysis.
121
Table 3-9: Capacity recommendations and utilization results against targets

ED 36 80.0 % 80.0 %
MICU 4 71.9 % 70.0 %
MPCU 28 84.0 % 85.0 %
MACU 180 88.2 % 90.0 %
Table 3-10: Standard set ED performance metric results and targets
ED utilization (%) 80.0 % 80.0 %
ED LWBS (%) 0.5 % < 2.0 %
ED triage-to-room time (hours) 0.33 hours minimize
ED triage-to-room time exceeding a 2 1.4 % < 5.0 %

hour threshold time limit (%)
ED discharged length-of-stay (hours) 4.42 hours minimize
ED admitted length-of-stay (hours) 5.44 hours minimize
122
Table 3-11: Standard set medical inpatient wards performance metric results and targets
MICU utilization (%) 71.9 % 75.0 %
MPCU utilization (%) 84.0 % 85.0 %
MACU utilization (%) 88.2 % 90.0 %
MICU boarding time exceeding a 12 hour 0.0 % < 5.0 %

MPCU boarding time exceeding a 12 hour 0.0 % < 5.0 %
MACU boarding time exceeding a 12 hour 0.0 % < 5.0 %
Fraction of attractive medical inpatient 0.9 % < 3.0 %
3.3.2.2 Change in the Emergency Department Patient Demand
The whole hospital simulation model incorporates some stochastic variation in the
arrival of emergency department patients according to time series indices that are day-of-
week and hour-of-day dependent. These indices are used in conjunction with the
reference value for the mean emergency department arrival rate, which is specified in
terms of patients per day (ppd), to generate arriving patients in the simulation model.
Throughout the fundamental analysis an assumption was made that this reference value
was held constant at the familiar 168.125 patients per day, which we now claim as the
unchanged baseline. In this study, we propose to vary the patient demand in the form of
the mean ED arrival rate as described in Table 3-12 and reference these values in terms of
the percentage change in the mean ED arrival rate for relevancy.
123
Table 3-12: Mean ED arrival rates and the corresponding percentage change
% Change mean ED -30% -20% -10% 0% 10% 20% 30%

arrival rate
Mean ED arrival rate 117.69 134.50 151.31 168.13 184.94 201.75 218.56
(ppd)
3.3.2.3 Sensitivity Analysis Results for Emergency Department Patient Demand
A similar one-factor-at-time approach is used to conduct the sensitivity analysis
examining the effects of change in the emergency department arriving patient demand.
Using the standard set of capacity recommendations provided in Table 3-9 and the
percentage change in the mean ED arrival rate references provided in Table 3-12 as
inputs, we execute a series of simulation experiments one-at-a-time in order to reveal the
sensitivity in the performance outcomes in response to these changes. We discuss several
related figures illustrating these sensitivity analysis results throughout the remainder of
this section.
We illustrate in Figure 3-34 the ED utilization and leaving-without-being-seen
(LWBS) rates with respect to the percentage change in the mean ED arrival rate from the
baseline. As expected, with a lowered mean ED arrival rate the utilization rate and
LWBS rate decline; for example, with a decrease of 30% change in the mean ED arrival
rate results in an ED utilization rate of 53% (a 27% decrease), and a LWBS rate near zero
percent (a 0.6% decrease). Above the mean ED arrival rate baseline reference (0%), the
patient LWBS rate dramatically increases as ED treatment room capacity approaches
maximum utilization. The LWBS threshold target (<2%) is violated above an 8%
124
increase in the mean ED arrival rate; and rises to a 15% LWBS rate with a 30% increase.
We also observe that above a 25% change in the mean ED arrival rate the ED utilization
is around 96%, effectively reaching the practical limit of the capacity. In the figures that
follow we will see how these behaviors ties together with other performance measures.
1.0
0.9
0.8
0.7 ED Utilization Rate
Percentage
0.6
0.5 ED Utilization Target
(80%)
0.4
LWBS Rate
0.3
0.2
LWBS Rate Target
0.1
(<2%)
0.0
-30% -20% -10% 0% 10% 20% 30%
% Change in Mean ED Arrival Rate
Figure 3-34: Utilization and LWBS rates with respect to the mean ED arrival rate
In Figure 3-35 the ED triage-to-room average wait time and the wait time
threshold exceeding 2 hours are illustrated with respect to the percentage change in the
mean ED arrival rate from the baseline. Below the baseline, the average wait time
remains very low and the 2 hour threshold target is maintained. However, above the
baseline the average wait time quickly increases and 2 hour threshold target is quickly
exceeded once the percent change in base mean ED arrival rate increases above 5%. This
125
indicates the ED triage-to-room performance measures are sensitive to increases in the
patient arrival rate and additional inpatient ward capacity is needed.
2.0 1.0
0.9
0.8
1.5 Average Wait Time
0.7
(h)
Percentage
0.6
Hours
1.0 0.5
2 Hr Threshold
0.4 Exceeded (%)
0.3
0.5
0.2 2 Hr Threshold
0.1 Exceeded Target
(<5%)
0.0 0.0
-30% -20% -10% 0% 10% 20% 30%
Figure 3-35: Wait time and threshold exceeded with respect to the mean ED arrival rate
In Figure 3-36 the ED discharged patient length-of-stay (LOS) and admitted
patient length-of-stay (LOS) are illustrated. As sustained emergency department patient
demand increases both discharged and admitted patient length-of-stays are observed to
increase; however, at greater patient demand levels the increase is disproportionately
observed for admitted patients. As sustained patient demand increases, the medical
inpatient wards experience higher capacity utilization and more patient congestion, which
eventually results in increased delays for patients seeking admission. Delay in admission
creates congestion in the ED with patients occupying treatment room areas and attending
medical staff. This diminishes overall patient throughput for the ED and, as a
126
consequence, introduces delay even for patients that are discharged home. Figures for
the medical inpatient wards provide additional insights that corroborate this behavior.
9
8
7
6
5
Hours
4 ED Discharged LOS
3 ED Admitted LOS
2
1
0
-30% -20% -10% 0% 10% 20% 30%
Figure 3-36: Discharged and admitted LOS with respect to the mean ED arrival rate
We observe in Figure 3-37 the further effects that high capacity utilization and
congestion in the medical inpatient wards have in limiting the timely transfer of patients
within the wards. Above an increase of 13% in patient demand the target delay (<3%)
for attractive medical patient transfers is violated. As sustained patient demand increases,
the ability to complete attractive medical patient transfers between ward encounters
greater time delay and results in increased occurrences of bed blockages. Ultimately, this
will result in patient bed misplacements, poorly aligned skilled nursing units, bad patient
experiences, staff dissatisfaction and increased ED congestion.
127
0.20
0.15
Percentage
Attractive Transfers
0.10 Delayed >12 Hrs
0.05 Delayed >12 Hrs
Target (<3%)
0.00
-30% -20% -10% 0% 10% 20% 30%
% Change in Mean ED Arrival Rate (ppd)
Figure 3-37: Patient transfers exceeding threshold with respect to mean ED arrival rate
Figure 3-38 through Figure 3-40 illustrate the observed behavior in the medical
inpatient wards regarding patient census at midday and midnight, and the various medical
ward utilization rates. Although the individual wards have different bed capacities,
transfer destinations, and average length-of-stays, the operating behavior across the
various wards is observed to be relatively similar. Specifically, as the mean ED arrival
rate increases the patient censuses and ward utilization rates increase accordingly. An
increase above a 15% change in the mean ED arrival rate generally results the maximum
ward utilization rates. Patient censuses have similar patterns, except for the medical PCU
ward which receives transfer patients and buffers patient overflow.
Figure 3-38 illustrates the observed behavior for the medical ICU (MICU) ward,
which consists of only 4 beds. This relatively small number of medical ICU beds
restricts the ability to absorb sizable changes in patient demand and limits the maximum
128
attainable utilization rate to around 83%. We observe that above a 15% change in the
mean ED arrival rate less than a 3% increase in incremental utilization can be realized.
When compared to the other medical wards, the average length-of-stay in the ICU is
relatively short at only 1.2 days which drives an extremely high frequency in bed turn-
overs and required cleanings. Since the majority of patients leaving the medical ICU are
transferred to progressive care unit or acute care unit wards in the morning hours, the
midday patient census is generally lower than the midnight patient census. Aside from
the arrival of newly admitted patients, few patient transfers occur during the evening and
overnight hours.
4 1.0
0.9
0.8
3
0.7 MICU Midnight Patient
Census
Percentage
MICU Beds
0.6
2 0.5 MICU Midday Patient
Census
0.4
MICU Utilization Rate (%)
0.3
1
0.2
MICU Utilization Rate
0.1
Target (70%)
0 0.0
-30% -20% -10% 0% 10% 20% 30%
Figure 3-38: MICU utilization and patient census with respect to mean ED arrival rate
Figure 3-39 illustrates the observed behavior for the medical PCU (MPCU) ward,
which consists of 28 beds. This larger number of medical PCU beds does not restrict the
129
ability to absorb sizable changes in patient demand as severely as was observed with the
MICU ward. The maximum attainable utilization rate appears to plateau at 94.8%.
However, we do observe that above a 25% change in the mean ED arrival rate less than a
1% increase in incremental utilization can be realized. The average length-of-stay in the
MPCU is relatively short at only 1.5 days which results in frequent bed turn-overs and
required cleanings. Since the majority of the patients leaving the medical PCU are
transferred to acute care unit or intensive care unit wards, the midday census is generally
lower than the midnight patient census, even after accepting new patients in transfer.
Figure 3-40 illustrates the observed behavior for medical ACU (MACU) ward,
which consists of 180 beds. We observe that this large pool of beds does not restrict the
ability to absorb additional demand well until nearly all available capacity has been
exhausted. For example, the utilization rate is 96.9% with an increase of 30% change in
the mean ED arrival rate, leaving little opportunity absorb additional demand. Contrary to
this, when examining the patient censuses occupancy does not exceed 166 beds, which
coincides with a 15% increased change in the mean ED arrival rate. This suggests that on
average 5.2% of the beds are unavailable due to the patient bed turn-over cycle.
Furthermore, we observe the midday patient census to be slightly higher than the
midnight patient census given that a majority of the patients leaving the ward are
discharged home after midday.
130
28 1.0
0.9
24
0.8
20 0.7 MPCU Midnight Patient
Census
MPCU Beds
Percentage
16 0.6
0.5 MPCU Midday Patient
12 Census
0.4
MPCU Utilization Rate
8 0.3
(%)
0.2
4 MPCU Utilization Rate
0.1
Target (85%)
0 0.0
-30% -20% -10% 0% 10% 20% 30%
Figure 3-39: MPCU utilization and patient census with respect to mean ED arrival rate
180 1.0
160 0.9
140 0.8
0.7 MACU Midnight Patient
120
Census
MACU Beds
Percentage
0.6
100
0.5 MACU Midday Patient
80 Census
0.4
60 MACU Utilization Rate
0.3
(%)
40 0.2
20 MACU Utilization Rate
0.1
Target (90%)
0 0.0
-30% -20% -10% 0% 10% 20% 30%
Figure 3-40: MACU utilization and patient census with respect to mean ED arrival rate
131
3.3.3 Observations and Conclusions
Throughout the analyses performed for the emergency department and medical
inpatient wards the whole hospital model has demonstrated consistent and reliable results.
This has been the case not only when the allocation of unit capacity was varied but also
when the emergency department patient demand. This provides further encouragement
that the model is both consistent in model formulation and robust enough to
accommodate situations of extreme workload or conditions of being under resourced.
The fundamental analysis for the emergency department and medical inpatient
wards allowed us to clearly demonstrate the relationships in allocated unit capacity
between two of the factors. In general, we were able to compare relationships between
the emergency department treatment room capacity and a specific medical inpatient ward
bed capacity. While the one-factor-at-a-time approach did allow us to produce insightful
illustrations and observations, the method as applied here was insufficient at revealing the
broader but lesser known interactions that may have been of interest. Visual inspection
generated a reasonable consolidated set of capacity recommendations.
The sensitivity analysis for the emergency department and medical inpatient
wards provided additional insight into the effects of emergency department patient
demand on performance measures. The analysis demonstrates that different performance
measures will deteriorate and violate threshold limits at different levels of patient
demand.
The earliest indication of deteriorating performance in the ED occurs with only a
5% increase in patient demand. This results in an average triage-to-room time delay of
132
0.46 hours, where the time delay exceeds the 2 hour threshold limit 5.36% of the time.
With a 10% increase, we observed the LWBS threshold increase to 2.51%, which is
slightly above the 2% threshold limit; and, the triage-to-room time delay exceeds the 2
hour threshold limit 9.95% of the time. Eventually with a 15% increase, we observe the
attractive medical inpatient transfers delayed more than 12 hours increase to 4.4% which
is above the 3% threshold limit. At these performance levels, the medical inpatient wards
have reached their maximum capacity to accept any further increased demand.
All adjustments to patient demand above the baseline demonstrate deterioration in
performance measures. For the administrator, it is a matter of determining which of these
concerns ranks higher, and a willingness to accept underperformance in these areas.
3.4 The Surgical Unit and Surgical Inpatient Wards
The analyses performed in this section for the surgical unit and the surgical
inpatient wards are presented in two parts. First, a fundamental analysis is performed to
evaluate the combined effect that surgical unit operating room capacity and surgical
inpatient ward bed capacities have on select performance measures. Second, a sensitivity
analysis is performed to evaluate the effect of adjusted scheduled elective surgery patient
demand in a well-balanced system has on select performance measures. Both these
analyses employ a one-factor-at-a-time approach using visual inspection to evaluate
results.
133
3.4.1 A Fundamental Analysis
We conduct a fundamental analysis where unit capacity is allocated to the surgical
unit in the number of operating rooms and the surgical inpatient wards in the number of
surgical intensive care unit (SICU), progressive care unit (SPCU), and acute care unit
(ACU) beds. The purpose of the fundamental analysis is to examine what effect these
unit capacity changes may have on select, representative performance measures in the
whole hospital model. We expect some performance measures will be more responsive
than others to unit capacity changes.
We present a framework in Table 3-13 that defines the unit capacity ranges and
increment sizes for each unit category input factor included in the fundamental analysis.
Using a one-factor-at-a-time approach, these input factors will be varied across the
specified range at intervals determined by the increment size. The illustrations presented
and discussed throughout the remainder of this section will frequently characterize the
relationship between two varying capacities.
Table 3-13: Unit capacity allocation by surgical unit and wards
Unit Category Range Minimum Range Maximum Increment Size
Operating rooms 1 8 1
Surgical ICU beds 1 8 1
Surgical PCU beds 12 36 2
Surgical ACU beds 100 180 10
134
Throughout this study, the scheduled elective surgery patient arrival rates, 30.0
patients per day for inpatients and 20 patients per day for outpatients, as well as the
emergency surgery patients, approximately less than 4 patients per day, remain constant
subject to hour-of-day and day-of-week time variations. As with most elective surgical
schedules, the surgery workload is forward loaded in the week and skewed toward the
earlier hours of the day. To reduce the unwanted ill-effects of select capacity restrictive
processes unrelated to the study focus certain areas in the model were over-provisioned.
The results obtained from the whole hospital model represent 52 weeks of simulated time
which followed an extensive conditioning period. Due to the unit capacity relationships,
we organize the presentation and discussion of these results by the surgical inpatient ward
categories. Using these results, we present a consolidated set of unit capacity
recommendations deduced through visual inspection, and review the corresponding
performance measurement results.
3.4.1.1 Surgical Intensive Care Unit Capacity
The allocation of capacity to the surgical unit in the number of OR theatres and
the surgical intensive care unit in the number of beds has a significant impact on a
number of operational performance metrics. This section seeks to explore the
consequences encountered when capacity allocations are varied.
Surgical unit operating room capacity utilization can be influenced by the
availability of surgical intensive care unit (SICU) bed capacity. In this study, the OR
capacity ranges from 1 to 8 theatres and the SICU capacity from 1 to 8 inpatient beds for
post-surgical care. In Figure 3-41 it is observed that when 5 or less SICU beds are
135
maintained that a high level of OR capacity utilization will result, from high congestion
within the surgical unit due to patient flow blockage into the surgical wards affecting
both inpatient and outpatient surgeries. Although capacity utilization may be shown as
high, the actual productivity in the number of completed patients is low. With 6 or more
SICU rooms allocated the OR capacity utilization curves begin to normalize with usage
below 70%. Figure 3-43 illustrates the case where outpatient elective surgery patients are
rescheduled at a high rate when less than 6 SICU rooms are maintained and less than 6
OR theatres are maintained; specifically 99.7% (sicu=1), 98.9% (2), 83.1% (3), 69.6% (4)
and 32.7% (5). Figure 3-42 illustrates where inpatient elective surgery patients are
cancelled due to the lack of inpatient surgical ward capacity. Although bed capacity
utilization is high, the cancellation rate depicted is low due to patient rescheduling.
Figure 3-44 illustrates the occurrence of high rates of inpatient elective surgery patient
rescheduling when OR capacity maintained is less than 5; for example, the reschedule
rate is 98.7% (sicu=1), 95.9% (2), 70.7% (3), and 45.1% (4), respectively.
136
OR Capacity Utilization Inpatient Surgery Cancellation
1.0 0.08
sicu = 1 sicu = 1
0.8
sicu = 2 0.06 sicu = 2
Percentage
Utilization
0.6 sicu = 3 sicu = 3

0.04
0.4 sicu = 4 sicu = 4
sicu = 5 0.02 sicu = 5
0.2
sicu = 6 sicu = 6
0.0 sicu = 7
0 sicu = 7
1 2 3 4 5 6 7 8 1 2 3 4 5 6 7 8
sicu = 8 sicu = 8
OR Capacity OR Capacity
Figure 3-41: Utilization with respect to Figure 3-42: Inpatient elective surgery
SICU capacity cancellation
Outpatient Surgery Rescheduled Inpatient Surgery Rescheduled

1.0 1.0
sicu = 1 sicu = 1
0.8 0.8
sicu = 2 sicu = 2
Percentage
Percentage
0.6 sicu = 3 0.6 sicu = 3
0.4 sicu = 4 0.4 sicu = 4

sicu = 5 sicu = 5
0.2 0.2
sicu = 6 sicu = 6
0.0 0.0
sicu = 7 sicu = 7
1 2 3 4 5 6 7 8 1 2 3 4 5 6 7 8
sicu = 8 sicu = 8
Figure 3-43: Outpatient elective surgery Figure 3-44: Inpatient elective surgery
rescheduled rescheduled
137
Figure 3-45 through Figure 3-48 illustrate the consequences on a set of
performance metrics as the capacity allocated to OR theatres and SICU beds are varied.
These measures include: (1) the elective surgery patient intake waiting time duration
occuring before the preoperative process; (2) the outpatient surgery estimated length-of-
stay time duration, and (3) the inpatient surgery estimated length-of-stay time duration,
which capture the duration from arrival to departure from the surgical unit; and (4) the
inpatient surgery bed placement delay as a percentage exceeding a threshold.
Collectively, these metrics suggest that the best operational performance may be achieved
at an OR capacity of at least 6 OR theatres and 7 SICU beds. At these levels, the average
intake waiting time would be 12.6 minutes, the outpatient length-of-stay would be 4.0
hours, and the inpatient length-of-stay would be 6.1 hours. Coinciding with this
increased inpatient length-of-stay, approximately 26.4% of inpatient surgery patients
would encounter a delay greater than 2 hours in bed placement.
138
Surgery Intake Waiting Time Inpatient Delayed Bed Placement
5
sicu = 1 1
4 sicu = 1
sicu = 2 0.8
sicu = 2
Percentage
3
Hours
sicu = 3 0.6 sicu = 3

2 sicu = 4
0.4 sicu = 4
sicu = 5
1 0.2 sicu = 5
sicu = 6
sicu = 6
0 sicu = 7
0
1 2 3 4 5 6 7 8 1 2 3 4 5 6 7 8 sicu = 7
sicu = 8
OR Capacity OR Capacity sicu = 8
Figure 3-45: Surgery intake waiting time Figure 3-46: Patient bed placement
delay exceeding threshold limit
Outpatient Surgery Length-of-Stay Inpatient Surgery Length-of-Stay

1000 1000
sicu = 1 sicu = 1
sicu = 2 sicu = 2
100 100
Log Hours
Log Hours
sicu = 3 sicu = 3
sicu = 4 sicu = 4
10 10
sicu = 5 sicu = 5
sicu = 6 sicu = 6
1 sicu = 7 1 sicu = 7
1 2 3 4 5 6 7 8 1 2 3 4 5 6 7 8
sicu = 8 sicu = 8
Figure 3-47: Outpatient surgery LOS time Figure 3-48: Inpatient surgery LOS time
duration duration
139
Inpatient Delayed Bed Placement
Exceeding an 8 Hour Threshold
1
0.8 sicu = 1
sicu = 2
Percentage
0.6
sicu = 3
0.4 sicu = 4
sicu = 5
0.2 sicu = 6
sicu = 7
0
1 2 3 4 5 6 7 8 sicu = 8
OR Capacity
Figure 3-49: Inpatient bed placement delay exceeding threshold limit
In the portion of the section that remains, the utilization of the SICU capacity with
respect to OR capacity is presented in the figures that follow. In Figure 3-50 the SICU
capacity utilization is illustrated which suggests that at least 6 SICU beds be maintained
in order to keep utilization below 90%. Figure 3-51 illustrates the fraction of surgical
patients experiencing more than a 12 hour transfer time to a non-critical care unit, or
discharge. This fraction begins to stabilize when at least 6 SICU are maintained for all
OR capacity allocation levels. Figure 3-52 describes the midnight bed census and Figure
3-53 describes the midday census levels. The midnight census is observed to be higher
than the midday census, which is largely expected since patient transfers from critical
care areas to a step down unit will often occur before midday.
140
SICU Capacity Utilization Fraction of Surgical Transfer Times
1
or = 1 0.06
0.8 or = 1
or = 2 0.05
Utilization
or = 2
0.6 0.04
Fraction
or = 3
or = 3
0.4 or = 4 0.03
or = 4
or = 5
0.02
0.2 0.01 or = 5
or = 6
0 0 or = 6
or = 7
1 2 3 4 5 6 7 8 1 2 3 4 5 6 7 8 or = 7
or = 8
SICU Capacity SICU Capacity or = 8
Figure 3-50: Utilization with respect to Figure 3-51: Patient transfer times
operating room capacity exceeding threshold limit
SICU Midnight Census SICU Midday Census

7 7
or = 1 or = 1
6 6
Beds Occupied
Beds Occupied
5 or = 2 5 or = 2
4 or = 3 4 or = 3
3 or = 4 3 or = 4
2 or = 5
2 or = 5
1 1
or = 6 or = 6
0 0
or = 7 or = 7
1 2 3 4 5 6 7 8 1 2 3 4 5 6 7 8
SICU Capacity or = 8 SICU Capacity or = 8
Figure 3-52: Midnight bed census with Figure 3-53: Midday bed census with
respect to operating room capacity respect to operating room capacity
These figures illustrate the relationships between OR capacity and SICU capacity
using several operational performance metrics. Further sensitivity analysis could be
141
performed specific to the exogenous input variables, such as the surgical unit arrival rate
for inpatients and outpatients, and the ED arrival rate.
3.4.1.2 Surgical Progressive Care Unit Capacity
Capacity allocation for OR theatres and surgical progressive care unit (SPCU)
beds both have significant impacts on the operational performance metrics. In this
section the interactive behavior of these two factors are explored by systematically
varying the allocated capacity levels, while holding emergency, outpatient, and inpatient
arrival rates constant.
OR capacity utilization is influenced by the number of OR theatres and the
number of surgical inpatient ward beds maintained. In this example, OR capacity is
varied on a range of 1 to 8 theatres, and SPCU capacity on a range of 14 to 32. The other
surgical wards are amply supplied to avoid restriction. Figure 3-54 illustrates the
situation when at least 26 SPCU beds are allocated, regardless of the OR capacity, the
OR capacity utilization is between 70 to 90%, which is above the desired range. With
limited SPCU bed capacity operations of the surgical unit are negatively impacted with
patient blockages, delayed patient bed placements, high rescheduled rates, and high
cancellations rates. Meaningful reductions are realized when allocated SPCU capacity is
at least 28 beds.
Figure 3-55 illustrates the situation where inpatient elective surgeries are
cancelled at high rates due to inadequate SPCU bed capacity allocation, especially when
increased patient volumes reach the surgical unit. Additionally, Figure 3-56 illustrates
where outpatient elective surgery patients are rescheduled at high percentage rates due to
142
surgical unit congestion caused by inadequate SPCU bed capacity. Similarly, Figure
3-57 illustrates the situation where inpatient elective surgery patients are rescheduled at
high percentages rates due to surgical unit congestion and blockage caused by inadequate
SPCU bed capacity. Cancelling and rescheduling elective surgeries adversely affects
hospital revenue and surgeon satisfaction.
Figure 3-58 through Figure 3-62 illustrate the changes in a set of performance
metrics as the capacity allocated to OR theatres and SPCU beds are varied. These
measures include: (1) the elective surgery patient intake waiting time duration occuring
before the preoperative process; (2) the outpatient surgery estimated length-of-stay
duration, and (3) the inpatient surgery estimated length-of-stay duration, which capture
the duration from arrival to departure from the surgical unit; and (4) the inpatient surgery
bed placement delay as a percentage exceeding a threshold. Collectively, these metrics
suggest that the best operational performance may be achieved at an OR capacity of at
least 5 theatres and SPCU capacity of at least 30 beds. At these levels, the average intake
waiting time would be 12.6 minutes, the outpatient length-of-stay would be 4.74 hours,
and the inpatient length-of-stay would be 11.75 hours. The high percentage (59.2%) of
inpatient surgery bed placement encountering a delay greater than 2 hours contributes to
this increased inpatient length-of-stay. Additional improvement many be seen beyond
the upper SPCU capacity range presented here.
143
1 spcu = 14 0.1
spcu = 14
0.8 spcu = 16 0.08
spcu = 16
Percentage
Utilization
spcu = 18
0.6 0.06 spcu = 18
spcu = 20 spcu = 20
0.4 0.04
spcu = 22 spcu = 22
0.2 spcu = 24 0.02 spcu = 24
0 spcu = 26 0 spcu = 26
1 2 3 4 5 6 7 8 spcu = 28 1 2 3 4 5 6 7 8 spcu = 28
OR Capacity spcu = 30 OR Capacity spcu = 30
SPCU capacity patient cancellation

1 1
spcu = 14 spcu = 14
0.8 0.8
spcu = 16 spcu = 16
Percentage
Percentage
0.6 spcu = 18 0.6 spcu = 18

spcu = 20 spcu = 20
0.4 0.4
spcu = 22 spcu = 22
0.2 0.2 spcu = 24
spcu = 24
0 spcu = 26 0 spcu = 26
1 2 3 4 5 6 7 8 spcu = 28 1 2 3 4 5 6 7 8 spcu = 28
patients rescheduled patients rescheduled
144
5
spcu = 14 1 spcu = 14
4
spcu = 16 0.8 spcu = 16
Percentage
3 spcu = 18 spcu = 18
Hours
0.6
spcu = 20 spcu = 20
2 0.4
spcu = 22 spcu = 22
1 spcu = 24 0.2 spcu = 24
spcu = 26 spcu = 26
0 0
1 2 3 4 5 6 7 8 spcu = 28 1 2 3 4 5 6 7 8 spcu = 28
OR Capacity OR Capacity spcu = 30
Figure 3-58: Elective surgery patient intake Figure 3-59: Inpatient bed placement delay
waiting time delay exceeding threshold limit

100 1000
spcu = 14 spcu = 14
spcu = 16 spcu = 16
100
Log Hours
Log Hours
spcu = 18 spcu = 18
10 spcu = 20 spcu = 20
spcu = 22 10 spcu = 22
spcu = 24 spcu = 24
spcu = 26 spcu = 26
1 1
1 2 3 4 5 6 7 8 spcu = 28 1 2 3 4 5 6 7 8 spcu = 28
duration duration
145
Inpatient Delayed Bed Placement Delay
1
0.9
spcu = 14
0.8
spcu = 16
0.7
Percentage
0.6 spcu = 18
0.5 spcu = 20
0.4 spcu = 22
0.3
spcu = 24
0.2
0.1 spcu = 26
0 spcu = 28
1 2 3 4 5 6 7 8 spcu = 30
OR Capacity
In the remaining portion of this subsection the utilization of SPCU capacity with
respect to OR capacity is presented in the figures that follow. Figure 3-63 illustrates the
SPCU capacity utilization suggesting that at least 32 SPCU beds be maintained when 3 or
more OR theatres are maintained to keep SPCU utilization below 90%. Figure 3-64
illustrates the fraction of surgical patients that experience more than a 12 hour transfer
across the surgical inpatient care units. This is observed to be unchanged when at least
28 SPCU beds are maintained across all OR capacity allocation levels. Figure 3-65
describes the midnight bed census and Figure 3-66 describes the midday census levels.
The midnight census is observed to be higher than the midday census, which is largely
expected since patient transfers from high levels of care to standard care will often occur
before midday.
146
The figures presented illustrate a representation of the relationship between
capacity allocation between the OR and the SPCU as described by several operational
performance metrics. In general, operational performance is better where at least 5 OR
theatres and at least 32 SPCU beds are maintained. Further investigation could be
performed to examine the sensitivity such finds have with regard to variances in the
surgical outpatient and inpatient arrival rates, as well as the emergency department
originating surgical arrivals.
147
SPCU Capacity Utilization Fraction of Surgical Transfer Times
1
or = 1 0.07
0.8 0.06 or = 1
or = 2
Utilization
0.05 or = 2
0.6
Fraction
or = 3
0.04 or = 3
0.4 or = 4 0.03 or = 4
or = 5 0.02
0.2 or = 5
or = 6 0.01
or = 6
0 or = 7 0
14 18 22 26 30 14 18 22 26 30 or = 7
or = 8
SPCU Capacity SPCU Capacity or = 8
Figure 3-63: Utilization with respect to Figure 3-64: Transfer time delay exceeding
operating room capacity threshold limit
SPCU Midnight Census SPCU Midday Census

30 30
or = 1 or = 1
25 25
Beds Occupied
Beds Occupied
or = 2 or = 2
20 20
or = 3 or = 3
15 15
or = 4 or = 4
10 10
or = 5 or = 5
5 5
or = 6 or = 6
0 0
or = 7 or = 7
14 18 22 26 30 14 18 22 26 30
or = 8 or = 8
SPCU Capacity SPCU Capacity
Figure 3-65: Midnight bed census with Figure 3-66: Midday bed census with
respect to operating room capacity respect to operating room capacity
148
3.4.1.3 Surgical Acute Care Unit Capacity
Capacity allocation for OR theatres and surgical acute care unit (SACU) beds
both have significant impacts on the operational performance metrics. In this section the
interactive behavior of these two factors is explored by systematically varying the
allocated capacity levels, while holding emergency, outpatient, and inpatient arrival rates
constant.
OR capacity utilization is influenced by the number of OR theatres and the
number of surgical inpatient ward beds maintained. In this example, OR capacity is
varied over a range of 1 to 8 theatres, and SACU capacity over a range of 100 to 160,
while other surgical inpatient wards are amply supplied to avoid restriction. Figure 3-67
illustrates that over this range OR capacity utilization falls between 43% and 68%. Few
negative impacts on patient blockages are seen due to limited SACU bed capacity.
Although declines are observed in the reschedule percentages as OR capacity increases,
Figure 3-68 illustrates that SACU bed capacity is still a significant cause of patient
surgery cancellation when too few available inpatient beds exist. With a SACU bed
capacity above 140 the cancellation rate is below 3%. Figure 3-69 illustrates the scenario
where outpatient elective surgery patients are rescheduled at high percentage rates due to
insufficient OR capacity when fewer than 5 OR theatres are maintained. Figure 3-70
illustrates the circumstance where inpatient elective surgery patients are rescheduled at
high percentage rates due to insufficient OR capacity when fewer than 4 OR theatres are
maintained.
149
1 0.2
0.8 sacu = 100 sacu = 100
0.15
Percentage
Utilization
sacu = 110 sacu = 110

0.6
sacu = 120 0.1 sacu = 120
0.4
sacu = 130 sacu = 130
0.2 0.05
sacu = 140 sacu = 140
0 sacu = 150 0 sacu = 150

1 2 3 4 5 6 7 8 sacu = 160 12345678 sacu = 160
SACU capacity patients cancelled

1 1
0.8 sacu = 100 0.8 sacu = 100
Percentage
Percentage
sacu = 110 sacu = 110

0.6 0.6
sacu = 120 sacu = 120
0.4 0.4
sacu = 130 sacu = 130
0.2 0.2
sacu = 140 sacu = 140
0 sacu = 150
0 sacu = 150
1 2 3 4 5 6 7 8 1 2 3 4 5 6 7 8
sacu = 160 sacu = 160
OR Capacity
OR Capacity
patients rescheduled patients rescheduled
Figure 3-71 through Figure 3-75 illustrate the changes in a set of performance
metrics as the capacity allocated to OR theatres and SACU beds are varied. These
measures include: (1) the elective surgery patient intake waiting time duration occuring
150
before the preoperative process; (2) the outpatient surgery estimated length-of-stay
duration, and (3) the inpatient surgery estimated length-of-stay duration, which capture
the duration from arrival to departure from the surgical unit; and (4) the inpatient surgery
bed placement delay as a percentage exceeding a threshold. Collectively, these metrics
suggest that the best operational performance may be achieved at an OR capacity of at
least 6 OR theatres and SACU capacity of 140, or more, beds. At these levels, the
average intake waiting time would be 12.6 minutes, the outpatient length-of-stay would
be 4.2 hours, and the inpatient length-of-stay would be 4.9 hours. The percentage of
inpatient surgery patients encountering a delay greater than 2 hours in bed placement is
neglible at these levels.
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5
1
4 sacu = 100
sacu = 100
sacu = 110
0.8
Percentage
3
Hours
sacu = 110
sacu = 120 0.6
2 sacu = 120
sacu = 130 0.4
sacu = 130
1 sacu = 140 0.2
sacu = 140
0 sacu = 150 0
sacu = 150
1 2 3 4 5 6 7 8 sacu = 160 1 2 3 4 5 6 7 8
sacu = 160
Figure 3-71: Elective surgery patient Figure 3-72: Inpatient bed placement delay
intake waiting delay exceeding threshold limit

30 15
25 sacu = 100 sacu = 100
20 sacu = 110 10 sacu = 110
Hours
Hours
15 sacu = 120 sacu = 120

10 sacu = 130 5 sacu = 130
5 sacu = 140 sacu = 140
0 sacu = 150 0 sacu = 150
1 2 3 4 5 6 7 8 sacu = 160 1 2 3 4 5 6 7 8 sacu = 160
duration duration
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Inpatient Delayed Bed Placement
1
0.9
0.8
sacu = 100
0.7
Percentage 0.6 sacu = 110
0.5 sacu = 120
0.4 sacu = 130
0.3
sacu = 140
0.2
0.1 sacu = 150
0 sacu = 160
1 2 3 4 5 6 7 8
OR Capacity
In the remaining portion of this subsection the utilization of SACU capacity with
respect to OR capacity is presented in the figures that follow. In Figure 3-76 the SACU
capacity utilization is illustrated, suggesting that at least 140 SACU beds be maintained
when 3 or more OR theatres are maintained to keep SACU utilization near 85%. Figure
3-77 illustrates the fraction of surgical patients that experience more than a 12 hour
transfer amongst all surgical inpatient care units with respect to both OR and SACU
capacity. This is observed to be unchanged when at least 140 SACU beds are maintained
for most OR capacity allocation levels. Figure 3-78 describes the midnight bed census
and Figure 3-79 describes the midday census levels. The midday census is observed to
be slightly higher than the midnight census, which may be explained by the majority of
patients being discharged from standard care in early afternoon.
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SACU Capacity Utilization Transfer Delay Exceeding 12 Hours
1 0.2
0.8 or = 1
0.15 or = 1
Utilization
or = 2
Fraction
0.6 or = 2
or = 3 0.1
0.4 or = 3
or = 4
0.05 or = 4
0.2 or = 5
or = 5
0 or = 6 0 or = 6
100
110
120
130
140
150
160
160
100
110
120
130
140
150
or = 7 or = 7
SACU Capacity or = 8 SACU Capacity or = 8
Figure 3-76: SACU utilization with respect Figure 3-77: Transfer time delay exceeding
to operating room capacity threshold limit
SACU Midnight Census SACU Midday Census

140 140
120 120 or = 1
or = 1
Beds Occupied
Beds Occupied
100 100 or = 2
or = 2
80 80 or = 3
or = 3
60 60 or = 4
40 or = 4 40
or = 5
20 or = 5 20
or = 6
0 or = 6 0
100
110
120
130
140
150
160
100
110
120
130
140
150
160
or = 7 or = 7
or = 8 or = 8
SACU Capacity SACU Capacity
Figure 3-78: SACU midnight bed census Figure 3-79: SACU midday bed census
In general, operational performance is better where at least 5 OR theatres are
maintained and at least 140 SACU beds are maintained. Further investigation could be
performed to examine the sensitivity of these findings to variances in the surgical
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outpatient and inpatient arrival rates, as well as the emergency department originating
surgical arrivals.
3.4.1.4 Capacity Recommendations
Based on results from the fundamental analysis, we present in Table 3-14 a
consolidated set of unit capacity recommendations deduced through visual inspection.
Performance metric results for this set are tabulated in Table 3-15 for the surgical unit
and Table 3-16 for the surgical inpatient wards.
Table 3-14: Capacity recommendations and utilization against targets

OR 6 59.3 % 60.0 %
SICU 7 79.2 % 65.0 %
SPCU 32 89.1 % 78.0 %
SACU 150 81.5 % 85.0 %
In Table 3-15, most all surgical unit performance measures satisfy their targets
and threshold limits; however, the inpatient surgical cancellation rate at 1.2% exceeds the
1.0% threshold limit. Ideally, elective surgery outpatient reschedules, inpatient
reschedules, and inpatient cancellations would not occur at all.
In Table 3-16, several surgical inpatient ward performance measures fail to
achieve both targets and threshold limits. Higher than expected SICU and SPCU
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utilization rates are observed, which may contribute bed blockages that potentially result
in the elective surgery inpatient cancellations. This directly contributes to the observed
SICU and SPCU bed placement delay times exceeding the 2 hour threshold limit and for
the fraction of attractive surgical inpatient transfers delayed exceeding targets. As a
result, the surgical unit length-of-stay durations for patients boarding into the SICU and
SPCU are excessive. These results suggest the number of beds in the wards needs to be
more closely evaluated in order to reduce the excessive capacity utilization rates.
Table 3-15: Surgical unit performance metric results and targets
OR utilization % 59.3% 60.0 %
IP cancellation % 1.2 % < 1.0 %
IP rescheduled % 0.0 % < 1.0 %
OP delayed or rescheduled % 0.04 % < 1.0 %

IP intake wait time delay (hours) 0.21 hours < 0.25 hours
OP intake wait time deal (hours) 0.21 hours < 0.25 hours
SU OP discharged SU LOS 4.22 hours minimize (4 hours)
Although some targets and threshold limits were respected, several capacity
utilization and performance measurement results did not align well with their intended
targets. In the next section on sensitivity to patient demand, we will improve and
enhance this consolidated set to better align with objectives. The enhanced consolidated
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set will then be used as a standard to examine adjustments in scheduled elective surgery
patient demand.
Table 3-16: Surgical ward performance metric results and targets
SICU utilization % 79.2 % 65.0 %
SPCU utilization % 89.1 % 78.0 %
SACU utilization % 81.5 % 85.0 %
SICU bed placement time exceeding a 2 28.9 % < 5.0 %

hour threshold time limit %
SPCU bed placement time exceeding a 2 56.3 % < 5.0 %
SACU bed placement time exceeding a 2 0.0 % < 5.0 %
Fraction of attractive surgical inpatient 5.2 % < 3.0 %
SU IP LOS boarding SICU (hours) 6.11 hours minimize (4.5 hours)
SU IP LOS boarding SPCU (hours) 9.74 hours minimize (5.0 hours)
SU IP LOS boarding SACU (hours) 4.86 hours minimize (4.5 hours)
3.4.2 Sensitivity to Adjustments in Patient Demand
We perform a sensitivity analysis in this section to examine what effect
adjustments in the scheduled elective surgery patient demand will have on select,
representative performance measures for the whole hospital model. First, we establish an
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enhanced consolidated set of capacity recommendations that will be used as a standard
throughout this study. Second, we introduce the reference used to describe the
adjustments in patient demand and the corresponding patients per day values used as
input in the whole hospital model. Third, we present and discuss the output results from
the whole hospital model for the performance measures specific to the surgical unit and
the surgical inpatient wards.
3.4.2.1 An Enhanced Set of Capacity Recommendations
We develop an enhanced set of capacity recommendations by using the results of
the fundamental analysis as a guide to reduce the search space and increase the number of
simulation experiments with a reduced increment size in the range. A simple heuristic
was used to eliminate nonconforming results and identify the best candidate sets that
minimize allocated unit capacity. The selected set of capacity recommendations, which
are summarized in Table 3-17 below, will be used as the standard set of capacity
recommendations throughout this study for experimentation purposes. In comparison to
the capacity recommendations from the fundamental analysis, the standard set includes
no change in OR capacity, increases SICU capacity by 1 bed, increases SPCU capacity
by 6 beds, and decreases SACU capacity by 2 beds.
Table 3-18 and Table 3-19 present the performance metric results from the
simulation experiments and the accompanying targets for the surgical unit and the
surgical inpatient wards, respectively. Not only are the utilization results greatly
improved and well aligned with their targets, but also performance metrics associated
with threshold limits are respected. These results indicate this standard set is a well-
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balanced combination of capacity recommendations upon which to perform the
sensitivity analysis.
Table 3-17: Standard set capacity recommendations and utilization results against targets

OR 6 59.5 % 60.0 %
SICU 8 69.6 % 65.0 %
SPCU 38 76.0 % 78.0 %
SACU 148 84.2 % 85.0 %
Table 3-18: Baseline surgical unit (SU) performance metrics and targets
OR utilization % 59.5 % 60.0 %
IP cancellation % 0.04 % < 1.0 %
IP rescheduled % 0.0 % < 1.0 %
OP rescheduled (delayed) % 0.04 % < 1.0 %

IP intake wait time delay (hours) 0.21 hours < 0.250 hours
OP intake wait time delay (hours) 0.21 hours < 0.250 hours
SU OP discharged SU LOS 4.33 hours minimize (4 hours)
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Table 3-19: Baseline surgical inpatient wards performance metric results and targets
SICU utilization % 69.6 % 65.0 %
SPCU utilization % 76.0 % 78.0 %
SACU utilization % 84.2 % 85.0 %
SICU bed placement time exceeding a 2 0.13 % < 5.0 %

SPCU bed placement time exceeding a 2 0.0 % < 5.0 %
SACU bed placement time exceeding a 2 0.0 % < 5.0 %
Fraction of attractive surgical inpatient 0.0 % < 3.0 %
PACU patients held overnight % 0.14 minimize (< 1.0 %)
SU IP LOS boarding SICU (hours) 4.86 hours minimize (4.5 hours)
SU IP LOS boarding SPCU (hours) 4.86 hours minimize (4.5 hours)
SU IP LOS boarding SACU (hours) 4.86 hours minimize (4.5 hours)
3.4.2.2 Change in Scheduled Elective Surgical Patient Demand
Although the simulation model incorporates some limited variation in the patient
arrival rate subject to time-series indices corresponding to the day-of-week and hour-of-
day, the reference to this index is based on the scheduled mean inpatient arrival rate and
the scheduled mean outpatient arrival rate. Previously, these values had been held
constant in the observational findings. In this study, we vary the scheduled mean
inpatient arrival rate and scheduled mean outpatient arrival rate as presented in Table
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3-20. Throughout the remainder of this section we refer to these mean arrival rates
values using a common reference to the percentage change in the mean surgical unit (SU)
arrival rates.
Table 3-20: Mean SU arrival rates and model inputs as patients per day (ppd) values
% Change mean SU arrival rates -30% -20% -10% 0% 10% 20% 30%
Mean inpatient SU arrival rate 21.0 24.0 27.0 30.0 33.0 36.0 39.0
Mean outpatient SU arrival rate 14.0 16.0 18.0 20.0 22.0 24.0 26.0
3.4.2.3 Sensitivity Analysis for Scheduled Surgical Patient Demand
A similar one-factor-at-a-time approach is used to conduct the sensitivity analysis
examining the effects of change in the surgical unit arriving patient demand. Using the
standard set of capacity recommendations stated in Table 3-17 and percentage changes in
the mean SU arrival rate provided in Table 3-20 as inputs, we execute a series of
simulation experiments one-at-a-time in order to reveal the sensitivity in the performance
outcomes in response to these changes. We discuss several related figures illustrating
these sensitivity analysis results throughout the remainder of this section.
Figure 3-80 shows the surgical unit OR utilization and intake waiting time delay
with respect to the percentage change in the mean SU arrival rate from the baseline. We
observe that a decrease in the mean SU arrival rates from the baseline results in reduced
OR utilization, but the average intake waiting time delay remains relatively unchanged.
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In contrast, an increase in the mean SU arrival rate from the baseline results in only a
slight increase in utilization, but the average intake waiting time delay nearly doubles
from 0.211 to 0.438 hours with a 30% increase. As will be shown in the figures that
follow, the availability of inpatient ward bed space substantially influences OR utilization
and intake waiting time delay.
1.0 1.00
0.9
0.8
0.75
0.7 Utilization Rate
Percentage
0.6
Hours
0.5 0.50 Utilization Rate Target
(60%)
0.4
Average Intake Wait
0.3
0.25 Time
0.2
Average Intake Wait
0.1
Time Target (<0.25 h)
0.0 0.00
-30% -20% -10% 0% 10% 20% 30%
% Change in Mean SU Arrival Rates
Figure 3-80: Utilization and intake delay with respect to the mean SU arrival rate
Figure 3-81 further illustrates this concern for available bed space within the
surgical inpatient wards. With a decrease in the mean SU arrival rates we observe that all
performance thresholds are achieved. However, with an increase in the mean SU arrival
rates performance threshold targets are rapidly violated. Scheduled inpatient surgeries
exceed the threshold target with only an increase of 5% in the mean SU arrival rates.
Scheduled outpatient surgeries begin to exceed the threshold target with an increase of
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11% for the mean SU arrival rates. The rescheduling of inpatients surgeries is not
observed since that is symptomatic of insufficient surgical time to complete procedures.
At an increase of 20% change in the mean SU arrival rates the percentage of inpatient
cancellation is 5.1% and the percentage of outpatient rescheduling is 7.8%.
0.20
0.16
Percentage
0.12
IP Cancelled (%)
IP Rescheduled (%)
0.08
OP Rescheduled (%)
0.04 Target (<1%)
0.00
-30% -20% -10% 0% 10% 20% 30%
Figure 3-81: Cancellation and rescheduling rates with respect to the mean SU arrival rate
Figure 3-82 illustrates the inpatient and outpatient surgery length-of-stay within
the surgical unit prior to being transferred into an inpatient ward or discharged home,
respectively. We observe more sensitivity in the outpatient surgical unit length-of-stay
than for inpatients in response to the percentage change in the mean SU arrival rates.
Outpatient surgeries generally involve shorter procedures than inpatient surgeries.
However, as the volume of scheduled surgeries increase the inpatient procedures will
often begin to “crowd-out” outpatient procedures, leading to increase length-of-stays.
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6.0
5.5
5.0
Hours
4.5
OP SU LOS (h)
4.0 IP SU LOS (h)
3.5
3.0
-30% -20% -10% 0% 10% 20% 30%
Figure 3-82: Patient length-of-stay with respect to the mean SU arrival rate
Figure 3-83 and Figure 3-84 illustrate the inpatient surgical unit length-of-stay
time and threshold adherence by destination ward type. Wards with fewer beds, such as
the ICU and PCU, suffer the greatest performance declines as the scheduled demand
increases. With a 20% increase in schedule demand the length-of-stay for patients destine
to the ICU and PCU increase to 5.25 h (9.4% increase) and to 5.08 h (5.83% increase),
respectively. Lastly, we observe in Figure 3-84 that an increase above 25% in scheduled
demand results in the transfer delay threshold for patients destined to the ICU being the
only threshold violated.
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6.0
5.5
Hours
5.0 IP SU LOS to ICU (h)

IP SU LOS to PCU (h)
4.5 IP SU LOS to ACU (h)
4.0
-30% -20% -10% 0% 10% 20% 30%
Figure 3-83: Inpatient LOS by destination ward with respect to the mean SU arrival rate
0.025
0.020
Percentage
0.015
IP SU LOS ICU >2hrs
IP SU LOS PCU >2hrs
0.010
IP SU LOS ACU >2hrs
0.005 Target (<1%)
0.000
-30% -20% -10% 0% 10% 20% 30%
Figure 3-84: Inpatient transfer delay exceeding threshold limit by destination ward
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The remaining figures in the section address the surgical inpatient wards. In
Figure 3-85 the percentage of attractive surgical inpatient transfers delayed more than 12
hours are illustrated. Under present conditions, we do not observe delays approaching
the 12 hour threshold. Figure 3-86, Figure 3-87, and Figure 3-88 illustrate the midday
and midnight population census, as well as, the utilization rate for the surgical ICU, PCU,
and ACU wards, respectively. All three figures illustrate similar behavior as the
scheduled demand increases; specifically, we observe bed occupancy and utilization
increase but at a diminishing rate just beyond the capacity recommended baseline as we
approach the limit of capacity. This suggests that above the baseline there is little
capacity to absorb additional scheduled demand, particularly in the case where ward bed
unit capacities are small, such as the surgical ICU and PCU.
It is also important to reflect upon the differences in the utilization targets
between the medical and surgical inpatient wards. As in most hospitals, the model
calendars the majority of scheduled surgeries on the earlier days of the week – most
notably Monday through Thursday. True to life, this causes a weekly cycle where
occupancy rises and falls in the surgical inpatient wards. As a result, the long-run
utilization rate is often below what is observed in the medical inpatient wards. Therefore,
it is difficult to increase the surgical inpatient ward occupancy rates even at the higher
scheduled demand. Likewise, the OR utilization measure may remain lower than
expected given a weekly front-loaded scheduled demand.
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0.05
0.04
Percentage
0.03
Delayed >12 Hours
0.02
Delayed Target (<3%)
0.01
0.00
-30% -20% -10% 0% 10% 20% 30%
Figure 3-85: Attractive surgery ward patient transfers exceeding threshold
8 1.0
7 0.9
0.8
6
0.7 SICU Midnight Bed
5 Census
Percentage
0.6
SICU Beds
4 0.5 SICU Midday Bed

Census
3 0.4
SICU Occupancy Rate
0.3
2 (%)
0.2
1 SICU Occupancy Rate
0.1
Target (65%)
0 0.0
-30% -20% -10% 0% 10% 20% 30%
Figure 3-86: SICU ward occupancy rate and census with respect to mean SU arrival rate
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36 1.0
0.9
30
0.8
0.7 SPCU Midnight Bed
24 Census
Percentage
SPCU Beds
0.6
18 0.5 SPCU Midday Bed
Census
0.4
12 SPCU Occupancy Rate
0.3
(%)
0.2
6 SPCU Occupancy Rate
0.1
Target (78%)
0 0.0
-30% -20% -10% 0% 10% 20% 30%
Figure 3-87: SPCU occupancy rate and census with respect to the mean SU arrival rate
150 1.0
140 0.9
130 0.8
120 0.7 SACU Midnight Bed
Census
Percentage
SACU Beds
110 0.6
100 0.5 SACU Midday Bed
Census
90 0.4
SACU Occupancy
80 0.3
Rate (%)
70 0.2
SACU Occupancy
60 0.1
Rate Target (85%)
50 0.0
-30% -20% -10% 0% 10% 20% 30%
Figure 3-88: SACU occupancy rate and census with respect to the mean SU arrival rate
168
3.4.3 Observations and Conclusion
Throughout the analyses for the surgical unit and surgical inpatient wards we have
observed that the whole hospital model demonstrates consistent and reliable results. This
has been the case not only when the allocation of unit capacity was varied but also when
the scheduled elective surgery patient demand was varied. This provides further
encouragement that the model is both consistent in model formulation and robust enough
to accommodate situations of extreme workload or conditions of being under resourced.
The fundamental analysis for the surgical unit and surgical inpatient wards
provided the ability to illustrate the relationships in allocated unit capacity between two
of the factors. In general, we were successful in comparing relationships between the
surgical unit operating room capacity and a specific surgical inpatient ward bed capacity.
While the one-factor-at-a-time approach did allow us to produce insightful illustrations
and observations, the method as applied here was insufficient at revealing the broader but
lesser known interactions that may have been of interest. In general, the use of visual
inspection in the surgical unit made determination of the consolidated set of capacity
recommendations challenging. The weekly occupancy cycles produced by the surgical
schedules contributed to this challenge.
The sensitivity analysis for the surgical unit and surgical inpatient wards allowed
us to better understand the effects that adjustments in scheduled elective surgery patient
demand has on performance measures. From this analysis, we observed that performance
measures will deteriorate and violate threshold limits at different levels of patient
demand.
169
The earliest indication of deteriorating performance in the surgical unit occurs
with only a 5% increase in patient demand, primarily caused by the limitation of SICU
capacity. This results in an average inpatient cancellation rate of 1.2%, which is only
slightly above the 1% threshold limit. With a 10% increase in patient demand, we
observe that the average intake waiting time increases from 0.21 to 0.34 hours, which is a
61.9% increase. This also exceeds the 0.25 threshold limit. More importantly, the MICU
and MPCU capacity utilizations have both reached plateaus and fail to absorb any further
patient demand. The results in an inpatient cancellation rate of 3.2%, which is well above
the threshold limit. Eventually with a 15% increase, all performance measures
demonstrate unacceptable results, particularly an inpatient cancellation rate of 4.3% and
an outpatient reschedule rate of 3.9%. This suggests that the surgical inpatient wards
quickly exhaust their ability to accept any further patient demand above a 5% increase,
making it very sensitivity to demand.
All adjustments to patient demand above the baseline demonstrate deterioration in
performance measures. For the administrator, it is a matter of determining which of these
concerns ranks higher, and a willingness to accept under performance in these areas.
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CHAPTER 4 CAPACITY DETERMINATION: A GOAL SEEKING APPROACH
4.1 Introduction
The whole hospital model represents a complex system with many endogenous
behaviors that contribute to the observed outcomes and performance. A fundamental
analysis uses a rather simple approach where factors are varied one-at-a-time and an
assessment of outcomes against an objective or two is made with a handful of constraints
observed. The approach, however, is not very efficient as the number of objectives to be
met increases, and the problem space grows in size. Under these circumstances it is
necessary to implement more formalism in the problem structure and introduce an
algorithm to assist in the search for the combination of inputs that will best satisfy
multiple objectives.
Within system dynamics, optimization contributes an important role in identifying
the best range of parameter values for policies in a model. Optimal solutions focus on
discovering the best combination of model parameters that maximize or minimize a
specified objective function. The system dynamics literature describes the
complimentary roles of system dynamics and optimization and how usage can provide
key understandings to decision makers (Coyle, 1985, 1996; Dangerfield and Roberts,
1996; Duggan, 2005; Keloharju, 1983; Keloharju and Wolstenholme, 1988, 1989). Coyle
(1996) describes the automation, through optimization, to explore the infinite number of
possible combinations and values of parameters. Coyle further describes the form of a
guided search in order to provide good approximations to optimal solutions using a hill
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climbing heuristic algorithm. The optimization of defense expenditures using system
dynamics provides an example its usage (Coyle, 1992; Wolstenholme and Al-Alusi,
1987).
The next advancement is to expand the concept to several objective functions. An
objective function can be formulated as a weighted combination of goals which produces
the desired model behavior over the simulation after the optimization process has
completed. The approach, which is similar to goal programming, has been described as
multi-objective optimization (Keloharju, 1983). The selection of an acceptable
combination of goals is based on the comparison of optimization results. Use of multiple
objectives, in really complex settings, presents additional concerns regarding the ability
to obtain an optimal solution. This is reflected in the abundance of publications and
developed genetic algorithms for policy optimization. Grossman (2002) states traditional
gradient algorithms typically fail once they have reached a local optimum; however,
genetic algorithms do not mistake a local optimum for global ones. Duggan (2005)
demonstrates the use of multiple objective optimization for a system dynamics model
using a genetic algorithm to identify non dominated solutions.
This research explores the determination of unit capacity for a whole hospital
where there are multiple objectives of interest to a hospital administrator that must be
satisfied. A goal seeking, or goal programming, approach is used to algorithmically
locate, through optimization and system dynamics modeling, the set of decision inputs
that minimize the multiple objectives while constraints are enforced. This study uses the
whole hospital model and optimization, using a gradient search heuristic algorithm, to
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determine the recommended hospital-wide unit capacity levels. The results would be
used to assist the hospital administrator in the strategic planning process.
The chapter is organized into three sections. The first section introduces the
methodology used for multiobjective problem solving in conjunction with the whole
hospital simulation model. The second section describes an implementation where unit
capacity is determined for the emergency department and medical wards. The third
section describes an implementation where unit capacity is determined for the surgical
unit and surgical wards. The chapter ends in discussion with conclusions and future
work.
4.2 Methodology
This section describes the methodology used to construct the goal programming
model that is used in capacity determination presented in the sections that follow.
Literature in the field of multi-criteria decision analysis (MCDA) describes how goal
programming compliments multiobjective optimization (Charnes and Cooper, 1961;
Jones and Tamiz, 2010; Lee, 1973; Mehrdad Tamiz et al., 1998; M. Tamiz et al., 1995).
Goal programming is attractive due to its simplicity and ease of use. Goal programming
can handle relatively large numbers of variables, constraints and objectives. The
approach attempts to satisfy goals rather than optimize by minimizing the
underachievement of goals. This is performed by providing a goal or target value to be
achieved for each of the normally conflicting objective measures. Deviation from the
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target values are then minimized in an objective function. A weighted sum is used in the
prioritization scheme for target achievement.
The target values and weights used in this study were obtained from an
experienced hospital administrator at UNC Medical Center in Chapel Hill, North
Carolina. These are presented in detail over the next two sections on capacity
determination. In general, strong importance is placed by the weightings on achievement
of the targets associated with the ED utilization, ICU utilization, OR utilization, the
LWBS rate, the surgery cancellation rate, the surgery reschedule rate, and the timely
transfer and placement of critical care patients. Unlike a production or manufacturing
system which may seek to maximize utilization or minimize processing time, hospital
utilization targets are established based on historical results. The targets range from 50%
to 85% utilization based on the function. Recommended capacity constraints were
determined based on subject matter expert guidance.
In the non-preemptive approach to goal programming, the weights act as a penalty
for failure to achieve a targeted goal. In many cases the objective is to minimize the
deviations from the desired and penalize when an outcome falls below. In the work
presented herein, the weights are used in conjunction with a nonlinear penalty function
based on the target deviation magnitude. Due to the sparse constraint set and absence of
a common unit of measure between some achievement targets, such as operating costs,
the nonlinear penalty function assists the minimization algorithm to rapidly converge on a
solution that where the targets are satisfied. In this case, the whole hospital model
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simulation model is treated as a black box function, receiving input and transmitting
output.
The continuous nature of the system dynamics model is exploited using an
algorithm to find a local minimum of a function. Powell’s conjugate direction method
(Powell, 1964), also known as “Powell’s hill climbing” algorithm, is incorporated in the
Vensim software optimization resources. The method is useful for calculating the local
minimum of a continuous but complex function, especially one without an underlying
mathematical definition, because it is not necessary to take derivatives. Avoidance of
trapping at local minimums is accomplished through the use of a multi-start option with
randomized initial point selection. Due to the size of the model a single simulation run
requires approximately 0.91 minutes to execute. Using the multi-start option, the number
of executions required to satisfy the algorithms optimization criteria ranged between 625
and 1,265 executions – the equivalent of up to one computing day. This was repeated for
multiple initial conditions, as illustrated in the next few sections.
4.3 Capacity Determination: Emergency Department and Medical Wards
Emergency departments and hospital medical wards are often characterized by
their capacity, both in terms of the number of emergency treatment rooms and inpatient
bed capacity, and the annual patient volume served. Hospital administrators are most
concerned in satisfying a number of objectives that include maximizing productivity of
these facilities, increasing patient flow, and maintaining a high quality of service
delivery. This section presents a mathematical model that utilizes a multiobjective
175
criterion in the determination of the optimal capacity levels for the emergency department
and medical inpatient wards. The effect of varied levels of emergency demand on the
optimal solution sets is examined.
The remainder of this section is organized into three areas. First, the problem
formulation is described and defined for both the objective function and the
multiobjective criteria used in the optimization. Second, the optimization solution set
results are presented and described for varied emergency department demands. Lastly,
observations and findings discovered while constructing and executing the multiple
objective optimizations are discussed.
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4.3.1 Problem Formulation
The multiobjective problem presented in this section is formulated as a nonlinear
mathematical programming model. The decision variables are the recommended unit
capacity levels for the number of emergency department treatment rooms and the medical
inpatient ward beds, necessary to satisfy the specified multiobjective criteria. Given the
unit capacity levels are the decision variables, the unit capacity levels considered in this
study are unconstrained. Figure 4-1 illustrates conceptually the relevant inputs and
outputs that directly influence hospital operations considered in this problem formulation.
The inputs include the unit capacity decision variables, the emergency department
arriving patient demand, and a pre-defined hospital profile detailing the modeled facility
attributes. The outputs include observable results such as delay time encountered for
door-to-room and admitted patient boarding, the percentage of goal attainment for delay
times and length-of-stay durations, the patient leaving-without-being-seen rates, the
capacity utilization rates, and the daily patient flow rates. More formal descriptions are
provided later.
Figure 4-1: Diagram of inputs and outputs for hospital operations
177
The objective of the problem is to minimize penalties, as defined as
minimize 4 (4-1)
∑ 𝑤𝑖 [𝛿𝑖 − 𝑓𝑖 (𝑋, 𝑡)]2 +
𝑖=1
11 (4-2)
∑ 𝑤𝑖 [max⁡(0, (𝑓𝑖 (𝑋, 𝑡) − 𝛿𝑖 ))2 ] +
𝑖=5
14 (4-3)
(𝑓𝑖 (𝑋, 𝑡) − 𝛿𝑖 ) 2
∑ 𝑤𝑖 [max⁡(0, ) ]+
𝛿𝑖
𝑖=12
16 (4-4)
∑ 𝑤𝑖 (𝑒 𝑓𝑖 (𝑋,𝑡)𝑡 − 1) +
𝑖=15
𝑀(1 − 𝑓17 (𝑋, 𝑡)/𝛾) (4-5)
where
𝑥𝑗 ⁡ unit capacity for ED treatment rooms and medical ward beds (j: 1 to 4)
𝑡 time reference (hour of simulation execution)
𝑤𝑖 weighted normalized value of priority (i: 1 to 16)
𝛿𝑖 target value for usage or time value (i: 1 to 16)
𝑓𝑖 functional simulation response (i: 1 to 17)
⁡𝑀 weighted value maximizing patient throughput
𝛾 expected patient discharge rate
Model input parameters include:
(1) emergency patient arrivals per day (varied between 134.50 to 201.75)
(2) direct medical patient arrivals per day (constant at 16 patients per day)
(3) modeled whole hospital profile (predefined)
Model decision variables include:
𝑥1 emergency department treatment rooms units (rooms)

𝑥2 medical intensive care unit (MICU) beds units (beds)
𝑥3 medical progressive care unit (MPCU) beds units (beds)
𝑥4 medical acute care unit (MACU) beds units (beds)
178
and
subject to 5⁡ ≤ 𝑥1 ⁡ ≤ 100 (4-6)
2⁡ ≤ 𝑥2 ⁡ ≤ 25 (4-7)
5⁡ ≤ 𝑥3 ⁡ ≤ 100 (4-8)
50⁡ ≤ 𝑥4 ⁡ ≤ 250 (4-9)
A detail description, including target, raw score and normalized weight, for
members of the objective function is provided in the tables that immediately follow.
Table 4-1 describes the functional simulation response related to unit capacity utilization
for the ED treatment rooms and the medical ward beds. Table 4-2 describes the
functional simulation response with threshold limits that include ED triage-to-room
delay, ED patient boarding delay, and DMA patient boarding delay. Table 4-3 describes
the functional simulation response for ED triage-to-exam delay, discharged length-of-stay
time duration, and admitted length-of-stay time duration. Table 4-4 describes the
functional simulation response for the ED leaving-without-being-seen (LWBS) rate and
the fraction of attractive medical ward patient transfers delayed 12 or more hours, both
which should be minimized. A final functional simulation response considers the
difference in the expected rate and the realized rate of medical inpatient ward discharge,
which is penalized with a weighted of value M, appearing in the objective function in
equation (4-5).
179
Table 4-1: Objective function equation (4-1) member parameters:
Reference 𝑖 Description Target 𝛿𝑖 Score Weight 𝑤𝑖
1 ED utilization rate 0.80 80 0.0879
2 MICU utilization rate 0.75 80 0.0879
3 MPCU utilization rate 0.85 50 0.0549
4 MACU utilization rate 0.90 35 0.0385
5 ED triage-to-room time exceeding < 5.0 % 35 0.0385

a 2 hour threshold time limit %
6 ED MICU boarding time < 5.0 % 80 0.0879
exceeding a 4 hour threshold time
limit %
7 ED MPCU boarding time < 5.0 % 50 0.0549
limit %
8 ED MACU boarding time < 5.0 % 35 0.0385
limit %
9 DMA MICU boarding time < 5.0 % 80 0.0879
limit %
10 DMA MPCU boarding time < 5.0 % 50 0.0549
limit %
11 DMA MACU boarding time < 5.0 % 35 0.0385
limit %
180
12 ED triage-to-exam time <0.20 hours 50 0.0549
13 ED discharged LOS time <4.25 hours 25 0.0275
14 ED admitted LOS time <5.25 hours 25 0.0275
15 ED LWBS Rate (<1%) minimize 100 0.1099
16 Fraction medical inpatient transfers minimize 100 0.1099

exceeding 12 hour threshold limit
(<1%)
4.3.2 Model Results
The multiobjective problem is executed in accordance with a random multi-start
procedure to improve the likelihood of locating a global optimum. Each simulation
execution represents 83 months of simulated time, which is used to obtain performance
results in steady state. A single solution result may require as many as 500 simulation
executions to determine an optimum for a set of decision variables values. Table 4-5
presents the optimal results for the set of decision variables at five different levels of ED
demand, where the mean number of daily arriving emergency department patients is
varied. The table presents the optimal unit capacity for ED rooms, MICU beds, MPCU
beds, and MACU beds.
181
Table 4-5: Multiobjective optimization results for the decision variables
% Change in ED Mean ED Rooms MICU Beds MPCU Beds MACU Beds

ED Demand Patients per Day (𝑥1 ) (𝑥2 ) (𝑥3 ) (𝑥4 )
-20% 134.50 30.59 2.85 24.15 148.78
-10% 151.31 35.00 3.19 26.77 160.46
0% 168.13 38.76 3.59 28.25 172.47
+10% 184.94 42.18 4.00 30.87 186.54
+20% 201.75 46.58 4.25 33.34 197.35
The results of the objective function provide an indication of the performance of
the optimal sets across the varied percent change in ED demand. The results would
ideally remain relatively constant across the variation. Figure 4-2 illustrates the objective
function results across the varied percent change in ED demand, where at the range
extreme index values less than a 1% difference is observed.
The annual volume of ED arriving patient cases treated and ultimately discharged
home, admitted to the hospital, or transferred to surgery are shown in Figure 4-3. The
figure clearly illustrates a linear trend for the volume of annual cases that corresponds
with the percent change in the ED demand. Patient disposition occurs in proportions of
78% discharged home, 16% admitted to the hospital, and 6% transferred for a surgical
procedure. Arriving patients may leave-without-being-seen either before treatment or
disposition due to encountering lengthy ED wait times or intense congestion.
182
1.05
Index Value
1.00
0.95
-20% -10% 0% 10% 20%
% Change in ED Demand
Figure 4-2: Objective function indexed value results (0%: 1 = -3,964,293)
80,000
60,000
Annual Cases
ED Arrivals
40,000
Discharged
Admitted
20,000
xfer Surgery
0
-20% -10% 0% 10% 20%
Figure 4-3: ED volume of annual cases arriving and by disposition
183
The results specific to the emergency department are illustrated in the three
figures that immediately follow. First, Figure 4-4 illustrates the optimal ED treatment
room capacity determined on the basis of corresponding ED demand, as well as the
capacity utilization and capacity utilization target. The optimal ED capacity is observed
to increase linearly as ED demand increases. On average the capacity utilization is
observed to be 76.1% across the varied ED demands, which is slightly below the desired
target utilization of 80%.
Second, Figure 4-5 illustrates results for ED waiting room delay (also known as
triage-to-room time), the percentage of waiting room delay exceeding 2 hours, and the
percentage of arriving patients that leave-without-being-seen or treated by a physician.
As shown, the optimal ED waiting room delay across the varied ED demand closely
approximates the targeted averaged delay of 0.20 hours (12 minutes). The percentage of
waiting room delay exceeding 2 hours is below 1%, substantially below the target 5%
acceptable upper limit (omitted due to scale). Lastly, the percentage of arriving patients
that leave-without-being-seen, a measure desired to be minimized, is observed on average
to be only 0.2% across the varied ED demands.
Lastly, Figure 4-6 illustrates results for the ED patient discharged and admitted
length-of-stay time durations. ED patients discharged to home experienced an average
length-of-stay of 4.42 hours, 3.95% greater than the targeted benchmark time of 4.25
hours. ED patients admitted to the hospital experienced an average length-of-stay of
5.45 hours, 3.89% greater than the targeted benchmark time of 5.25 hours.
184
80 100%
70
80%
60
50
ED Capacity 60%
40 ED Unit Capacity
30 40% Utilization (%)
20 Utilization Tgt (%)

20%
10
0 0%
-20% -10% 0% 10% 20%
Figure 4-4: Emergency department treatment room unit capacity and utilization
0.25 5.0%
0.20 4.0%
0.15 3.0%
ED Wait (h)
Hours
ED Wait Target
0.10 2.0%
LWBS (%)
0.05 1.0% ED Wait >2 h (%)
0.00 0.0%
-20% -10% 0% 10% 20%
Figure 4-5: ED waiting time, delay exceeding threshold, and percent LWBS
185
8.0
6.0
ED Discharged LOS
Hours
4.0
ED Discharged Tgt.
ED Admitted LOS
2.0
ED Admitted Tgt.
0.0
-20% -10% 0% 10% 20%
Figure 4-6: ED LOS times and targets for discharged and admitted patients
Results for the unit capacity decisions specific to the medical inpatient wards are
presented in the four figures that immediately follow. Figure 4-7 illustrates the average
daily volume of patients discharged from and transferred within the medical inpatient
wards with respect to the varied ED demand. The percentage of attractive patient
transfers delayed more than 12 hours, a measure desired to be minimized, is observed to
be below 1% (average = 0.76%) across varied ED demand and capacity.
Figure 4-8 illustrates the medical ICU ward unit capacity and utilization rate, as
well as the utilization rate target. The optimal MICU capacity is observed to increase
linearly as ED demand increases. The average capacity utilization is 80.6% across the
varied ED demands, significantly above the desired target utilization of 75.0%. In
addition, Figure 4-8 illustrates a percentage for both ED and DMA patient boarding delay
186
times exceeding 4 and 2 hour thresholds, respectively. In both cases resulting measures
are observed to be negligible, especially when compared to the targeted 5% upper limit.
Figure 4-9 illustrates the medical PCU ward unit capacity, the utilization rate, and
the utilization rate target. The optimal MPCU capacity is observed to increase linearly as
ED demand increases. The average capacity utilization is 82.2% across the varied ED
demands, slightly below the desired target utilization of 85%. Figure 4-9 also illustrates
the percentages for both ED and DMA patient boarding delay times exceeding 4 and 2
hour thresholds, respectively. Although the ED measured results are negligible, the
DMA measured results average 2.04% across the varied ED demand, which is consistent
with shortened time duration of 2 hours. Both measured results are significantly below
the targeted 5% upper limit.
Lastly, Figure 4-10 illustrates the medical ACU ward unit capacity, the utilization
rate, and the utilization rate target. The optimal MACU capacity is observed to increase
linearly as ED demand increases. The average capacity utilization is 91.6% across the
varied ED demands, slightly above the desired target utilization of 90.0%. In addition,
Figure 4-10 illustrates the percentages for both ED and DMA patient boarding delay
times exceeding 4 and 2 hour thresholds, respectively. The ED measured results are
negligible, and the DMA measured results average 2.06% across the varied ED demand.
Both measured results demonstrate being significantly below the upper limit target of
5%.
187
50 5.0%
40 4.0%
Patients per Day
30 3.0%
Discharges (ppd)
20 2.0% Transfers (ppd)
Xfer Delay >12 h (%)
10 1.0%
0 0.0%
-20% -10% 0% 10% 20%
Figure 4-7: Medical patient volume and patient transfer delay exceeding target
6 100%
5
80%
4 MICU Unit Capacity

MICU Capacity
60%
Utilization (%)
3
Utilization Target (%)
40%
2 Bed Delay Tgt (%)
20% ED Delay >4 h (%)

1
DMA Delay >2 h (%)
0 0%
-20% -10% 0% 10% 20%
Figure 4-8: MICU unit capacity, utilization, and patient placement delay exceeding
targets
188
50 100%
40 80%
MPCU Unit Capacity

MPCU Capacity
30 60%
Utilization (%)
20 40%
Bed Delay Tgt (%)
10 20% ED Delay >4 h (%)

DMA Delay >2 h (%)
0 0%
-20% -10% 0% 10% 20%
Figure 4-9: MPCU unit capacity, utilization, and patient placement delay exceeding
targets
240 100%
200
80%
160 MACU Unit Capacity

MACU Capacity
60%
Utilization (%)
120
40%
80 Bed Delay Tgt (%)
20% ED Delay >4 h (%)

40
DMA Delay >2 h (%)
0 0%
-20% -10% 0% 10% 20%
Figure 4-10: MACU unit capacity, utilization, and patient placement delay exceeding
targets
189
4.3.3 Observations and Findings
The previously presented results for the multiobjective problem solution sets
demonstrate the methodology can be used to obtain recommendations for unit capacity
levels as decision variables. Although these results appear to be rather straightforward
with unit capacity levels trending rather linearly given the change in ED demand, the
situation is significantly more complex than represented. In these results certain related
unit capacities were allowed to vary along with the fluctuations in ED demand, or were
sufficiently overprovisioned. The intent is to reveal the restrictive bottlenecking that may
occur for unit capacities of interest when trivial constraints are lessened.
Three restrictive factors discovered in earlier results were addressed through
overprovisioning or proportionally fluctuating capacity levels. First, with a 10% increase
in ED demand the limited capacity of the MRI for medical imaging emerged as a
significant bottleneck and patients in the ED requiring medical imaging began to
encounter extended delays. Second, with a 10% increase in ED demand the rate of
patient examination proved to be insufficient during peak patient arrival times. Third,
with a 20% increase in ED demand the rate of patient treatment demonstrated to be
insufficient resulting in increased congestion in the ED.
Despite these complications, solution sets were determined across the change in
ED demand when overprovisioning is not allowed. However, these solution sets
illustrate a declining ability to satisfy objectives. Three figures specific to the emergency
department illustrate these complications and the effect on unit capacity
recommendations are presented below.
190
Figure 4-11 illustrates the dramatic deflection observed for a 20% increase in ED
demand, indicating the programming models decline in satisfying multiple criteria.
Figure 4-12 illustrates a substantial increase in recommended ED unit capacity levels to
accommodate the resulting patient congestion levels with increased ED demand.
Although the recommended unit capacity is increased to satisfy multiple criteria, the
utilization of this capacity is observed to decline. Figure 4-13 illustrates the situation
where increases in waiting room time above targets occur, threshold limits are exceeded,
and patients began leaving-without-being-seen, as the ED demand increases. These
results occurred despite a significant increase ED unit capacity, and without these
outcomes would have been disastrously worse.
1.50
1.25
Index Value
1.00
0.75
0.50
-20% -10% 0% 10% 20%
Figure 4-11: Objective function indexed value results
191
80 100%
70
80%
60
50
ED Capacity 60%
40 ED Unit Capacity
30 40% Utilization (%)
20 Utilization Target
20%
10
0 0%
-20% -10% 0% 10% 20%
Figure 4-12: ED treatment room unit capacity and utilization
0.25 5.0%
0.20 4.0%
0.15 3.0%
ED Wait (h)
Hours
ED Wait Target
0.10 2.0%
ED Wait >2 hrs (%)
0.05 1.0% LWBS (%)
0.00 0.0%
-20% -10% 0% 10% 20%
Figure 4-13: ED waiting time, waiting time delay exceeding target, and LWBS
percentage
192
4.4 Capacity Determination: Surgical Unit and Surgical Wards
Surgical units and surgical inpatient wards are frequently described and compared
by their capacity, in terms of the number of operating theaters and inpatient bed capacity,
and in relation to the annual surgical patient volume completed. In addition, hospital
administrators are concerned with balancing a number of objectives regarding the
productivity of these capacities, appropriate patient flows, and the quality of service
experience. This section presents a mathematical model that utilizes a multiobjective
approach for the determination of capacity levels in the surgical unit and surgical
inpatient wards. The effect of varied levels of scheduled elective surgical unit demand on
the optimal solution sets is examined.
The remainder of this section is organized into three areas. First, the problem
formulation is described and defined for both the objective function and the
multiobjective criteria used in the optimization. Second, the optimization solution set
results are presented and described for varied surgical unit demands. Finally,
observations and findings discovered while constructing and executing the multiobjective
optimizations are discussed.
193
4.4.1 Problem Formulation
The multiobjective problem presented in this section is formulated as a nonlinear
mathematical programming model. The decision variables are the recommended unit
capacity levels for the number of surgical unit operating rooms and the surgical inpatient
ward beds, which are unconstrained, necessary to satisfy the multiobjective criteria.
Figure 4-14 illustrates the inputs and outputs that directly affect hospital
operations considered in this problem formulation. The inputs include the unit capacity
decision variables, the surgical unit scheduled elective surgery outpatient and inpatient
demands, and the defined hospital profile describing the modeled facility characteristics.
The outputs include observable results such as delay time encountered for patient intake
and post-surgery patient bed placement, the percentage goal attainment for delay times
and length-of-stay durations, the surgery cancellation and reschedule rates, the capacity
utilization rates, and daily patient flow rates. A formal description of these measures is
provided later in this section.
Figure 4-14: Diagram of inputs and outputs for hospital operation
194
The objective of the problem is to minimize penalties, as defined as
minimize 4 (4-10)
∑ 𝑤𝑖 [𝛿𝑖 − 𝑓𝑖 (𝑋, 𝑡)]2 +
𝑖=1
7 (4-11)
∑ 𝑤𝑖 [max⁡(0, (𝑓𝑖 (𝑋, 𝑡) − 𝛿𝑖 ))2 ] +
𝑖=5
13 (4-12)
(𝑓𝑖 (𝑋, 𝑡) − 𝛿𝑖 ) 2
∑ 𝑤𝑖 [max⁡(0, ) ]+
𝛿𝑖
𝑖=8
18 (4-13)
∑ 𝑤𝑖 (𝑒 𝑓𝑖 (𝑋,𝑡)𝑡 − 1) +
𝑖=14
𝑀(1 − 𝑓19 (𝑋, 𝑡)/𝛾) (4-14)
where
𝑥𝑗 ⁡ unit capacity for operating rooms and inpatient beds (j: 1 to 4)
𝑡 time reference (hour of simulation execution)
𝑤𝑖 weighted normalized value of priority (i: 1 to 18)
𝛿𝑖 target value for usage or time value (i: 1 to 18)
𝑓𝑖 functional simulation response (i: 1 to 18)
⁡𝑀 weighted value encouraging maximum patient throughput
𝛾 expected patient discharge rate
Model input parameters include:
(1) surgical inpatient arrivals per day (varied 24.0 to 36.0 patients per day)
(2) surgical outpatient arrivals per day (varied 16.0 to 24.0 patients per day)
(3) modeled whole hospital profile (predefined)
Model decision variables are defined below:
𝑥1 surgical unit operating rooms units (rooms)

𝑥2 surgical intensive care unit (SICU) beds units (beds)
𝑥3 surgical progressive care unit (SPCU) beds units (beds)
𝑥4 surgical acute care unit (SACU) beds units (beds)
195
and
subject to 2⁡ ≤ 𝑥1 ⁡ ≤ 25 (4-15)
2⁡ ≤ 𝑥2 ⁡ ≤ 25 (4-16)
5⁡ ≤ 𝑥3 ⁡ ≤ 100 (4-17)
50⁡ ≤ 𝑥4 ⁡ ≤ 250 (4-18)
A detail description, including target, raw score and normalized weight, for
members of the objective function is provided in the tables follow. Table 4-6 describes
the functional simulation response related to unit capacity utilization for the surgical unit
operating rooms and the surgical ward beds. Table 4-7 describes the functional
simulation response with threshold limits that include surgical unit bed placement delays
in excess of 2 hours to the various surgical inpatient wards. Table 4-8 describes the
functional simulation response for arriving surgical patient intake delay, surgical
outpatient length-of-stay duration until discharged and surgical inpatient length-of-stay
duration until admitted to the appropriate surgical inpatient ward.
Table 4-9 describes the functional simulation response for the criteria should be
minimized. This includes the fraction of attractive surgical ward patient transfers delayed
8 or more hours, the percentage of surgical patients cancelled or rescheduled, and the
percentage of surgical patients held overnight in the PACU due to insufficient available
ward beds. A final functional simulation response considers the difference in the
expected rate and realized rate of surgical inpatient ward discharge, which is penalized
with a weighted of value of M, appearing in the objective function in equation (4-14).
196
Reference 𝑖 Description Target 𝛿𝑖 Score 𝑠𝑖 Weight 𝑤𝑖
1 OR utilization rate 0.60 80 0.0874
2 SICU utilization rate 0.57 80 0.0874
3 SPCU utilization rate 0.78 50 0.0546
4 SACU utilization rate 0.85 30 0.0328
5 SU to SICU bed placement delayed < 5.0% 50 0.0546

in excess of 2 h
6 SU to SPCU bed placement < 5.0% 35 0.0383
delayed in excess of 2 h
7 SU to SACU bed placement < 5.0% 25 0.0273
delayed in excess of 2 h
197
8 SU OP arrival intake delay < 0.25 h 5 0.0055
9 SU IP arrival intake delay < 0.25 h 5 0.0055
10 SU LOS outpatient to discharge < 4.0 h 20 0.0219
11 SU LOS inpatient to SICU < 4.5 h 30 0.0328

admission
12 SU LOS inpatient to SPCU < 4.5 h 25 0.0273
admission
13 SU LOS inpatient to SACU < 4.5 h 20 0.0219
admission
14 Fraction of attractive SIPW minimize 80 0.0874

transfers delayed in excess of 8
hours
15 SU inpatient cancellation rate minimize 100 0.1093
16 SU inpatient reschedule rate minimize 100 0.1093
17 SU outpatient reschedule rate minimize 100 0.1093
18 SU PACU midnight census minimize 80 0.0874
4.4.2 Model Results
The multiobjective problem is executed in accordance with a random multi-start
procedure to improve the likelihood of locating a global optimum. Each simulation
execution represents 83 months of simulated time, which is used to obtain performance
198
results in steady state. In order to obtain a single optimization result approximately 325
simulations are executed on average; however, in some observed cases as many as 500
simulation executions are needed. Table 4-10 presents the optimal solution set results for
the decision variables at five different levels of SU demand, where the mean number of
daily arriving elective surgery inpatients and outpatients are varied. The table presents
the optimal unit capacity for surgical unit operating rooms, SICU beds, SPCU beds, and
SACU beds.
Table 4-10: Multiobjective results for the decision variables
% Change in SU IP Mean SU OP Mean Surgical SICU SPCU SACU

SU Demand Patients per Patients per ORs Beds Beds Beds
Day Day (𝑥1 ) (𝑥2 ) (𝑥3 ) (𝑥4 )
-20% 24.0 16.0 5.04 7.88 31.95 126.08
-10% 27.0 18.0 5.66 8.56 34.37 137.43
0% 30.0 20.0 6.24 9.13 37.09 147.44
+10% 33.0 22.0 6.76 9.60 39.58 159.31
+20% 36.0 24.0 7.34 10.28 42.40 169.83
The results of the objective function provide an indication of the performance of
the optimal solution sets across the varied percent change in SU demand.
Figure 4-15 illustrates the ideal case where the objective function results across
the varied percent change in SU demand demonstrate an indiscernible change from the
indexed value of 1, obtained where there is 0% change in SU demand. The resulting
annual volumes of arriving surgical unit cases by originating source are shown in Figure
199
4-16. The figure illustrates a linear trend for the volume of annual cases for both
scheduled elective outpatient and inpatient surgeries which correspond to the percent
change in the SU demand. Annual cases for emergency surgery are unaffected by the
change in SU demand since it influenced only by a change in ED demand, which is not
varied in this scenario. The results specific to the surgical unit are illustrated in the three
figures that immediately follow.
Figure 4-17 illustrates the optimal surgical unit operating room capacity
determined on the basis of corresponding SU demand, as well as the capacity utilization
and capacity utilization target. The optimal SU operating room capacity is observed to
increase linearly as SU demand increases. Operating room capacity utilization on
average is 59.2% across the varied SU demand levels, corresponding with the desired
target utilization of 60.0%.
200
1.05
Index Value
1.00
0.95
-20% -10% 0% 10% 20%
% Change in SU Demand
10,000
8,000
Annual Cases
6,000
Emergency
4,000 Outpatient
Inpatient
2,000
0
-20% -10% 0% 10% 20%
Figure 4-16: Annual surgical unit demand volume by origination source
201
Figure 4-18 illustrates results for the surgical unit inpatient cancellation rate, the
inpatient reschedule rate, the outpatient reschedule rate, and the frequency at which
surgical patients are held in the PACU overnight. It is desirable to minimize these
measured results across all demand levels. As shown, the capacity determined solution
set illustrates cancellation and reschedules percentages that on average are less than
0.05%. In addition, these solution results illustrate the frequency at which surgical
patients are held in the PACU overnight due to insufficient surgical ward capacity is on
average less than 0.15%. These figures suggest an almost indiscernible occurrence of
cancellation, reschedules, and patients held over at the specified unit capacity levels.
Figure 4-19 illustrates results for the surgical unit patient discharged and admitted
length-of-stay time durations. Outpatient surgery patients discharged home experienced
an average length-of-stay of 4.22 hours, which is 5.5% greater than the target benchmark
time of 4.0 hours. Inpatient surgery patients admitted to the hospital experienced an
average length-of-stay of 4.87 hours, which is 8.2% greater than the target benchmark
time of 4.5 hours. Although these results appear relatively stable, a slight drift upwards is
observed in the length-of-stay time durations as the change in SU demand increases.
202
8 100%
80%
6
OR Capacity
60%
4 Unit Capacity
40% Utilization Rate
20%
0 0%
-20% -10% 0% 10% 20%
Figure 4-17: Surgical unit capacity, utilization, and utilization target
0.20%
0.15%
Percent
IP Cancellation
0.10%
IP Rescheduled
OP Rescheduled
0.05%
PACU Overnight
0.00%
-20% -10% 0% 10% 20%
Figure 4-18: Surgical unit cancellation rate, rescheduling rate, and patients held overnight
203
5.0
OP Discharged LOS
Hours
4.5
SICU Admitted LOS
SPCU Admitted LOS
SACU Admitted LOS
4.0
-20% -10% 0% 10% 20%
Figure 4-19: Surgical unit length-of-stay time by patient destination
The results for the unit capacity decisions pertaining to the surgical inpatient
wards are presented in the four figures that follow. First, Figure 4-20 illustrates the
average daily volume of patients discharged from and transferred within the surgical
inpatient wards with respect to the varied change in SU demand. The percentage of
attractive surgical ward patient transfers delayed more than 8 hours, a measure desired to
be minimized, is observed to be less than 0.1% on average.
Second, Figure 4-21 illustrates the surgical ICU ward unit capacity, the utilization
rate, and the utilization rate target. The optimal SICU capacity increases linearly as the
change in SU demand increases. The average capacity utilization is 61.2% across the
varied SU demands, slightly higher than the desired utilization of 57.0%. Figure 4-21
also illustrates the percentage of surgical patient boarding delay times that exceed a 2
204
hour threshold. In this case, the measures are relatively negligible with an average of
0.5%, which is significantly below the acceptable 5% upper limit criteria.
Third, Figure 4-22 illustrates the surgical PCU ward unit capacity, the utilization
rate, and the utilization rate target. The optimal SPCU capacity increases linearly as the
change in SU demand increases. Average capacity utilization is 77.8% across the varied
SU demands, well matched to the desired target utilization of 78.0%. Figure 4-22 further
illustrates the percentage of surgical patient boarding delay (bed placement) times that
exceed a 2 hour threshold. These measures are negligible with an average of 0.5%,
significantly below the 5% upper limit criteria.
Lastly, Figure 4-23 illustrates the surgical ACU ward unit capacity, the utilization
rate, and the utilization rate target. The optimal SACU capacity increases linearly as the
change in SU demand increases. Average capacity utilization is 84.1% across the varied
SU demands, closely approximating the desired target utilization of 85.0%. Figure 4-23
illustrates the percentage of surgical patient boarding delay (bed placement) times that
exceed a 2 hour threshold. These measures are negligible with an average of 0.5%,
significantly below the acceptable 5% upper limit criteria.
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40 1.00%
35
30
Patients per Day
25
20 0.50% Discharges
15 Transfers
10 Xfer Delay > 8 hrs (%)
5
0 0.00%
-20% -10% 0% 10% 20%
Figure 4-20: Surgical ward discharges and transfers, and transfer delay exceeding target
12 100%
10
80%
8
SICU Capacity
60% SICU Unit Capacity

6 Utilization Rate
40% Utilization Target
4
Bed Delay > 2 hrs (%)
20%
2 Bed Delay Target (%)
0 0%
-20% -10% 0% 10% 20%
Figure 4-21: SICU unit capacity, utilization rate, and placement delay exceeding target
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60 100%
50
80%
40
SPCU Capacity
60% SPCU Unit Capacity
30 Utilization Rate
20
20% Bed Delay Target (%)
10
0 0%
-20% -10% 0% 10% 20%
Figure 4-22: SPCU unit capacity, utilization rate, and placement delay exceeding target
240 100%
200
80%
160
SACU Capacity
60% SACU Unit Capacity

120 Utilization Rate
80
20% Bed Delay Target (%)
40
0 0%
-20% -10% 0% 10% 20%
Figure 4-23: SACU unit capacity, utilization rate, and placement delay exceeding target
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4.4.3 Observations and Findings
The previously presented results for the multiobjective optimization solution sets
demonstrate the methodology can be used to obtain recommendations for the unit
capacity levels of the surgical unit and surgical inpatient wards. While these results
depict unit capacity levels trending linearly with the change in SU demand, the conditions
are highly controlled. Specifically, in these optimizations certain limiting capacities are
overprovisioned in order to more clearly evaluate the unit capacity levels of interest that
align with the decision variables. The intent is to reveal the restrictive bottlenecking that
may occur for unit capacities of interest when trivial constraints are lessened.
Two restrictive capacity factors discovered in earlier results were addressed
through the overprovisioning and proportional scaling to surgical unit demand. The first
is the capacity of beds configured in the preoperative care area where patients are
prepared prior to surgery. Inadequate bed capacity restricts patient flow when surgical
unit demand increases. Surplus bed capacity simply results in underutilization. The
second is the capacity of beds configured in the postoperative care area, commonly
known as the post anesthesia care unit (PACU), where patients recover from surgery
before being discharged or placed in an inpatient ward. Inadequate bed capacity restricts
patient flow when surgical unit demand increases which in turn will delay new surgery
starts since space is limited in surgery recovery. Surplus bed capacity simply results in
underutilization.
When overprovisioning is not allowed and these capacities are fixed, the
multiobjective optimization is still able to determine solution sets across the changes in
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surgical unit demand. The results, however, illustrate deteriorating performance
satisfying the multiobjective criteria. Four figures specific to the surgical unit operations
are presented below to illustrate the combined effect of these restrictions on unit capacity
recommendations.
First, Figure 4-24 illustrates the variances that appear at 10% and 20% increases
in surgical unit demand, indicating the programming models decline in satisfying an
objective. Second, Figure 4-25 illustrates a dramatic increase in the recommended
operating room theater unit capacity necessary to overcome an insufficient number of
post-operative care recovery beds during peak volumes due to throughput blockages.
Despite these increases in unit capacity, the operating room theater capacity utilization
shows a slow decline, even with an increase surgical unit demand. Third, Figure 4-26
illustrates the pre-operative and post-operative care unit bed capacity utilization rates. As
surgical demand increases, post-operative care bed capacity rapidly achieves maximum
utilization; as a result, pre-operative care bed capacity utilization moderately declines due
to schedule delay that dictates reducing the rate of surgical patient intakes. Finally,
Figure 4-27 illustrates the affects a constrained post-operative bed capacity has on
surgical patient cancellations, and reschedules. Notably, outpatient surgical patients
incur the most impact with increased patient reschedules as the surgical schedule is
disrupted. No impact is observed on the reschedule of inpatient surgical patients, which
receive a higher schedule priority. Little variation is noticed in inpatient cancellations or
patients held overnight in the PACU occurrences.
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1.50
1.25
Index Value
1.00
0.75
0.50
-20% -10% 0% 10% 20%
20 100%
80%
15
OR Capacity
60%
10 Unit Capacity
40% Utilization Rate
20%
0 0%
-20% -10% 0% 10% 20%
Figure 4-25: Surgical unit capacity, utilization, and utilization target
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100%
80%
Percent 60%
Pre-Op Utilization
40%
Post-Op Utilization
20%
0%
-20% -10% 0% 10% 20%
Figure 4-26: Surgical pre-operative and post-operative care unit capacity utilization
0.50%
0.40%
0.30%
Percent
IP Cancellation
IP Rescheduled
0.20%
OP Rescheduled
0.10% PACU Overnight
0.00%
-20% -10% 0% 10% 20%
Figure 4-27: Surgical cancellation rate, rescheduling rate, and patients held overnight
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4.5 Conclusions and Future Work
This chapter presents the first known effort to use a goal seeking approach in
conjunction with a whole hospital model to determine of hospital-wide unit capacities
which satisfy a set of multiobjective criteria. The results demonstrate significant
improvement over alternative approaches, such as the one-at-a-time capacity analysis,
and the method accommodates a more expansive set of multiobjective criteria and
constraints. While costs were not incorporated, the use of weighted penalty functions,
which ensures convexity, performed suitably in obtaining feasible solution set results.
Throughout this chapter a persistent matter of restrictive capacities, other than
those imposed by the decision variables, within the simulation model is encountered. In
certain cases maintaining these restrictions is appropriate, for example where long-term
structural limitations exist, and the resulting endogenous dynamic behavior is of interest.
However, in some cases restrictions are imposed by limitations associated with flexible
resources or capacities that can be adjusted in the short-term or within a planning
horizon. Although overprovisioning and resource scaling may be used to circumvent
these restrictive capacities, it is very difficult to discern which factors in the simulation
model will become restrictive under particular conditions. The next chapter addresses a
similar challenge utilizing a factor screening methodology to determine which factors
have the most impact on change. Such methods could be used to identify factors that
should be included in future problem formulations or disregarded altogether.
Finally, this chapter concludes with comments on solution set results and issues
pertaining to future work. The resulting unit capacity utilizations for both intensive care
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units were 3% to 5% higher than the specified utilization targets, even though they
received relatively strong weightings. Although concerning, other performance measure
objectives related to critical patient flow, which received the highest weightings, were
satisfied. The utilization targets were established with insight to results from other
analytic models, subject-matter-expert guidance and rule-of-thumb. This suggests that
the utilization targets be further explored. Perhaps future work should consider
incorporating elements of risk in the model performance measures, especially in cases
where a small unit lack of vacancy may have a significant impact.
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CHAPTER 5 SENSITIVITY ANALYSIS USING THE OVERALL CAPACITY
EFFICIENCY METRIC
5.1 Introduction
Developing a system dynamics based simulation model provides a natural means
to describe the flow of patients, resources, materials, and information in a whole hospital
where interdependencies between clinical and ancillary units exist. Incorporating
information about the condition and state of these units affords an opportunity to explore
the hospital-wide dynamic behavior in a manner not previously investigated. In the
literature for emergency department and hospital operations a commonly discussed and
studied problem is that of restricted patient flow and congestion (GAO, 2009; Hoot and
Aronsky, 2008; Moskop et al., 2009a, 2009b; Trzeciak and Rivers, 2003). Frequently,
improvement studies aimed at improving emergency department patient flow and
congestion have concluded with the analysis that inability to board patients in a timely
manner is the problem. Seeking to improve the situation, experts in healthcare and
operations management propose various methods to control patient flow (Adini et al.,
2011; Hall, 2013), improve capacity management (Proudlove et al., 2003; Story, 2010),
and optimize operational throughput (Shiver and Eitel, 2009). Additionally, simulation
studies are used to investigate emergency department overcrowding problems by
improving patient flow and resource utilization (Paul et al., 2010). Exploiting the whole
hospital system dynamics model we demonstrate it is possible to examine the
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mechanisms beyond the emergency department boundary to identify constrained unit
capacity impeding performance.
Measuring performance of the emergency department with respect to hospital-
wide capacity presents a challenge. Under an ideal situation it would be desirable to
measure the input, throughput, and output performance of the emergency department;
however, since activities vary greatly depending on a patient’s condition, use of such a
measure provides limited insight. In practice, emergency departments diligently monitor
and report the level of congestion, or overcrowding, present using a scale or index
reference and respond when necessary to avert a crisis situation, if possible. Two such
reference calculations are presently utilized in the United States: the National Emergency
Department Overcrowding Scale (NEDOCS), and the Emergency Department Work
Index (EDWIN). These models attempt to quantify emergency department crowding
conditions using a set of operational variables with the degree of crowding as assessed by
physicians and nurses. Differences in the effectiveness of these two calculations are
described and compared by Weiss et al. (2006). Additionally, study by Hoot et al.
(2007) and Hoot and Aronsky (2006) investigated use of the calculations to forecast the
potential for overcrowding. Lost with these models is any information or guidance that
would indicate the cause of the overcrowding.
In this work, we develop a performance metric based on the Overall Equipment
Effectiveness (OEE) hierarchical metric modified to fit the emergency department
context. OEE was first described by Seiichi Nakajima in the 1960’s as part of the total
productive maintenance (TPM) improvement initiative (Nakajima, 1988). Since then, the
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literature has become populated with guides, references, applications, and evaluations
that demonstrate OEE implementation benefits in the industrial setting (De Ron and
Rooda, 2006; Hansen, 2002; Muchiri and Pintelon, 2008; Stamatis, 2010). The benefit
this metric offers in the ability to examine not only a composite index, but also individual
indices for availability, performance, and quality, helps facilitate the identification of
factors responsible for poor performance. Use of this metric for the emergency
department is demonstrated by conducting a sensitivity analysis for the whole hospital
model. Due to the scale of the model, a factor screening method was first applied to
identify the most important factors followed by regression methods in order to determine
the most relative factors.
In Chapter 2 we described the system dynamics simulation model used to
represent the whole hospital for a medium size, semi-urban, community hospital. This
chapter presented interesting results evaluating the timely throughput for patient flow
hospital-wide. The metric proposed within will help complement those findings and
assist in providing enhanced detail.
Analysis of the prior chapter’s findings yielded a number of recommended
extensions and embellishments, some which have been incorporated into the model used
in this study. Notably, improvements were made in the level of detail for service times
and the variety of diagnostic resources present in both the diagnostic laboratory and
radiology imaging areas of the model. This detail was also extended to include the daily
demands originating from physician rounding, preoperative/operative surgical
procedures, outpatient activity, and as well as onsite clinic. As a result, a more realistic
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representation of the workload and prioritization in these ancillary services has been
achieved. In addition, structure was added in the emergency department to align with
the origination of diagnostic testing requests, and reflect the often recursive nature of test
orders precipitating from physician consultation. The staff at UNC Hospitals in Chapel
Hill helped to provide valuable insight and data for representing these areas in the model,
and offered guidance on how to improve the model functional detail and scalability.
The remainder of this chapter is used to present a paper that describes the
establishment of an innovative metric for measuring the emergency department
performance attributes and utilize this metric to conduct a sensitivity analysis on the
whole hospital model. This paper was published in Proceedings of the 2014 Winter
Simulation Conference (WSC), held in Savannah Georgia USA, which has been included
in its entirety within, absent the authors’ biographies. This paper is co-authored with
Professor Stephen D. Roberts.
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5.2 Proceedings of the 2014 Winter Simulation Conference
The subsection is organized into two sections. First we present the paper that
appeared in the Proceedings of the 2014 Winter Simulation Conference titled “Sensitivity
Analysis for a Whole Hospital System Dynamics Model.” Second we present
supplemental work that provides further verification and analysis for the sensitivity
analysis conducted in the paper.
5.2.1 Proceedings Paper
Inserted in this section is the proceedings paper of the 2014 Winter Simulation
Conference.
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5.2.2 Supplemental Analysis
In the proceedings paper presented in the previous section a significant amount of
information regarding the sensitivity analysis findings were shown in table form. Due to
imposed space constraints it was not possible to include additional illustrations to that
might be of interest to the reader. Attempts to illustrate the numerous combinations of
factors included in the sensitivity analysis would simply be overwhelming and space
consuming. Therefore, in this section we provide a series of simple one-at-a-time (OAT)
analysis radar charts illustrating the OCE metric response to the percentage change for
the eight factors selected among the group screen design results. Results in the radar
chart for the OCE component metrics demonstrate similar behavior as identified in the
group screening design for the individual factors as shown in Table 1 of the paper. This
provides some verification that the proper first order effects were indeed identified.
The overall OCE composite metric is illustrated in Figure 5-1. This figure
illustrates the response in the OCE composite metric to the percentage change in the
individual unit capacity factor as identified. Using the OAT approach, we observe a
significant impact on the OCE metric when (1) increasing the ED patient arrival rate
(edARRV), (2) decreasing the number of medical ACU ward beds (mwACUBED), (3)
increasing the medical ACU ward length-of-stay, (4) increasing the direct medical patient
arrival rate (dmaARRV), and (5) varying the number of ED treatment rooms. The least
noticeable change occurred with variations in the factors for the laboratory capacity
(labCAP), and the radiology capacity (radCAP). It is also important to note that in
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certain cases an increase or decrease is observed not to appreciably affect the metric.
This may due to the existence of sufficient, or potentially surplus, unit capacity.
The OCE availability component metric is illustrated in Figure 5-2. This figure
illustrates the response in the OCE availability component metric to the percentage
change in the individual unit capacity factor as specified. Once again using the OAT
approach, we observe that (1) decreasing the number of medical ward ACU beds
(mwACUBED), (2) increasing the length-of-stay in the medical ward ACU beds
(mwACULOS), and (3) increasing the direct medical admissions (dmaARRV),
demonstrate the greatest decline in OCE availability metric. The least noticeable changes
occurred with variations in the factors for laboratory capacity (labCAP), radiology
capacity (radCAP), and the ED treatment cycle time (edTMTCT).
The OCE performance component metric is illustrated in Figure 5-3. This figure
illustrates the response in the OCE performance component metric to the percentage
change in the individual unit capacity factor as specified. Using the OAT approach, we
observe that (1) the decreasing the number of medical ward ACU beds (mwACUBED),
(2) increasing the length-of-stay in the medical ward ACU beds (mwACULOS), (3)
varying the ED patient arrival rate (edARRV), (4) varying the number of ED treatment
rooms (edTMTRM), and (5) increasing the direct medical arrival rate (dmaARRV),
realize the greatest change in the OCE performance metric. A noticeable response is
present for most all factors in the radar chart shown.
Lastly, the OCE quality component metric is illustrated in Figure 5-4. This figure
illustrates the response in the OCE quality component metric to the percentage change in
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the individual unit capacity factor as indicated. A sizable response is observed to occur
for all factors except radiology capacity (radCAP), laboratory capacity (labCAP), and the
emergency treatment cycle time (edTMTCT). Increases associated with the factors for
direct medical patient arrivals (dmaARRV), ED patient arrivals (edARRV), and length-
of-stay for medical ward ACU beds (mwACULOS), reduce the quality score. An
increase associated with the number of ED treatment rooms (edTMTRM) improves the
quality score. A decrease associated with the factor for ED patient arrivals (edARRV)
improves the quality score. A decrease associated with the factors for the number of
medical ward ACU beds (mwACUBED), and the number of ED treatment rooms
(edTMTRM), reduces the quality score.
dmaARRV
50%
radCAP 25% edARRV

-10%
0%
-5%
-25%
-1%
labCAP -50% edTMTCT 0%
1%
5%
10%
mwACUBED edTMTRM
mwACULOS
Figure 5-1: OCE composite metric responding to percentage change
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dmaARRV
20%
radCAP 10% edARRV

-10%
0%
-5%
-10%
-1%
1%
5%
10%
mwACUBED edTMTRM
mwACULOS
Figure 5-2: OCE availability component metric responding to percentage change
dmaARRV
20%
radCAP 10% edARRV

-10%
0%
-5%
-10% -1%
1%
5%
10%
mwACUBED edTMTRM
mwACULOS
Figure 5-3: OCE performance component metric responding to percentage change
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dmaARRV
20%
radCAP 10% edARRV

-10%
0%
-5%
-10% -1%
1%
5%
10%
mwACUBED edTMTRM
mwACULOS
Figure 5-4: OCE quality component metric responding to percentage change
In addition to the OCE metric results we provide an additional illustration using
the response for patients that leaving-without-being-seen or treated from the emergency
department area, mainly attributed to delay or congestion. It is observed that variations in
nearly all factors, except laboratory capacity (labCAP), have a potential influence on the
left-without-being-seen (LWBS) rate.
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dmaARRV
120%
90%
radCAP 60% edARRV
30%
0% -10%
-30% -5%
-60%
-1%
-90%
1%
5%
10%
mwACUBED edTMTRM
mwACULOS
Figure 5-5: LWBS rate measure responding to percentage change
5.3 Extensions and Limitations
The proceedings paper appearing earlier in this chapter introduces the proposed
Overall Capacity Efficiency (OCE) metric and demonstrates its benefit in conducting a
sensitivity analysis for the whole hospital. Based on the experience of developing and
using the metric, this section first describes possible extensions, and second discusses
some of its limitations that may warrant further investigation.
5.3.1 Extensions
Two extensions of the Overall Capacity Efficiency metric are suggested. First,
the OCE metric can be redefined and reconfigured for use in the surgical department.
While the surgical department is more controllable through scheduling and procedural in
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nature, there are instances where congestion and schedule overruns do occur. A
modification of the OCE metric in the context of the surgical department might be useful
in identifying those unit capacity factors contributing to poor performance.
Second, as presented in the paper the OCE metric treats the flow of all patients
with equal importance and priority. Inherent to our whole hospital system dynamics
model the patients are considered well mixed both in flows and stocks. Therefore, it is
often difficult to identify individual differences such as patient acuity or calculate a case
mix index. This loss of detail could be mitigated by segmenting similar patient types but
at great cost in the added complexity introduced to the model. If we could clinically
stratify and track patients using a reference, such as the five-level Emergency Severity
Index (ESI) used in triage, we could further embellish the OCE metric using a weighted
measuring scheme with prioritization corresponding to patient acuity levels. While
attractive, incorporating this feature might be best left for a discrete event simulation
model, or a mixed model environment, where individual attributes are retained.
5.3.2 Limitations
Calculating the OCE metric for the performance subcomponent in particular
requires advance knowledge of the theoretical length-of-stay times for patients admitted
and discharged (TLOSa, TLOSd). This time specification would likely be based on
estimates through historical records, or from expert input, or through goal setting. The
uncertainty in the specification for this time specification may have a negative influence
on the calculated OCE metric result. In the WSC paper we observe the case in Figure 3
for a period of time between hours 11 AM and 4 PM where the actual length-of-stay was
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less than the expected theoretical length-of-stay, resulting in an OCE performance
subcomponent score that was greater than one. In this particular case a decision was
made to restrict the score such that they do not significantly exceed a value of one.
5.4 Conclusions
In this chapter we proposed and developed a performance measure based on the
well-known Overall Equipment Effectiveness (OEE) metric, which we refer to as the
Overall Capacity Effectiveness (OCE) metric, to provide a useful performance measure
representative of emergency department operations. The OCE metric demonstrated to be
a useful performance measure which can be separated into three components,
corresponding with availability, performance and quality dimensions. This allows for an
in-depth examination into unit capacity factors influencing both dynamic behavior and
system performance. The proceedings paper presented in this chapter illustrates the
benefit of using the OCE metric for conducting a sensitivity analysis of the whole
hospital system dynamics model. In this study, a group screening method known as
sequential bifurcation was first used to individually evaluate the OCE metric components
in order to identify the unit capacity factors that were most important to system
performance. All identified important factors were then used as the basis for performing
the sensitivity analysis using regression analysis to determine which factors were the
most important for improving system performance. The regression analysis results with a
second-order polynomial model revealed both main and interactive effects in the model,
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which correspond to the unit capacity factors. These findings have been summarized in
the proceedings paper.
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CHAPTER 6 EXPLORING HOSPITAL RESILIENCE TO DEMAND SURGE
6.1 Introduction
A sudden sizable patient demand surge due to a disruptive event can have a
significant impact on hospital operations in the days and weeks that follow. Hospital
disaster preparedness establishes a plan and guidelines with regard to the use of space,
staff, supplies and standard of care. Less understood, however, are the capacity
dynamics, which must adapt over the duration of the demand surge event in order to
effectively facilitate patient flow and avoid points of congestion hospital-wide.
Ineffective strategies that either restrict capacity adaptation options or delay their
activation will result in poor outcomes and extend the time duration required for the
hospital to return to normal conditions.
This research explores hospital resilience to patient demand surge. The whole
hospital model is extended with several modifications to respond to a demand surge,
including a bed management control process and adaptive capacity features. The whole
hospital model is configured to represent a community hospital and a natural disaster
event is simulated to generate a patient demand surge. Hospital resilience is explored
using strategies formulated with combinations of the adaptive capacity features enabled
with varied specifications. Outcome results for recovery times are presented with respect
to varying demand surge volume and time.
This chapter is organized into five major sections. First, the literature related to
patient demand surge and capacity management is reviewed. Second, the problem
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framework which establishes the foundation for adaptive capacity and modifications to
the whole hospital model is discussed. Third, the methodology used to explore hospital
resilience is described. Fourth, the observations and analysis from experiment outcome
results are presented. Finally, conclusions determined from these analyses useful to the
hospital administrator are offered, along with guidance for future work.
6.2 Literature Review
Hospital resiliency is an emerging concept that has become prominent in recent
years with increased focus on emergency management preparedness relating to natural
and manmade disasters. Recent major disasters such as Superstorm Sandy, the Haiti
earthquake, Hurricane Katrina, and the events of September 11th have brought attention
to the need for increased health system preparedness, as well as improving health system
resiliency. In this context, hospital resiliency is described as the ability of hospitals to
resist, absorb, and respond to the impact of disasters while maintaining and surging
essential health services, and then to recover to its original state or adapt to a new one.
According to Zhong et al. (2014), this implies “a comprehensive perspective of a
hospital’s ability to cope with disasters include inherent strength (ability to resist and
absorb disasters) and adaptive flexibility (strategies for maintaining and surging essential
health services and adaptation for future disasters)”. Although the meaning of hospital
resiliency may be broadly interpreted, hospital resilience aims to improve hospital pre-
event strength, thus promoting the rapidity of response and recovery, through redundant
resources and resourceful strategies.
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While hospital resilience to large scale disasters has received significant attention
and funding in recent years, the majority of this work is pre-event or preparedness
oriented in nature. Despite the vast amount of resources involved in this effort, rarely
will these plans be called into action and little empirical evidence is available to support
such planning. In comparison, hospitals across the nation face a more frequent concern
that involves being unable to care for the number of arriving patients requiring immediate
or emergent care due to insufficient capacity. Hospital administrators conclude once a
hospital receives one more patient than they are equipped to provide for at the expected
level of care, they have reached an internal hospital crisis. Improving hospital
operational resiliency in the context of mitigating or averting such internal crises reduces
both the magnitude of the operational deterioration in performance and its duration.
Limited research has been conducted to examine hospital resiliency related to internal
hospital crises.
A closely related topic to hospital resilience is that of health care system surge
capacity. Although still emerging, surge capacity as a concept suffers from the lack of a
unifying terminology and standards. Watson et al. (2013) present a state of the art review
for surge capacity, and identify future priorities. They identify the considerable variation
in concepts, terms, definitions and applications, as well as the absence of detailed and
comparable data, which pose barriers to the organization and advancement of the
concept. These differences are evident in proposed conceptual frameworks for surge
capacity (Bonnett et al., 2007; Kaji et al., 2006) and hospital resilience (Zhong et al.,
2014; Zhong et al., 2015).
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Surge capacity research is dominated by studies that focus on resource
preparedness for terrorism (CDC, 2007; Kearns et al., 2014; Waage et al., 2013), natural
disasters (Lurie et al., 2013) and pandemic events (Adisasmito et al., 2015).
Preparedness also includes applications which predict surge demand (Chase et al., 2012),
model resource requirements (Stein et al., 2012), identify resource gaps (Adisasmito et
al., 2015; Rudge et al., 2012), determine patient allocation (Sun et al., 2014), and support
resource deployment (Salman and Gul, 2014). Stratton and Tyler (2006) describe the
characteristics of the demand for medical care for a community in the initial phases
during sudden-impact disasters. Guidance on the standard of care provided during surge
capacity event is well established (Altevogt, 2009; IOM, 2012; Koenig et al., 2011) and
proposed measures of quality are being developed (Bogucki, 2012).
A major area of opportunity includes the development of strategies for managing
or allocating scarce resources during mass casualty events (Barbera and Macintyre, 2009;
Boyer et al., 2009; Kelen et al., 2009). This includes considerations to support a surge
response through equipment stockpiling, medical supply stockpiling, staff preparation,
space and capacity allocation, deployable critical care services and transportation (Einav
et al., 2014). Timbie et al. (2013) presents a systematic review of strategies that
concludes the current evidence base is inadequate to inform policymakers on appropriate
strategies. Insightful strategies include Hick et al. (2004) for patient care surge capacity
and Hick et al. (2012) for principles for allocating scarce resources in disasters. Current
insights in the form of lessons learned in managing past surge capacity events include
natural disasters (Adalja et al., 2014; Kanter, 2012), terrorist events (Tadmor et al.,
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2006), impact of a hospital closure (Adalja et al., 2011), and measurable financial
impacts (Braithwaite et al., 2013). Although considerable research activity is taking
place for surge capacity, considerable gaps exist in the research that mandate the
development of better strategies to manage and allocate capacity using evidence based
methods.
Few examples are found in the literature where hospital resiliency under patient
surge demand has been studied using simulation modeling. Lane et al. (2000)
constructed a whole hospital system dynamics model specifically to study the long term
policy concerns of the public regarding the impact of planned adjustment to bed capacity
on long waiting times for admissions versus accident and emergency department
admission delays. An extension of this work considered a historical hospital internal
crisis event resulting from an unexpected patient surge. Although the extension was
insightful to better understanding the unfolding crisis, no additional study conducted to
develop guidance on how hospital resiliency could be improved. Hirsch (2004)
constructed a system dynamics model to explore the consequences of incidents for health
care systems where major catastrophes have occurred. While the health care system is
the focus, this work is mostly concerned with the capacity for dealing with widespread
damage to health care facilities and the consequences on the community as a result. The
work does not provide guidance on improving hospital resiliency or adjusting unit
capacity. Hoard et al. (2005) introduces a conceptual framework using systems modeling
to study rural disaster preparedness and planning (Manley et al., 2006). The framework
is used to consider four major types of disaster events likely to occur in the rural
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environment where outside assistance may be delayed three or more days. Using
preplanned policy-oriented responses to a disaster event the impact on performance and
the time to recovery were assessed. The work focused mainly on preparedness and did
not employ any methods that provided guidance on how hospital operational resiliency
could be improved.
This research seeks to fill a gap in the literature by examining how capacity may
affect hospital operational resiliency and recovery time in response to patient demand
surge events.
6.3 Problem Framework
Hospitals face daily challenges in matching patient demand with limited medical
resources. To succeed in their mission a hospital must address five capacity concerns.
First, the emergency department must be appropriately sized and staffed to provide
adequate access to emergency treatment in a timely manner with respect to patient acuity
levels and discourage patients from leaving-without-being-seen. Second, the hospital
must proactively monitor and coordinate capacity allocation hospital-wide to prevent
patient congestion and bed blockages. Third, the hospital must maintain adequate
resource and capacity availability such that the surgery schedule is not disrupted either
due to cancellation or rescheduling. Fourth, the hospital must manage and coordinate
inpatient capacity to ensure patients receive the appropriate treatment and recovery stay
durations to avoid possible hospital admission. Last, the hospital must be able to adapt
capacity to meet a wide range of patient demand surge fluctuations.
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A disruptive surge event resulting in a significant patient demand surge volume
makes accomplishing these objectives more difficult. A sudden demand surge of arriving
patients can quickly exceed the on-hand medical capability and capacity. Initially, the
emergency department will be the main recipient of these patients. However, the effects
of the disruptive event will soon impact activities hospital-wide. The hospital must
quickly adjust by increasing capacity availability to facilitate patient flow throughout the
hospital and prevent bottlenecks. Generally, this implies that various areas of the hospital
must move from the conventional operating mode to a contingency or crisis operating
mode to muster resources and additional capacity. The consequence of failing to do so in
a timely manner will likely be seen first in the emergency department as the inability to
accommodate higher acuity patients due to capacity blockages.
A disruptive surge event can be considered in terms of a shock to the system that
affects a key performance measure, as illustrated in Figure 6-1. Sheffi and Rice (2005)
detail the eight phases, identified in the figure, that occur as a resilient enterprise
responds to a shock. Similarly in the hospital enterprise, preparation is made in advance
with the establishment of hospital disaster plans and policies for the use of hospital staff,
medical supplies and facility space. Once a disruptive surge event occurs, the hospital
experiences a period of initial impact due to the arriving patient demand surge and a
period of preparation for recovery, or adaptation, necessary to meet the demand. The
time required to recover, either to the original baseline or a new normal, is of primary
interest. The elapsed time from the initial event to the recovery is used to assess the
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competitiveness among surge response policies or strategies. Erol et al. (2010) provide
perspectives on how enterprise resilience to disruptions can be measured.
Figure 6-1: A disruptive event impact and recovery timeline (Sheffi and Rice, 2005)
The remainder of this section presents four topics that include: (1) the
representative hospital used in the study; (2) the hospital adaptive capacity used to
respond to patient demand surge; (3) the modifications implemented in the whole hospital
model; and (4) the illustration of the adaptive features in action. These topics establish
the foundation for the exploration pursued in subsequent sections.
6.3.1.1 Hillsborough Hospital
In this research the whole hospital model is configured to represent a newly
constructed, medium size, semi-urban community hospital, known as Hillsborough
hospital, which is located in the Town of Hillsborough, North Carolina. Hillsborough
hospital was constructed by the UNC Health Care system to improve community access
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to care and to alleviate congestion in the nearby UNC Medical Center campus located 15
miles to the south in Chapel Hill. The hospital situated on a 40 acre campus with a
265,000 square foot new hospital that includes a bed tower wing and a diagnostic and
treatment center, a 60,000 square foot medical office building, and a 14,000 square foot
central utility plant. Figure 6-2 below shows an architectural rendering of the hospital
entrance and bed tower wing. The $200 million hospital complex includes 50 licensed
acute care unit floor beds, 18 licensed intensive care unit beds, six operating rooms, two
procedure rooms and an emergency department, with a planned staff of 500. Emergency
department operations began in July 2015 and hospital operations opened in August
2015.
Figure 6-2: Architectural rendering of UNC Health Care Hillsborough campus
Hillsborough hospital is organized into four units that consist of an emergency
department, a surgical unit, an inpatient intensive care unit, and an inpatient acute care
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unit. The emergency department maintains a total of 10 treatment rooms that can be used
for patients of all acuity level, and an urgent care desk used only for low acuity patients
during peak hours. Under a demand surge event, nearby clinical space could be
repurposed to provide treatment space for up to three low acuity patients at a time, given
available medical staff.
The surgical unit consists of preoperative, intraoperative, and post-anesthesia care
units. The preoperative care unit maintains 29 bays where patients receive preparation
for surgery. The intraoperative unit maintains a total of 6 operating rooms and 2
procedure rooms used for performing surgery. The post-anesthesia care unit (PACU)
maintains 18 postoperative bays to provide care for patients recovering from anesthesia.
Licensed inpatient bed capacity is equally divided between surgical and medical
wards for both intensive care unit and acute care floor unit beds. The surgical ward bed
capacity consists of an intensive care unit with 9 beds and a traditional floor unit with 25
beds. The medical ward consists of an intensive care unit with 9 beds and a traditional
floor unit for acute care patients with 25 beds. The capacity within the Hillsborough
hospital extends beyond the number of licensed beds. Under a demand surge event
additional areas of capacity will be drawn upon to augment the licensed bed capacity.
This will be further described in the next section on hospital capacity adaptation.
All practices cited in this study were developed in conjunction with the hospital
director. As the facility matures, the configuration and practices presented in this study
may evolve over time.
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6.3.2 Hospital Capacity Adaptation
Hospital capacity adaptation involves the modification of the capacity allocated to
specific areas of the hospital to improve the patient flow and accommodate patients. The
capacity allocated may include staffed bed capacity, unstaffed bed capacity, flexible bed
capacity, and reserve bed capacity. Reserve bed capacity is drawn mainly from the
surgical unit in the form of preoperative care unit bays to serve as floor beds, and post-
anesthesia care unit bays to serve as critical care beds.
Activation of these resources is dependent on the transition between the hospital
operational modes, or states. These states include: (1) the conventional operating state
where the base bed capacity is sufficient in satisfying demand; (2) the contingency
operating state where the base capacity is insufficient and additional resources must be
called upon to satisfy demand; (3) the crisis operating state where the base capacity may
have been compromised or where resources under the contingency operating state are
insufficient to satisfy demand. Activation of the contingency or crisis operating state
influences decisions to cancel surgery, reschedule surgery, activate ambulance diversion,
initiate inpatient early discharge, and transfer patients externally.
Table 6-1 provides the Hillsborough hospital capacity adaptation schedule
corresponding to the disaster preparation plan. This schedule shows the capacity levels
that include the maximum allocated quantity, the conventional state quantity, the
contingency state quantity, and the crisis state quantity. The schedule identifies the
sources of capacity and the potential locations for allocation. Capacity is allocated in
proportion to forecasted demand.
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Table 6-1: Hillsborough hospital unit capacity allocation adaptation schedule
Unit Unit Unit Capacity Allocated by Operational State

Description Capacity Conventional Contingency Crisis
Emergency Department:
ED treatment rooms 12 10 11 12
Critical Care (ICU-PCU):

Medical beds 9 5 9 9
Surgical beds 9 5 9 9
Reserve (PostOp bays) - - 6 12
Critical Care Capacity 10 24 30
Standard Care (ACU):

Medical beds 25 20 25 25
Medical - Flexible beds 5 - 5 5
Surgical beds 25 20 25 25
Surgical - Flexible beds 5 - 5 5
Reserve (PreOp bays) - - 12 18
Standard Care Capacity 40 72 78
Surgical Department:
PreOp unit bays 29 29 17 11
PostOp unit bays 18 18 12 6
6.3.3 Model Modifications
The whole hospital model previously described in Chapter 2 requires several
enhancements to explore the effects of adaptive capacity features on hospital recovery in
response patient demand surge. This section presents the modifications, which include:
(1) the implementation of split patient flows according to patient acuity within the
emergency department; (2) the implementation of the hospital operational states; (3) the
implementation of high congestion states for ED and surgical unit; and (4) the
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implementation of the adaptive capacity features used to respond and recover from a
demand surge event.
Three causal loop diagrams are used to illustrate these enhancements and identify
the relationship between the model structure, the operational states, the congestion states
and the adaptive capacity features. Figure 6-3 illustrates the causal loop diagram for
patient flow through the emergency department and into the inpatient wards. Figure 6-4
illustrates the causal loop diagram for patient flow through the surgical unit and into the
inpatient wards. Figure 6-5 illustrates the causal loop diagram for the bed capacity
management control process used to negotiate and allocate capacity.
6.3.3.1 Split Patient Flows
Split patient flows allow patients of varying acuity levels to be prioritized and
treated differently within the emergency department processes. For example, a high
acuity patient should receive the immediate life preserving care as needed and a low
acuity patient may have to wait to be seen by a physician. In the face of a patient demand
surge event, hospital recovery times will be influenced by the activities performed
hospital-wide which are dependent on patient acuity levels and timings; therefore, it is
important to include this level of detail.
Wuerz et al. (2000) introduced the Emergency Severity Index (ESI) triage
algorithm to evaluate patient acuity during the registration and assessment process upon
arrival at the emergency department. The algorithm is a five-level tool used to categorize
patients based on the immediacy of intervention to preserve life and anticipated resource
demand. Over time, the ESI algorithm has received refinements and validation (Eitel et
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al., 2003; Elshove‐Bolk et al., 2007; Tanabe et al., 2004; Wuerz et al., 2001). Improved
emergency department patient flow and operation are often realized following
implementation (Daniels, 2007). The Agency for Healthcare Research and Quality
maintains an implementation handbook for practitioners (AHRQ, 2013). Experienced
ED nurses use the ESI to rate patient acuity, from level 1 (most urgent) to level 5 (least
resource intensive). The ESI is unique among triage tools in including both acuity and
resource needs in its system of categorizing ED patients. A flow diagram for the ESI
triage algorithm version 3 appears in Appendix C, as presented and discussed in Tanabe
et al. (2004).
In the model, the ESI triage algorithm is used to identify patient acuity and
determine the split patient flow followed. For the demand surge event, the injuries or
illnesses sustained will affect the hospital surge response and recovery. In Hillsborough
hospital, the ESI breakdown and split patient flows for arriving patients is illustrated in
Appendix D. Model parameter values are presented in the tables found in Appendix B.
As illustrated in the figure, higher acuity patients receive prioritization into the
ED treatment area. During periods with heavy patient demand, lower acuity patients
must often wait until demand abates. Blockage and congestion may occur in the ED
when insufficient bed capacity availability exists to board a patient requiring admission
and they cannot be moved from the treatment room occupied. This restricts throughput
in the ED resulting in further delays.
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6.3.3.2 Operational States
The continuum of surge capacity is described by the National Incident
Management System (2009), in the Guidance for Establishing Crisis Standards of Care
for Use in Disaster Situations. Hick (2009) introduces the organization and relationship
between the continuum of surge capacity and hospital operational states, which include
the conventional, contingency and crisis operational states. Additionally, Hick et al.
(2010) describe the surge capacity and infrastructure considerations for mass critical care.
The relationship between hospital operational states, infrastructure concerns, and incident
demand are illustrated in Appendix E.
The hospital operational states communicate and activate features within the
model that adapt to conditions as needed and manage negotiation of the bed capacity
allocation or reallocation process. The three hospital operational states, which include
the conventional, contingency and crisis operational states, are described in Table 6-2
below. The activated contingency and crisis operational states are depicted in relation to
the model structure in the causal loop diagrams presented in Figure 6-3, Figure 6-4, and
Figure 6-5.
6.3.3.3 Congestion States
The emergency department high congestion state communicates the need to
release flexible bed capacity or expand treatment capacity in order to alleviate congestion
and improve patient flow. The surgical unit high congestion state communicates the need
to release flexible bed capacity to alleviate congestion. Table 6-3 describes
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implementation of the congestion states. Additionally, the activated high congestion
states are depicted in relation to the model structure in the causal loop diagrams presented
in Figure 6-3, Figure 6-4, and Figure 6-5.
Table 6-2: Description of operational states
State Description
Conventional Default state condition if sufficient bed capacity availability to meet demand
exists with the base bed capacity allocation.
Contingency Activate if less than 2 floor beds or 1 ICU bed remain available in the
inpatient wards under the conventional state, or if forecasted bed capacity
availability is expected to be insufficient to meet demand using the maximum
conventional state allocated capacity. Activation will release flexible bed
capacity and reserve bed capacity proportional to demand. Activation may
enable ED capacity expansion. Monitor hourly upon activation.
Crisis Activate if less than 1 floor bed or 1 ICU bed remain available in the inpatient
wards under the contingency state, or if forecasted bed capacity availability is
expected to be insufficient to meet demand using the maximum contingency
state allocated capacity. Activation will release additional reserve bed
capacity proportional to demand and enable ED capacity expansion.
Table 6-3: Description for congestion states
State Description
ED high congestion Activate to release flexible bed capacity if 30% or more of the treatment
rooms are blocked by patients on admission hold for an available inpatient
bed after 8pm. Release ED capacity expansion if condition persists for more
than 2 hours. Monitor hourly upon activation.
SU high congestion Activate to release flexible bed capacity if 30%, or more, of the postoperative
care unit bays are blocked by patients waiting for an available inpatient bed in
the surgical ward. Monitor hourly upon activation.
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6.3.3.4 Adaptive Features
Adaptive capacity features respond to the condition of the hospital determined by
the active operational or congestion states. Table 6-4 below describes the emergency
department adaptive features and Table 6-5 describes the hospital adaptive features
implemented in the model. The ED adaptive features and the hospital adaptive features
are illustrated in causal loop diagrams presented in Figure 6-3 and Figure 6-4,
respectively. The adaptive capacity features included in the model were validated by the
Hillsborough hospital director.
Table 6-4: Description for ED adaptive features
Feature Description
Ambulance diversion Activate ambulance diversion state to divert ambulance transported
patients to other hospitals when severe congestion, long waiting delay
times, or treatment room blockage persist in the ED.
ED capacity expansion Activate between 1 and 3 makeshift treatment spaces in the ED to expand
throughput if an ED high congestion state, a hospital contingency state, or
a hospital crisis state is active. Monitor hourly upon activation and
withdraw after 4 hours of weak demand.
Urgent care desk Activate urgent care treatment space in the ED for simple treatment of low
acuity patients (ESI 4 & 5) on a regular daily schedule and when a hospital
contingency state, or hospital crisis state is active.
Waiting patient transfer Activate the transfer of transportable medium acuity patients away from
the ED waiting area to an external facility at a specified rate during the
surge event and initial recovery response.
Holding patient transfer Activate the transfer of transportable patients occupying a treatment room
while on admission hold due to inpatient bed availability to an external
facility at a specified rate during the surge event and initial recovery
response.
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Table 6-5: Description for hospital adaptive features
Feature Description
Early discharge Activate the early discharge of inpatients from the floor wards if
forecasted demand indicates insufficient available bed capacity. Early
discharge reduces a patient length-of-stay up to a maximum specified
percentage for both ICU and floor bed wards. Aggressive reductions that
are sustained will result in elevated readmission rates.
Inpatient transfer Activate the transfer of a specified predetermined number of transportable
low acuity inpatients to an external facility to increase available bed
capacity with a declared disaster.
Flexible bed capacity Activate the release and allocation of flexible bed capacity, which consists
of unstaffed bed capacity and temporary bed capacity erected within the
medical and surgical floor units. Initiated when the contingency or crisis
state is active.
Reserve bed capacity Activate the release and allocation of reserve bed capacity, which consists
of reallocating and repurposing some of the preoperative care unit bays for
floor equivalent beds and postoperative care unit (PACU) bays for critical
care equivalent beds. Initiated when the contingency state or a crisis state
is active.
Surgery cancellation Activate the cancellation and reschedule of scheduled elective surgery in
proportion to the need if: (1) the forecasted demand indicates insufficient
available surgical ward bed capacity; (2) the surgical time remaining is
insufficient; or, (3) the preoperative care unit bay capacity or postoperative
care unit (PACU) bay capacity have been repurposed.
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Activate ED ED Patient Activate Inpatient
ED Discharged
Patient External External Transfer Inpatient External External Transfer
Treatment Delay Rate
Transfer Rate Transfer
S S O S S
ED Patient Inpatient
ED Waiting
Discharge Rate Transfer
Patient Transfer S S
S Inpatient Ward Activate Inpatient
Activate Ambulance ED Admitted Treatment Delay Early Discharge
Diversion State B2 B5 Treatment Delay B9
ED Patient Arrivals S
O S O S O S O S O S O
Regular S
S ED Patient Patients Occupying Patient Treatment Patients Occupying
ED Patient Arrivals S B3 ED Patient Patients Occupying Inpatient Ward
Arrival Rate Waiting Area Area Intake Rate Treatment Area B6 B10
Surge Admission Rate Inpatient Ward Discharge Rate
S S B8
S O O S B4 O O
O
R1 B1 S O
Waiting O B7 Inpatient Ward
Delay Time Bed Availability
S ED Treatment S
Returning LWBS S O
Patient Arrivals Patient LWBS Room Availability S
Reported ED High
Rate Congestion State Inpatient Ward S S
S S S
Bed Capacity S Potential
Readmission S S S Allocated Inpatient Ward
Patients ED Treatment Activate ED Bed Capacity Readmission
Activate Flexible S Patients
Room Capacity Capacity Expansion Bed Capacity
S S S
Activate Reserve
Activated Contingency Bed Capacity
or Crisis State
S
R2
Legend
Constant or Auxilary Variable
Rate or Flow Equivalent R1 Reinforcing Loop

Stock or Level Equivalent
Adaptive Capacity Feature B1 Balancing Loop
Operational State Info
Figure 6-3: Causal loop diagram for the ED and inpatient ward
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Activate Inpatient
SU Outpatient Inpatient External External Transfer
Procedure Delay Transfer Rate
O S S
Outpatient Surgery Inpatient External

Discharge Rate Transfer
S
S Inpatient Ward Activate Inpatient
SU Inpatient Treatment Delay Early Discharge
Activate Surgery Emergency Surgery Procedure Delay B8
Cancellation State Patients Holding B4
S O S O
S S S S O S O
Scheduled S
Inpatient Surgery O Patients Occupying Patient Surgery Patients Occupying Inpatient Surgery Patients Occupying Inpatient Ward
Arrivals B2 B5 B9
Surgery Patient Waiting Area Intake Rate Surgical Unit Admission Rate Inpatient Ward Discharge Rate
S B7
Arrival Rate S B3
O O O S O
Scheduled S S O
Outpatient Surgery SU Capacity O
Arrivals R1 B1 Waiting Inpatient Ward
S O Availability S O B6
Delay Time Bed Availability
Rescheduled S S Reported SU High S S
Surgery Patient S
Arrivals O Congestion State Potential
Reschedule Readmission
S SU Operative Inpatient Ward
S Surgery Rate S S Patients
Capacity Allocated Reallocate SU Bed Capacity
O Available Operative Capacity S Allocated
S
Surgical S Inpatient Ward
Schedule S Bed Capacity
SU Operative Activate Reserve Activate Flexible
Capacity Bed Capacity Bed Capacity S
S S Readmission
Patients
Activated Contingency
or Crisis State
Legend ED Patient
Arrivals
Rate or Flow Equivalent R1 Reinforcing Loop
Adaptive Capacity Feature B1 Balancing Loop
Figure 6-4: Causal loop diagram for surgical unit and inpatient ward
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Unallocated Reserve
Reported Bed Capacity
O
SIPW Bed Activated Reported
Requests MIPW Bed
Reserve Bed B4a Contingency State Requests
Reported Allocation Rate
S S Activated Crisis Reported
SIPW Bed MIPW Bed
Occupancy Reserve Bed S Allocate Reserve State
S Occupancy
Deallocation Rate
O Release SIPW Bed O Bed Capacity O
O Release MIPW Bed
S Allocation
S S SIPW Bed Allocation S
MIPW Bed S S
Allocation Rate B4b
SIPW Bed B1a Allocation Rate MIPW Bed
Demand B2a Demand
S
Forecast S S S S O S Forecast
O Available Bed S
Allocated SIPW Allocate to SIPW B1d B2d Allocate to MIPW B2c Allocated MIPW
B1c Capacity for
Bed Capacity Bed Capacity Allocation Bed Capacity Bed Capacity
S S
O O S O S O
SIPW Bed S MIPW Bed
B1b B2b
Supply Activated Supply
B3b S
S Contingency State
O Request SIPW Bed Flexible Bed Request MIPW Bed
S or Crisis State
Allocation Allocation Rate O Allocation O
S Allocate Flexible S
Bed Capacity S Activated ED High
Congestion State
Flexible Bed O S
Deallocation Rate Activated SU High
B3a Congestion State
Legend O
Unallocated Flexible
Bed Capacity
Reported Bed Occupancy
Rate or Flow Equivalent & Pending Requests

R1 Reinforcing Loop
Congestion State Info
B1 Balancing Loop
Figure 6-5: Causal loop diagram for bed capacity management

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6.3.4 Adaptive Features Illustrated
The previous sections describe model modifications where split patient flows,
operational states, high congestion states and adaptive capacity features are implemented.
This section illustrates the adaptive features in action for two different scenarios using the
same surge event resulting in 200 patient arrivals. The results, in measurable occupancy
and patient flow rates, are presented over time for the emergency department, the surgical
unit, and the medical and surgical inpatient wards.
Scenario 1 severely restricts the adaptive capacity features enabled to include the
ED capacity expansion, the urgent care desk, elective surgery cancellation, and flexible
bed capacity. Scenario 2 utilizes a combination of all available adaptive capacity features
enabled. Figure 6-6 and Figure 6-7 present the time-series results where the surge event,
initial impact period, recovery period, and the feature activation durations are identified
for scenarios 1 and 2, respectively.
Important differences are observed in the results illustrated in Figure 6-6 and
Figure 6-7 with respect to time. First, the restricted use of the adaptive features in
scenario 1 result in extended initial impact and recovery durations, as well as adaptive
feature activation, than observed in scenario 2. Second, the restricted use of adaptive
features in scenario 1 result in significantly increased ED occupancy, sharply higher
LWBS rates, and increased inpatient occupancy over time compared to scenario 2. This
example demonstrates the impact of adaptive capacity features on outcomes.
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Figure 6-6: Scenario 1 time-series plots for adaptive feature activation
262
Figure 6-7: Scenario 2 time-series plots for adaptive feature activation
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6.4 Methodology
The methodology used to study hospital resiliency to disruptive events and the
consequential demand surge is introduced in four parts within this section. First, the
behavior and characteristics of the demand surge event used are described. Second, the
actions that can be used by a hospital in responding to a demand surge event are
described. Third, the strategies formulated on a set of actions to be used by a hospital are
defined. Last, the simulation experiment used to study the individual strategies is
defined. The results are discussed in the sections that follow.
6.4.1 Surge Event Characteristics
The patient demand surge event used in this study is a hypothetical natural
disaster in the form of a moderate sized tornado that strikes the semi-urban area close to
the Town of Hillsborough, North Carolina. Hillsborough Hospital is the nearest medical
facility where most people seek immediate medical assistance for a variety of sustained
injuries and medical problems. Hillsborough Hospital does not sustain any damage to its
capabilities with the event.
Injured patients arrive to the ED at a sudden rate immediately following the
tornado strike. In the initial hours following the tornado strike the expected number of
injured patients and their arrival duration remain uncertain. While there is much
uncertainty, the number of injured patients expected to arrive will substantially exceed
the routine patient arrival rate. This study considers the number of injured victims that
will arrive at the hospital for assistance to be between 0 and 300.
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The most acute patients will likely arrive within the first 2 hours after the tornado
strike, and will represent roughly 65% of the total number of tornado victims that will go
to the hospital. Tornado victims that arrive within 2 to 4 hours will represent roughly
25%. Thereafter, the arrival rate decreases rapidly and the final 10% of tornado victims
arrive between 4 to 24 hours after the strike. Within 24 hours most all injured victims
will have sought medical assistance. Figure 6-8 illustrates the tornado victim emergency
patient arrival rate behavior plotted overtime where the three example demand surge
intensities (100, 200, and 300 arriving patients) are provided.
Figure 6-8: Surge event patient arrivals by demand surge volume
Injured patients arriving at the ED consist of 30% of high acuities (ESI 1, 2, and
3), 40% of medium acuity (ESI 4), and 30% of low acuity (ESI 5). The low acuity
patients are often considered the worried wounded. Medium and lower acuity patients,
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who are subject to lengthy waits, are most likely to leave-without-being-seen (LWBS) to
seek treatment at another locations as congestion and waiting time delay increase.
6.4.2 Surge Demand Response
The adaptive capacity features and leverage points were previously introduced in
the section on modifications made to the whole hospital model. This section presents and
discusses the actions enabled through the inclusion of selective adaptive capacity
features. A combination of selected adaptive capacity features and their specifications
are used to formulate strategies, which will be defined in the subsequent section. Actions
can be organized with regard to ED operations and hospital operations.
While an emergency department director may have many concerns to manage
under a surge event, there are five actions they can directly take with limited coordination
to address capacity. First, they can activate ambulance diversion to redirect ambulances
to the nearest facility to prevent additional congestion and further waiting time delay. As
a matter of policy, many hospitals refrain from using ambulance diversion except under
the direst of circumstances since past practices have led to abuse. Second, they can
decide to expand treatment capacity by repurposing a neighboring clinical area to provide
treatment for medium and lower acuity patients (ESI 4 and 5). This expansion may be
limited to one, two or three additional treatment areas. Third, they can decide activate or
repurpose the urgent care clinical capacity treatment areas to provide minor wound
treatment and medical assistance for low acuity patients (ESI 5). Fourth, they can decide
to transfer patients from the waiting area to an external facility, and at what level of
intensity, in order to alleviate congestion. Last, they can decide whether to transfer
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patients that occupy a treatment room with an admission hold to an external facility, and
at what level of intensity, in order to avoid treatment room blockage.
There are five actions a hospital administrator can take to help address capacity
across the organization. First, they can initiate requests for the early discharge of patients
who are approaching the end of their treatment length-of-stay. Early discharge practices
may reduce the length-of-stay duration from 10% to 30%, depending on the stance taken.
Second, they can decide to activate flexible bed capacity which will be temporarily setup
in the inpatient wards, and allocate the resources that influence the setup responsiveness.
Third, they can decide to activate reserve bed capacity which will reallocate and
repurpose clinical areas to be used as inpatient ward capacity. Fourth, they can decide to
activate a surgery cancellation policy determined based on a forecast of available surgical
bed capacity or hospital operation status. Last, they can decide to transfer inpatients to
external facilities, and the maximum number of patients to be transferred, resulting in
increased bed availability.
6.4.3 Strategy Definition
In the previous section the actions available to an emergency department director
or hospital administrator are described. This section describes how these actions may be
combined to formulate a strategy, and where tradeoffs are made, with the best intention in
mind to pursue a specific goal or objective. First, the concept of tradeoffs due to
capability limitations and constraints is introduced and discussed. Second, a set of nine
objectives are described. Third, strategies are formulated based on the stated objectives
using a select set of actions.
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Under a demand surge event the emergency department may have limited
resources with which to pursue certain activities. Figure 6-9 illustrates the relationship
where the allocation of resource and effort results in tradeoffs between the three activities
available to the emergency department. These include the external transfer of patients,
the capacity expansion of treatment areas, and the activation of the urgent care desk. A
strong emphasis on any one activity will draw resources away from one or more
neighboring activities. Therefore, it is important to consider tradeoffs in strategy making.
Figure 6-9: Emergency department tradeoff dimensions
Similarly, under a demand surge event the hospital may have limited resources in
which to pursue certain activities. Figure 6-10 illustrates the relationship between three
activities available to be pursued in the hospital that require the allocation of resource.
These include the external transfer of patients, the early discharge of patients, and the
activation of flexible or reserve bed capacity. All these activities require incremental
effort to be expended primarily by the responsible nursing unit to complete. A strong
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emphasis on one activity will result in drawing resource away from one or more of the
remaining activities. Therefore, it is important to consider tradeoffs in strategy making.
Figure 6-10: Hospital tradeoff dimensions
The concern for various tradeoffs is important when drawing up a set of
objectives that will be used to formulate a set of strategies. Table 6-6 presents the
general description of the objectives and goals used to formulate nine strategies. These
strategies are later described in further detail. Using these descriptions, Table 6-7
identifies the corresponding adaptive capacity features and parameterization for each
strategy. Table 6-8 provides additional detail regarding the adaptive capacity feature
specification and parameterization for each of the strategies.
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Table 6-6: Description of strategy objectives
Strategy Strategy Description

S1 Middle of the road: Accept all arriving patients, during and post surge event,
with balanced emphasis on the external transfer of patients from the ED once
triaged or treated, and flex/reserve bed capacity activation.
S2 Maximize ED recovery with AD: Limit patients arriving post surge event
through ambulance diversion combined with a balanced emphasis on the
external transfer of patients from the ED once triaged or treated, and flex/reserve
bed capacity activation.
S3 Maximize ED recovery with transfer: Accept all arriving patients, during and
post surge event, with priority on transferring ED holding patients to external
facilities when insufficient bed capacity is available and transferring inpatients
to external facilities to minimize reserve bed capacity usage. Flexible bed
capacity receives less priority through slower activation.
S4 Maximize hospital bed availability: Accept all arriving patients, during and post
surge event, with less emphasis on the external transfer of patients holding but
place a high priority on making space within the inpatient wards through the use
of patient early discharge.
S5 Maximize patient flow: Ambulance diversion is used to limit patient arrivals in
the post surge event period, activation of flexible bed capacity in the wards is
limited, and the external transfer of inpatients to other facilities is used to free up
bed capacity.
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Table 6-6: Description of strategy objectives (continued)
Strategy Strategy Description

S6 Minimize patient readmission: Minimize patient early discharge from the
inpatient wards, provide external transfer of inpatients to other facilities, and
maximize the speed at which both flexible and reserve bed capacity is activated.
S7 Maximize ED throughput: Increase ED throughput by maximizing the expansion
of ED treatment capacity and increase bed availability through aggressive early
discharge of inpatients.
S8 Maximize system throughput with inpatient transfers: Increase system
throughput by maximizing the expansion of ED treatment capacity and by
maximizing inpatient transfers to external facilities.
S9 Maximize system throughput: Increase system throughput by maximizing the
expansion of ED treatment capacity, maximizing flexible bed responsiveness,
and limited external transfers.
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Table 6-7: Adaptive capacity feature selection and parameterization by strategy
Strategy
Adaptive Capacity Features S1 S2 S3 S4 S5 S6 S7 S8 S9
Emergency Department Operations:

(a) Ambulance diversion - on - - on - - on -
(b) Expansion capacity M M M M M M H H H
(c) Urgent care desk on on on on on on on on on
(d) External transfer from wait area M M M M M M L L L
(e) External transfer from hold admit M M H L M M L L L
Hospital Operations:
(f) Early discharge M M M H M L H M L
(g) Flexible bed capacity M M L L L H L L H
(h) Reserve bed capacity M M M M M H M M M
(i) Surgery cancellation on on on on on on - - on
(j) External transfer from ward - - L - L L - H L
Legend: 'on' = active; L = low parameter; M = medium parameter; H = high parameter
Table 6-8: Adaptive capacity feature specification and parameterization description
Parameterization
Adaptive Capacity Features Specification L M H
Emergency Department Operations:

(a) Ambulance diversion on / off - - -
(b) Expansion capacity additional locations 1 2 3
(c) Urgent care desk on / off - - -
(d) External transfer from wait area patients per hour 0.50 1.00 1.25
(e) External transfer from hold admit patients per hour 0.15 0.30 0.45
Hospital Operations:
(f) Early discharge max. LOS reduction rate 0.10 0.20 0.30
(g) Flexible bed capacity bed activations per hour 1.00 2.00 3.00
(h) Reserve bed capacity bed activations per hour 2.00 4.00 6.00
(i) Surgery cancellation on / off - - -
(j) External transfer from ward max. allowable transfers 2 3 4
Legend: 'on' = active; L = low parameter; M = medium parameter; H = high parameter
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6.4.4 Experimentation
Table 6-9 below specifics the variables and distribution sampling used in the
Monte Carlo experiment. The experiment includes nine variables which are sampled
according a specified distribution and identified parameters. These variables include the
disruptive event start time, the demand surge volume and the demand surge duration.
Variables also include the length-of-stay in the various inpatient wards, the forecast
sensitivity for bed availability, and the expected number of daily ED arrivals. A total of
500 simulation runs were completed for each of the nine identified strategies.
Observations made from the experiment results are presented in the next section.
Table 6-9: Variable distribution parameterization
Variable Units Distribution Min Mean Max
Start Time day | 24 hour Uniform T | 00:00 - H | 23:59

Surge Demand patients Uniform 0.00 - 300.00
Surge Duration hours Triangular 19.99 24.00 28.01
Daily ED Arrivals patients/day Triangular 35.00 38.00 42.00
SIPW LOS (icu) hours Uniform 21.60 - 26.40
SIPW LOS (flr) hours Uniform 82.73 - 101.11
MIPW LOS (icu) hours Uniform 21.60 - 26.40
MIPW LOS (flr) hours Uniform 82.73 - 101.11
Forecast Sensitivity fraction Uniform 0.10 - 0.30
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6.5 Observations
The observation results for the nine strategies used to respond to the demand
surge event are presented in three sections that provide unique perspectives. First, the
individual strategy results are presented, compared and discussed for the Monte Carlo
experiment where multiple parameters are simultaneously varied. Second, the individual
strategy results are presented, compared, and discussed for an illustrative experiment
where demand surge volume is varied under a predetermined set of initial starting
conditions. Third, two individual strategies selected from the nine strategies are
compared and contrasted with respect to demand surge volume over time. These three
perspectives provide insight into the hospital dynamics occurring under varied demand
surge volumes and provide evidence as to which strategies perform better.
6.5.1 The Monte Carlo Experiment
The observation results from the Monte Carlo experiment are organized into
multiple sections. First, summary statistics are presented for the number of hours spent in
the operational states, ambulance diversion state, and surgery cancellation state, which is
followed by the number of surgery cancellations, and emergency department waiting time
delay. This provides a reference point for the individual strategies. Thereafter,
observation results are presented for the flow recovery times with respect to the
individual strategies. A flow recovery time is determined by the number of hours
necessary for a particular patient flow dimension to return to the baseline, which is absent
the disruptive event resulting in the demand surge. The flow recovery times examined
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included: (1) ED admission and discharge flow recovery times; (2) ED LWBS flow
recovery time and LWBS percentage; (3) surgical unit inpatient and outpatient flow
recovery times; and (4) medical and surgical inpatient ward flow recovery times.
6.5.1.1 Summary Observations
As previously described, hospital operations may be classified in one of three
states with regard to bed capacity availability across the medical and surgical wards,
which include: (1) a conventional state where patient demand is satisfied with normal
capacity operation; (2) a contingency state where additional capacity is activated to meet
increased patient demand; and (3) a crisis state where additional capacity is activated to
meet increased patient demand or where a portion of the facility may have been
compromised. A series of box-plot diagrams, which illustrate the median value and
quartile range, are presented in Figure 6-11 for the contingency and crisis state hours of
activation specific to ICU and floor bed types. Based on the range of demand surge
volumes presented in the experiment, the contingency state is activated for the floor ward
bed type only. The operational state for the ICU bed type remains in the conventional
state due to the substantial initial bed supply – the conventional state is not shown in the
figure.
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Figure 6-11: Contingency state and crisis state activation hours
Figure 6-11 illustrates the circumstance where all strategies experience hours
spent in the contingency state, specifically for the floor type beds. The median time spent
in this state ranges between 18 to 23 hours, with drastically differing ranges, based on the
varied parameter ranges of the experiment. Notably, strategies S3, S5, S6 and S8 exhibit
lower median values and lower quartile ranges – an indicator of better outcomes. By
comparison, strategies S1, S2, S4, and S7 exhibit higher median values and much
narrower but higher ranges – indicators of poorer outcomes. Strategy S7 demonstrates
the poorest outcome with a very high and tightly defined range combined with a
significant number of identified outliers.
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Figure 6-12 and Figure 6-13 introduce a series of box-plot diagrams that present
activation status, waiting time delay, and occurrence information. Specifically, Figure
6-12 (a) presents the number of activation hours spent in the ambulance diversion state,
which is a feature available only for strategies S2, S5, and S8. Strategy S8 exhibits
greater usage of the ambulance diversion feature than either strategy S2 or S5. This can
be attributed to the lowered rate of ED patient transfers to external facilities in strategy
S8. Figure 6-12 (b) presents the average waiting time delay experienced by a patient
arriving to the emergency department during the duration of the demand surge event.
Although waiting delay times for the strategies are similar, the median and range are
observed to be slightly lower for strategies S7, S8, and S9. These strategies employ the
maximum allowable ED expansion capacity considered which primarily benefits higher
acuity patient arrivals in being seen quicker. However, these strategies also utilize a
lowered rate of ED patient transfer to external facilities which limits patient flow and
results in a higher rate of patients leaving-without-being-seen specifically for the lower
acuity patients. The result is a lower average waiting time delay for strategies S7, S8,
and S9.
Figure 6-13 presents the number of activation hours spent in the surgery
cancellation state and the number of surgery cancellations. Notably, surgery cancellation
has been restricted in the case of strategies S7 and S8. In Figure 6-13 (a) the median
value for the number of activation hours spent in the surgery cancellation state for the
various strategies are nearly identical; however, considerable differences in variability are
demonstrated by the numerous identified outliers. Although difficult to distinguish, the
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quartile range and distribution of outliers suggest slightly better outcomes for strategies
S3, S5, and S6. Figure 6-13 (b) illustrates that the number of surgery cancellations is not
substantially different between the strategies, where the range indicates between 3.5 to 5
inpatient surgeries are cancelled due to the surge event.
Figure 6-12: Ambulance diversion state activation and ED waiting delay time
Figure 6-13: Scheduled surgery cancellation state activation and quantity cancelled
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6.5.1.2 ED Patient Flow Recovery Time
The ED patient flow recovery time reflects the number of hours required for a
patient flow to return to the baseline absent a disruptive event and consequential surge
demand. Two interrelated patient flows are considered: (1) the patient flow for admission
patients; and (2) the patient flow for discharge patients. Admission patients represent a
small proportion, less than 20%, of the total number of patients presenting in the ED;
however, these patients are generally higher acuity patients requiring significant
diagnostic resources and treatment time. Patients not admitted to the hospital are
discharged from the ED. These patients are generally lower acuity patients that are
subject to longer waiting delay times to be seen by a physician. As a result, these patients
are susceptible to abandoning the waiting area either due to congestion or waiting time.
Figure 6-14 contrasts the admission patient and discharge patient flow recovery
times for the outcome results from the Monte Carlo simulation experiment for the nine
individual strategies considered. An ideal outcome result would be expected to appear in
the lower left-hard quadrant (the 3rd quadrant) of the graph. A poor outcome result
would be expected to appear in the upper right-hand quadrant (the 1st quadrant) of the
graph. An outcome result in either remaining quadrant (the 1st and 4th quadrants)
indicates strength in one dimension and weakness in the other dimension. Figure 6-15
provides further clarification with box-plots that individually present the patient flow
recovery times for discharge patients and admission patients by individual strategy.
The following observations can be made from Figure 6-14 and Figure 6-15 with
regard to the individual strategies. Poor performing strategies include strategies S1, S2,
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S3, S4, and S7, which demonstrate long patient flow recovery times mainly for the
discharge patients. Strategies S4 and S7 are designated bad strategies since their median
and quartile ranges for both admission and discharge patient flow recovery times are
visibly higher. Notably, strategies S4 and S7 have lower rates of ED patient transfer to
external facilities and depend on the maximum ED capacity expansion (strategy S7) or
aggressive patient early discharge (strategy S4) to avoid patient flow blockages. Strategy
S4 results in a high percentage of low acuity patients leaving-without-being-seen due to
limited patient flow, and strategy S7 results in some patients being discharged too soon,
increasing the risk for potential patient readmissions.
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Figure 6-14: Patient flow recovery times for discharge patients versus admission patients
Figure 6-15: Patient flow recovery times for discharge and admission patients
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Strategies S5, S6, S8 and S9 represent better performing strategies as indicated by
their rapid recovery times. These strategies minimize admission patient flow recovery
times between 40 and 100 hours and minimize discharge patient flow recovery times
between 150 and 250 hours for the experimental range considered. The fastest recovery
times are demonstrated by strategies S5 and S6, where S5 excels at the admission
recovery time and S6 excels at the discharge recovery time. Similarities in the outcome
results profiles for strategies S6 and S9, as shown in Figure 6-14, may be attributed to
their aggressive activation and availability of flexible and reserve floor beds. All of these
strategies utilize a balanced combination of adaptive capacity features with moderate
parameter settings to obtain the better outcome results.
6.5.1.3 ED Patients Leaving-Without-Being-Seen
Lower acuity patients in the ED waiting area encountering a delay to be seen by a
physician may choose to leave the hospital if their condition is not urgent. This section
examines two dimensions of this behavior which include: (1) the ED patients that leave-
without-being-seen as a percentage of the demand surge volume; and (2) the ED patients
that leave-without-being-seen patient flow recovery time. The rate at which patients
depart the waiting area is a non-linear function of the average waiting delay. As patient
demand surge volumes increase the likelihood arriving patients encounter congestion or
lengthy waiting delay times increases. The adaptive capacity features, which vary by
strategy, will mitigate the patient demand surge in varying degrees.
Figure 6-16 contrasts the patient flow recovery times and the rate of departure for
patients in the waiting area that leave-without-being-seen by a physician. An ideal
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outcome would appear in the lower left-hand quadrant (the 3rd quadrant) of the figure,
indicating rapid patient flow recovery times and lower rates of departure for patients that
leave-without-being-seen. Less desirable results appear in the upper right-hand quadrant
(the 1st quadrant) of the figure, indicating slow patient flow recovery times and high rates
of departure for patients that leave-without-being-seen. Figure 6-17 provides further
clarification with box-plots that individually present the patient flow recovery times and
the rate of departure with the strategies depicted.
This distinctive pattern observed in Figure 6-16 is the result of variations in
patient demand surge and the activation levels for various adaptive capacity features.
Smaller patient demand surge volumes often fail to activate the adaptive capacity features
in a responsive manner. This contributes to higher rates of departure for patients that
leave-without-being-seen; however, because of the lower patient demand volume the
patient flow recovery time is relatively short in duration. This circumstance is illustrated
in Figure 6-16 where the patient flow recovery times are observed below 45 hours, under
all strategies. In comparison, higher patient demand surge volumes typically activate the
adaptive capacity features in a responsive manner and mitigate the potential rate of
departure by increasing patient flow throughout the hospital. In the region where patient
flow recovery times are observed between 45 and 70 hours the adaptive capacity features
are relatively successful in mitigating demand surge volumes. However, the effects of
extremely high patient demand surge volumes are shown to overwhelm the adaptive
capacity features. This is illustrated by the dispersion in outcome results that appear in
the upper-right quadrant (the 1st quadrant).
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The following observations can be made from Figure 6-16 and Figure 6-17 with
regard to the individual strategies. Differences in the results between these strategies can
be subtle. Poorer performing strategies include S7 and S9, which exhibit frequent
occurrences of slow patient flow recovery times combined with higher rates of departure
for patients that leave-without-being-seen by a physician. Both strategies utilize the
maximum ED capacity expansion considered but combined with limited patient transfer
to external facilities. The outcome results under strategy S7 are observably poorer,
particularly with regard to recovery time, due to the reliance on aggressive early
discharge of patients, the slow response in activating flexible bed capacity, the
restrictions on surgery cancellation, and the restriction on inpatient transfers to external
facilities.
Mediocre results are observed for strategies S1, S3, S4, and S6, which produce
similar outcomes. These strategies include a mixture of adaptive capacity features where
patient early discharge, flexible bed availability, reserve bed availability and external
patient transfer capabilities are varied. The shift in focus and capability, as demonstrated
through the subtle differences amongst these strategies, is shown to deliver negligible
benefit since the strengths and weaknesses of the features appear to offset one another.
Strategies S2, S5 and S8 represent the better performing strategies associated with
rapid patient flow recovery times and lower rates of departure. Both strategies activate
the ambulance diversion feature when high congestion and waiting delay times occur in
order to shield the ED from further high acuity patient arrivals during the post event
recovery period. While the number of patients diverted is a small proportion of the total
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patient arrivals the effect on the ED is significant. Strategy S2 utilizes a balanced
combination of adaptive capacity features but does not consider inpatient transfers to
external facilities. Strategy S5 utilizes inpatient transfers to external facilities to clear bed
capacity and avoid bed blockages that would otherwise impede patient flows. In
comparison, strategy S8 aggressively utilizes the ambulance diversion feature but with
less beneficial results. Strategy S8 also utilizes the maximum allowable ED capacity
expansion considered but limits the ED patient transfer to external facilities, similar to the
already cited poor performing strategies S7 and S9.
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Figure 6-16: ED LWBS patient flow recovery times versus rate of departure
Figure 6-17: ED LWBS patient flow recovery times and rate of departure
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6.5.1.4 Surgical Unit Patient Flow Recovery Time
The surgical unit (SU) patient flow recovery time reflects the number of hours
required for patient flow to return to the baseline absent a disruptive event and
consequential demand surge volume. Two patient flows in the surgical unit are
considered: (1) inpatient flows, which lead to a hospitalization stay; and (2) outpatient
flows, which lead to a patient discharge home. In this experiment the number of
scheduled inpatient surgeries slightly exceeds the number of outpatient surgeries.
Sizable patient demand surge events can disrupt scheduled surgery in multiple
ways. First, patients requiring emergency surgery compete for surgical unit resources
which may result in scheduled surgery postponement by cancellation or rescheduling.
Second, emergency surgery patients also compete for available surgical bed capacity
which may lead to schedule surgery cancellations if there is a shortfall in bed capacity.
Third, the general patient demand surge may compete for available surgical inpatient
ward bed capacity. This may result in scheduled surgery cancellations as the adaptive
capacity features force the reallocation of available bed capacity. Fourth, surgical unit
resources, such as the pre-operative care unit capacity and post-operative care unit
capacity may be repurposed for hospitalization, which may result in scheduled surgery
cancellations, as the adaptive capacity features respond. Due to higher resource
requirements, scheduled inpatient surgery will often be more affected, and for a longer
period, than scheduled outpatient surgery by a disruptive event.
A challenge in evaluating surgical unit patient flow recovery times is that
scheduled surgery cancellations are often determined in a narrow decision making time
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window using forecast bed availability information. As a result, the differences between
strategies in the number of scheduled surgery cancellations are often not substantial.
Figure 6-18 contrasts the surgical unit inpatient and outpatient flow recovery
times for outcome results from the Monte Carlo simulation experiment for the nine
individual strategies considered. Figure 6-19 provides further clarification with box-plot
diagrams that present the inpatient flow recovery times and the outpatient flow recovery
times for the individual strategies.
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Figure 6-18: Surgical unit outpatient flow versus inpatient flow recovery times
Figure 6-19: Surgical unit outpatient flow and inpatient flow recovery times
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The following observations are made regarding the individual strategies based on
Figure 6-18 and Figure 6-19. Given the similar dispersion seen for outcome results of all
strategies it is difficult to definitively determine which strategies are better or worse.
However, some subtle differences are observed. Strategy S5 results tend to cluster in the
lower left-hand quadrant more than all other strategies shown. This strategy utilizes all
adaptive capacity features which improves patient flow throughout the hospital and
results in rapid patient flow recovery times. Strategy S2 demonstrates similar outcome
results but with a noticeable drift into the neighboring quadrants. This is attributed to the
lack of inpatient transfers to external facilities in order to increase bed availability.
Strategies S1, S3, S4, S6 and S9 demonstrate very similar dispersion patterns for
the outcome results making it difficult to determine whether one strategy would be better
than another. By comparison, strategies S7 and S8 are distinctively different given the
limited outcomes that appear below 100 hours for the outpatient flow recovery time and
the abundant outcomes below 250 hours for the inpatient flow recovery time. Strategies
S7 and S8 restrict use of the surgery cancellation feature; however, this decision may
result in lengthened disruptions caused by increased congestion, delays and rescheduling
as the surgical unit deals with a patient overload. Strategy S8 is observed to have a
much tighter cluster of outcome results with lower inpatient flow recovery times, making
it preferred over strategy S7.
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6.5.1.5 Medical and Surgical Inpatient Ward Flow Recovery Time
The inpatient ward patient flow recovery time reflects the number of hours
required for a patient flow to return to the baseline absent a disruptive event and
consequential surge demand. Two patient flows are considered: (1) the medical inpatient
ward (MIPW) patient flow; and (2) the surgical inpatient ward (SIPW) patient flow.
Patients arrive to the medical inpatient ward on a regular daily basis, with the most likely
point of entry through the ED or as a direct admission patient. This maintains the
medical ward occupancy. By comparison, patients arrive to the surgical inpatient ward
following surgery which is largely determined based on the surgical schedule. This
creates great fluctuations in the surgical ward occupancy over the week duration. With
intense demand surge volumes, the medical and surgical inpatient bed capacity may serve
as substitutes to meet patient demand as determined through reallocation by the adaptive
capacity features. Strategies that utilize an aggressive flexible bed capacity response, an
aggressive patient early discharge response, or inpatient transfer to external facilities may
avoid bed capacity reallocation.
Figure 6-20 contrasts the medical inpatient ward and surgical inpatient ward
patient flow recovery times for outcome results from the Monte Carlo simulation
experiment for the nine individual strategies considered. Figure 6-21 provides further
clarification with box-plot diagrams that present the medical inpatient ward patient flow
recovery times and surgical inpatient ward patient flow recovery times for the individual
strategies.
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Figure 6-20: Medical versus surgical inpatient ward patient flow recovery times
Figure 6-21: Medical ward and surgical ward patient flow recovery times
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The following observations are made with regard to the individual strategies
based on Figure 6-20 and Figure 6-21. After careful examination, the nine strategies can
be grouped into one of four categories. The first category consists of strategy S7, which
is identified as a very poor strategy due to long recovery times in both dimensions.
Restrictions on the use of ambulance diversion activation, scheduled surgery cancellation,
patient transfers to external facilities, as well as the inclusion of maximum ED capacity
expansion and aggressive patient early discharge provide turbulent outcome results that
exhibit lengthy recovery times. The second group consists of strategies S3, S5, S6, and
S9, which exhibit outcome results that are well dispersed across the figure. While these
strategies utilize a combination of adaptive capacity features, they specifically seek to
increase bed capacity availability through inpatient transfers to external facilities. The
desire to provide adequate bed availability, and imprecision in forecasts, may lead to
circumstances where more capacity is vacated than necessary, which may result in longer
patient flow recovery times. The third group consists of strategies S1, S2, and S4 which
exhibit outcome results more tightly clustered and located in the fourth quadrant, which
indicates improved recovery times compared with other strategies. These strategies
attempt to contain the demand surge event onsite as much as possible by moderately
limiting ED patient transfers and restricting inpatient transfers to external facilities.
Strategy S2 illustrates a tighter cluster set which is attributed to its use of the ambulance
diversion feature. Strategy S4 is slightly more loosely organized which is attributed to
the aggressive use of patient early discharge.
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The final group which represents the best observed outcome results consists
solely of strategy S8. Strategy S8 utilizes ambulance diversion, maximum allowable ED
capacity expansion, limited ED patient transfer to external facilities, moderate patient
early discharge, and aggressive inpatient transfers to external facilities. Additionally, the
strategy restricts the cancellation of scheduled surgery, which may negatively impact the
observed outcome results.
Overall, reasonably good outcomes may be obtained with strategies, such as S1,
S2, and S4, which rely on a select set of adaptive capacity features with generally
moderate parameter settings. Better outcome results can be obtained with a strategy such
as S8 which aggressively makes use of a few adaptive capacity features. However,
aggressive feature selection may have negative consequences, such as in the emergency
department recovery time.
6.5.2 Observations for Recovery Time with Varied Demand Surge Volume
In this section the relationship between varied demand surge volumes and the
adaptive capacity features is explored with respect to the individual strategies. For clarity
in discussion, the outcome results illustrated herein are absent the variability previously
introduced under the Monte Carlo experiment. Instead, a common set of initial starting
conditions are used for the individual strategies. The figures presented throughout this
section illustrating the recovery times reflect the number of hours required for a patient
flow to return to the baseline absent a disruptive event and consequential surge demand.
The individual strategies employ various combinations of adaptive capacity features and
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specifications that effect their activation, responsiveness and duration. Seven examples
and illustrations are provided.
6.5.2.1 Contingency Operational State
The Monte Carlo experiment outcome results previously presented in Figure 6-11
revealed that only the contingency state for floor bed capacity was activated when the
demand surge was encountered. Figure 6-22 illustrates the number of hours spent in the
contingency state for each strategy in response to the range patient demand surge volume.
Figure 6-22: Contingency state activation time by demand surge volume
A substantial portion of the activity that differentiates individual strategies is
observed to occur with a demand surge volume between 25 and 100 arriving patients.
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The number of hours in the contingency state appears to be similar for all strategies with
demand surge volumes above 200 arriving patients. Strategy S5 is the best performing
strategy with fewest hours spent in the contingency state across the entire range of
demand surge volumes. In comparison, strategy S7 is a much poorer performing strategy
with more hours spent in the contingency state. These observations are consistent with
results from the previous section.
6.5.2.2 ED Patient Flow Recovery Time
Figure 6-23 and Figure 6-24 illustrate the number of hours required by strategy
for the admission patient flow rate and discharge patient flow rate, respectively, to return
to their corresponding baselines absent the disruptive event and the consequential surge
demand. The figures illustrate recovery times that diverge among strategies once the
demand surge volume exceeds 100 arriving patients.
In both figures, strategy S7 is observed to be a poor strategy as illustrated by the
number of hours required in the recover times, which exceeds the times observed for all
other strategies. The strategy maximizes ED capacity expansion for treatment,
aggressively initiates patient early discharges, and restricts ED patient transfers to
external facilities. Additionally, the strategy limits schedule surgery cancellation to
decision making based on bed availability forecast without regard to the hospital
operational state. This strategy induces further congestion into an already overburdened
system.
Most strategies perform well across the range of the demand surge volumes as
shown in Figure 6-23 for the admission patient flow recovery times. Better performing
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strategies include S2 and S5, which are shown to require fewer hours in recovery time
than other strategies. Both strategies utilize the ambulance diversion feature to control
patient arrivals during the post disruptive event and demand surge period. Activation of
the ambulance diversion feature is noticeably observed in Figure 6-23 where the
admission patient flow recovery times show dramatic declines of up to 20 hours in the
region for the demand surge segment between 150 and 230 arriving patients. This
circumstance diminishes with increased demand surge volumes above 230 arriving
patients. While activation of the ambulance diversion feature reduces the admission
patient flow recovery times, a substantial corresponding benefit is not observed in the
discharge patient flow recovery times.
By comparison, strategy S8 also activates the ambulance diversion feature.
Although the strategy activates the ambulance diversion state for more hours than
strategies S2 and S5, the overall effect on admission patient flow recovery times is
relatively minor. This is illustrated for the strategy where the demand surge volume is in
the range between 150 and 170 arriving patients. This muted effect is attributed to the
maximized ED capacity expansion and reduced ED patient transfer to external facilities.
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Figure 6-23: ED admission patient flow recovery time by demand surge volume
Strategies S5, S6, S8 and S9 are the better performing strategies for discharge
patient flow recovery times across the range of demand surge volumes, as illustrated in
Figure 6-24. These strategies require significantly fewer hours for recovery times than
other strategies. These strategies are differentiated by their use of the ambulance
diversion feature activation (used by strategies S5 and S8) and their use of inpatient
transfers to external facilities (used by strategies S5, S6, S8, and S9). Strategy S5 is
observed to be the best strategy with respect to minimizing both admission and discharge
patient flow recovery times. It utilizes a combination of all the adaptive capacity features
in order to promote hospital wide patient flow. While this strategy may not be the most
responsive for various features, the outcome results illustrate a well performing strategy
due to maintaining patient flow.
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Figure 6-24: ED discharge patient flow recovery time by demand surge volume
6.5.2.3 Surgical Unit Patient Flow Recovery Time
The surgical unit inpatient flow and outpatient flow recovery times are illustrated
in Figure 6-25 and Figure 6-26, respectively. Inpatients are transferred from the surgical
unit post-operative care unit to the surgical inpatient ward (SIPW). Outpatients are
discharged from the surgical unit post-operative care unit to home. A disruptive event
and demand surge volume, even at small volumes, can have a significant and prolonged
effect which disrupts a surgical schedule for both inpatient and outpatient flows. This is
illustrated in Figure 6-25. At moderate demand surge volumes between 50 and 150
arriving patients, the adaptive capacity features for most strategies mitigate the demand
surge and bend the curves for the recovery times. However, with demand surge volumes
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above 150 arriving patients the adaptive capacity features are no longer able to mitigate
the demand surge. This is particularly noticeable for strategies S1, S2, S4, S7 and S9.
By comparison, for outpatient flows an increase in demand surge volume corresponds to
an increase in recovery time, as shown in Figure 6-26. This is due to scheduled surgery
cancellations in order to accommodate emergency surgery patients, as well as surgical
unit capacity reallocation and repurposing.
The best strategies with regard to minimizing the required number of hours in
recovery time, as illustrated in Figure 6-25, include strategies S3, S5, and S6. These
strategies demonstrate similar behaviors across the range of demand surge volumes.
These strategies utilize similar, but varied, combinations of adaptive capacity features
that include the transfer of inpatient end ED patients to external facilities, and the
cancellation of scheduled surgery as appropriate. Strategy S5 utilizes the ambulance
diversion feature, which contributes to a further reduction in the inpatient flow recovery
times under high demand surge volumes. The ambulance diversion feature activation
benefit is most evident where the demand surge volume is between 150 and 250 arriving
patients.
In contrast, strategy S8 performs moderately well at lower demand surge volumes
and demonstrates markedly improved performance in recovery times where the demand
surge volume exceeds 150 arriving patients. Strategy S8 utilizes several adaptive
capacity features, such as ambulance diversion and patient early discharge, which tend to
activate with increased patient congestion and delay. The effects are observable in both
inpatient flow and outpatient flow recovery times.
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Strategy S9 performance is competitive for both inpatient flow and outpatient
flow recovery times at lower demand surge volumes; however, with demand surge
volumes above 130 patient arrivals the recovery times are observed to dramatically
increase. The strategy maximizes ED capacity expansion and rapidly activates the
flexible bed capacity; however, minimized patient early discharge usage and limited
patient transfer capability results in insufficient bed availability and inhibits general
patient flow. This limitation is pronounced at the higher demand surge volumes.
Strategies S1, S2, S4, and S7 are observed to perform poorly with respect to
inpatient flow recovery time. While these strategies utilize a varied set of adaptive
capacity features, they restrict inpatient transfers to external facilities which results in the
reallocation and repurposing of surgical inpatient ward beds and surgical unit capacity.
Strategies S4 and S7 attempt to mitigate this restriction through an aggressive patient
early discharge policy in order to improve bed availability. While this may be of some
benefit, strategy S7 is clearly the worst performing strategy which is differentiated by
further limitation on ED patient transfers to external facilities and restriction on
scheduled surgery cancellation.
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Figure 6-25: Surgical unit inpatient flow recovery time by demand surge volume
Figure 6-26: Surgical unit outpatient flow recovery time by demand surge volume
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6.5.2.4 Medical-Surgical Inpatient Wards Patient Flow Recovery Time
The surgical inpatient ward and medical inpatient ward patient flow recovery
times are illustrated in Figure 6-27 and Figure 6-28, respectively. The patient flow
considered in these illustrations is specific to floor bed capacity. These figures illustrate
significant differences among strategies for both the surgical and medical inpatient ward
flow recovery times as observed across the range of demand surge volumes. The surgical
inpatient ward flow recovery times vary wildly with increased demand surge volumes
due to the activation of various adaptive capacity features and dynamic bed capacity
management. In contrast, the medical inpatient ward flow recovery times demonstrate a
much more consistent behavior where increases in recovery times correspond to increases
in demand surge volumes.
Surgical inpatient ward patient flows are susceptible to disruptions caused by
scheduled surgery cancellations, reallocation of surgical unit capacity, accommodation of
emergency surgery patients, and reallocation of surgical inpatient ward bed capacity.
Figure 6-27 illustrates the case where low demand surge volumes, which activate fewer
adaptive capacity features, result in disruptive effects lasting from 7 to 10 days. By
comparison, higher demand surge volumes which activate the majority of adaptive
capacity features, accompanied by temporary bed increases, experience more rapid
patient flow recovery times. However, with higher demand surge volumes the cyclic
nature of the surgical unit surgery schedule introduces oscillations observable in the
recovery times.
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Strategies observed in Figure 6-27 that provide better recovery time performance
include S1, S2, S4 and S8. Among these, strategy S2 exhibits the best recovery time
performance across the range for the demand surge volumes. Strategy S2 benefits from a
combination of adaptive capacity features, which include ambulance diversion and
scheduled surgery cancellation. Strategies with poor recovery time performance include
S3, S5, S6, S7 and S9. While this group of strategies utilizes a variety of adaptive
capacity features, they are generally over reliant on one or two features to increase
available capacity, such as aggressive patient early discharge or maximizing ED capacity
expansion. This can be extremely detrimental to maintaining patient flow. Strategy S5 is
an exception given that it utilizes most all the adaptive capacity features.
As illustrated in Figure 6-28, medical inpatient ward flow recovery times are
influenced by the demand surge volume. Strategies S3, S5, S6 and S8 are observed to be
the better strategies. These strategies utilize inpatient transfer to external facilities to
vacate bed capacity in preparation to receive demand surge arriving patients. A potential
downside is the case where too many inpatient transfers to external facilities occur, based
on incomplete information or standing policy, which results in low occupancy. This
scenario is illustrated with strategy S8 where the demand surge volume is limited
between 1 and 50 arriving patients and a lengthy recovery time is incurred.
Strategies S1, S2, S4 and S7 are underperforming strategies. These strategies
include inpatient transfers to external facilities and, in most instances, limit emergency
patient transfers to external facilities. In contrast, strategy S9 utilizes emergency patient
and inpatient transfers to external facilities and limits patient early discharge usage. This
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results in competitive recovery times at lower demand surge volumes; however, the
recovery times deteriorate substantially with higher demand surge volumes.
Figure 6-27: Surgical inpatient ward flow recovery time by demand surge volume
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Figure 6-28: Medical inpatient ward flow recovery time by demand surge volume
6.5.3 Observations for Varied Demand Surge Volume Over Time
In this section the relationship between the demand surge volume and the adaptive
capacity feature set is examined with respect to two selected strategies over the course of
time. For clarity in the discussion, the outcome results illustrated herein do not consider
the variability previously introduced under the Monte Carlo experiment. Instead, a
common set of initial starting conditions are used for the individual strategies.
Illustrations provided in this section are used to present the status of an adaptive capacity
feature, the number of patients occupying a unit, the rate of patients diverted, the number
of surgery cancellations, and the number of patient early discharge beds recovered.
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The strategies selected for comparison are strategy S4 and strategy S5. Results
from the two previous sections revealed that strategy S5 frequently outperforms other
strategies with respect to recovery times. Strategy S5 utilizes a combination of all
adaptive capacity features in order to facilitate patient flow throughout the hospital. In
comparison, strategy S4 utilizes a combination of fewer adaptive capacity features where
limitations are placed on patient transfers to external facilities and patient early discharge
is aggressively used. Nine areas of interest are compared for the two strategies.
6.5.3.1 Contingency State Activation
Figure 6-29 illustrates the contingency state activation over time for the floor bed
capacity and with respect to demand surge volume. The active state profiles for the two
strategies are similar but subtly differences are noted. At the lower demand surge
volumes strategy S4 utilizes more active contingency state hours than strategy S5.
Revisiting Figure 6-11 this observation is confirmed with the Monte Carlo experiment
results where the median value for strategy S5 is lower than for strategy S4. In this
instance, strategy S5 benefits from a robust combination of adaptive capacity features to
prevent blockages in patient flow leading to a rapid recovery out of the contingency state
and back to the conventional state.
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Figure 6-29: Contingency state activation over time by demand surge volume
6.5.3.2 Ambulance Diversion State Activation
Figure 6-30 illustrates the ambulance diversion state activation, a feature available
only to strategy S5, over time with the effective diversion rate shown. The ambulance
diversion state may be activated when a period of high congestion or long waiting delay
is encountered in the ED. In the illustration it is observed that ambulance diversion
occurs with demand surge volumes of 20 arrival patients or more. The number of hours
spent in active ambulance diversion state is observed to be relatively proportional to the
demand surge volume. The number of patient diversions per hour is depicted in the
region illustrating the ambulance diversion state activation. A demand surge volume near
the upper bound of 300 arriving patients illustrates the case where the ED remains in an
ambulance diversion state for nearly two days.
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Figure 6-30: Ambulance diversion state activation over time by demand surge volume
6.5.3.3 ED Waiting Area and Treatment Room Occupancy
Figure 6-31 illustrates the number of patients in the ED waiting area to be seen by
a physician or clinician. Although the number of patients in the waiting area appears
similar, careful inspection reveals strategy S5 is more responsive in addressing the patient
backlog.
Figure 6-31: ED waiting area patient occupancy
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Figure 6-32 illustrates the ED treatment room patient occupancy over time and
with respect to demand surge volume. Under conventional state operations a total
capacity of 10 treatment rooms are maintained. With a demand surge event, capacity
expansion will occur in adjoining clinical areas repurposed to provide additional patient
treatment capacity when high congestion conditions and contingency or crisis state
operations exist. Both strategies S4 and S5 provide a maximum allowable capacity
expansion of 2 additional treatment rooms, as illustrated in the figure. While treatment
room occupancy appears similar, strategy S5 is observed to be slightly more responsive
in returning to the baseline due to its better patient flow.
Figure 6-32: ED treatment room patient occupancy
Figure 6-33 illustrates the ED treatment room patient occupancy for admission
hold patients over time and with respect to demand surge volume. Neither strategy
shows an indication of significant treatment room blockage due to insufficient inpatient
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bed availability. This may be attributed to the activation of the various adaptive capacity
features.
Figure 6-33: ED treatment room patient occupancy with a patient admission hold
6.5.3.4 Patient Early Discharge Recovered Bed Days
Figure 6-34 illustrates the number of recovered beds days due to inpatient early
discharges over time and with respect to demand surge volume. As shown, strategy S4
aggressively utilizes the early discharge feature by permitting a maximum reduction of
the inpatient length-of-stay by 30%. Strategy S5, by comparison, moderately utilizes the
early discharge practice by permitting a maximum reduction of the inpatient length-of-
stay by only 20%. In both cases the early discharge feature is observed to be activated
due to shortages in bed availability over a ten day period following the disruptive event.
This action dampens the residual fluctuations caused by the demand surge volume.
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Figure 6-34: Inpatient hospital ward early discharge bed days recovered
6.5.3.5 Scheduled Inpatient Surgery Cancellation
Figure 6-35 illustrates the number of surgery cancellations per day caused by
inadequate surgical unit capacity or insufficient forecasted surgical inpatient ward bed
availability. This is presented over time and with respect to demand surge volume. The
effect of surgery cancellation persists briefly where similar numbers of inpatient surgeries
are cancelled for both strategies. Revisiting Figure 6-12 for the Monte Carlo experiment
results confirms the similar cancellation durations and number of patients for the two
strategies.
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Figure 6-35: Scheduled inpatient surgery cancellation
6.5.3.6 Medical-Surgical Inpatient Ward Occupancy
Figure 6-36 and Figure 6-37 illustrate the surgical inpatient ward and medical
inpatient ward floor bed patient occupancy, respectively, over time and with respect to
demand surge volume. As shown in Figure 6-36, the changes observed in the surgical
inpatient ward floor bed patient occupancy do not appear dramatic. Surgery cancellation,
a feature which is available under both strategies, reduces demand for available surgical
inpatient bed capacity from scheduled surgery patients. The available capacity is used to
accommodate emergency surgery patients and fulfill bed capacity reallocation demands.
In the figure, strategy S4 demonstrates higher occupancy than strategy S5, which is
distinguishable on day 6, 7 and 8. The impact of a surge event on the surgical inpatient
ward is observed to persist for the duration of five to seven days. This is partly due to the
surgical unit surgery schedule which typically does not perform surgeries on weekends.
As a result, this allows an opportunity for the surgical inpatient ward to recover.
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While occupancy changes are observed in both wards due to demand surge, the
medical inpatient ward demonstrates a much higher occupancy coupled with additional
allocated bed capacity, as shown in Figure 6-37. Strategy S4 is observed to have a much
higher occupancy across the demand surge volume when compared to strategy S5.
Strategy S4 depends on the aggressive early discharge of patients to make available
needed bed capacity. This can be slow to accomplish and yields a limited amount of
capacity for every patient discharged. Strategy S5 depends on transfers to external
facilities for emergency patients and inpatients to promote patient flow, and on the
moderate discharge of patients to make available needed bed capacity. In both cases, the
impact of the surge event on the medical inpatient ward occupancy persists between eight
to nine days.
Figure 6-36: Surgical inpatient ward floor bed patient occupancy
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Figure 6-37: Medical inpatient ward floor bed patient occupancy
6.6 Conclusions and Future Work
This chapter presents the first known exploration of hospital resilience and
recovery under the conditions of a patient demand surge where capacity adaptation is
integrated and strategies are compared. The results from these strategies demonstrate
important differences in the patient flow recovery times required to return to the baseline
patient flow absent the demand surge. While patient flow recovery times have been the
primary measure of performance in this study, it has been demonstrated that concern for
the other measures of impact, such as the leaving-without-being-seen rates over time or
the number of surgical cancellations, are necessary to make a complete assessment. A
major outcome of this work is to provide information useful to a hospital administrator
planning a response strategy in preparation for a future demand surge event.
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Although the nine strategies studied were not exhaustive, the outcome results
generated, especially from the Monte Carlo experiment, provide meaningful insight. The
results indicate that no one strategy considered is dominant; however, a few strategies are
clearly dominated. The better performing strategies leverage a broad combination of
adaptive capacity features, in moderation, as opposed to the aggressive overuse of a few
adaptive capacity features. Notably, a broader combination facilitates better patient flow
hospital-wide which in turn leads to better performance. For example, strategies such as
S2, S5 and S6 represent the better strategies for the ED patient flow, ED LWBS patient
flow, ED LWBS rate, and surgical unit patient flow recovery times. Although
parameterized slightly differently, these strategies utilize a broad combination of adaptive
capacity features. In comparison, strategy S8 is the best strategy for improving inpatient
ward flow recovery time, using a limited set of adaptive capacity features emphasizing
ambulance diversion, maximum ED capacity expansion, and maximum inpatient external
transfers. Finally, strategy S7, which aggressively utilizes the maximum ED capacity
expansion and maximum patient early discharge, is a dominated strategy as demonstrated
by poor performance.
Based on this study the following general observations and recommendations are
made. A broad combination of adaptive capacity features provides a distinct advantage
to facilitating patient flow and improved performance. Adaptive capacity features
contribute individually and interactively. The ability to transfer ED patients to external
facilities during intense demand surge period is extremely important to improve patient
flow recovery times and minimize impacts. Administrators should establish plans to
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coordinate with neighboring area hospitals and skilled nursing facilities that would have
the ability to accept these patients. Likewise, the ability to divert ambulances to other
hospitals is beneficial but mainly in reducing the recovery time. The ability to expand
ED capacity with makeshift treatment space is beneficial; however, results demonstrated
that it was not necessary to substantially expand the capacity. Instead, it is more
important to maintain overall throughput in the ED by avoiding bed blockages due to
insufficient available bed capacity preventing patient admission boarding. Therefore, it is
important that adequate available bed capacity be made available either through
allocation of flexible or reserve bed capacity, or by clearing existing bed capacity through
early discharge or inpatient transfer to external facilities. The benefit of maintaining a
ready reserve of available inpatient bed capacity, dedicated for a demand surge response,
is demonstrated in the best strategies.
Lastly, while this chapter presents a considerable scope for hospital resilience and
recovery an abundance of future work remains. First, although a demanding challenge
for a hospital a natural disaster, such as a tornado strike, represents only one disaster type
which hospitals must be prepare. Extension to this work should consider other demand
surge events with a range of characteristics to compare and evaluate strategies. Second,
at present Hillsborough hospital underutilizes the large number of critical care beds,
allowing it to absorb patient surge demand without activation of the contingency
operational state for ICU beds. Extension to this work should consider the case where
critical care beds are more heavily utilized and dependent on the contingency operational
state activation to allocate additional capacity. Third, the Monte Carlo experiment varied
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a number of input parameters and the start time of the surge event. Extension to this
work should consider increasing the dimensionality, the range, and the experiment count
to boost the richness of the outcome results. Machine learning techniques could be used
to identify the trends and relationships in this much larger data set. Fourth, the adaptive
capacity features for certain strategies may deactivate earlier, as specified, than
potentially desired in order to maximize the benefit. Extension to this work should
consider experimentation with various specifications and the residual time duration
before resource and capacity is drawn down. Fifth, the strategies and available adaptive
capacity features utilized remain fixed throughout the demand surge event considered.
Extension to this work should consider the case where strategy switching may be
permitted during the demand surge event. Finally, the research focuses on whole hospital
dynamic capacity and provides little insight as to other operational impacts. Extensions
to this work should consider incorporating staff resources and hospital cost.
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CHAPTER 7 CONCLUSION
7.1 Contributions of Dissertation
This dissertation provides a strategic platform useful for the modeling and
exploration of whole hospital capacity dynamics which is believed to be insightful for the
planning oriented hospital administrator. The strategic platform provided is a generalized
whole hospital model for a medium size, semi-urban community hospital with emphasis
on the acute care process. The model was reviewed and validated with subject matter
experts to ensure faithful representation of whole hospital behavior under a variety of
conditions. Chapter 2 presented the detailed description of the whole hospital model and
the collaboration achieved with subject matter experts from member hospitals of the
UNC Healthcare System. We demonstrated the applicability of the whole hospital model
through the exploration four different questions posed as chapters in the dissertation.
Chapter 3 addresses the first question which focused on the unit capacity
allocation required to maintain and improve patient flow and key performance measures.
A fundamental analysis approach, using the whole hospital model to simulate varied
levels of unit capacity, was used to develop insight into the relationship between various
unit capacity groups. The purpose of this simple analysis approach was oriented toward
understanding the relationships and interdependencies on unit capacity allocation rather
than determining a set of inputs that maximize performance. Sensitivity analysis
determined that unit capacity allocation between the emergency department and the
medical inpatient ward units were more insightful using fundamental analysis than the
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unit capacity allocation between the surgical unit and the surgical inpatient ward units.
This was in part due to the inherent complexities involved with elective surgery
scheduling.
Chapter 4 addresses the second question which is focused on the unit capacity
allocation required hospital-wide to satisfy a set of multiple objective criteria and
constraints. A goal seeking approach, which treats the whole hospital as a black box
function, was presented as efficient way to obtain the capacity determination where a
multiple objectives are satisfied. This approach represented an improvement over
recommended solutions obtained using the fundamental analysis approach. The approach
also allowed more objectives and constraints to be considered. Due to the size of the
whole hospital model and the lack of parallelization in the toolset, the generation of
results in the goal seeking approach proved not to be that efficient. The results provided
a solution that did well in satisfying the multiple objectives. Once again, it was
determined that the surgical unit and the surgical inpatient ward units were very sensitive
to changes in demand. In comparison, the emergency department and the medical
inpatient ward unit were less sensitive to changes in demand, with the ability to absorb
short time fluctuations of up to 10%.
Chapter 5 addresses the third question which is focused on the identification of
capacity related factors found hospital-wide that most significantly affect emergency
department operations. A sensitivity analysis for the whole hospital model was
completed in a two stage process. First, a factor screening design using sequential
bifurcation was used to identify the important factors, and then a regression analysis used
320
on the important factors to identify the significant factors. Modifications to the Overall
Equipment Efficiency (OEE) hierarchical metric provided a useful composite
performance measure for the emergency department response variable. Results from the
sensitivity analysis indicated the availability of emergency department treatment rooms
and standard acute care medical beds were the most significant factors to performance
objective achievement. Results also indicate that emergency department performance
depends on the appropriate unit capacity allocated in clinical and ancillary departments
hospital-wide to maintain patient flow.
Chapter 6 addresses the fourth question which is focused on the exploration of
hospital resilience and recovery when a patient demand surge caused by a natural disaster
is encountered. In this exploration, strategies utilizing different adaptive capacity feature
combinations were compared using the recovery times observed in areas throughout the
hospital. A Monte Carlo experiment was performed to simulate the disaster event
occurrences and generate the recovery times required to return to the non-disaster
baseline for the defined set of strategies. Results of the experiment indicated that
strategies utilizing a broad set of adaptive capacity features have better hospital-wide
patient flows and recovery times. The results indicate that adaptive capacity features
such as ambulance diversion, ED capacity expansion, and early discharge are critically
important when the ability to transfer patients to external facilities is restricted.
Furthermore, the results show that no one strategy is a dominant strategy and a small
number of strategies may be dominated. This exploration provides beneficial insight for
321
a hospital administrator planning a response strategy in preparation for a future demand
surge event.
7.2 Future Work
The main opportunity for advancement of this work would be to develop further
enhancements to the whole hospital model, integrate data driven information, and extend
the exploration and analysis particularly for hospital resilience and recovery. First, the
whole hospital model would benefit from enhancements that would make hospital
capacity cost and staff cost data available to the model. In the fundamental analysis and
capacity determination using goal seeking, accessibility to cost related information would
have benefitted the analyses. Access to this data would permit exploration beyond the
limits of capacity allocations issues. Meta-modeling techniques could be used to improve
the efficiency of both sensitivity analysis and optimization efforts. Second, the extension
of the hospital resilience and recovery work presents many further opportunities for both
exploration and analysis. The work presented should be expanded to consider many
different types of natural, pandemic and manmade disasters and should exercise a larger
number of potential response strategies. Increasing both the scale and dimensionality of
the Monte Carlo experimentation should be considered; however, this is software and
hardware capability dependent, and will require enhanced data analytic methods to
exploit the results. Model exploratory analysis may help reduce the search space
examined, and machine learning may be able to abstract the relationships found in a large
data set which could lead to interesting discoveries. Lastly, this work considered the
322
effect of the patient demand surge from disaster event on an individual hospital with
some outside assistance. Future work should extend beyond the individual hospital to
consider the interrelationship between the community and system of area hospitals in
evaluating hospital resilience and recovery.
7.3 Applicability to the Broader Research Community
This dissertation contributes to the industrial and systems engineering literature in
four significant ways. First, the research describes and develops a verified and validated
generalized whole hospital model based on system dynamics that is representative of a
medium size, semi-urban, community hospital which is both scalable and configurable.
The work contributes a modeling resource useful for the purpose of studying how unit
capacity affects system behavior and performance where hospital-wide interdependencies
between units exist. The model provides a useful resource for the researcher evaluating
how policies and strategies to improve response to patient demand surge events or for the
administrator examining how unit capacity should be allocated in the strategic planning
process.
Second, capacity determination using a goal seeking approach attempts to allocate
unit capacity hospital-wide such that multiple objectives of interest to a hospital
administrator might be satisfied. Results from this work reveal that the goal seeking, or
goal programming, approach is useful in hospital-wide capacity determination and offers
an improvement over the simple one-at-a-time approach. This work provides
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contributions to areas of strategic hospital capacity planning and health care performance
improvement.
Third, use of the modified OEE hierarchy of metrics as a key performance
indicator enables the search for significant capacity factors hospital-wide using both
factor screening design and regression based sensitivity analysis. Results from this work
revealed that unit capacity allocation hospital-wide can have a significant effect on the
emergency department performance. This work provides contributions to many areas
which include: (1) an example of a factor screening design use in system dynamics; (2)
insights to improve hospital management and productivity; and (3) the application of an
innovative, modified structured hierarchy of metrics for a whole hospital and a service
based industry.
Last, the exploration of hospital resilience and recovery under the conditions of a
severe patient demand surge uniquely integrates capacity adaptation and compares
strategies. Insight from this work is useful to a hospital administrator planning a
response strategy in preparation for a future demand surge event. This work contributes
insights for capacity dynamics and strategic response considerations to the literature
related to disaster preparedness, planning and management, which is currently dominated
by static planning models, management organizational tools, and preparation checklists.
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APPENDICES
336
APPENDIX A. SIPOC DIAGRAMS BY UNIT
337
338
339
APPENDIX B. WHOLE HOSPITAL MODEL PARAMETER VALUES
Parameter Reported values Data Source Simulated input Assumptions
Arrivals 35 to 45 patients per day Institutional information Maximum = 45 patients per day 70% of arrivals between noon
and midnight
ESI distribution ESI level distribution ESI level distribution ESI level distribution Lower ESI values have priority
(Estimated) In literature (Daniels, 2007) (ESI 1 seen before ESI 2, etc…)
1 = 2.0 % 1 = 1.4 - 2.1 % 1= 2.0 %
2 = 22.0 % 2 = 18.2 - 23.2 % 2= 22.0 %
3 = 39.0 % 3 = 37.0 - 42.0 % 3= 39.0 %
4 = 27.0 % 4 = 29.3 - 19.7 % 4= 27.0 %
5 = 10.0 % 5 = 14.1 - 13.0 % 5= 10.0 %
LWBS rate Average = 1.0 -2.0% Institutional information Vulnerable to LWBS (4% max): ED waiting room congestion &
Maximum = 4.0% Reported in literature ESI 1 & 2 do not leave by lwbs wait time effect leaving rate
ESI 3 - upto 25%, if > 90 mins
ED unit capacity 10 treatment bays Institutional information 10 treatment bays 7 x 24 x 365

2 urgent care desks 2 urgent care desks Limited hours
ED exam time delay 19.8 minutes (0.33h) Reported in literature 19.8 minutes (0.33h)
ED treatment ESI level distribution Institutional information Treatment time duration

1 = 0.23 1 = 45 minutes (0.75h)
2 = 0.23 2 = 75 minutes (1.25h)
3 = 0.22 3 = 30 minutes (0.50h)
4 = 0.20 4 = 19.8 minutes (0.33)
5 = 0.20 5 = 19.8 minutes (0.33)
ED radiology/imaging by ESI level Institutional information Time based on equipment

1 = 0.32 availability and cycle time
2 = 0.32
3 = 0.33
4 = 0.30
5 = 0.30
ED evaluation time by ESI level Institutional information by ESI level

1 = 45 minutes (0.75h) 1 = 45 minutes (0.75h)
4 = 19.8 minutes (0.33h) 4 = 19.8 minutes (0.33h)
5 = 19.8 minutes (0.33h) 5 = 19.8 minutes (0.33h)
ED observation proportion by ESI level Institutional information delay time by ESI

1 = 0.08 1 = 255 minutes (4.25h)
2 = 0.12 2 = 320 minutes (5.33h)
3 = 0.05 3 = 210 minutes (3.5h)
4 = 0.00 4 = 135 minutes (2.25h)
5 = 0.00 5 = 135 minutes (2.25h)
Admission rate Proportion of admitted by Institutional information & Proportion of admitted by

ESI level: Reported in literature: ESI level:
1 = 0.73 1 = 0.52 - 1.00 1 = 0.73
2 = 0.54 2 = 0.42 - 0.57 2 = 0.54
3 = 0.24 3 = 0.15 - 0.31 3 = 0.24
4 = 0.02 4 = 0.01 - 0.02 4 = 0.02
5 = 0.00 5 = 0.00 - 0.01 5 = 0.00
Admission boarding ~18% ED patients admitted; Institutional information ~18% ED patients admitted;
to medical ward 72.7% directed to medical 72.7% directed to medical
1. MICU = 12% ( 1.9%) 1. MICU = 12% ( 1.9%)
2. MFLR= 88% (14.1%) 2. MFLR= 88% (14.1%)
Admission transfer 27.3% directed to surgical Institutional information 27.3% directed to surgical
to surgical unit 1. Emergent = 8.0% (<2%) 1. Emergent = 8.0% (<2%)
2. Addon = 19.7% (~4%) 2. Addon = 19.7% (~4%)
340
Parameter Reported values Data source Simulated input Assumptions
Radiology and Equipment quantity: Institutional information Cycle Time (minutes/patient) Priority sequence:
medical imaging 1 MRI unit MRI = 45 minutes (0.75h) 1. STAT: ED, Surgery
2 CT units CT = 30 minutes (0.50h) 2. Routine: Clinics, Wards
3 Xray units Xray= 15 minutes (0.25h)
2 US units US = 30 minutes (0.50h)
Laboratory Labwork by priority: Institutional information Labwork by priority: STAT and Routine subject
1. STAT (ED & Surgery) 1. STAT (ED & Surgery) to workload demand and
2. Routine (Ward, Clinics) 2. Routine (Ward, Clinics) congestion; however
TAT duration by priority: TAT duration by priority: STAT receives prioritization
1. STAT = 45 minutes 1. STAT = 45 minutes
2. Routine = 45 - 75 minutes 2. Routine = 45 - 75 minutes
Med-surg ward Bed Capacity Institutional information Approx. patient LOS

capacity and LOS 1. 25 Med beds 1. Med ACU = 3 days (72h)
2. 25 Surg beds 2. Surg ACU = 3 days (72h)
3. 9 ICU beds (critical) 3. M/S ICU = 1 day (24h)
4. 9 PCU beds (critical) 4. M/S PCU = 1 day (24h)
Med-surg ward Proportion transferred Institutional information Patient LOS Patient discharge:
transfer proporation 1. Med ICU to ACU: 0.80 1. Med ACU LOS = 2 days (48h) 1. Order initiated by 10am
and duration (LOS) 2. Med ACU to ICU: 0.10 2. Med ICU LOS = 1.5 days (36h) 2. Discharge between 2 to 6pm
3. Surg ICU to ACU: 0.80 3. Surg ACU LOS = 2 days (48h)
4. Surg ACU to ICU: 0.10 4. Surg ICU LOS = 1.5 days (36h)
Surgical unit Scheduled arrivals Institutional information Scheduled arrivals Surgery Scheduled Mon- Fri:
arrivals 1. OP = ~ 9.75 per day and by approximation 1. OP = ~ 9.75 per day 7:30AM to 6:00PM (4PM Latest)
2. IP = ~ 12.75 per day 2. IP = ~ 12.75 per day 7:30AM to 6:00PM (4PM Latest)
3. ED = (OP 45%, IP 55%) 3. Emergency (OP 45%, IP 55%) Emergent (6AM to 10PM): 33%
ED add-on to schedule: 67%
Surgical unit 1. Operating Rooms = 6 Institutional information 1. Operating Rooms = 6 Priority is ED emergent patients,
capacity 2. Procedure Rooms = 2 2. Procedure Rooms = 2 then scheduled outpatient and
inpatient patients, followed by
ED add-on patients.
341
APPENDIX C. EMERGENCY SEVERITY INDEX TRIAGE ALGORITHM
342
APPENDIX D. EMERGENCY DEPARTMENT SPLIT PATIENT FLOW
343
APPENDIX E. SURGE CAPACITY OPERATIONAL STATES
Figure: Surge capacity and infrastructure considerations for mass critical care (Hick et al., 2010)
344
APPENDIX F. ISERC 2014 PROCEEDINGS PAPER
345
346
347
348
349
350
351
352
353
354

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ABSTRACT

result in circulating a bottleneck around the hospital. Hospital-wide improvements should

construct a generalized whole hospital simulation model representative of a medium size

semi-urban community hospital. To make this model produce a faithful representation of a

hospital-wide that most significantly affect emergency department operations. A sensitivity

performed to identify the important factors and subsequently a regression analysis is

factors in achieving performance objectives. The fourth question addressed focuses on

model were used.

All Rights Reserved

A dissertation submitted to the Graduate Faculty of

Raleigh, North Carolina

I wish to acknowledge my committee members who were generous with their

LIST OF TABLES ............................................................................................................................... xii

1.2 Description of Research ........................................................................................................... 2

Chapter 2 A Description of the Whole Hospital Model .................................................................... 8

2.1.1 Health System Collaboration ................................................................................. 8

2.1.2 System Dynamics ................................................................................................. 10

2.1.3 Previous Related Work ........................................................................................ 11

2.1.4 Chapter Organization ........................................................................................... 11

2.2 Model Conceptualization and Development .......................................................................... 12

2.2.1 Community Hospital Acute Care Patient Flow .................................................... 13

2.2.1.1 The Emergency Department.............................................................................. 15

2.2.1.2 The Surgical Unit .............................................................................................. 16

2.2.1.3 The Medical/Surgical Inpatient Wards ............................................................. 18

2.2.2 Model Boundaries ................................................................................................ 19

2.2.3 Model Formulation............................................................................................... 21

2.2.3.1 The Dynamic Hypothesis .................................................................................. 21

2.2.3.2 The Structural Formulation ............................................................................... 24

2.2.4 Model Assumptions ............................................................................................. 27

2.2.5 Model Inputs ........................................................................................................ 29

2.3 A Detailed Model Description ............................................................................................... 29

2.3.1.1 Model Boundaries ............................................................................................. 30

2.3.1.2 The Dynamic Hypothesis .................................................................................. 32

2.3.1.3 Model Structural Formulation ........................................................................... 36

2.3.1.4 Model Inputs ..................................................................................................... 39

2.3.1.5 Dynamic System Behavior ................................................................................ 40

2.3.2 Surgical Department............................................................................................. 41

2.3.2.1 Model Boundaries ............................................................................................. 42

2.3.2.2 The Dynamic Hypothesis .................................................................................. 43

2.3.2.3 The Structural Formulation ............................................................................... 46

2.3.2.4 Model Inputs ..................................................................................................... 49

2.3.2.5 The Dynamic Behavior ..................................................................................... 49

2.3.3 Medical-Surgical Inpatient Wards ....................................................................... 55

2.3.3.1 Model Boundaries ............................................................................................. 56

2.3.3.2 The Dynamic Hypothesis .................................................................................. 57

2.3.3.3 The Structural Formation .................................................................................. 62

2.3.3.4 Model Inputs ..................................................................................................... 64

2.3.3.5 Observed Model Behavior ................................................................................ 64

2.3.4 Radiology and Medical Imaging Diagnostics ...................................................... 66

2.3.4.1 Model Boundaries ............................................................................................. 67

2.3.4.2 The Dynamic Hypothesis .................................................................................. 71

2.3.4.3 The Structural Formulation ............................................................................... 75

2.3.4.4 Observed Model Behavior ................................................................................ 76

2.3.5 Laboratory Diagnostics ........................................................................................ 80

2.3.5.2 The Dynamic Hypothesis .................................................................................. 81

2.3.5.3 The Structural Formulation ............................................................................... 83

2.3.5.4 Model Inputs ..................................................................................................... 87

2.3.5.5 Observed Model Behavior ................................................................................ 87

2.4 Model Calibration and Validation.......................................................................................... 90

2.4.1 Model Calibration ................................................................................................ 90

2.4.2 Model Validation ................................................................................................. 92

2.5 Model Limitations.................................................................................................................. 93

2.6 Conclusions ............................................................................................................................ 94

Chapter 3 Insights from a Fundamental Analysis ........................................................................... 95