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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.
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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
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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
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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
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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
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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
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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
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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

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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