Health Care Manag Sci
DOI 10.1007/s10729-017-9407-5
Decreasing patient length of stay via new flexible exam room
allocation policies in ambulatory care clinics
Vahab Vahdat 1 & Jacqueline Griffin 1 & James E. Stahl 2,3
Received: 20 May 2016 / Accepted: 26 June 2017
# Springer Science+Business Media, LLC 2017
Abstract To address prolonged lengths of stay (LOS) in
ambulatory care clinics, we analyze the impact of
implementing flexible and dynamic policies for assigning
exam rooms to providers. In contrast to the traditional
approaches of assigning specific rooms to each provider
or pooling rooms among all practitioners, we characterize
the impact of alternate compromise policies that have not
been explored in previous studies. Since ambulatory care
patients may encounter multiple different providers in a
single visit, room allocation can be determined separately
for each encounter accordingly. For the first phase of the
visit, conducted by the medical assistant, we define a dy-
namic room allocation policy that adjusts room assign-
ments based on the current state of the clinic. For the
second phase of the visit, conducted by physicians, we
define a series of room sharing policies which vary based
on two dimensions, the number of shared rooms and the
number of physicians sharing each room. Using a discrete
event simulation model of an outpatient cardiovascular
clinic, we analyze the benefits and costs associated with
the proposed room allocation policies. Our findings show
that it is not necessary to fully share rooms among pro-
viders in order to reduce patient LOS and physician idle
* Jacqueline Griffin
ja.griffin@northeastern.edu
1
Department of Mechanical and Industrial Engineering, Northeastern
University, Boston, MA, USA
2
General Internal Medicine, Dartmouth-Hitchcock Medical Center,
Lebanon, NH, USA
3
Geisel School of Medicine, Lebanon, NH, USA
time. Instead, most of the benefit of pooling can be
achieved by implementation of a compromise room allo-
cation approach, limiting the need for significant organi-
zational changes within the clinic. Also, in order to
achieve most of the benefits of room allocation policies,
it is necessary to increase flexibility in the two dimensions
simultaneously. These findings are shown to be consistent
in settings with alternate patient scheduling and distinc-
tions between physicians.
Keywords Room allocation policies . Outpatient clinics .
Discrete event simulation . Ambulatory care .
Patient length of stay
1 Introduction
In recent years, demand for ambulatory care services in the
United States has steadily increased, particularly in compari-
son to demand for hospital inpatient services [1]. For example,
in 2010, more than 100 million patients received care in out-
patient departments [2] while only 35 million patients were
admitted to hospitals [3]. As outpatient clinic demand in-
creases, the need for high quality of care in clinical operations
remains critical [4]. According to the Institute of Medicine
(IoM) (2001), quality of care is described by multiple attri-
butes, including timeliness and efficiency. Correspondingly, a
healthcare organization can improve quality by reducing wait
times while avoiding wastage of limited health resources. Two
key measures of timeliness of care, which are commonly used
in healthcare improvement studies, are (1) length of stay
(LOS), the period of time from the moment that the patient
enters the outpatient clinic to the departure time and (2) wait
time (WT), the total amount of time the patient spends waiting
for any resource while in the outpatient clinic [5–7]. WT can

be further divided into subsections based on where the waiting
occurs including WT in the waiting area of the clinic and WT
in the exam room. Due to the strong relationship between
these two timeliness metrics, the following analysis focuses
primarily on LOS and WT in specific locations (e.g., exam
room, waiting room). Additionally, efficiency metrics
pertaining to physician idle time and clinic closing time are
also examined.
One of the driving factors, among others, in timeliness of
care is the efficiency with which resources are deployed.
Much of the research related to health care efficiency and
resource utilization in outpatient clinics, or ambulatory care
settings, examine the impact of changes to variable resources,
such as physicians and nurses, which can be adjusted to match
changing needs [8–14]. This focus on variable resources over-
looks the important role of the management of fixed resources,
such as exam rooms, in the delivery of outpatient care. In fact,
one common problem in healthcare organizations is the simul-
taneous underutilization of physical, or fixed, resources paired
with poor quality of patient care. For example, in some out-
patient clinics exam rooms are used less than half of the time
the clinic is open while, at the same time, the average patient
wait time in the waiting area is high [15–17].
Much of the research examining the allocation of physical
resources in healthcare primarily addresses the assignment of
specialized rooms such as operating theaters [18–21], inten-
sive care units [22–24], and critical care units [25, 26]. A
limited number of researchers examine the allocation of iden-
tical, generally equipped exam rooms in outpatient clinics.
With a focus on generally equipped rooms, which are most
prevalent in ambulatory care clinics, we develop a discrete
event simulation (DES) model of an outpatient clinic to ex-
amine how new strategies for managing these resources can
drive improvements in quality of care. Specifically, we exam-
ine the role of exam room assignment policies and the benefit
that flexibility of resources can contribute to patient wait times
and lengths of stay.
While multiple strategies exist for assigning physicians to
rooms, primarily one of two approaches are used in ambulatory
care settings: (i) dedicated assignment and (ii) sharing, or
pooling, of rooms. In the majority of clinics, each room is
assigned to a specific provider for an entire session, referred to
as a Bdedicated^ room allocation policy [27]. Correspondingly,
each patient is only visited in a room designated to his or her
physician. One disadvantage of such a policy is that room avail-
ability may be a bottleneck, leading to longer wait times for the
initiation of a patient’s visit. The greatest advantage of using a
dedicated room allocation policy is the ease of implementation
and consistency in patient and physician flows throughout
the day.
Alternatively, in a Bpooled^ room allocation policy, all
rooms are shared among all of the practicing physicians. In
this policy, patients may be visited in any available room.
Vahdatzad V. et al.
Previous research has demonstrated that this policy can in-
crease room utilization [15, 28] and decrease patient wait
times [29] with some limitations. In some clinics, the pooling
of rooms causes longer walking distances for physicians due
to the design of the space and is perceived not to be practical
[28]. Another disadvantage of this policy is that unexpected
increases in the length of visits by one provider or patient may
directly influence other physicians and patients. Additionally,
complicated patient flows may cause extra workload for clinic
staff and providers. Similar effects occur in call centers in
which pooling resources leads to increased variability which
correspondingly offsets any gained efficiencies [30].
In order to achieve advantages of both dedicated and
pooled room allocation policies, we evaluate the use of
Bhybrid^ room allocation policies, which allow for the system
to achieve a middle ground between dedicated and pooled
policies. We demonstrate how increased flexibility in room
assignment policies can contribute to better overall patient
quality of care, while imposing minimal changes to the status
quo dedicated policies.
We distinguish the room assignment policies correspond-
ing to the two phases of patient-provider interaction, which
occur in most outpatient clinics. The first phase of care for a
patient is the completion of intake questions, tests, and mea-
surements by a Nurse Practitioner (NP) or Medical Assistant
(MA). In the second phase of care, the patient is visited by his
or her physician (MD). Often the patient will wait in an exam
room between these two stages. Alternatively, in some clinics,
such as ophthalmic centers, patients have a sequence of mul-
tiple visits and return to the waiting area after each phase of the
visit, rather than remaining in one room [31]. Most commonly,
room assignment decisions for the MA-patient and MD-
patient visit phases are not distinct and are assumed to be the
same. As we demonstrate, new paradigms for increasing flex-
ibility in room assignments in either, or both, the MA-patient
and the MD-patient phases can significantly improve not only
the patient experience, through decreases in WT and LOS, but
also physicians’ experiences, through reduced delays for ini-
tiating patient visits and reduced overtime.
The research presented below focuses on the study of a
cardiovascular outpatient clinic in a major teaching hospital.
While the results correspond to this institution, the value of
exploring new strategies for utilizing limited exam rooms and
increasing flexibility in room assignments can be extrapolated
to other ambulatory care clinics, as demonstrated via a sensi-
tivity analysis in Section 5. Specifically, the generalizable
contributions of this work include:
& A new focus on and study of flexibility in room assign-
ments for crowded ambulatory care settings, which allows
for gaining much of the benefits of pooling resources
while limiting the operational challenges that can
occur with such a strategy. Benefits and barriers to
Decreasing patient length of stay via new flexible exam room allocation policies in ambulatory care clinics
implementation of this flexibility are investigated, ac-
counting for multiple stakeholder perspectives.
& The distinct modeling of exam room allocation policies
for two phases of patient care, specifically the MA-
patient and MD-patient visits, allowing for analysis of
the individual contributions of such policies and the cu-
mulative benefit of joint deployment.
& The definition and analysis of two different strategies, or
policy structures, for increasing flexibility in room
assignments.
– When considering the MA-patient phase of the visit, we
examine adaptive policies in which decisions for assigning
rooms evolve based on the current state of the system.
– When considering the MD-patient phase of the visit, while
assuming that room assignments remain fixed over time,
we examine the relative benefits of changing two features
of room sharing, the number of rooms being shared and the
number of physicians sharing each of the rooms.
& The demonstration that most of the benefit of pooling can
be achieved by implementation of a compromise room
allocation approach, limiting the need for significant orga-
nizational changes within the clinic. These compromise
approaches are most beneficial when changes are made
to both features of room sharing.
The remainder of the paper is organized as follows. In the
following section, we provide a review of relevant literature
pertaining to physical resource allocation in healthcare set-
tings and more specifically to research concerning room allo-
cation in outpatient clinics. In Section 3, a summary of the
cardiovascular clinic underlying this research and a compre-
hensive review of the constructed discrete event simulation
model, assumptions, data collection, and validation are pre-
sented. In Section 4, we present a holistic description of the
room allocation policies for both MA and MD visits, and
discuss the corresponding results pertaining to patients, pro-
viders, and the clinic. Strengths and weaknesses of the pro-
posed room allocation policies in each phase, and opportuni-
ties to extend and generalize the results for other outpatient
clinics are explored in Section 5. Finally, in Section 6, we
conclude by reviewing contributions of this research and pro-
posing suggestions for future research.
2 Literature review
There is a wealth of literature examining the application of
operations research to healthcare systems incorporating
methods such as network queueing analysis, Markov models,
linear programming, and discrete event simulation (DES)
[32, 33]. One of the primary advantages of the use of DES
in healthcare management research is the ability to represent
complex interdependencies which drive clinic behavior while
accounting for high levels of uncertainty. In turn, computer
simulation models are used to evaluate resource and staff
utilization and forecast patient-related metrics under varying
operational and physical constraints [5]. DES is used in case
studies of emergency departments [34], intensive care units
[35], hospitals [36], demographic health provision [37], and
outpatient clinics [38–41]. For example, Hashimoto and Bell
[42] use DES to evaluate and suggest policies for staffing
and scheduling to improve patient flow in an internal medi-
cine clinic.
Beyond the focus on DES methods, a variety of operations
research methods are used to address the design and imple-
mentation of new resource allocation policies in health sys-
tems. For instance, Balasubramanian et al. [43] implement a
two-stage stochastic programming approach to examine the
value of flexibility in primary care practices. They investigate
the value of allowing providers to visit patients of other pri-
mary care providers to increase patients’ Btimely access^. For
this purpose, they propose Bfull flexibility^ such that a patient
may see any primary care provider, Bdedicated^ where each
patient can only be seen by her or his primary care provider,
and Bpartial flexibility^ where each patient may be visited by
one of two physicians. Similarly, Rau et al. (2013) investigate
the impact of pooling therapists and demonstrate that while
pooling decreases the average patient wait time significantly,
adding more therapists to the pool does not achieve further
reductions [44]. Rather than focusing on policies for the as-
signment of practitioners to patient visits, we instead examine
the value of flexibility in the assignment of providers and
patients to examination rooms.
Queueing systems analysis is another common method
of researching the relative benefits and disadvantages of
dedicated and pooled resources. While some research ac-
credits pooling as a method to reduce variability [45],
others identify conditions such that pooling queues adds
variability and hence reduces efficiency of a system [46,
47]. For example, dedicated resource allocation may in-
crease efficiency when there are heterogeneous customers
with varying service level requirements [48]. With the fo-
cus on interdependencies among various types of resources
and the dynamic reallocation of resources based on the
definition of multiple interdependent system characteris-
tics, a DES method is identified to be the preferable meth-
odology for this study, rather than a queueing approach.
Beyond a focus on the relative merits of dedicated and
pooled resources, a variety of research focuses on the design
of policies and strategies for allocation of resources. A review
of the related literature pertaining to the allocation of fixed, or
physical, resources is presented in Section 2.1. Further a re-
view of research pertaining to the allocation of rooms, a par-
ticular class of physical resources, is provided in Section 2.2.

2.1 Physical resource allocation
Physical resource allocation in healthcare applications can be
broadly categorized into either inpatient or outpatient con-
texts. Inpatient resource allocation traditionally refers to hos-
pital beds, critical/intensive care units [49–51], and operating
theaters. Due to the high cost of adding hospital bed capacity
[52], multiple studies examine new strategies for bed alloca-
tion [52–56] and bed management [18, 57] in hospitals. As a
result, many researchers work to maximize patient through-
put, minimize wait times and total patient length of stay, or
maximize occupancy of beds in hospitals to increase efficien-
cy of care. Resar et al. (2011) use real-time demand capacity
management to predict bed demand and supply. Their im-
provements not only reduce patient wait times and boarding,
but also decrease the number of patients who leave without
being seen [58].
Operating rooms are a hospital’s largest revenue and cost
center [59, 60], but decisions about allocation are challenging
due to the existence of elective (e.g. scheduled patients for
operation) and non-elective patients (e.g. walk-in patients to
emergency departments) with highly variable lengths of clin-
ical procedures and expected lengths of stay. Cardoen et al.
[18] provide a comprehensive review of operating room plan-
ning and scheduling. Persson and Persson [61] evaluate poli-
cies for maximizing the utilization of operating room time in
an orthopedic surgery department using discrete event simu-
lation. They propose various management policies and ana-
lyze the results with respect to uncertainty of patient arrivals
and surgical procedures. Unlike operating rooms, outpatient
clinics consist of generally equipped exam rooms that are non-
procedural and have high turnover rates. To the best of our
knowledge, minimal research has been completed to address
allocation of these rooms in outpatient clinics.
2.2 Room allocation problem in outpatient clinics
The most common strategies for allocating generally equipped
clinic examination rooms among physicians or providers in
outpatient clinics include dedicated and pooled policies. Cote
[27] evaluates the impact of the number of exam rooms allo-
cated to each provider in a family practice outpatient clinic. He
finds that by providing additional dedicated rooms to a phy-
sician, wait times shift from the waiting area to the exam room
and LOS remains statistically unchanged. In this regard, Berg
et al. [17] recommend that no more than two dedicated
rooms should be assigned to each endoscopist in a colonos-
copy suite.
Alternatively, to prevent long lengths of stay and low room
utilization, which can occur with dedicated room policies,
pooling of rooms among physicians is suggested. This is sim-
ilar to the pooling strategy used in computer network science
[62] and inventory management [63] applications. Rohleder
Vahdatzad V. et al.
et al. [64] use DES to examine benefits of pooling resources
when designing a new outpatient facility. Similarly,
Santibanez et al. [29] and Haraldsson [15] examine pooled
room allocation policies in outpatient clinics. Both analyze
results using DES and find significant improvements in WT
and LOS. While room pooling improves patient care, it may
not be a feasible or practical solution in some ambulatory care
clinics. Norouzzadeh et al. [28] discuss the complexity and
practicality of pooling 20 rooms among 12 residents and 6
faculty physicians with the presence of 8 MAs in an internal
medicine outpatient clinic. To increase practicality of room
sharing, they propose a Bpods^ model where rooms are divid-
ed into two groups and rooms are shared among practitioners
within the same pod. The results show improvements in room
utilization variance. While analysis of the relative benefits of
pooled and dedicated policies exists, there is minimal research
focusing on policies for room sharing, including how many
rooms should be shared and which clinic members should
share the rooms. This research demonstrates that a middle-
ground approach to room sharing can achieve the benefits of
both dedicated and pooled policies.
3 Cardiovascular clinic discrete event simulation
model
Our study of room assignment policies is conducted in a car-
diovascular outpatient center of a teaching hospital in the
northeast region of the United States. The cardiovascular cen-
ter has more than 60,000 patient visits per year and more than
160 physicians, fellows, and nurses working in the depart-
ment. The center is divided into three specialty clinics and this
research targets the most complex of the three. Clinic man-
agers note that historically long patient wait times in the
waiting area, and correspondingly long patient lengths of stay,
are a significant concern. Using this cardiovascular clinic as a
motivating example, this research explores the use of flexible
room assignments, particularly in clinics in which an even
distribution of rooms among physicians is not possible, by
characterizing the intrinsic balance between changes to
existing policies and improvements in patient LOS. For this
purpose, we develop a comprehensive simulation model, as
described in Section 3.2, that incorporates details pertaining to
patient, MA, and MD flows and their interactions. A summary
of the key characteristics of the clinic is provided in
Section 3.1.
3.1 Clinic overview
In this clinic, patients visit with a specific cardiologist, cardiac
surgeon, or vascular surgeon on a scheduled appointment ba-
sis. Prior to the physician visit, a Medical Assistant (MA)
prepares the patient in his or her examination room, performs
Decreasing patient length of stay via new flexible exam room allocation policies in ambulatory care clinics
an electrocardiogram (EKG) and other vitals tests, and reports
the results to the physician. Subsequently, the physician re-
views the results at his or her desk, walks to the room, visits
with the patient, and possibly orders blood tests which are
performed in the clinic’s phlebotomy lab. Once the patient
completes any necessary laboratory tests, he or she checks-
out and schedules subsequent appointments. In some cases,
patients do not check-out and, instead, leave the clinic imme-
diately. Figure 1 presents a visual representation of the most
common patient flow pattern in the clinic.
3.1.1 Initial room allocation policies
With regard to room allocation policies, each room is assigned
to a specific physician for an entire session. MAs are
instructed to perform EKGs in a room corresponding to the
patient’s physician. After the MA completes his or her activ-
ities, the patient remains in the exam room until the physician
is available to initiate the visit. After the physician visit, the
MA cleans the room and prepares it for the next visit.
In the clinic, there are 6 rooms for every 4 physicians.
Correspondingly, rooms cannot be evenly distributed among
physicians and each physician is assigned to one or two exam
rooms. Physicians’ appointment schedules are created inde-
pendently and without a standard scheduling template.
Correspondingly, physicians vary with respect to the number
of patients seen. For each day, managers distribute rooms such
Fig. 1 Schematic view of patient flow in the cardiovascular clinic.
Arrows show patient flows and numeric labels denote precedence. Each
patient checks-in upon arrival and waits in the waiting area for an
available Medical Assistant (MA) and exam room. Once available, the
MA calls the patient, completes vitals in a designated station, and routes
the patient to the exam room dedicated to his or her physician. If required,
that those with the highest patient volumes have two rooms.
On average, physicians with two rooms have 20% more pa-
tients than physicians with one room.
For physicians with two exam rooms, the MA will visit a
patient in one of the rooms while the physician is visiting with
another patient in the second room. For physicians with one
room, the MA and physician visit the patient sequentially. In this
case, MAs aim to perform EKG tests prior to the appointment
time. The physician completes other work pertaining to previous
patients in his or her office while the EKG is being performed.
3.1.2 Preliminary clinic analysis
In order to analyze the initial state of the clinic including
patient WT and LOS, and average resource utilization, one
week of observations was performed in which all patients,
physicians, MAs, and rooms were observed throughout each
session. A summary of the data collected during this observa-
tion period is summarized in Table 1. In the clinic, patient
LOS varies from 19 to 182 min with a mean of 77 min.
During the clinic observation period, it was often seen that
some physicians would have multiple patients waiting for ex-
am rooms while other physicians’ rooms were unused. This
can be partially explained by variation in scheduling and prac-
tice behaviors among physicians, including day-to-day varia-
tions. Correspondingly, while patients are waiting for an av-
erage of 23 min in the waiting area, rooms are occupied 46%
the MA completes an electrocardiogram (EKG) in the room and
delivers the results to the physician. The physician reviews the results
and visits the patient in the exam room. Upon completion, the patient
leaves the room and walks toward the phlebotomy lab to complete nec-
essary tests. Some patients may check-out and schedule subsequent visits
prior to leaving the clinic

Table 1 Summary of process and wait times in cardiovascular clinic
from observation data
Time durations (in minutes)
Patient performance metrics Min Mean Max
Length of stay (LOS) 19 77 182
Wait time in waiting area 0 23 89
Visit time with medical assistant (MA) 2 10 16
Visit time with physician 6 22 67
Scheduled appointment length 15 27 60
of the time the clinic is open. The clinic managers sought a
method for addressing these concerns that did not require
changing the scheduling processes. The incongruence of long
waits for patients to enter an exam room with high levels of
room availability, led to the hypothesis that adjusting room
assignment policies could benefit patients and the system as
a whole, without requiring changes to the scheduling proto-
cols and changing physicians’ practice behaviors. The effects
of room sharing in addition to the implementation of more
efficient patient scheduling is examined in Section 5.
3.2 Discrete event simulation model
A discrete event simulation model is developed using
Rockwell Arena 14.0 software. The simulation model cap-
tures details and complexities of the clinic as outlined above.
Using collected data to generate inputs to the simulation mod-
el, we incorporate the observed variability in different clinical
processes including appointment length, patient arrival pat-
terns, treatment duration, and post-visit operations. After val-
idation of the simulation model, a study of the impact of room
allocation policies with respect to patient LOS and WT in the
waiting area is conducted.
As is needed for all simulation models, multiple assumptions
are made in the model development. First, we assume that the
cardiovascular clinic has limited operating hours from 8:00 AM
to 5:00 PM, but continues operating until all scheduled patients
leave the clinic and all tasks are completed by MAs and physi-
cians. Based on feedback from staff and through clinic obser-
vations, we assume eight physicians practice each day. With a
total of 12 rooms considered, it is assumed that four physicians
will be assigned two rooms and the remaining four will have
one room each. Based on historical data, physicians with two
rooms have 20% more patients than physicians with one room.
Patient characteristics are assumed to be consistent over all
physicians and the likelihood of appointment lengths do not
differ between physicians. The time required to visit patients
is assumed to be a function of appointment length rather than
physicians’ practicing patterns. All four MAs in the clinic are
shared among all physicians and exam rooms, working as a
Vahdatzad V. et al.
team to prepare patients and perform EKG tests. Patients of
each physician are assumed to be seen and prioritized based
on arrival time to the clinic. Hence, the queue discipline for
each physician is initially first-come first-served (FCFS). The
clinic is modeled as a terminating system in which each day
operates independently and all resources and patients are ini-
tialized at the beginning of each simulation. Correspondingly,
no warm-up period is utilized in the analysis, which consists of
500 replications to account for the stochastic nature of the pro-
cedures such as visit times by MAs and physicians. The number
of replications is selected in a way to generate tight confidence
intervals on all metrics of interest, such that the half-width is
within 5% of the average [39].
3.2.1 Data collection and analysis
A comprehensive analysis is performed on data from more
than 60,000 appointments between August 2012 and August
2013. From the analysis, no standard physician scheduling
template can be identified as a result of last-minute patient
additions. Therefore, hourly patient arrival patterns with no
significant batch arrival behavior are identified and modeled
as a non-stationary Poisson process. Seasonality based on the
day of the week is disregarded since each day is simulated
independently and the day-to-day variations are captured in
the model inputs. Additionally, variability in the scheduled
appointment lengths is identified (Fig. 2), and corresponding-
ly incorporated into the model. No historical data pertaining to
the visit types (e.g., post-surgery, check-up) was available to
further distinguish the drivers of the observed variability.
Observation data was collected over three different time pe-
riods, with each observation period correspondingly focusing
on the perspectives of the (i) patients, (ii) medical assistants, and
(iii) the overall clinic. The first patient-focused observation oc-
curred in September 2013 and yielded information about the
duration of and likelihood of patient processes including check-
in, EKG, vitals, MA-patient visit, patient wait time in the exam
room, MD-patient visit, check-out, and phlebotomy tests. To
ensure a thorough data collection, observations occurred across
a variety of time periods (8 am-1 pm; 1 pm–5 pm) and days of
the week. In November of 2013, we observed the MA process-
es and tasks that do not consist of direct contact with the patient
(e.g. inventory management, room cleaning, and paperwork),
henceforth referred to as ‘documentation’. Finally, in order to
observe the overall clinic behavior at once, a systematic obser-
vation was performed which included observation of all pa-
tients, physicians, MAs, and rooms from the beginning to the
end of each session for an entire week.
The data collected from these observation periods are used
to define the model parameters and statistical distributions
within the discrete event simulation model. For ease of inter-
pretation and validation by hospital staff, triangular distribu-
tions are utilized to fit process times where applicable. As
Decreasing patient length of stay via new flexible exam room allocation policies in ambulatory care clinics
Fig. 2 Distribution of scheduled
appointment lengths.
Approximately half of the
appointments are 20 minutes, but
the scheduled appointment length
can vary from 15 to 90 minutes.
The simulation model assigns
appointment lengths to each
patient based on this distribution
demonstrated in Section 3.2.2, the model’s accuracy is vali-
dated using this assumption.
A summary of the model inputs, as informed by the data
collection and analysis, are provided in Tables 2 and 3. The
MD-patient visit time varies significantly based on appoint-
ment length, patient type (i.e. new or returning patient), and
clinic type (e.g. cardiology, surgery, radiology, and trans-
plant). As a result, a triangular distribution based on the ratio
of the actual physician visit time to the scheduled visit time is
considered in the model (i.e. min: 0.5, mode: 0.75, max: 1.25).
In addition to the time with patients, physicians are required to
complete additional paperwork, or documentation, in their
offices following visits. The documentation time for the phy-
sician may overlap with the MA-patient visit or periods of
time when no patients are in the clinic. The model assumes
that if a patient is ready and waiting for the physician, the
documentation process will be postponed to prioritize the vis-
it. All documentation must be completed by the end of the day.
With the focus on room assignments to providers, the
Table 2 Probability of patient requiring an EKG, check-out, or
phlebotomy services
Probability Distribution
Variable Yes
Patient requires an EKG test 0.85
Patient requires check-out 0.75
Patient requires phlebotomy 0.20
simulation model incorporates all of these details to ensure
accuracy in the representation of the system.
3.2.2 Model validation
In order to verify the accuracy of the simulation model, we track
each entity’s progression to ensure logical accuracy of the mod-
el. The model results were presented to a team consisting of
clinicians and managers in several meetings. The team mem-
bers’ points of view and suggestions informed updating and
tuning of the model. At the conclusion of this process, it was
agreed that the represented outputs are consistent with the clinic
operations. Further, as the value of animation to applied projects
is shown by Ledlow and Bradshaw (1998), an animation of a
simulated clinic day was presented to clinic managers and staff
[65]. Figure 3 shows a snapshot of the clinic simulation anima-
tion that is consistent with the clinic layout. The animation
depicts patient flows and utilization of physicians, MAs, rooms,
and EKG machines throughout a one-day period.
The model is validated statistically by comparing outputs
of the model to observation data. Specifically, patient LOS
and WT in waiting area, being the primary outputs of interest
for the analysis, are examined. As shown in Table 4, 95%
confidence intervals of both observed and simulated data are
No
compared. The results show no statistically significant differ-
0.15 ences between the means of the observed and simulated data.
0.25 In addition, a two-sample t-test confirms that there is no
0.80 evidence to conclude that the underlying means are different
at a 95% confidence level [66]. Therefore, the simulation
 Vahdatzad V. et al.

Table 3 Process time duration

distributions. Triangular Triangular distribution parameteters for process durations (in minutes)
distribution is fitted to all patient
flow processes Process Minimum Mode Maximum

Check-in 0.50 1.20 2.20

Patient preparation (without EKG) 2.00 4.00 11.00
Vitals 0.75 1.50 2.25
EKG machine preparation 1.00 2.00 4.00
EKG test 4.00 6.00 11.00
MA documentation per patienta 4.00 7.00 8.00
MA reporting visit results to physician 0.50 0.75 1.25
Physician documentation per patienta 7.00 10.00 12.00
Check-out 1.00 3.50 12.00
Phlebotomy 8.00 10.00 12.00
Patient walking time from/to waiting area 1.00 2.00 5.00
a
Documentation refers to the tasks conducted in relation to a visit that are not conducted in the presence of the patient

model is assumed to be an accurate representation of the true
system and is used as the foundation for the analysis of the
impact of different room allocation policies on WT in waiting
area and LOS in the following sections.
4 Results
Utilizing the validated simulation model of the cardiovascular
clinic, described above, we examine how changes to room
allocation policies within a clinic, particularly those that in-
crease flexibility and resource sharing, can improve patient
lengths of stay with minimal impact to physicians’ access to
rooms. There are multiple strategies that can be implemented
that constitute ‘changes in room allocation’ which strike a
balance between traditional dedicated policies and fully
pooled resource sharing. Similarly, these policies can be de-
fined for different phases of the patient’s visit. We evaluate the
impact of MA-room and MD-room allocation policies, indi-
vidually and simultaneously. In Section 4.1, we present a

Fig. 3 Animation snapshot of final simulation model using Arena 14.0. The model depicts the dynamic state of patients, physicians, MAs, staff, exam
rooms, and EKG machines throughout the day in an outpatient cardiovascular clinic
Decreasing patient length of stay via new flexible exam room allocation policies in ambulatory care clinics
Table 4 Simulation model validation. Patient LOS and WT in waiting area of simulation model and observed data are compared. Results validate the
model and show no statistically significant differences between observed and simulated outputs
Simulated
Metric Mean
Patient length of stay 76.10
Patient wait time in waiting area 23.19
paradigm for MA-room assignment policies including adap-
tive policies which adjust room allocations based on the state
of the clinic. Next, in Section 4.2, we present the concept and
outcomes of hybrid MD-room allocation policies which char-
acterize varying levels of room sharing among physicians.
Finally, in Section 4.3, we analyze the cumulative effective-
ness of these MA- and MD-room allocation policies.
4.1 MA-room allocation policies
The first phase of a patient’s visit consists of the MA-patient
visit in which an EKG and vitals are performed. In the initial
clinic setting, a Bfixed^ allocation policy is employed in which
MAs are restricted to perform the EKG and vitals in one of the
rooms assigned to the patient’s physician. Correspondingly,
patients who have been waiting for a long time, or Bdelayed
patients,^ may wait for a specific room to become available
even when other rooms (assigned to other physicians) are
available. Alleviating long waits to complete EKGs and vitals,
in the Bflexible^ allocation policy the MA-patient visit may
occur in any available room, regardless of the physician’s
room assignments. In the flexible policy, patients will return
to the waiting area following the MA-patient visit and wait
until a room designated to their physician becomes available.
Alternatively, we analyze a third Badaptive^ strategy for
identifying which room an MA-patient visit should occur in.
The adaptive MA-room allocation policy is a combination of
the flexible and fixed policies. More specifically in this policy,
only when a physician is behind schedule, with several of his or
her patients in the waiting area, will the MA-patient visit occur
in the first available room, as in the flexible policy. Otherwise,
the MA-patient visit will occur in a room designated to the
MA-room Allocation Policy Spectrum
Patient
Delayed patient
Exam room
Fixed
Fig. 4 MA-room Allocation Policy Spectrum. While in a fixed MA-
room allocation policy, MAs visit patients only in rooms designated to
the patient’s physician. In a flexible allocation policy, MAs can visit the
patient in any available room. In an adaptive policy, if a patient is
Observed
95% CI Mean 95% CI
[74.24, 77.95] 77.42 [72.03, 82.80]
[21.81, 24.51] 23.41 [20.32, 26.53]
physician. When the adaptive policy is implemented, in order
to expedite the process of preparing a patient to visit with the
physician, the MAs will perform the EKG and vitals of the
most-delayed patients in any available room even if all rooms
dedicated to the physician are occupied. For all other patients
and physicians, a fixed allocation policy is used. A depiction of
the differences between these three policies is shown in Fig. 4.
With the purpose of only changing policies for a subset of
physicians, who are behind schedule, the adaptive policy is
defined by a parameter corresponding to the number of de-
layed patients required to utilize a flexible, rather than fixed,
MA-room assignment approach. To account for this policy
structure in the simulation model, every time a patient
checks-in, the number of patients waiting for his or her partic-
ular physician in the waiting area is checked. If the number of
patients in the queue is higher than the predefined threshold
level and an MA is available, the patient with the longest
current wait time (for that physician) will be prioritized to
begin the MA-patient visit in any available room. To assure
consistency of the FCFS policy, if during the MA-patient visit
a room assigned to the physician becomes available it will be
reserved for the patient.
The sensitivity of the effectiveness of reducing LOS corre-
sponding to the Bdelayed^ queue length parameter, or thresh-
old, is shown in Fig. 5. The flexible policy is achieved when
the queue length parameter is set to zero. In other words, even
if there are no patients in queue waiting to be visited, upon
arrival each patient has the MA-patient visit in the first avail-
able room before returning to the waiting area. If an incremen-
tal increase in the threshold level does not imply a change in
average LOS, a fixed allocation policy is achieved. It can be
inferred that with high threshold levels patients will always
Adaptive Flexible
experiencing a long wait, the MA will visit the patient in any available
room, similar to the flexible policy, while other patients are visited in
designated rooms, as in the fixed policy

Fig. 5 Average patient length of stay (LOS) with respect to MA-room
allocation policy. The horizontal-axis defines the threshold of the number
of patients in queue of each physician. When the queue length exceeds the
use designated rooms since the queue length will rarely reach
the predefined level.
For any positive threshold level not corresponding to a
fixed allocation policy, we denote it as an adaptive MA-
room allocation policy. For the cardiovascular clinic, this cor-
responds to queue lengths between 1 and 8. For instance, if the
threshold equals 2, each time a patient arrives, the number of
patients in the queue of his or her physician should exceed two
before moving to a flexible policy from a fixed policy. In the
model of the cardiovascular clinic, the most significant reduc-
tion in LOS, compared with the fixed policy, occurs when the
threshold varies between 1 and 3. The average LOS among all
patients decreases approximately 5 minutes using this adap-
tive MA-room policy. Interestingly, the flexible MA-room
allocation policy is not strictly better than the adaptive policy
for all threshold levels. This phenomenon occurs due to the
extra time required for patients to change clothes after the
EKG and to move either to the waiting area or to a newly
available exam room, which in turn leads to increased walking
distances and times for both patients and the MAs, who are a
scarce system resource.
The results show that an adaptive MA-room allocation pol-
icy with certain thresholds outperforms both flexible and fixed
room allocation policies. While the flexible policy leads to a
smaller average LOS, compared with the fixed policy, it is
important to note that implementation of a flexible policy
may introduce more operational complexity and require im-
provements in communication and information flow.
Vahdatzad V. et al.
threshold, the MA-room policy transitions to a flexible policy. The
adaptive policy in which the threshold level is one patient leads to the
smallest LOS
Correspondingly, an adaptive policy can achieve much of
the benefits while potentially minimizing the challenges of a
fully flexible policy.
Overall, the results demonstrate that an adaptive policy,
even one with a high threshold value, can lead to a significant
improvement over a fixed policy. Thus by introducing flexi-
bility in the design of operational policies, with a correspond-
ing shift when significant delays are seen, the overall system
performance can be improved.
4.2 MD-room allocation policies
In the second phase of the patient experience, defined as the
MD-patient visit, the physician and the patient meet in an
exam room. The initial system corresponds to the Bdedicated^
MD-room allocation policy, in which each room is assigned to
exactly one physician and physicians are assigned to either
one or two exam rooms. As outlined above, with a dedicated
MD-room allocation policy long wait times for rooms can
occur. Alternatively, in a Bpooled^ MD-room allocation poli-
cy, as has been examined in previous studies [15, 29], rooms
are not assigned to specific physicians. Instead, a patient oc-
cupies the first available room and the physician is informed
of where to visit with the patient. In some clinical settings,
where specialized equipment is needed, a pooled MD-room
allocation policy may not be feasible.
As an alternative to the pooled and dedicated MD-room
allocation policies, a Bhybrid^ MD-room allocation policy
Decreasing patient length of stay via new flexible exam room allocation policies in ambulatory care clinics

may be used. In this policy, each room is assigned to a subset (S). We correspondingly define a low (L), moderate (M), and
of physicians who share the room. Any of the assigned pro- high (H) level of flexibility for each of these two parameters.
viders may use the room for MD-patient visits, and corre- The nine hybrid MD-room allocation policy scenarios
spondingly MA-patient visits. While this hybrid policy of are depicted in Fig. 6. Based on the clinic layout, each
sharing rooms falls along a spectrum between the pooled of four physicians are assigned to a pod of six rooms.
and dedicated policies, there are multiple options for how While the figure refers only to six rooms and four phy-
partial room sharing can be implemented. Specifically, these sicians, this pattern is repeated for every group of six
policies may vary with respect to the number of physicians rooms in the simulation model. Due to the structure of
sharing each room and the number of rooms being shared. the space in the cardiovascular clinic and operational
With a variety of possibilities for implementation of such a challenges, sharing of rooms beyond the pods is not
policy, we analyze the relationship between these room shar- considered to be a feasible approach. The base scenario
ing flexibility features and reductions in LOS as compared corresponds to a dedicated MD-room allocation policy
with fully dedicated or pooled MD-room allocation policies. where two physicians have one dedicated room each
For implementation of a hybrid MD-room allocation policy, and two physicians have two dedicated rooms each. In
patients are assumed to be prioritized to occupy a dedicated alignment with the observation data, physicians A and
room rather than a shared room, if both are available. Nine B, whom originally have two rooms, will have approx-
hybrid MD-room allocation policy scenarios are investigated. imately 20% more patients. Scenario HPHS corresponds
Each is defined by the (i) number of physicians sharing each to a pooled MD-room allocation policy in which all
room, or physician flexibility (P), and (ii) the number of rooms physicians have access to all rooms within the 6-room
that are shared among multiple physicians, or space flexibility pod.

Fig. 6 Proposed hybrid Assignment of 4 physicians to 6 exam rooms

MD-room allocation policy
Dedicated MD -room

scenarios. Each scenario shows a Ph A Ph A

Base Model (dedicated MD-room policy)
variation of assigning six rooms
among four physicians. Scenarios Ph B Ph B
Each of physicians A and B have two dedicated rooms
differ in the number of shared Each of physicians C and D have one dedicated room
rooms (space flexibility) and the Ph C Ph D
number of physicians with access
to the shared rooms Pooled policy
(physician flexibility)
A,C, A,C, A,B, A,B,
A,B A,B
D D C,D C,D
High ( HS )

B,C, B,C, A,B, A,B,

A,B L P H S A,B M PHS H H
D D C,D P S C,D
A,C, B,C, A,B, A,B,
C,D C,D
D D C,D C,D
Number of room s being s hared
Space f lexi bili ty (S)

A,C, A,B,
A A,B A A
Moderate ( MS )

D C,D
B,C, A,B,
B L P M S A,B B MPMS B H PM S
D C,D
A,C, B,C, A,B, A,B,
C,D C,D
D D C,D C,D

A A A A A A
Low ( LS )

B LP LS B B M P LS B B H P LS B

A,C, B,C, A,B, A,B,

C,D C,D
D D C,D C,D

Low ( L P ) Moderate (M P ) High ( H P)

Physician flexibility (P)

Number of physicians sharing each room
Low High

Scenarios LPLS, LPMS, and LPHS correspond to a low level
of physician flexibility with at most two physicians assigned
to each room. In scenario LPLS, each pair of physicians with
one room share their rooms while the remaining physicians’
room allocations remain unchanged. In scenario LPMS, as
compared to scenario LPLS, each physician with two rooms
instead has one dedicated and two shared rooms, such that
only one-third of the rooms are dedicated. Further expanding
on these two scenarios, in scenario LPHS all rooms are shared
by two physicians and no rooms are dedicated to a single
physician. By comparison to each other, scenarios LPLS,
LPMS, and LPHS have low, moderate, and high levels of space
flexibility, respectively, as defined by the number of rooms
shared by multiple physicians.
A moderate level of physician flexibility is seen in scenarios
MPLS, MPMS and, MPHS in which three of the four physicians
are assigned to each shared room. The implementation of these
scenarios is exemplified by examining scenario MPMS. While
in the base model each of physicians A and B have two exam
rooms, in this scenario each of these physicians has one dedi-
cated room and access to two shared rooms. Thus patients are
prioritized to be visited in the physician’s dedicated room unless
occupied. If occupied, any of the available shared rooms
assigned to the physician may be used. If all three rooms are
full, the patient will wait in the waiting area until one of the
rooms becomes available. Physicians with one dedicated room
in the base model have access to four of the shared rooms in
scenario MPMS and their patients may be seen in any of the four
available rooms. If no shared rooms are available, patients will
wait in a queue, with a first-come first-served (FCFS) queue
discipline, until one of the rooms becomes available.
In scenarios HPLS, HPMS, and HPHS all physicians have
access to every shared room, but the number of shared rooms
varies. In scenario HPLS only one-third of the rooms are
shared. While in scenarios HPMS and HPHS two-thirds of all
rooms are shared with moderate and high levels of space flex-
ibility, respectively. While this proposed hybrid MD-room
assignment matrix covers several cases of room sharing
among physicians, there are many possible room sharing sce-
narios that can be implemented. Thus, rather than examine all
possible scenarios, we characterize the relationship between
the space flexibility (S) and physician flexibility (P) charac-
teristics in hybrid MD-room allocation policy scenarios in
order to contrast the partial room sharing approach with the
two common pooled and dedicated policies that researchers
often limit consideration to.
4.2.1 Analysis of MD-room allocation policies
The effects of MD-room allocation policies on the timeliness
of care provided to patients can be measured with multiple
performance metrics including LOS, waiting times in the
waiting area and in the exam room, and the likelihood of
Vahdatzad V. et al.
blocking (in which a patient is waiting due to lack of avail-
ability of an exam room). Beyond the patient experience, MD-
room allocation policies also affect the experience of physi-
cians within the clinic. Since room sharing is expected to also
impact the physician experience, we examine the effect of the
policies on room blocking, or the frequency with which phy-
sicians are blocked from accessing a resource.
Patient length of stay analysis The average patient LOS,
denoting the difference in clinic arrival and departure times
for patients, for each of nine hybrid MD-room allocation sce-
narios is depicted in Fig. 7. All of the partial room sharing
scenarios outperform the dedicated MD-room allocation pol-
icy (base model), which has an average LOS of 76 minutes.
When a greater percentage of physicians have access to more
shared rooms, patient LOS decreases significantly. The best
results are achieved when the number of rooms being shared
and the number of physicians sharing rooms are both high in
scenario HPHS, or a pooled policy. As shown by comparison
with scenarios adjacent to HPHS, specifically MPMS, MPHS,
and HPMS, the incremental impact of additional flexibility in
one parameter is highly dependent on the second parameter.
Correspondingly, in order to increase patient quality of care, it
is not necessary to use a fully pooled MD-room allocation
policy. Instead, it is possible to achieve a similar average
LOS with a partial room sharing strategy.
When holding the level of one parameter constant, intuitively
the overall trend dictates that increasing flexibility, from low to
high, leads to a decrease in LOS. Counterintuitively, if the num-
ber of rooms being shared, or space flexibility, is low, increasing
the number of physicians participating in sharing worsens aver-
age LOS (Scenarios LPLS, MPLS, and HPLS). This occurs due to
the fact that when the number of physicians having access to a
small percentage of shared rooms increases, physicians who
only have access to shared rooms are more likely to have long
wait times for access. Additionally, if physician flexibility re-
mains low, increasing space flexibility will result in minimal
improvements (Scenarios LPLS, LPMS, and LPHS).
In addition to a comparison of the mean LOS between the
scenarios, Fig. 8 presents results depicting the variation in
LOS. The minimum and 25th-percentile observed LOS values
do not differ substantially among the scenarios, as they corre-
spond to times when the clinic is not overcrowded. A more
significant difference in the variation in LOS between scenar-
ios is seen in the comparison of the maximum and 75th-
percentile LOS values. In scenarios M P H S, H P M S, and
HPHS, which achieve smaller average LOS, the variation in
LOS is also decreased as compared with other scenarios.
Overall, when space and physician flexibility increase propor-
tionally, not only does the average LOS decrease, but the
variation is also reduced.
While the results of the analysis demonstrate that any
partial room sharing decreases patient LOS compared with
Decreasing patient length of stay via new flexible exam room allocation policies in ambulatory care clinics

Fig. 7 Average LOS

corresponding to nine hybrid
MD-room allocation policy
scenarios. Scenarios vary in both
physician flexibility, the number
of physicians assigned to shared
rooms, and space flexibility, the
number of rooms designated as
shared. All nine scenarios
outperform the dedicated
MD-room allocation policy, but
the efficacy varies between
scenarios

a dedicated MD-room allocation policy, it also highlights
that if partial room sharing is going to be effective improve-
ments to both parameters, space flexibility and physician
flexibility, must be implemented. Additionally, when greater
flexibility is assumed to require greater implementation
costs, it is not necessary to share all rooms among all phy-
sicians in the pod to reduce patient LOS. In fact, much of
the benefit can be achieved through moderate increases in
flexibility in room sharing, if both space and physician flex-
ibility are implemented.

Fig. 8 Comparison of LOS

variation for the nine hybrid
MD-room allocation policy
scenarios. LOS variation
decreases when space and
physician flexibility increase
proportionally

Wait time analysis In conjunction with decreases in LOS
from added flexibility, patient wait times (WT) also decrease.
Patients experience waiting either (i) in the waiting area, or (ii)
in an exam room when the provider is not yet available. As
shown in Fig. 9, although the total patient wait time decreases
significantly as space and physician flexibility increases, the
hybrid MD-room allocation policy scenarios exhibit different
behaviors with regard to length of wait time in each area.
While less flexible scenarios result in longer wait times in
the waiting area, patients wait less when they are in the exam
room. In scenarios with more flexible policies, patients wait
longer in the exam rooms due to the reduction in likelihood
that room availability is a system bottleneck.
In addition to comparing average wait times, the likeli-
hood of a patient experiencing an Bexcessive^ wait time is
also analyzed. Excessive wait time refers to instances in
which a patient is perceived as having a long wait time in
either the waiting area or the exam room. Evidence from
previous studies confirms an inverse relationship between
long wait times and patient satisfaction [67, 68].
Additionally, many patients are not willing to wait more
than a pre-defined amount of time for receiving care [69].
While patient wait time tolerance varies depending on dif-
ferent social and personal factors [70], we consider any
wait time more than 30 minutes as an excessive wait time.
Figure 10 presents the percentage of patients experiencing
excessive wait times in the waiting area or the exam room
in each of the MD-room allocation scenarios.
Results from the excessive wait time analysis are consistent
with the previous results. Scenarios LPHS, MPLS, and HPLS are
not significantly better than the dedicated MD-room allocation
policy with respect to the rate of excessive wait times, even
though they perform better with respect to the average total
wait time. Also, scenarios MPHS and LPMS slightly outper-
form the pooled scenario (HPHS) showing that, if excessive
Fig. 9 Patient wait time
decomposition based on
MD-room allocation policies.
Average patient wait time
significantly decreases as
physician and space flexibility
increases proportionally. Despite
this overall decrease, the average
wait time in the exam room
increases with proportional
increases in flexibility
Vahdatzad V. et al.
wait time is identified to be the most important characteristic
for managers, implementing a policy with balanced space and
physician flexibility is advised.
Patient blocking analysis The reduction in time spent in the
waiting area can be explained by an analysis of the reasons
patients are not seen immediately, or experience patient
blocking, after checking in. Patient blocking may be a result
of rooms or MAs being unavailable. Patients in the waiting
area are not directly blocked by physician unavailability since
patients are required to be roomed and visited by MAs first.
Only when both the room and the MA are available, will there
be no patient blocking. As shown in Fig. 11, all of the hybrid
MD-room allocation policy scenarios outperform the dedicat-
ed MD-room allocation policy with respect to the total per-
centage of time with patient blocking. As flexibility in room
sharing increases, the likelihood of blocking from a lack of
MA availability increases slightly due to the reduction in the
likelihood that room availability is a bottleneck.
Physician blocking and idle time analysis In addition to the
impact on the patient experience, the change in MD-room al-
location policies also affects the other primary stakeholders,
the physicians. Physician delays, or physician blocking, occurs
when a physician is unable to visit the next patient directly after
completing a visit with another patient. Correspondingly, the
rate of physician blocking provides insight into the amount of
physician idle time, as blocking implies that physicians are
prevented from moving on to their next tasks. Blocking does
not occur if no patients are waiting in the clinic (Bno patient^).
Additionally, blocking does not occur if the next patient is
waiting and ready in another exam room (Bpatient ready^).
Blocking may occur for two reasons. First, the next patient is
in the waiting area due to the lack of availability of an exam
room (Broom blocking^). In this case, the physician must
Decreasing patient length of stay via new flexible exam room allocation policies in ambulatory care clinics

Fig. 10 Excessive patient wait

time comparison among
MD-room allocation policies.
When physician and space
flexibility increase proportionally
the frequency of patients
experiencing excessive wait times
in either the waiting area or the
exam room decreases. With
respect to excessive wait time
frequency, scenario MPHS
outperforms other scenarios

wait until the newly available room is cleaned and an MA can
complete the vitals and EKG process. Second, the next patient
is in an exam room with the MA completing the vitals and
EKG process (BMA blocking^). In this case, the physician is
idle until the MA completes this process.
A summary of the likelihood of a physician experiencing or
not experiencing blocking, and the underlying cause, for each
of the policies is presented in Fig. 12. The likelihood of having
no patients waiting and the likelihood of MA blocking remain
consistent for the various MD-room allocation policies. As
flexibility in room sharing increases, the rates of room
blocking decrease and the rates of patients being ready in-
crease, proportionally. Thus, from a physician’s perspective,
the likelihood of experiencing idle time decreases with the
implementation of the shared policies.
Clinic closing time analysis Beyond the focus on patients
and physicians, an overall view of the efficiency and ef-
fectiveness of the clinic as a whole is achieved with an
analysis of the clinic closing time. For a simulated day,
the clinic closing time refers to the time that the last pa-
tient leaves the clinic and all MAs and physicians com-
plete their documentation activities. Similar to the
blocking rate, an earlier clinic closing time implies that
the system is more efficient and includes less idle time for
physicians and MAs. 95% confidence intervals of clinic
closing time are presented in Fig. 13. These results indi-
cate that not only does the average closing time of the
clinic change, but also the variability in the observed clos-
ing time decreases as both space and physician flexibility
increase.

Fig. 11 Patient blocking analysis

based on MD-room allocation
policies. Patient blocking refers to
the unavailability of a resource
causing a patient not to be seen
immediately. Room blocking
decreases as physician and space
flexibility increase
 Vahdatzad V. et al.

Fig. 12 Physician blocking

analysis based on MD-room
allocation policies. The likelihood
of physicians experiencing delays
decreases with the
implementation of more flexible
room allocation policies

Overall, our findings imply the effectiveness of
implementing flexible MD-room allocation policies for pa-
tients, physicians, and clinic performance. These policies de-
crease patient LOS and WT (including excessive wait times),
improve physicians’ access to rooms, reduce idle time, and
improve clinic performance by reducing clinic closing time.
Therefore, benefits of room sharing result in improvements for
all stakeholders of an outpatient clinic.
4.3 Interactions between MA-room and MD-room
allocation policies
While flexibility and pooling of resources has been shown to
be beneficial for MA-room and MD-room allocation policies
independently, the two policies are intrinsically linked.
Specifically, as MD-room sharing increases this allows for
more Bassigned^ rooms where an MA can complete the MA-
patient visit without returning to the waiting area. Further, not
all combinations of MA-room and MD-room allocation poli-
cies are feasible. For example, flexible and adaptive MA-room
allocation policies do not apply when a pooled MD-room al-
location policy is implemented. This relationship is further
articulated in Table 5. When both flexible MA-room and
pooled MD-room allocation policies are implemented, patients
will no longer return to the waiting area between visit phases.
For ease of presentation and interpretation of the results, we
consider the adaptive MA-room allocation policy to require a
threshold of 2 patients in a physician’s queue before changing
to a flexible policy. When the number of patients in the waiting
area queue for each physician exceeds 2, the most delayed

Fig. 13 Comparison of the

observed clinic closing times for
each MD-room allocation policy.
With increases in physician and
space flexibility, the average
clinic closing time decreases
leading to less physician and
MA overtime
Decreasing patient length of stay via new flexible exam room allocation policies in ambulatory care clinics
Table 5 Relationships between simultaneous implementation of MA-room and MD-room allocation policies
MD-room allocation policy
Dedicated
MA-room Fixed MAs visit a patient only in one
allocation policy of the rooms designated to
that patient’s physician.
Physicians only visit patients in
designated rooms.
Adaptive MAs visit most delayed patient
(of a physician that is
running behind) in any
available room.
Delayed patient will return to
the waiting area and wait
until a room designated to the
patient’s physician
is available.
Physicians only visit patients in
designated rooms.
Flexible MAs visit all patients in any
available room.
Patients will return to the
waiting area and wait until a
room designated to the
patient’s physician is
available.
Physicians only visit patients in
designated rooms.
patient is visited in any available room, while other patients are
visited in designated or shared rooms of their physician.
Figure 14 presents the corresponding average patient LOS for
Fig. 14 Interactions between
MD-room and MA-room
allocation policies. In all
scenarios, using an adaptive or
flexible policy decreases the
average LOS, but as the number
of physicians sharing rooms and
the number of rooms being
shared increases, the impact of the
MA-room allocation policy
becomes less significant
Hybrid Pooled
MAs visit a patient only in one of the Not applicable
(dedicated or partially-shared)
rooms assigned to that
patient’s physician.
Physicians only visit patients in one
of the assigned rooms – whether
partially-shared or dedicated).
MAs visit most delayed patient of a Not applicable
physician that is running behind
in any available room.
Delayed patient will return to the
waiting area and wait until a
dedicated or partially-shared
room allocated to the patient’s
physician is available.
Physicians only visit patients in one
of the assigned rooms – whether
partially-shared or dedicated).
MAs visit all patients in any MAs visit all patients in any
available room. available room.
Patient will return to the waiting area Each patient remains in room
and wait until a dedicated or after the MA-visit.
partially-shared room allocated to Physician visits patient in the
the patient’s physician is avail- same rooms where
able. MA-visit occurred.
each of the nine hybrid MD-room allocation policy scenarios
and the dedicated MD-room allocation policy in combination
with fixed, flexible, and adaptive MA-room allocation policies.

Regardless of the MD-room allocation policy, the fixed MA-
room allocation policy results in a greater average LOS for
patients than adaptive or flexible policies. Adaptive and flexible
MA-room allocation policies result in similar LOS performance
across all MD-room allocation policies. In scenarios MPMS,
MPHS, and HPMS, in which both the space flexibility and the
physician flexibility are moderate or high, differences among
MA-room allocation policies are negligible. In other words,
MD-room allocation policies have a more significant influence
than MA-room allocation policies in influencing LOS in the
simulated system. Thus, if physicians have access to an appro-
priate number of rooms and rooms are shared, MA-room allo-
cation can be disregarded without affecting patient LOS.
Correspondingly, if a dedicated MD-room allocation policy is
used, implementing an adaptive MA-room allocation policy
can improve the system performance.
5 Discussion
The results demonstrate the potential value of implementing
new room allocation policies in outpatient clinics and further
support the need to consider implementing new room sharing
strategies, at various phases of the patient visit. This new
paradigm of deploying room sharing strategies in various
phases of the visit can result in improvements in timeliness
of care, namely with respect to length of stay and wait time,
while also achieving beneficial results for practitioners, with
decreased blocking rates, and the clinic as a whole, with less
overtime. The advantages and disadvantages of implementing
these adaptive MA-room and hybrid MD-room allocation pol-
icies are presented in Sections 5.1 and 5.2, respectively. To
further demonstrate the generalizability of these findings, an
analysis of the sensitivity of the results with alternate under-
lying assumptions is presented in Section 5.3.
5.1 Advantages and disadvantages of adaptive MA-room
allocation policies
The numerical results above demonstrate that using alternative
policies for MA-room assignments (i.e. adaptive and flexible
policies), a rarely examined part of the patient experience, can
improve average patient LOS in comparison to the traditional
fixed policy. Despite these results, transitioning to either an
adaptive or flexible policy will likely increase complexity of
patient flows and may require additional decision making by
staff or management. A summary of patient process flows, and
the additional processes and decisions required to implement
these policies, is shown in Fig. 15. The shaded procedures and
decisions will be included when flexible or adaptive MA-
room allocation policies are used.
The advantage of using an adaptive MA-room allocation pol-
icy rather than a flexible MA-room allocation policy is that rather
Vahdatzad V. et al.
than implementing more complex flows for all patients, it will
instead only be practiced for the subset of patients that are
experiencing long wait times in the waiting area. Beyond dem-
onstrating the effectiveness of an adaptive policy, the results of
the analysis, allow for determination of an appropriate threshold
by which to define the adaptive policy. In addition to improving
patient satisfaction through decreased average length of stay and
wait times [71–73], patient satisfaction is expected to increase
since the treatment process will be initiated more quickly.
The primary disadvantage of the flexible and adaptive MA-
room policies is that the MA-patient visit may occur in a dif-
ferent room than the MD-patient visit and that the patient may
need to return to the waiting area between these two phases.
This may be particularly burdensome for patients with mobility
restrictions. In implementation, characteristics pertaining to the
patient type may be considered before adopting such a policy.
5.2 Advantages and disadvantages of MD-room allocation
policies
The results presented in Section 4.2.1, demonstrate the impor-
tance of sharing rooms particularly at clinics which initially
have uneven room assignments. When a physician has access
to only one room, each time a patient arrives to the clinic, the
MD-patient visit can only begin after the MA-patient visit is
complete. In our analysis of historical room schedules, the
number of patients seen per physician is not linearly propor-
tional to the number of rooms. Correspondingly, rooms are a
significant bottleneck for physicians with one dedicated room
and having access to more rooms, even if shared with other
physicians, reduces the average patient LOS.
When a physician has two dedicated exam rooms, it is
expected that rooms will not be a significant bottleneck since
each physician can visit a patient in one room while an MA-
patient visit occurs in the second room. With variability in the
length of appointments and arrival patterns, there remains the
possibility that the next patient will not have completed the
MA-patient visit before the physician is available. This often
happens when MAs, who serve multiple physicians, are not
available. As a result, a physician may have to wait, or is
blocked, between visits. Hence, although rooms are not sig-
nificant bottlenecks, physicians with two rooms can benefit
from access to additional shared rooms, as it allows MAs more
opportunities to prepare the next patient in advance.
Correspondingly, the effects of implementing the MD-room
allocation policies are not equivalent for physicians that have
only one room and physicians with two rooms in the dedicated
MD-room allocation policy. As shown in Fig. 16, physicians
with one room experience greater rates of room blocking than
physicians with two rooms, but the difference between the two
subsets of physicians decreases as space-flexibility increases.
As the number of physicians that have access to shared rooms
increases, room blocking decreases significantly for physicians
Decreasing patient length of stay via new flexible exam room allocation policies in ambulatory care clinics

Process Flows with the Implementation of Flexible and Adaptive MA-Room Allocation Policies

Patient arrival Check in

Waiting area
Wait for
MA/room

(MA blocking)
(Room blocking) Yes

No
MA available?

(Room blocking)
Yes

(Room blocking)
No No Empty Empty
MD behind No Vitals No
designated designated
schedule? completed?
room? room?

Yes
Yes Yes Yes

Route to waiting Route to any Route to Route to

area available room designated room designated room

Physician visit
Room

No
Vitals Phlebotomy?
80%

Yes
20% Phlebotomy tests
No EKG?
15%

General decisions and processes 85% Yes

No Schedule
appointment
EKG test 25% required?
Extra decisions in “flexible” and
“adaptive” MA-room allocation Yes
75%
Physical flows Check out
No Patient in
Decision flows designated
room? Patient discharge
Yes

Fig. 15 Process flows with the implementation of flexible and adaptive MA-room allocation policies. When transitioning from a fixed policy to a
flexible or adaptive policy, shaded processes are added to the general process and patient flows.

with one room while slightly increasing for physicians with
two rooms. In scenarios in which all rooms are shared, the
gap between room blocking for physicians with one and two
rooms is minimal, causing more uniform access for all physi-
cians. Thus while the blocking rate for the one type of physi-
cian increases, this results in all physicians having a more
similar experience and rate of blocking.
While the findings presented above provide actionable in-
sights for the simulated clinic, a critical question pertaining to
implementation is the practicality of room sharing in different
clinics. Physical factors such as clinic layout and distance
between physicians’ offices and exam rooms would need to
be considered before implementing a room sharing strategy in
other practices. Additionally, operational factors such as room

Fig. 16 Room blocking rate comparison for physicians with one and two rooms in the initial dedicated policy. As room sharing increases, physicians
with one room experience less room blocking and there is a slight increase in blocking for physicians with two rooms
ownership protocols and patient scheduling patterns can lead
to the consideration of different room sharing policies, wheth-
er partially or fully adaptive.
First and foremost, key to a successful implementation of
room sharing is a subset of protocols for managing how the
rooms will be shared and prioritized among physicians. In the
proposed simulation model, several rules were added to assure
appropriateness of room sharing. For instance, patients are
prioritized to occupy dedicated rooms, if both dedicated and
shared rooms of their physician are available. Additionally,
patients of one physician are not allowed to occupy more than
three rooms at the same time, unless no other physicians can
utilize the space.
In general, the queue policy for rooms are FCFS, first-come
first-served, but at the time that a room becomes available, the
first patient in the queue should satisfy one of the following
conditions to be routed to the available room.
& Physician of the patient is available and not busy.
& Physician of the patient has completed a visit and no other
patient of same physician is waiting in a room.
& No other patient is in queue for the room.
If none of these condition holds, the same conditions will
be checked for the next patient in the queue. In clinic obser-
vations, we found that the MAs are cognizant of the physi-
cian’s schedules, whether running late or on time, and often
were comfortable with prioritizing tasks accordingly to ensure
effective patient flow.
Depending on the structure and culture of the clinic,
managing how to share all rooms between physicians
Vahdatzad V. et al.
while also keeping all stakeholders satisfied may be a chal-
lenging daily problem. From a clinic administration per-
spective, room sharing execution may be more difficult
as the number of rooms or the number of physicians using
partial sharing increases. This challenge of implementation
can be lessened through the use of a hybrid-room alloca-
tion policy, in which full space-flexibility is not used. The
results above demonstrate that this can achieve similar ben-
efits as compared with a fully flexible system.
5.3 Sensitivity analysis
As mentioned earlier, it is crucial, yet difficult, to generalize
the results for other outpatient clinics with disparate settings.
Two of the main characteristics of the studied system, believed
to contribute to the value of deploying flexible room sharing
policies, include (i) varying patient volumes among physicians
and (ii) inefficient scheduling practices. Correspondingly, we
conducted a sensitivity analysis to evaluate the benefit of the
same MD-room sharing policies when these characteristics are
changed. As shown below, the results of the analysis remain
the same for these alternate settings, although the scale of the
benefit varies. This supports the generalizability of the results
for application in other outpatient clinics.
5.3.1 Clinics with consistent patient volumes
among physicians
One of the primary assumptions, informed by the cardiovas-
cular clinic’s data, is the relationship between the average
daily number of patients seen by a physician and the number
Decreasing patient length of stay via new flexible exam room allocation policies in ambulatory care clinics
of rooms assigned to the physician. As discussed above, our
assumption is that physicians are assigned to one or two
rooms, where physicians with two rooms have approximately
20% more patients than physicians with one room. In other
settings, the number of rooms assigned to physicians may not
be a function of the daily volume of patients and instead may
be informed by other factors. An alternate model, in which all
physicians have the same patient volume, even while physi-
cians have different numbers of rooms in the initial system, is
constructed. To ensure consistency for comparison of the re-
sults, the MA-room allocation policy remains the same while
the effects of changes to the MD-room allocation policy are
investigated.
For the new setting with consistent patient volumes by
physicians, and all else remaining the same as above, the av-
erage LOS with the initial dedicated MD-room allocation pol-
icy is 77.1 minutes, slightly higher than the initial setting
presented in Section 4.2.1, (i.e. 76.1 minutes). Similar to the
previous setting, the results in Fig. 17, demonstrate that in
order to achieve the best results both space and physician
flexibility are needed. Otherwise, minimal or no improvement
is obtained by limiting the focus to one type of flexibility.
Overall, the partial room sharing scenarios (i.e. MPMS ,
HPMS, and MPHS) achieve similar, although slightly better,
results than the pooled policy, HPHS. Interestingly, in this
setting, a fully pooled policy does not perform best, further
supporting the value of considering hybrid approaches.
In an alternate setting with consistent patient volumes by
physicians, each physician may have access to the same num-
ber of rooms. In such a setting, flexibility can only be achieved
Fig. 17 LOS comparison of
hybrid MD-room allocation
policies when the number of
patients per physician is
consistent among providers
with respect to physician flexibility, not space flexibility
(LPHS , MPHS , HPHS). Interestingly, the scenario with a mod-
erate level of physician-flexibility results in the best perfor-
mance in such a system indicating that extreme levels of flex-
ibility may not always achieve the best results.
5.3.2 Impact of patient scheduling
One of the key characteristics of the studied clinic, in practice
and in the model, is a potentially inefficient scheduling system
which leads some physicians to have multiple patients waiting
while others have no patients waiting. Correspondingly, imple-
mentation of hybrid room allocation policies is found to be
beneficial. To study the relative effects of the scheduling policy
and the flexibility in room sharing, we constructed an alternate
simulation model which approximates the system with an im-
proved scheduling mechanism.
In the statistically verified model of the initial system,
patients’ arrivals follow a non-stationary Poisson process,
where the number of patients per hour of the day varies and
patients are assigned to a physician based on a fixed proba-
bility distribution function. While no one appointment sched-
uling structure that performs well under all circumstances
exists [8], in the improved scheduling mechanism each phy-
sician has a distinct template and exactly one patient is sched-
uled for a visit at a time. This corresponds to the individual-
block variable intervals scheduling scheme used in other ap-
plications [74–76]. In the updated simulation, the scheduled
appointment length distribution remains unchanged, but the
arrivals of patients are such that the time between patient
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arrivals for a particular physician is equal to the appointment
length of the prior patient. If a patient’s appointment runs
long this can result in multiple patients of the same physician
being in the system.
Additionally, in this updated simulation, the information
regarding appointment lengths is used to improve room as-
signments. In addition to the previous conditions applied to
patient selection from the queue (Section 5.2), now if a patient
is waiting for a physician with both dedicated and shared
rooms, and the previous patient in a dedicated room is expect-
ed to leave the room in less than 5 minutes, the next patient
will wait for that room. These updates approximate a more
idealistic system that uses information about appointment
times to ensure a more efficient clinic.
The results of the analysis of this new system, which is
equivalent to the original clinic setting in all features except
the use of the new scheduling policies, are shown in Fig. 18. In
this new setting, with the revised scheduling policies, the av-
erage LOS in the base model with a dedicated MD-room al-
location policy is 73.1 minutes, less than what achieved in the
initial system. Similar to what is found in the initial clinic
analysis (Section 4), significant benefits can be achieved by
deploying partial room sharing policies which adjust for both
the number of rooms being shared as well as the number of
physicians sharing these rooms.
When the system is updated to have a consistent number of
patients per physician in addition to implementing the new
scheduling policies, results consistent with the other simulated
systems are found (Fig. 19). Partial room sharing with regard
to one flexibility feature without changing the other feature
shows minimal or no benefits for the average patient LOS. But
Fig. 18 Comparison of hybrid
MD-room allocation policies
with an individual-block
variable intervals revised
scheduling policy
Vahdatzad V. et al.
as both the number of rooms being shared and the number of
physicians sharing each room change simultaneously, the re-
duction in LOS is significant.
The results of this sensitivity analysis demonstrate the gen-
eralizability of the key findings from the initial clinic setting.
While other factors such as alternative scheduling mecha-
nisms and reduced variability in the patient volume per phy-
sician may influence system performance, regardless of these
changes implementation of partial room sharing policies re-
mains beneficial and much of the benefit of this sharing can be
achieved with a compromise approach that does not require
full pooling of resources with respect to space flexibility and
physician flexibility.
Correspondingly, a key finding that can be applied across
clinics is that flexibility should not be considered only with
respect to one dimension. In order to achieve benefits of hy-
brid MD-room allocation, as shown above, it is necessary to
increase flexibility in the two features simultaneously to
achieve system efficiencies. Focusing on only one dimension
of flexibility may result in no change or decreased perfor-
mance. More generally, the ratio of rooms being shared and
physicians sharing rooms should be proportional, resulting in
a similar turnover rate among all rooms, to achieve benefits.
6 Conclusions
To date most research examining patient flows within healthcare
settings disregards the critical interplay between operational pol-
icies and room allocation in ambulatory care settings.
Correspondingly, in seeking to improve timeliness of care, the
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Decreasing patient length of stay via new flexible exam room allocation policies in ambulatory care clinics
Fig. 19 Impact of hybrid
MD-room allocation policy in
clinics with the revised
scheduling policy and a consistent
number of patients per physician.
In this case, the difference in the
average LOS between the
dedicated and fully pooled
policies is significantly higher
than in previous models
focus is generally on the need for additional capacity rather than
adjustments to operational policies. Further, when room usage is
examined discussions tend to focus on two extreme perspectives
– dedicated and pooled assignments of resources.
As we demonstrate, through consideration of flexible room
allocation policies that bridge the spectrum between the ded-
icated and pooled perspectives, significant improvements in
physician idle time, demonstrated through decreased physi-
cian blocking and earlier clinic closing times, and timeliness
of patient care, as measured by the average patient length of
stay, rates of excessive wait times in the waiting area and exam
rooms, can be achieved. Further, the traditional approaches of
pooled and dedicated room allocation do not always produce
the best results.
We expand beyond the common physician-centric room
allocation focus and examine room allocation for two distinct
phases of the visit, the MA-patient visit and the MD-patient
visit. We examine three different MA-room allocation poli-
cies: Bfixed^, Bflexible^, and Badaptive^ that are enacted for
patients that are significantly delayed. In the second phase,
we examine three MD-room allocation policies: Bdedicated^,
Bpooled^, and Bhybrid^ enabling sharing of subsets of rooms
among subsets of physicians. This allows for an in-depth
study of the value of resource sharing, or flexibility, indepen-
dently and in aggregate. Via the use of a discrete event sim-
ulation model, applied to a congested cardiovascular clinic,
we demonstrate the value of these paradigms for innovation
in exam room management in outpatient clinics and how
much of the benefits of resource pooling can be achieved
without fully changing the entire system, which may be dif-
ficult to implement. Additionally, the results signify the
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importance of increasing both space and physician flexibility
simultaneously, in order to achieve the best results. Further
via a sensitivity analysis, we demonstrate how the results for
this cardiovascular clinic can be generalized to other clinic
settings.
We find that even with no changes to the MD-room
allocation policies, decreases in patient LOS can be
achieved through implementation of room sharing for
the MA-patient phase of the visit. Alternatively, when
MD-room allocation is appropriately defined, such that
the number of shared rooms and the number of physicians
per shared room are increased proportionally, the choice
among MA-room allocation policies is minimally signifi-
cant. Thus while the first priority of a clinic should be to
increase room sharing among physicians, if this cannot be
achieved, improvements to LOS can be made through use
of adaptive MA-room allocation policies.
This research addresses the minimally explored role of
room assignments in outpatient clinics and presents a new
taxonomy of exam room sharing – accounting for multiple
phases in the visit and defining key flexibility parameters –
that may be influential in a variety of service sector applica-
tions, including other outpatient clinics. This taxonomy and
analysis method may be further expanded to consider addition-
al parameters for defining partial resource sharing and further
applied to other phases of patient visits for other ambulatory
care specialties in future research. For instance, patient sched-
uling patterns and appointment lengths are parameters that
may impact room sharing policies.
Further opportunities exist to utilize optimization models to
minimize the walking distances for both patients and

physicians while simultaneously adjusting room allocation
policies [77]. Additionally, a dynamic programming approach
may be used to further define the appropriate threshold poli-
cies dependent on multiple clinic factors. Finally, extensions
to the simulation modeling assumptions regarding homoge-
neous physician behaviors and the use of triangular probabil-
ity distributions for processing times may provide additional
insights into the integration of flexibility in room allocation
for other outpatient clinics.
References
1. Chokshi DA, Rugge J, Shah NR (2014) Redesigning the regulatory
framework for ambulatory care services in New York. The Milbank
Quarterly 92(4):776–795
2. Control C.f.D. (2014) National Hospital Ambulatory Medical Care
Survey: 2010 Outpatient Department Summary Tables
3. Centers for Disease Control, N.S. (2013) National hospital dis-
charge survey, 2010
4. America, I.o.M.C.o.Q.o.H.C.i (2001) Crossing the quality chasm: a
new health system for the 21st century. National Academies Press
5. Jun JB, Jacobson SH, Swisher JR (1999) Application of discrete-
event simulation in health care clinics: a survey. J Oper Res Soc
50(2):109–123
6. Jacobson SH, Hall SN, Swisher JR (2006) Discrete-event simula-
tion of health care systems, in patient flow: reducing delay in
healthcare delivery. Springer p 211–252
7. Rohleder TR et al (2011) Using simulation modeling to improve
patient flow at an outpatient orthopedic clinic. Health Care Manag
Sci 14(2):135–145
8. Cayirli T, Veral E (2003) Outpatient scheduling in health care: a
review of literature. Prod Oper Manag 12(4):519–549
9. Guler MG (2013) A hierarchical goal programming model for
scheduling the outpatient clinics. Expert Syst Appl 40(12):
4906–4914
10. Hahn-Goldberg S et al (2014) Dynamic optimization of chemother-
apy outpatient scheduling with uncertainty. Health Care Manag Sci
17(4):379–392
11. Harper PR, Gamlin HM (2003) Reduced outpatient waiting times
with improved appointment scheduling: a simulation modelling ap-
proach. OR Spectr 25(2):207–222
12. Kaandorp GC, Koole G (2007) Optimal outpatient appointment
scheduling. Health Care Manag Sci 10(3):217–229
13. Patrick J (2012) A Markov decision model for determining optimal
outpatient scheduling. Health Care Manag Sci 15(2):91–102
14. Lee S et al (2013) A simulation study of appointment scheduling in
outpatient clinics: open access and overbooking. Simulation-
Transactions of the Society for Modeling and Simulation
International 89(12):1459–1473
15. Haraldsson HH (2014) Improving efficiency in allocating pediatric
ambulatory care clinics
16. Overmoyer B et al (2014) Using real time locating systems (RTLS)
to redesign room allocation in an ambulatory cancer care setting. In
ASCO Annual Meeting Proceedings
17. Berg B et al (2010) A discrete event simulation model to evaluate
operational performance of a colonoscopy suite. Med Decis Mak
30(3):380–387
18. Cardoen B, Demeulemeester E, Belien J (2010) Operating room
planning and scheduling: a literature review. Eur J Oper Res
201(3):921–932
Vahdatzad V. et al.
19. van Veen-Berkx E et al (2016) Dedicated operating room for emer-
gency surgery generates more utilization, less overtime, and less
cancellations. Am J Surg 211(1):122–128
20. Hosseini N, Taaffe KM (2015) Allocating operating room block
time using historical caseload variability. Health Care Manag Sci
18(4):419–430
21. Hulshof PJ et al (2013) Tactical resource allocation and elective
patient admission planning in care processes. Health Care Manag
Sci 16(2):152–166
22. Lin F, Chaboyer W, Wallis M (2009) A literature review of
organisational, individual and teamwork factors contributing to
the ICU discharge process. Aust Crit Care 22(1):29–43
23. Shortell SM et al (1994) The performance of intensive care units:
does good management make a difference? Med Care 32(5):508–
525
24. Seung-Chul K, Ira H (2000) Flexible bed allocation and perfor-
mance in the intensive care unit. J Oper Manag 18(4):427–443
25. Marmor YN et al (2013) Recovery bed planning in cardiovascular
surgery: a simulation case study. Health Care Manag Sci 16(4):
314–327
26. Sinuff T et al (2004) Rationing critical care beds: a systematic re-
view. Crit Care Med 32(7):1588–1597
27. Cote MJ (1999) Patient flow and resource utilization in an outpa-
tient clinic. Socio Econ Plan Sci 33(3):231–245
28. Norouzzadeh S et al (2015) Simulation modeling to optimize
healthcare delivery in an outpatient clinic. In Proceedings of the
2015 Winter Simulation conference. IEEE Press
29. Santibanez P et al (2009) Reducing patient wait times and improv-
ing resource utilization at British Columbia Cancer Agency's am-
bulatory care unit through simulation. Health Care Manag Sci
12(4):392–407
30. Dijk NM, Sluis E (2008) To pool or not to pool in call centers. Prod
Oper Manag 17(3):296–305
31. Pan C et al (2015) Patient flow improvement for an ophthalmic
specialist outpatient clinic with aid of discrete event simulation
and design of experiment. Health Care Manag Sci 18(2):137–155
32. Brandeau ML, Sainfort F, Pierskalla WP (2004) Operations re-
search and health care: a handbook of methods and applications,
vol 70 Springer Science & Business Media
33. Rais A, Viana A (2011) Operations research in healthcare: a survey.
Int Trans Oper Res 18(1):1–31
34. Connelly LG, Bair AE (2004) Discrete event simulation of emer-
gency department activity: a platform for system-level operations
research. Acad Emerg Med 11(11):1177–1185
35. Zhu Z, Hoon Hen B, Liang Teow K (2012) Estimating ICU bed
capacity using discrete event simulation. Int J Health Care Qual
Assur 25(2):134–144
36. Steins K (2010) Discrete-event simulation for hospital resource
planning: possibilities and requirements
37. Paul JA et al (2006) Transient modeling in simulation of hospital
operations for emergency response. Prehosp Disaster Med 21(4):
223–236
38. Gunal MM, Pidd M (2010) Discrete event simulation for perfor-
mance modelling in health care: a review of the literature. Journal of
Simulation 4(1):42–51
39. Griffin J et al (2012) Improving patient flow in an obstetric unit.
Health Care Manag Sci 15(1):1–14
40. Klein RW et al (1993) Simulation modeling and health-care deci-
sion making. Med Decis Mak 13(4):347–354
41. Thorwarth M, Arisha A (2009) Application of discrete-event sim-
ulation in health care: a review
42. Hashimoto F, Bell S (1996) Improving outpatient clinic staffing and
scheduling with computer simulation. J Gen Intern Med 11(3):182–184
43. Balasubramanian H, Muriel A, Wang L (2012) The impact of pro-
vider flexibility and capacity allocation on the performance of pri-
mary care practices. Flex Serv Manuf J 24(4):422–447
Decreasing patient length of stay via new flexible exam room allocation policies in ambulatory care clinics
44. Rau CL et al (2013) Using discrete-event simulation in strategic
capacity planning for an outpatient physical therapy service.
Health Care Manag Sci 16(4):352–365
45. Hopp WJ, Spearman ML (2011) Factory physics. Waveland Press
46. Joustra P, Van der Sluis E, Van Dijk NM (2010) To pool or not
to pool in hospitals: a theoretical and practical comparison for
a radiotherapy outpatient department. Ann Oper Res 178(1):
77–89
47. Van Dijk NM (2000) On hybrid combination of queueing and sim-
ulation. In Proceedings of the 32nd conference on Winter simula-
tion. Society for Computer Simulation International
48. Vanberkel PT et al (2012) Efficiency evaluation for pooling re-
sources in health care. OR Spectr 34(2):371–390
49. Griffiths JD, Knight V, Komenda I (2013) Bed management in a
critical care unit. IMA J Manag Math 24(2):137–153
50. Kim SC et al (1999) Analysis of capacity management of the inten-
sive care unit in a hospital. Eur J Oper Res 115(1):36–46
51. Ridge JC et al (1998) Capacity planning for intensive care units.
Eur J Oper Res 105(2):346–355
52. Hall R (2012) Bed assignment and bed management. In Handbook
of Healthcare System Scheduling. Springer, p 177–200
53. Harper PR, Shahani AK (2002) Modelling for the planning and
management of bed capacities in hospitals. J Oper Res Soc 53(1):
11–18
54. Proudlove N, Gordon K, Boaden R (2003) Can good bed manage-
ment solve the overcrowding in accident and emergency depart-
ments? Emerg Med J 20(2):149–155
55. Vassilacopoulos G (1985) A simulation-model for bed allocation to
hospital inpatient departments. SIMULATION 45(5):233–241
56. Griffin J et al (2012) Development of patient-bed assignment algo-
rithms to support bed management processes for improvements in
the rate of overflow assignments and average request to assign
metrics. In Critical Care Medicine. Lippincott Williams &
Watkins, Philadelphia
57. Griffin JA (2012) Improving health care delivery through multi-
objective resource allocation. In Industrial and Systems
Engineering. Georgia Institute of Technology
58. Resar R et al (2011) Using real-time demand capacity management
to improve hospitalwide patient flow. Jt Comm J Qual Patient Saf
37(5):217–227
59. Macario A et al (1995) Where are the costs in perioperative care?
Analysis of hospital costs and charges for inpatient surgical care.
Anesthesiology 83(6):1138–1144
60. Association, H.F.M. (2003) Achieving operating room efficiency
through process integration. Healthcare financial management:
Journal of the Healthcare Financial Management Association,
57(3): p. suppl 1
61. Persson MJ, Persson JA (2009) Analysing management policies for
operating room planning using simulation. Health Care Manag Sci
13(2):182–191
62. Wischik D, Handley M, Braun MB (2008) The resource pooling
principle. Acm Sigcomm Computer Communication Review 38(5):
47–52
63. Gerchak Y, He QM (2003) On the relation between the benefits of risk
pooling and the variability of demand. IIE Trans 35(11):1027–1031
64. Rohleder TR, Bischak DP, Baskin LB (2007) Modeling patient
service centers with simulation and system dynamics. Health Care
Manag Sci 10(1):1–12
65. Ledlow GR, Bradshaw DM (1998) Animated simulation: a valu-
able decision support tool for practice improvement. Journal of
healthcare management/American College of Healthcare
Executives 44(2):91–101 discussion 101-2
66. Kelton WD, Law AM (2000) Simulation modeling and analysis.
McGraw Hill, Boston
67. Leddy KM, Kaldenberg DO, Becker BW (2003) Timeliness in
ambulatory care treatment: an examination of patient satisfaction
and wait times in medical practices and outpatient test and treatment
facilities. J Ambul Care Manage 26(2):138–149
68. Bar-dayan Y (2002) Waiting time is a major predictor of patient
satisfaction in a primary military clinic. Mil Med 167(10):842
69. Shaikh SB et al (2012) How long are patients willing to wait in the
emergency department before leaving without being seen? West J
Emerg Med 13(6):463-467
70. Rondeau KV (1998) Managing the clinic wait: an important quality
of care challenge. J Nurs Care Qual 13(2):11–20
71. Michael M et al (2013) Improving wait times and patient satisfac-
tion in primary care. J Healthc Qual 35(2):50–59 quiz 59-60
72. Anderson RT, Camacho FT, Balkrishnan R (2007) Willing to wait?:
the influence of patient wait time on satisfaction with primary care.
BMC Health Serv Res 7(1):31
73. Dansky KH, Miles J (1997) Patient satisfaction with ambulatory
healthcare services: waiting time and filling time. Hosp Health
Serv Adm 42(2):165–177
74. Cayirli T, Veral E, Rosen H (2006) Designing appointment sched-
uling systems for ambulatory care services. Health Care Manag Sci
9(1):47–58
75. Wijewickrama A, Takakuwa S (2006) Simulation analysis of an
outpatient department of internal medicine in a university hospital.
In Proceedings of the 38th conference on Winter simulation. Winter
Simulation Conference
76. Ho C-J, Lau H-S (1992) Minimizing total cost in scheduling out-
patient appointments. Manag Sci 38(12):1750–1764
77. Vahdatzad V, Griffin J (2016) Outpatient clinic layout design ac-
counting for flexible policies. In Proceedings of the 2016 Winter
Simulation conference. IEEE Press