College 5 Objective Function and (specialist planning)

Read 2 – Charles Debats, Section 3.4 until 3.4.4, page 24-29

The problem was that sometimes all beds outside the operating room were used and
therefore the operating room was blocked and the patient could not get out of the OR
MILP - > mixed integer linear problem
A very clear way to model a problem is an LP or MILP
You want to minimize or maximize something.
- The objectives are clear
- The constraints are clear
Disadvantage?
However, these models are for deterministic situations and you have to
make choices what to put in objective and what to put in constraints!
LP models do not include uncertainty, only expected variables are used for parameters
The mixed integer costs lots of time due to the integers. IF it takes hours and the
For situations that change rapitly, it is more useful to use another model.
For a tactical decision a LP can be used.
Also make sure what to put in the objection and what in the constraints
A softer constraint can be put in the objective function
Heuristics are easier to understand, for example sort all patients on operating time, while
LPs are quite complicated to understand

- Why MILP and not just LP?

In MILP the values can only take integer values and in LP this is not the case. For assigning
the nurses to shifts, a nurse can only work per shift and not for example just 1.5 hour. Which
could be the answer from an LP. The same for patients assigning to resources, a patient can
not be assign to 0.5 resource.
Het is du seen integer problem en niet MILP want alle decision variables zijn 1 of 0 en er is
geen continuous decision variable
- Why does he use patient classification ?
So a difference can be made between de patients going to PACU and the patients that do
not. And only certain patient classifications can be assigned to certain ORs
A MILP already takes a lot of time therefore, making the model less complex is necessary.
Patients are grouped based on a reasonable forecast, The operating times are approximated
in bigger blocks and therefore it is enough to have larger groups
- Exactly which problem is solved by solving problem (3.1)?
The objective function now minimizes the total OR over costs and the total nurse salary.
Overutilization of the ORs in terms of overtime is penalized with cost 𝐶𝑂𝑗 per time interval 𝑡,
whereas violating permitted opening time of postoperative departments is penalized through an
increased labor costs 𝐶𝑆𝑟𝑡 for working beyond regular opening hours (is for the PACU nurses).
You try to have enough care for all patients is the PACU.

The sequence of patients is planned, Normally short operating time patients together with long
PACU durations are in the morning then the PACU is filled quick.

Post Anesthesia Care Unit

Also people for a short time in the PACU at the end of the day.

By finding the best tradeoff between postoperative labor costs and expected costs for OR
overtime, we strive to reduce the inflow of patients at the PACU, which in turn should result in
less variability in bed demand and peaks in workload for the nursing staff.

So the inflow of patients at the PACU is reduced by penalizing the overutilization of ORs and
penalizing the permitted opening time of postoperative departments are violated.

Minimize the overtime and the

- Describe the first 4 constraints (3.2)-(3.5)

3.2) X_kijt indicates 1 if patient k arrives at resource i,j on time interval t. A resource can
only be occupied by one patient at a time.
It is assigning a patient to the operating room or PACU, one of the patients’ operations
start at

3.3) Y_kijt indicates 1 if patient k occupies resource i,j at time interval t. A patient can
only be assigned to one bed at a time. Y tells us that a resource is still occupied.
Whenever a resource starts doing something,
𝑖𝑛𝑑𝑖𝑐𝑎𝑡𝑒𝑠 1 𝑖𝑓 𝑝𝑎𝑡𝑖𝑒𝑛𝑡.

3.4) When the stage is intraoperative period, during the operation, only one patient that
arrived can be equal to the

If an operation starts,
X_k1jt
k is patient
j is operating room
t is time
if operation takes four periods
X_1111 = 1
Y_1111 = 1, Y_1112 = 1, Y_1113 =1, Y_1114 = 1
X_1215 =1

3.5)After an operation is finished, the PACU time starts

- Describe the adaptations (3.11) and (3.14) on page 29.

3.11) a nurse capacity safety margin a is introduced so an unexpected nurse capacity
shortage is prevented, een soort van buffer voor de nurses needed in cause of unexpected
increase in demand.

potential nurse capacity shortage due to an unexpected increase in nurse demand, is prevented
with the introduction of a nurse capacity safety margin (𝑎).

He solves a deterministic problem however the real problem is stochastic so in some periods
there could more demand. Therefore, additional nurses can be necessary. Therefore a safety
factor is added, to increase the total nurse capacity

3.14) beta_lpt, indicates 1 if nurse p works during time interval t (- y_lpt, indicates 1 if nurse
p starts the lunch break at time interval t) This addition, ensures that also during lunch time
there are enough nurses?
These are the ones that are available minus the ones that have a break, and
On every period, needs enough nurses, enougn nurses taking into account a break
- Suppose the number and schedule of nurses would be fixed. What kind of objective would
make sense?
When the situation is changed and the number of nurses and their schedules are fixed, it
would make sense to adjust the objective function as the total salary of the nurses is fixed.
The objective function could be adjusted to maximize the target patient throughput while
penalizing for overtime at the ORs. This way the inflow of patients can be stabilized as well.
MILP and Objective function
Read 2 – Charles Debats, Section 5.3, page 46-47
In the simulation, he simulates the number of used beds. When taking the average over the
f.e. 100 runs, a smooth result is shown.

- First consider the results of the MILP and adapted MILP

Two different
There is not al lot of change in terms of total, as still 6 full time nurses are necessary and
one part time
However, in the initial situations, non of the nurses have to start before 9 o clock. In the other
situation it is also possible that operations end earlier and that at the end a nurse is working
longer. So the working times are more spread out.

- Then consider the comparison with the simulation

If you want to ensure to have enough nurses, the real number of nurses should be based on
the confidence interval for example 95% interval. As nurses are not a really hard constrait, a
nurse can still treat another patient. Charles makes a mix with a deterministic and a
simulation to create the best possible sil
Read 8 – Lona van Ruitenburg, Section 6.4, until objective function

- Exactly which problem is solved by using this objective function?

;QODw_ total number of patients in the delay list for a consult in week w

; ;QORw _ total number of patients in the delay list for an operation in week w

Aantal wachtende op de lijst * de weight ervan

Dus je wil de totale wachtende minimaliseren

X is weight factor so it gives the relative importance to QODw

Goal was to set number of sessions in such a weak such that the queues are minimized

X is the relative wait for people waiting for the OR and for the OD, the queuing list is
decreased.

- Can you think of alternative objective functions?

Give a penalty for delays, so delays are
For the queuing time it is necessary to know when the people entered the queue. IF this
period is bigger than z perioids, than use a penalty for people that are waiting for more than
3 periods.
It also possible by approximation:
Qor / Yor -3. So approximate how many people are waiting too long and for how long they
are waiting too long.

These would give better, more fair measures. More fair distribution among the patients
Read 23 – Marieke Bergefurt, page 31 + objective function p32

- Exactly which problem is solved by using this objective function ?

Bedden tekort plus constant for penalizing the surplus times too many beds plus penalize for
wrong hospitazation,
Mimimize bed surplus, bed shortage and wrong hospitilation.

How can we have a bed deficit: Because it is about the target, if you are above the target
you use to many beds. Still it is possible to send patients to another departments

- Can you think of alternative objective functions by extending the

problem?
Others are:
The nurses that are needed for this bed
Avoid too many beds occupied, but on the other hand the queue for patients fluctuating is
not very good
So in general he focusses too much on the beds and does not add for example take into
consideration the patients or nurses
Next topic: specialist distribution (not to include in essay)
Specialists are among the most important resources in the hospital.
- They are often leading resources (planned first)
- They have to distribute their time over various activities (OT, outpatient
department, ward, teaching, learning, conferences, administration,
management) All this have to be distribution in such a way that it its in an operating schedule
with other specialists
- They prefer independence and are not so easy to ‘control’

- Although the topic is important, only very few projects deal with
planning specialist time or assigning patients to specialists

A lot of .. can be gained by planning the specialists in a smart way, however, the specialists
like to heave this control themselves.
Next topic: specialist distribution (not included in essay)
Read 8 – Lona van Ruitenburg, Section 6.4, until objective function
- How does this influence the work of the specialists?
They have less freedom and control, as
For every period, the number of sessions in the OR and the number of sessions in the OD in
a specific department in a specific week. And by controlling this, so many patients you can
deduct from you queue if you have … number of sessions. By playing with these numbers,
specialist how many should do a OD and how many an OR.
- Suppose you have more control over the specialists, what would you do?
Restrict the number of holidays,
The capacity was something that was given by lona. So you set a lower bound that all times
there are …. Number of specialists. So a minimum number of specialists.

How much capacity do I really want so I don’t have a too long week

In the Netherlands there is a law that says that patients can wait 4-6 weeks. Therefore the
specialist can be forced to stay as well / work
Next topic: specialist distribution (not included in essay)

Read 31 – Jojanneke Telgen, Section 5.1.3.2 (p15-16) and

Section 7.1 (p 42-43)

What is the current problem: In terms of utilization, two are fully utilizates, and specialist A is
very minimal occupied.
This results in a longer waiting time, but treatment 1c could be done much better if you have
a different distribution of the patients over the specialists.
One noted that the distribution is very uneaven
In the most suitable method utilization between 0.9-0.95

- Does the solution solve the problem?

If you look at expecting waiting times, the problem is solved. 4 specialists could not agree on
the consultation time.
Not all patients can be seen by specialist. There could be also preferences from patients.

- Which practical elements could prevent implementation and how could

you deal with those?