126 IEEE TRANSACTIONS ON SYSTEMS, MAN, AND CYBERNETICS: SYSTEMS, VOL. 46, NO.
1, JANUARY 2016
A System-Theoretic Approach to Modeling and
Analysis of Mammography Testing Process
Xiang Zhong, Jingshan Li, Senior Member, IEEE, Susan M. Ertl, Carol Hassemer, and Lauren Fiedler
Abstract—Mammography is the standardized testing process
for early detection of breast cancer. In this paper, a system-
theoretic method based on a Markov chain model is presented
to analyze such processes. Specifically, the general testing pro-
cess in a single exam room is formulated using a Markov chain
model. To resolve the dimensionality issue, an iteration method,
referred to as shared resource iteration, is introduced to analyze
the scenarios of two or more exam rooms. Formulas to evalu-
ate the patient length of stay and staff efficiency are developed.
The extension to non-Markovian scenarios is also investigated
and an empirical formula is proposed. The experimental results
indicate that such a method results in a high accuracy of per-
formance estimation. A case study at a breast imaging center
of the University of Wisconsin Medical Foundation is presented
to illustrate the applicability of the model. In addition, the
impact of patient volume increase is also studied, which shows
that a capacity increase is necessary to accommodate the high
demand.
Index Terms—Length of stay, mammography test,
Markov chain, patient flow, shared resource iteration, staff
utilization.
I. I NTRODUCTION
A. Motivation
REAST cancer is the most common cancer in women
B worldwide, with nearly 1.7 million new cases diagnosed
in 2013 (the second most common cancer overall). In the
U.S., it is estimated that in 2014 there will be 232 670
new cases of invasive breast cancer and 62 570 new cases
of in situ breast cancer (http://ww5.komen.org/breastcancer/
statistics.html). With the rapid growth in health service
demand, the efficient and safe use of radiology services
for diagnosis and treatment is of the utmost importance
for the wellbeing of both patients and healthcare providers.
Mammography uses low-energy X-rays and allows the visu-
alization of fine details in the breast tissue, and is regarded as
the most effective tool for routine breast cancer prevention
Manuscript received September 16, 2014; revised December 23, 2014;
accepted February 15, 2015. Date of publication June 23, 2015; date of cur-
rent version December 14, 2015. This work was supported by the National
Science Foundation (NSF) under Grant CMMI-1233807. This paper was rec-
ommended by Associate Editor S. Das. (Corresponding author: Jingshan Li.)
X. Zhong and J. Li are with the Department of Industrial and Systems
Engineering, University of Wisconsin, Madison, WI 53706 USA (e-mail:
xzhong4@wisc.edu; jingshan@engr.wisc.edu).
S. M. Ertl, C. Hassemer, and L. Fiedler are with the University
of Wisconsin Medical Foundation, Middleton, WI 53562 USA
(e-mail: sue.ertl@uwmf.wisc.edu; carol.hassemer@uwmf.wisc.edu;
lauren.fiedler@uwmf.wisc.edu).
Color versions of one or more of the figures in this paper are available
online at http://ieeexplore.ieee.org.
Digital Object Identifier 10.1109/TSMC.2015.2429643
2168-2216 c 2015 IEEE. Personal use is permitted, but republication/redistribution requires IEEE permission.
See http://www.ieee.org/publications_standards/publications/rights/index.html for more information.
screening and early diagnosis of cancer [2]. Lot of efforts
on mammography have been devoted to cost-effectiveness
studies, such as economic evaluation of health technologies
(see [3]–[8]). Such work mainly focuses on modeling for eco-
nomic evaluation of health technologies, and is contingent on
the expected prevalence of resource utilization and equipment
failures. To ensure effective use of mammography testing pro-
cesses, patient flow analysis and work management are of
significant importance. However, the research related to it has
not received enough attention. To the best of our knowledge,
except for a simulation study [7] in a mammography clinic of
the Brazilian Cancer Institute, no such research is available.
In this paper, we introduce a system-theoretic approach
based on Markov chain analysis to study the patient flow of
mammography testing. To accomplish this, the general mam-
mography testing procedures are described. A Markov chain
model of patient flow in a single exam room is developed
first. Then an iterative method, referred to as shared resource
iteration, for evaluating the scenario of two exam rooms is
introduced. The convergence of the recursive procedure is jus-
tified. The method is then extended to the case of multiple
exam rooms. Furthermore, the non-Markovian scenarios are
investigated. An empirical formula is presented to estimate
the patient length of stay with general distributions of service
time and interarrival time. Finally, to illustrate the applicabil-
ity of the method, a case study at a breast imaging center of
the University of Wisconsin Medical Foundation (UWMF) is
introduced. It is shown that the method provides an accurate
estimation of system performance. What-if analysis is then
carried out to evaluate the impacts of demand increase and to
identify the most efficient way to accommodate more patient
arrivals.
The remainder of this paper is structured as follows.
Section I-B reviews the related literature. In Section II, the
operations in the mammography testing process are described
and an analytical model is formulated. Section III presents
the analytical method to evaluate patient length of stay and
staff utilization. Section IV introduces a case study at a breast
imaging center at the UWMF. Finally, the conclusion is given
in Section V. All the proofs are provided in the Appendix.
B. Related Literature
Patient flow in hospitals and clinics has attracted sub-
stantial research effort, in which simulations and queueing
theory models have dominated the quantitative studies (see
reviews [9]–[12]). Emerging methods in economic modeling
ZHONG et al.: SYSTEM-THEORETIC APPROACH TO MODELING AND ANALYSIS OF MAMMOGRAPHY TESTING PROCESS
Fig. 1. Mammography patient flow in the breast imaging center.
of imaging costs and outcomes using discrete-event simula-
tion (DES) have been summarized and reported in [13]. It is
concluded that DES is playing an increasingly important role
in modeling of annual screening programs, diagnosis, and
treatment of chronic recurrent disease and modeling the uti-
lization of imaging equipment. Specifically, Coelli et al. [7]
developed a discrete-event computer simulation model to sim-
ulate changes in patient arrival rates, number of equipment
units, available personnel, equipment maintenance scheduling
schemes, and exam repeat rates in a mammography clinic of
the Brazilian Cancer Institute. In [8], a DES model is devel-
oped to estimate the unit cost of mammography examinations
at clinics by considering simulated changes in resource utiliza-
tion rates and in examination failure probabilities. Moreover,
the radiology testing (CT scan) process is studied in terms of
patient scheduling and resource allocation to improve patient
access to care and medical resource utilization in [14].
While simulations are widely applied and can provide
detailed analysis, many of them are case study based and
may suffer from long model development and simulation
time. Increasing variance has also brought a mounting aware-
ness of the limitations of conventional simulation techniques.
Queueing theory model, as an analytical tool, can provide
quick analysis and more insights. Reference [11] summarizes
queueing theory applications in healthcare, such as waiting
time and utilization analysis, system design, and appoint-
ment systems, at different scales, from individual departments
(or units) to healthcare facilities and regional healthcare sys-
tems. Reference [15] introduces an M/M/s queueing model
to estimate the number of providers needed in an emergency
department. To determine bed capacity of maternity facilities
in a perinatal network, a queueing theory model is used in [16]
to evaluate refused admission probability and such a model
is embedded into a multiperiod mixed-integer optimization
algorithm for necessary capacity decisions.
In addition to queueing models, other analytical methods
have been introduced to conduct flexible analysis and gain
insights. For example, in [17], a Markov chain model is devel-
oped to analyze the work flow and staffing level in a CT
division of the UWMF. In the study of rapid response pro-
cess to improve patient safety in acute care, the response
process is modeled as a complex network with split, merge,
and parallel structures and an analytical method is developed
127
to evaluate the decision time and its variability [18], [19]. To
study the general care delivery services within patient rooms,
Wang et al. [20] modeled the process using closed, paral-
lel, and reentrant network and limited resources. Formulas
to evaluate the patient length of stay and staff utilizations
are developed and system-theoretic properties are discussed.
Moreover, a three-level strategy model to design a hospital
department is presented in [21] with three basic elements:
1) modeling module; 2) optimization module; and 3) simu-
lation and decision module. Reference [22] introduces a new
modeling methodology to address organization problems of
health care systems using Petri nets-based metamodel.
In spite of these efforts, analytical models addressing the
breast imaging test processes in clinics and hospitals are not
available. The goal of this paper is to contribute to this end.
II. S YSTEM D ESCRIPTION AND P ROBLEM F ORMULATION
A. Process Description
A typical breast imaging center consists of mammog-
raphy equipment, exam rooms, receptionists, technologist
assistants (TA), radiology technologists (Tech), and imaging
radiologists. The capacity of these resources varies according
to test center size, demand, and purpose. However, the general
procedures are usually standardized. Screening and diagnos-
tic imaging are performed at designated exam rooms. Usually
the receptionist deals with all types of patient visits at the
reception desk, not limited to mammography patients. The TA
is responsible for bringing patients from the reception area
to the changing room, preparing patients’ paperwork, deal-
ing with schedule changes, and all other miscellaneous work.
The radiology technologists are usually dedicated to their spe-
cific exam rooms taking images. The imaging radiologist is
required when working with a diagnostic patient. The radiol-
ogist is not dedicated to the mammography unit. He/she also
works for other radiology departments and is seldom consid-
ered as a constraint in this system. Thus in this paper we view
TA, Tech, and exam room (equipment) as the primary con-
straints of interest. A work flow in a typical breast imaging
center is shown in Fig. 1. The sequential stages of screening
and diagnostic visits are described below.
1) A patient checks-in at the reception desk, fills
basic information form and is seated in the
128 IEEE TRANSACTIONS ON SYSTEMS, MAN, AND CYBERNETICS: SYSTEMS, VOL. 46, NO. 1, JANUARY 2016
Fig. 2. Mammography patient flow model. One exam room.
lobby (waiting room). The receptionist notifies the
TA (through electronic system).
2) The patient walks from the waiting room to the changing
(sub-waiting) room escorted by the TA, and changes into
gown and waits to be called.
3) The Tech reviews basic information of the patient,
sets up mammography equipment, and performs the
mammography procedure.
4) For a screening patient, after the procedure, the Tech
reviews the pictures to make sure they are technically
acceptable. If not, the procedure will be repeated until
the images are satisfying. Then the images are submitted
for interpretation by radiologists. The patient could leave
directly and the results will be mailed afterwards.
5) For a diagnostic patient, after the procedure, the radi-
ologist oversees the study and determines if additional
images are needed or not. Depending on the mammo-
gram results, the radiologist may request the patient
to take additional tests, including physical examination,
ultrasound, cyst aspiration, etc. Based on the results of
the completed diagnostic evaluation, the radiologist will
discuss with the Tech about the findings, options, and
recommendations for the patient; and provide results in
writing before the patient leaves the facility.
6) Finally, the patient changes clothes and leaves, or con-
tinues with other procedures, such as ultrasound test.
Then the exam room will be cleaned up by the Tech
and ready for the next patient.
In this paper, we focus on the process from patient checking-
in to the end of the mammography test procedure. The possible
follow-up processes are not included since some of them are
not carried out in the same visit.
B. Structural Modeling
As described above, the technologist works independently in
each exam room. Therefore, we focus our study on one exam
room initially, and then extend the scope to the system with
more exam rooms. In this case, the work flow can be simplified
into a serial process which includes patient checking-in (fill-
ing in forms), rooming by TA (changing into gown), imaging
procedure (for screening patients, this procedure only involves
image taking, while for diagnostic patients, radiologist review-
ing is also included), and finally, patient changing clothes and
leaving. Such a work flow is illustrated in Fig. 2.
Within each exam room, only one patient is permitted at
a time. However, the TA will bring the next patient into
sub-waiting room for preparation right before her scheduled
imaging time, even if the exam room is still occupied. So
there is a maximum of two patients in sub-waiting room and
exam room. Typically, the TA could leave once the patient fin-
ishes changing into gown. Moreover, since most of the patients
arrive ahead of their appointment time, a finite capacity of
waiting area can be assumed for these patients.
For the imaging procedure, diagnostic patients have to wait
for results and comments from the radiologist which leads
to a longer stay comparing to screening patients. Thus, the
radiology technologist’s service times among different types
of patients can be significantly different. Except this the other
service times for different types of visits are relatively similar.
In addition, although the technologists work independently, all
the exam rooms share only one TA, which may introduce an
availability issue.
Based on these discussions, an analytical model is formu-
lated below.
C. Notations, Assumptions, and Problem Formulation
The following notations are introduced to address the
services, resources, and their interactions.
1) The work flow of the mammography testing consists of
the following steps, labeled as a)–d), respectively.
a) Patient checking-in.
b) TA rooming.
c) Imaging procedure, where for a screening patient,
the image will be taken and reviewed by the
Tech; for a diagnostic patient, the Tech will take
and review the image and the results will be
examined by the radiologist (in some cases, extra
examinations are needed).
d) Patient checking-out.
2) The number of exam rooms in the breast imaging center
is denoted as M, and each room can accommodate one
patient only.
3) A patient needs to wait in the lobby (wait room) if she
arrives early and is blocked by previous patients, or the
TA is not available. The maximum capacity of waiting
for each exam room is denoted as Qi , i = 1, 2, . . . , M.
Without loss of generality, we start with Qi = 5 and
extend to larger numbers later.
4) The number of Tech is denoted as n1 , and the number
of TA is denoted as n2 .
In addition, the following assumptions about arrivals and
services are introduced.
1) The interarrival time of the incoming patients for each
room follows exponential distribution with parameter λi ,
i = 1, 2, . . . , M.
2) The four processes a patient has to complete for
each visit, i.e., patient checking-in, TA rooming, image
taking, and patient checking-out, are denoted as ser-
vices 1–4, respectively. The completion of each pro-
cess is affected by various resource constraints as
described above. The service time for service j in exam
room i is exponentially distributed with parameter τj,i ,
j = 1, . . . , 4, i = 1, 2, . . . , M. Then, the corresponding
processing rate is cj,i = (1/τj,i ).
Remark 1: Although each patient has a scheduled
appointment time, variation still occurs in the arrival
time. The exponential assumption for both interarrival
time and service times is introduced to make the
ZHONG et al.: SYSTEM-THEORETIC APPROACH TO MODELING AND ANALYSIS OF MAMMOGRAPHY TESTING PROCESS
analysis tractable. In Section III-F, such an assumption
will be relaxed and an extension to non-Markovian case
will be discussed.
3) The resource cannot be released until the correspond-
ing service is finished. An ongoing service cannot be
disrupted before finishing, i.e., if the resource is being
used, the next patient has to wait until the current service
finishes.
4) In the current system, n1 = M, and n2 = 1. Thus, each
Tech is dedicated to an exam room, while the TA is
shared for all rooms.
In an appropriately defined state space, the subsystem satis-
fying assumptions 1–4 is a stationary random process. Let
Ti , i = 1, 2, . . . , M, denote the patient length of stay for
each exam room in the system. In the framework defined by
assumptions 1–4, Ti is a function of all system parameters
 
Ti = fT Qi , c1,i , c2,i , c3,i , c4,i , λi . (1)
Denote the staff utilizations as ρTech and ρTA , for the
Tech and TA, respectively, which are also functions of all
parameters.
Then, the problem to be addressed is: under assump-
tions 1–4, develop a method to evaluate the patient length
of stay Ti , and staff utilization ρTech and ρTA as functions of
system parameters.
Solutions to the problem are presented below.
III. P ERFORMANCE A NALYSIS
To study this problem, we first analyze the scenario of
one exam room, referred to as the subsystem. A Markov
chain model is developed and the corresponding results are
derived. Then the system with two exam rooms is evaluated.
By defining a link probability P, which is the TAs occupancy
calculated in each room jointly, an iterative method is intro-
duced to adjust the efficiency loss due to shared resource
among exam rooms. The convergence property of the itera-
tion method for two rooms is justified. Then the recursive
procedure for the system with multiple exam rooms is pre-
sented and validated by numerical experiments. Furthermore,
extensions to non-Markovian scenarios are investigated.
A. State Space
Let S = {s1 , s2 , s3 , s4 } denote the states of the subsys-
tem, where si represents the number of patients in stage i,
i = 1, . . . , 4. For example, s2 = m indicates that there are m
patients in process 2 (TA rooming). The feasible states satisfy
the following constraints.
1) sj ≥ 0, j = 1, . . . , 4.
2) s1 ≤ Q1 , queue length constraint.
3) s2 + s3 ≤ 2, resource constraint.
4) s4 ≤ 1, resource constraint.
The total number of feasible states is denoted as K, it is a
function of the queue length and the possible allocation of a
patients in such a process. When there is no queue, we have
the following states: (0,0,0,0), (0,1,0,0), (0,0,1,0), (0,0,0,1),
(0,1,1,0), (0,0,1,1), (0,1,0,1), (0,0,2,0), (0,2,0,0), (0,0,2,1),
(0,2,0,1), and (0,1,1,1). If the queue length is Q1 , then under
129
the aforementioned constraints, we have (Q1 + 1) × 12 states.
In the subsystem model, Q1 = 5, which implies that there
are 72 feasible states. Then the steady state probability for a
feasible state Sk , k = 1, . . . , K, is defined as
 
Pk = P sk1 , sk2 , sk3 , sk4 , k = 1, 2, . . . , K.
B. Transitions
The state transition can be triggered by one of the follow-
ing events: 1) a patient arrives; 2) a patient checks-in; 3) the
TA rooming finishes; 4) the imaging procedure finishes; and
5) a patient checks-out. Note that such events cannot occur
simultaneously. Specifically, for a state Sk = {sk1 , sk2 , sk3 , sk4 },
the following events can occur.
1) When a patient arrives, if the waiting room is full
(although unlikely), i.e., sk1 = Q, then the patient is lost
due to space limit and no transition occurs. Otherwise,
it can go to state {sk1 + 1, sk2 , sk3 , sk4 } with arrival rate λ.
2) When a patient checks-in, if the exam room and sub-
waiting room are occupied or there is a patient waiting
for rooming already, i.e., sk2 + sk3 = 2, then no transi-
tion occurs and the patient remains waiting in the lobby.
Otherwise, the patient goes to sub-waiting room after
checking-in, and Sk moves to state {sk1 − 1, sk2 + 1, sk3 , sk4 }
with rate c1 . Note that such an event occurs only when
there is a patient to check-in, i.e., sk1 ≥ 1.
3) When the patient finishes rooming, he/she leaves sub-
waiting room and starts diagnosis test with rate c2 . Thus,
Sk is changing to state {sk1 , sk2 − 1, sk3 + 1, sk4 } and sk2 ≥ 1.
4) After the imaging test, if sk4 = 1, then the patient waits
for checking-out and no transition occurs. Otherwise,
he/she goes to check-out and Sk transits to state
{sk1 , sk2 , sk3 − 1, sk4 + 1} with rate c3 and sk3 ≥ 1.
5) Finally, when the patient checks-out, Sk moves to state
{sk1 , sk2 , sk3 , sk4 − 1} with rate c4 . Again, such an event
occurs only when there is a patient to check-out, i.e.,
sk4 ≥ 1.
Let (k, l) define the transition rate from state Sk to Sl ,
k, l = 1, . . . , K, k = l, which takes one of the values of c1 ,
c2 , c3 , c4 , or λ. In addition

K
(l, l) = − (l, j), j = l, l = 1, 2, . . . , K. (2)
j=1
Thus, a transition matrix  with dimension K × K and rank
K − 1 is obtained. An illustrative example of  for two exam
rooms with Q = 1 is shown in the Appendix. By taking into
account the normalization condition

K
Pl = 1 (3)
l=1
we construct a new matrix , where
(l, j) = (l, j), l = 1, . . . , K, j = 1, . . . , K − 1
(l, K) = 1, l = 1, . . . , K. (4)
Following [23], the balance equation can be written as
X = Y (5)
130 IEEE TRANSACTIONS ON SYSTEMS, MAN, AND CYBERNETICS: SYSTEMS, VOL. 46, NO. 1, JANUARY 2016

where vectors X and Y are

X = [P1 , P2 , . . . , PK ]
Y = [0, . . . , 0, 1]. (6)
Therefore, the steady state probabilities can be obtained
by solving the balance equation. By summarizing the above
derivation procedure [expressions (2)–(6)], the following the-
orem is introduced to calculate the probability of each state.
Theorem 1: Under assumptions 1–4 (Section II-C), the Fig. 3. Mammography patient flow model. Two exam rooms.
steady state probability of staying at a state k, Pk , k =
1, . . . , K, can be calculated as follows:
dash rectangular indicates that those processes share the same
X = Y −1 (7) resource (TA in this case).
Remark 3: Note that although all the patients check-in at
where  and Y are defined in (2) and (6), respectively, and Pi
the same reception desk, the registration time is short and
is an element of X.
the receptionists are typically available when an individual
Since here we obtain an irreducible Markov chain with finite
patient arrives, so we do not view it as a process with resource
number of states, a unique steady state solution always exists.
constraint.
By just adding one exam room, the complexity of the sys-
C. Patient Length of Stay and Staff Utilization tem increases enormously. The size of state space increases
Define TP as the system throughput rate, i.e., the rate patient significantly and the transitions are subject to the resource
leaving from the last service, and WIP as the average number constraints. For example, by setting the queue length con-
of patients in the system. By Little’s law, the average patient straint to 5, the number of feasible states will grow to 1892.
length of stay, T1 , can be obtained. Therefore, to avoid the complexity of expanding Markov chain
Proposition 1: Under assumptions 1–4 with one exam room and provide the possibility of further extension to more exam
K  4 l  rooms, an iterative approach, the shared resource iteration
WIP l=1 Pl j=1 sj method, is introduced. First, let pi , i = 1, 2, be the time per-
T1 = = K (8) centage of TAs occupancy in room i during a patient’s length
TP c4 l=1 Pl sl4
of stay. Assume such an occupancy is known and denoted
where Pl is solved from (7) and (0)
as pi . Here the subscript indicates the room number, and the

K superscript represents the iteration number (0 refers to initial
TP = c4 Pl sl4 (9) value). By cause of sharing, the transition rate of TAs service
l=1 in room 1 is decreased due to her occupancy in room 2. Thus,
⎛ ⎞

K 
4 in the first iteration, we have
⎝Pl  
WIP = slj ⎠. (10) (1) (0)
c2,1 = c2,1 1 − p2 .
l=1 j=1

In addition to patient length of stay, the staff utilizations Then the average length of stay for a patient in room 1 can
can be calculated as be calculated using Proposition 1, denoted as function fT (·)
 
Proposition 2: Under assumptions 1–4 with one exam room (1) (1)
T1 = fT Q1 , c1,1 , c2,1 , c3,1 , c4,1 , λ1 .

K
ρtech = Pl · Isl >0 (11) Also obtained is the occupancy of TA in room 1
3
l=1 (1) 1
p1 = (1)
.
K
c2,1 T1
ρTA = Pl · I sl2 >0
. (12)
l=1 Using this new probability, we analyze the TA occupation in
room 2. The transition rate is updated as
Remark 2: The utilization of the TA and the Tech only indi-  
cates the time percentage they spent with the mammography c(1)
2,2 = c2,2 1 − p(1)
1 .
test patients. Typically they have multiple job duties, which
are not included here. Similarly, the length of stay and TA occupancy can be
calculated
 
D. Two Exam Rooms T2(1) = fT Q2 , c1,2 , c(1)
2,2 , c3,2 , c4,2 , λ 2
The above results only consider one exam room. In other 1
words, it assumes that the TA is always available. However, p(1)
2 = (1)
.
c2,2 T2
when the system consists of two exam rooms, the TA will be
shared by both exam rooms. Such a work flow is illustrated This finishes the first iteration. In the next iteration, using
(1)
in Fig. 3, where the rectangular represents the process and the the updated probabilities pi , i = 1, 2, we repeat the procedure
ZHONG et al.: SYSTEM-THEORETIC APPROACH TO MODELING AND ANALYSIS OF MAMMOGRAPHY TESTING PROCESS 131

(2)
to obtain a new estimate pi , and the process continues. The
iteration terminates when all the differences between pki and
(k)
pk+1
i are sufficiently small. Then the corresponding T1 and
(k)
T2 are the estimated average length of stay of the patients
in two exam rooms, obtained through Proposition 1. Such a
process can be represented by the procedure below.
Procedure 1:
(k) (k−1)
c2,1 = c2,1 (1 − p2 )
 
T1(k) = fT Q1 , c1,1 , c(k)
2,1 , c3,1 , c4,1 , λ 1
1
p(k)
1 = (k)
(13)
c2,1 T1
 
c(k)
2,2 = c2,2 1 − p(k)
1 Fig. 4. Mammography patient flow model. Multiple exam rooms.
 
(k) (k)
T2 = fT Q2 , c1,2 , c2,2 , c3,2 , c4,2 , λ2
(k) 1 Procedure 2:
p2 = ⎛ ⎞
c2,2 T2(k)
(k)

i−1
(k)

M
(k−1) ⎠
k = 1, 2, . . . (14) c2,i = c2,i ⎝1 − pj − pj
j=1 j=i+1
with initial condition  
(k) (k)
Ti = fT Qi , c1,i , c2,i , c3,i , c4,i , λi
p(0)
2 = 0.
(k) 1
The convergence of the procedure has been investigated. pi = (k)
Proposition 3: Under assumptions 1–4, Procedure 1 is con- c2,i Ti
vergent and i = 1, 2, . . . , M
exp (k) k = 1, 2, . . . (16)
Ti = lim Ti , i = 1, 2 (15)
k→∞
exp
with initial conditions
where Ti represents the patient length of stay at room i under
(0)
exponential assumptions of service times and interarrival time, pi ∈ [0, 1)
denoted by superscript “exp.”
and
Proof: See the Appendix.
(0)
Note that the initial condition p2 = 0 is introduced mainly 
M

for the proof of convergence. For any values of p(0) p(0)

i < 1, i = 1, 2, . . . , M.
2 ∈ (0, 1),
i=1
the procedure always leads to the same convergent value.
In addition, it usually takes three to five iterations to The convergence property for such systems still holds, how-
converge. ever, the proof is much more complicated and will be part
of future work. Thus, the convergence is verified through
E. Extensions to Multiple Exam Rooms extensive numerical tests using randomly selected parameters.
Next, we evaluate the general system with more than two Based on the typical range of the parameters, we randomly
exam rooms. The work flow is illustrated in Fig. 4. For select the number of exam rooms M, service rate cj,i (1/min),
such an intercorrelated system, directly developing a Markov and arrival rate λi (1/min) from the following sets:
chain model of the entire system is impossible. For exam- M ∈ {2, 3, 4, 5}
ple, for three exam rooms, if the queue length constraint
cj,i ∈ (0.025, 0.1), j = 1, 2, 3, 4, i = 1, . . . , M
is set to 5, then the number of feasible states is increased
to 69 120. When the number of subsystems is large or the λi ∈ (0.01, 0.03), i = 1, . . . , M. (17)
correlation between the subsystems is complex, one may face
The convergence criterion is met when the differences in pi
a state space explosion. Therefore, the iterative method is
between two iterations are small
desirable.  
 (k) (k+1) 
The recursive procedure for multiple exam rooms is similar pi − pi  < 10−5 , i = 1, . . . , M.
to that of the two exam rooms system. The main differ-
ence is that when the transition rate is updated for one exam In all the cases we tested, the convergence is observed. Thus,
room, it needs to exclude the cases that the TA is serving we conclude that Procedure 2 is convergent and the following
in all other exam rooms. Then the procedure iterates among limits exist:
all exam rooms. Such a procedure can be represented as exp (k)
follows. Ti = lim Ti , i = 1, 2, . . . , M. (18)
k→∞
132 IEEE TRANSACTIONS ON SYSTEMS, MAN, AND CYBERNETICS: SYSTEMS, VOL. 46, NO. 1, JANUARY 2016
Fig. 5. Convergence of pi for three identical rooms.
Fig. 6. Convergence of pi for four nonidentical rooms.
To illustrate such a property, the iterations of pi (i.e., the
inverse of Ti divided by service rate) are shown in Fig. 5, for
the scenario of three identical rooms, and in Fig. 6, for the case
of four nonidentical rooms. In Fig. 5, the time percentages the
TA spent in rooms 1–3 are denoted as broken lines marked
by square, diamond, and circle, respectively. The horizontal
axis is slotted by iterations. Thus, the dynamic changes of pi
during each iteration is shown in the figure. As one can see,
all pi ’s converge after roughly three iterations and they all
converge to the same value since the three rooms are identical.
In Fig. 6, broken lines marked by square, diamond, and circle
represent p1 to p3 in rooms 1–3, respectively, and the solid
line illustrates p4 . Again all pi ’s converge after about three
iterations. However, since all rooms are not identical, these
pi ’s are not the same. In summary, in all the cases we have
tested, the TA occupancy pi for each room converges only in
three to five iterations.
The staff utilization can also be evaluated using the conver-
gent pi following Proposition 2.
Remark 4: This iterative method could be easily extended
to the scenario of multiple number of shared resources. To
simplify the analysis, assume each shared resource (see TA) is
identical and independent. Similar to the single shared resource
case, a transition can fail due to that all the resources are work-
ing with other patients. Then the probability that all resources
are not available can be represented by (q(k) )s , where s is
the number of shared resources (such as the number of TAs),
and q(k) denotes the probability that the resource is not avail-
able as the only shared resource during the kth iteration.
For patient room i
(k)

i−1
(k)

M
(k−1)
qi = pj + pj . (19)
j=1 j=i+1
Then the processing rate c2,i in Procedure 2 will be updated as
  s 
c(k)
2,i = c 2,i 1 − q(k)
i . (20)
The other formulas in Procedure 2 will remain the same.
To investigate the accuracy of this iterative method, multiple
experiments have been conducted. It has been shown that the
performance of this algorithm is similar to that of the single
shared resource case.
F. Extensions to Nonexponential Scenarios
In the above analysis, exponential interarrival time and
service times are assumed. However, in most cases, the expo-
nential assumption may not hold. To relax this assumption,
the following adjustments are carried out.
1) Dependence on Distribution Type: First, based on exten-
sive numerical experiments using simulations, we investigate
the dependence of patient length of stay on the distribution
type, when the coefficients of variation (CV) of the interar-
rival time and service times are between 0 and 1. In practice,
the CVs are most likely smaller than 1 since the probabil-
ity of finishing a service is usually an increasing function of
time [24]. In all simulation experiments carried out in this
paper, results from 20 working days are collected. Each sim-
ulation experiment consists of 20 replications. The confidence
intervals are mostly within 2% of the performance measure.
Dozens of examples have been tested to compare the length of
stay. The parameters are randomly selected from the same data
set (17). Based on the observed data, all the CVs fall into the
range between 0.1 and 0.9. The CVs are selected within this
range. First, four distributions, triangular (Tri), uniform (Uni),
gamma (Ga), and lognormal (Ln), are assumed for both inter-
arrival and service times. Then, four mixes of them (denoted
as Mix distribution) have been established, i.e., each service or
interarrival time follows a distribution randomly selected from
Tri, Uni, Ga, and Ln. Identical mean and CV are assumed for
each distribution. In all the examples we have tested, the dif-
ferences in length of stay are small. If we define δ to quantify
the maximum relative difference among length of stay Ts,i
under distribution i, i ∈ {Uni, Tri, Ln, Ga, Mix 1, . . . , Mix 4},
then
maxi Ts,i − mini Ts,i
δ= 1
· 100%.
8 i Ts,i
Usually δ is within 5% when CV is less than 0.5. The largest
difference is observed when CV is close to 1, but is still
within 10%. This indicates that, the length of stay is prac-
tically independent of distribution type, but mainly depends
on the mean and CV. Figs. 7 and 8 illustrate such a property
for two systems (denoted as systems 1 and 2, respectively) of
three-identical exam rooms with the service times and inter-
arrival time following triangular, uniform, gamma, lognormal,
and mixed distributions. Patient length of stay and its 95%
ZHONG et al.: SYSTEM-THEORETIC APPROACH TO MODELING AND ANALYSIS OF MAMMOGRAPHY TESTING PROCESS
Fig. 7. Impact of distribution type on length of stay. System 1 (δ = 0.2%).
Impact of distribution type on length of stay. System 2 (δ = 4.5%).
Fig. 8.
confidence interval from the simulation results for each distri-
bution are shown, δ = 0.2% and 4.5% for systems 1 and 2,
respectively. The differences among different distributions are
increasing with CV. Such a result is consistent with the obser-
vations in other healthcare systems (see care delivery within
patient room [20] and rapid response process [19]) and in
manufacturing systems as well (see [25]).
2) Empirical Formula: Next, if the scheduled interarrival
time is long enough (longer than the sum of each service time,
which is typical in most clinical settings), and there is no
variability in service time (i.e., CVi = 0), then the patient
length of stay can be calculated using the total service time
(since there is no TA availability problem). Thus, we define
such a length of stay as

4
1 Tisims
Tifix = .
cj,i
j=1
Then the length of stay under nonexponential assumptions can
be adjusted based on Tifix by the CVs of service times and
interarrival time. To do this, based on the results of extensive
numerical studies, define
4 CV2j,i
j=1 cj,i
CVeff,i = 4 1 . (22)
j=1 cj,i
exp
Then the length of stay can be adjusted based on Tifix , Ti , and
CVeff,i using an empirical formula. Specifically, we hypothe-
size that there exists a linear relationship of lengths of stay
between CV = 0 and 1 based on numerical investigations.
In other words, there exist empirical formulas to calculate
non-exp
the patient length of stay in the system, Ti , when both
133
TABLE I
ACCURACY OF E MPIRICAL F ORMULA . (a) S YSTEM 1 AND (b) S YSTEM 2
interarrival time and service times are nonexponential
 
non-exp
Ti = CV2arrival,i Ticv − Tifix + Tifix (23)
where
 
exp
Ticv = CVeff,i Ti − Tifix + Tifix (24)
and CVarrival,i is the CV of patient interarrival time for exam
room i.
3) Accuracy: Following the proposed method, the patient
length of stay and the staff utilizations in general sce-
nario can be calculated. To evaluate the accuracy of such
a method, dozens of simulation experiments have been car-
ried out using a simulation software package SIMUL8. Define
non-exp
Tisims and Ti as the length of stay obtained by simula-
tion and empirical formula, respectively. Let  be the relative
difference, defined as
non-exp
Ti − Tisims
= · 100%.
(21)
Among all the randomly generated scenarios, the average
of absolute difference || is less than 3%, and the largest one
is within 10%. Illustration examples are shown in Table I and
Figs. 9 and 10. Two systems of three-identical exam rooms are
tested here. The mean service times and the interarrival time
are fixed throughout the tests. The CVs of the distributions
of the services and arrival are chosen from [0,1] in ascending
sequence from tests 1–9 for each system. In both figures, the
results from simulations and the empirical formula are repre-
sented by red crosses and blue squares, respectively. As one
can see, the differences in length of stay between the results
from simulation and the empirical formula are within 5% and
the T non-exp is within the 95% confidence interval of T sims in
most of the cases. Therefore, we calculate that empirical for-
mula (23) provides an accurate estimate of length of stay in
most cases when CVs take value from 0 to 1.
134 IEEE TRANSACTIONS ON SYSTEMS, MAN, AND CYBERNETICS: SYSTEMS, VOL. 46, NO. 1, JANUARY 2016
Fig. 9. Comparison of length of stay between simulation and the empirical
formula. System 1.
Fig. 10. Comparison of length of stay between simulation and the empirical
formula. System 2.
IV. C ASE S TUDY
A case study of patient flow of the mammography testing
process at a breast imaging center of the UWMF in Madison,
WI, is presented to illustrate the applicability of the method
introduced above. In recent years, the imaging center has
experienced an increasing demand for mammography testing.
In 2012, it conducted around 11 000 procedures, including
7400 screening mammograms, 3600 diagnostic mammograms,
and thousands of breast ultrasounds, bone densities, biopsies,
and breast MRIs as well. From 2013, the clinic will collabo-
rate with the University of Wisconsin Carbone Cancer Center,
which will bring an estimated 1000 influx of mammography
patients into the breast imaging center. Therefore, the model
developed in Section III is used to investigate the impact of
demand change and propose recommendations.
A. Model Development
The breast imaging center at UWMF performs mainly
screening, diagnostic imaging, and bone density tests. It con-
sists of a changing (subwaiting) room, a bone density room, an
ultrasound room, a staff lounge and three examination rooms,
each equipped with one mammography machine. Due to the
high demand in screening, two of the exam rooms are des-
ignated for screening test while the third is for diagnostic
imaging. There are about 45–60 daily visits total for screen-
ing and diagnostic mammography. The staff team consists
of three radiology technologists (Tech), two imaging radiol-
ogists, and one technologist assistant (TA). The technologists
Fig. 11. UWMF breast imaging center patient flow model.
TABLE II
M ODEL VALIDATION
are cross-functional so that they can perform both diagnos-
tic and screening imaging. However, they are dedicated to
one exam room each day. The TA is responsible for bringing
patients from the reception area (waiting room) to the chang-
ing room (sub-waiting room), preparing patients’ paperwork,
dealing with schedule changes, and any other miscellaneous
work. A diagnostic appointment is scheduled for every 30 min
while a screening appointment for every 20 min, starting from
eight in the morning. Such a work flow is illustrated in Fig. 11.
Using the method introduced previously, an analytical
model has been developed.
B. Validation
To validate the model, the results obtained from the above
analysis are compared with that obtained from hundreds of
observations and records from Heathlink database within one
working month in the breast imaging center. Same simulation
setups are used in the case study and the confidence intervals
are typically within 2% of the performance measures.
Let LoSobserved and LoSmodel denote the average lengths of
stay obtained by data collection and the analytical model,
respectively. Introduce
= LoSobserved − LoSmodel
LoSobserved − LoSmodel
= · 100%.
LoSobserved
The results of such comparisons are shown in Table II. As
one can see, the differences between them are very small.
Therefore, the model is validated and can be used for further
analysis.
C. Demand Change Analysis
Using the validated model, the impact of demand change
is investigated. To respond to a demand increase, usually the
scheduled interarrival times are decreased. With a 5% demand
increase, the interarrival times are decreased from 20 to 19 min
ZHONG et al.: SYSTEM-THEORETIC APPROACH TO MODELING AND ANALYSIS OF MAMMOGRAPHY TESTING PROCESS
TABLE III
D EMAND C HANGE (A) AND (B) D EMAND
I NCREASED BY 5% AND 10%
and from 30 to 28.5 min, for screening and diagnostic patients,
respectively. For a 10% increase in demand, such times
are reduced to 18 and 27 min, respectively. Note that with
the increasing demand, there is higher possibility that more
patients have to wait in the queue. To avoid the scenario that
patients will be rejected in the analytical model due to limited
queue length, the queue size for each room is increased to
Qi = 10 and Qi = 20, i = 1, 2, 3, for 5% and 10% demand
increase, respectively. The resulting changes in patient length
of stay and staff utilization in one room are shown in Table III.
As one can see, a 5% demand increase will lead to an
18.3% increase in length of stay for screening patients and a
13.7% increase for diagnostic patients. The utilization of the
TA and Tech of both patient types is increased by 6% and 9%,
respectively. Although not favorable, such demand change can
still be accommodated with the current clinic setting.
However, the breast imaging center does not have the capac-
ity to accommodate a 10% demand surge. In this scenario,
the patient length of stay will increase substantially, with the
45% and 41% spike for screening and diagnostic patients,
respectively. In addition, the utilization of the TA and the Tech
is increased by 12% and 16%, respectively.
Although more patients can be served, it will lead to sub-
stantially overloading the providers and increasing the patient
waiting time. Therefore, more capacity and resources are
needed in this scenario (note that the provider utilization is
for one room and only involves the work in contact with the
patients, while many other responsibilities are not included).
To accommodate such demand changes, several possible
solutions are proposed, which include extending work time
(either starting work earlier or finishing later or shrinking
break time), diffusing the patients to other clinic sites, or
adding extra exam rooms with equipment and technologists.
Since the TAs workload in contact with patient is not high,
there is no need to increase the number of TAs. In this
case, we test the scenario that one additional exam room
and one more Tech are added. With the same amount of
arrival, the new arrival rate is decreased by 25% for each
exam room (due to adding one room). We compare the two
135
Fig. 12. Patient LoS with respect to increasing demand.
scenarios (three exam rooms, three technologists, and four
exam rooms, four technologists) in respect to the average
patient length of stay. The results are shown in Fig. 12.
From these results we can conclude that the current system
is running in a relatively high intensity, i.e., the patient length
of stay increases rapidly with respect to demand increase.
While in the case of four exam rooms, the workload of each
room is reduced, the increase in patient length of stay is
moderate when demand increases. For example, the increase
in screening patients and diagnostic patients’ length of stay
is only around 2 min if the demand is increased by 14%.
Therefore, with capacity (room, equipment, and technologist)
increase, the breast imaging center will be able to accommo-
date the surge in patient volumes. The clinic leadership has
accepted the recommendation.
V. C ONCLUSION
In this paper, an analytical model is developed and an itera-
tive method is proposed to study the general work flow of
a mammography testing process. A case study at a breast
imaging center of the UWMF is presented to demonstrate the
applicability of the method. The model can accurately esti-
mate the patient length of stay and staff utilization. Using this
model, demand change analysis is carried out to investigate the
impacts of patient demand increase. It is shown that with very
high demand, extending work time or adding more equipment
and resources is needed.
In future work, we plan to investigate optimal control poli-
cies. For example, the model can be used to determine the
minimum number of TAs required to achieve the desired
patient length of stay. The model introduced in this paper can
also be extended to study other healthcare delivery systems,
which have characteristics such as multiple stages of ser-
vices, limited care providers and multiple patient rooms. The
results of this paper could provide hospital/clinic profession-
als a quantitative tool to evaluate current system performance,
investigate the effects of different configurations, and to pre-
dict care service efficiency for future plans, which are critical
for assisting decision making in healthcare management.
ACKNOWLEDGMENT
The authors would like to thank C. Davis, A. Shanedling,
and M. Sommer of the University of Wisconsin, Madison, and
the staff at the UWMF for their help in the case study.
136 IEEE TRANSACTIONS ON SYSTEMS, MAN, AND CYBERNETICS: SYSTEMS, VOL. 46, NO. 1, JANUARY 2016

(k) (k−1)
A PPENDIX Proof of Lemma 1: When p1 < p1 , we obtain
Illustrative Example: Let Q = 1, there exist 24 feasible  
(k) (k) (k−1) (k−1)
c2,2 = c2,2 (1 − p1 ) > c2,2 1 − p1 = c2,2 .
states, named as states S1 –S24 below
(0, 0, 0, 0), (0, 1, 0, 0), (0, 0, 1, 0), (0, 0, 0, 1), (0, 1, 1, 0) As Ti is monotonically decreasing with respect to
cj,i [26], [27], it can be concluded that
(0, 0, 1, 1), (0, 1, 0, 1), (0, 0, 2, 0), (0, 2, 0, 0), (0, 0, 2, 1)
(0, 2, 0, 1), (0, 1, 1, 1), (1, 0, 0, 0), (1, 1, 0, 0), (1, 0, 1, 0) T2(k) < T2(k−1) .
(1, 0, 0, 1), (1, 1, 1, 0), (1, 0, 1, 1), (1, 1, 0, 1), (1, 0, 2, 0) This leads to
(1, 2, 0, 0), (1, 0, 2, 1), (1, 2, 0, 1), (1, 1, 1, 1). (k) 1 1 (k−1)
p2 = (k)
> (k−1)
= p2
Following the event description and (2) in Section III-B, the  c2,2 T2 c2,2 T2
can be established, which is a 24 × 24 matrix. The elements which follows that
of the matrix (the transitions) are listed as follows:
(k) (k−1)
p2 > p2 .
(1,13) = λ; (1,1) = −λ
(2,14) = λ; (2,3) = c2 ; (2,2) = −(λ + c2 ) Continue such arguments, we have
   
(3,15) = λ; (3,4) = c3 ; (3,3) = −(λ + c3 ) (k+1) (k) (k−1) (k)
c2,1 = c2,1 1 − p2 < c2,1 1 − p2 = c2,1
(4,16) = λ; (4,1) = c4 ; (4,4) = −(λ + c4 )
and
(5,17) = λ; (5,8) = c2 ; (5,7) = c3
(k+1) (k)
(5,5) = −(λ + c2 + c3 ) T1 > T1 .
(6,18) = λ; (6,3) = c4 ; (6,6) = −(λ + c4 ) Then, it follows that
(7,19) = λ; (7,6) = c2 ; (7,2) = c4 (k+1) 1 1 (k)
p1 = (k+1)
< (k)
= p1 .
(7,7) = −(λ + c2 + c4 ) c2,1 T1 c2,1 T1
(8,20) = λ; (8,6) = c3 ; (8,8) = −(λ + c3 )
(9,21) = λ; (9,5) = c2 ; (9,9) = −(λ + c2 ) Proof of Lemma 2: The proof is similar to that of
(10,22) = λ; (10,8) = c4 ; (10,10) = −(λ + c4 ) Lemma 1.
(0)
Proof of Proposition 3: From p2 = 0, we have
(11,23) = λ; (11,12) = c2 ; (11,9) = c4
(1)
(11,11) = −(λ + c2 + c4 ) c2,1 = c2,1
 
(12,24) = λ; (12,10) = c2 ; (12,5) = c4 (1) (1)
T1 = fT Q1 , c1,1 , c2,1 , c3,1 , c4,1 , λ1
(12,12) = −(λ + c2 + c4 ) 1
(1)
(13,2) = c1 ; (13,13) = −c1 p1 = .
c2,1 T1(1)
(14,9) = c1 ; (14,15) = c2 ; (14,14) = −(c1 + c2 )
It follows that
(15,5) = c1 ; (15,16) = c3 ; (15,15) = −(c1 + c3 )  
(16,7) = c1 ; (16,13) = c4 ; (16,16) = −(c1 + c4 ) c(1)
2,2 = c2,2 1 − p(1)
1
 
(17,20) = c2 ; (17,19) = c3 ; (17,17) = −(c2 + c3 ) (1) (1)
T2 = fT Q2 , c1,2 , c2,2 , c3,2 , c4,2 , λ2
(18,12) = c1 ; (18,15) = c4 ; (18,18) = −(c1 + c4 )
which leads to
(19,11) = c1 ; (19,18) = c2 ; (19,14) = c4
(1) 1
(19,19) = −(c1 + c2 + c4 ) p2 = (1)
> 0.
c2,2 T2
(20,18) = c3 ; (20,20) = −c3
(21,17) = c2 ; (21,21) = −c2 Thus, we obtain
 
(22,20) = c4 ; (22,22) = −c4 c(2)
2,1 = c2,1 1 − p(1)
2 < c(1)
2,1
(23,24) = c2 ; (23,21) = c4 ; (23,23) = −(c2 + c4 )
which implies that
(24,22) = c2 ; (24,17) = c4 ; (24,24) = −(c2 + c4 ). (2) (1)
T1 > T1
All other (i,j) = 0, when (i, j) does not belong to the above
combinations. and
To prove Proposition 3, the following lemmas are needed. 1
p(2)
1 = < p(1)
1 .
Lemma 1: Under assumptions 1–4, in Procedure 1, if p(k)1 < c2,1 T1(2)
(k−1) (k+1) (k)
p1 , then p1 < p1 , for k ≥ 2.
Continuing such arguments we obtain
Lemma 2: Under assumptions 1–4, in Procedure 1, if p(k)2 >
(k−1)
p2
(k+1)
, then p2
(k)
> p2 , for k ≥ 2. c(2) (1)
2,2 > c2,2 , T2(2) < T2(1)
ZHONG et al.: SYSTEM-THEORETIC APPROACH TO MODELING AND ANALYSIS OF MAMMOGRAPHY TESTING PROCESS
which implies that
(2) (1)
p2 > p2 .
From Lemmas 1 and 2, we obtain that p1 is mono-
tonically decreasing, while p2 is monotonically increasing.
Since p1 and p2 are probabilities bounded by 0 and 1, by
the theorem for convergence of a monotone sequence of real
(n)
numbers, we conclude that as n → ∞, {pi }, i = 1, 2, are
convergent, i.e.,
(n)
lim p = pi , i = 1, 2.
n→∞ i
(n)
Using the convergent pi , a convergent value of Ti can be
obtained. Thus, we have
(n)
lim T = Ti , i = 1, 2.
n→∞ i
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Xiang Zhong received the B.S. degree from
Tsinghua University, Beijing, China, in 2011. She
is currently pursuing the Ph.D. degree with the
Department of Industrial and Systems Engineering,
University of Wisconsin, Madison, WI, USA.
Her current research interests include analysis,
modeling, and design and optimization of healthcare
and manufacturing systems.
Jingshan Li (S’97–M’00–SM’06) received the
B.S. degree from Tsinghua University, Beijing,
China, in 1989, the M.S. degree from the Institute
of Automation, Chinese Academy of Sciences,
Beijing, in 1992, and the Ph.D. degree in electrical
engineering—systems from the University of
Michigan, Ann Arbor, MI, USA, in 2000.
He was a Staff Research Engineer with the
Manufacturing Systems Research Laboratory,
General Motors Research and Development Center,
Warren, MI, USA, from 2000 to 2006, and
the Department of Electrical and Computer Engineering and Center for
Manufacturing, University of Kentucky, Lexington, KY, USA, from 2006
to 2010. He is currently a Professor with the Department of Industrial
and Systems Engineering, University of Wisconsin, Madison, WI, USA.
His current research interests include modeling, analysis, and control of
manufacturing and healthcare systems.
Prof. Li was a recipient of the 2010 National Science Foundation Career
Award, the 2009 IIE Transactions Best Application Paper Award, the 2005
IEEE T RANSACTIONS ON AUTOMATION S CIENCE AND E NGINEERING Best
Paper Award, the 2006 IEEE Early Industry/Government Career Award in
Robotics and Automation, and multiple awards in international conferences.
He is a Department Editor of the IIE Transactions and an Associate Editor of
the IEEE T RANSACTIONS ON AUTOMATION S CIENCE AND E NGINEERING,
the International Journal of Production Research, Flexible Service and
Manufacturing, and the International Journal of Automation Technology. He
was an Associate Editor of Mathematical Problems in Engineering.
138 IEEE TRANSACTIONS ON SYSTEMS, MAN, AND CYBERNETICS: SYSTEMS, VOL. 46, NO. 1, JANUARY 2016

Susan M. Ertl received the bachelor’s degree in
nursing from the University of Wisconsin (UW),
Madison, WI, USA, and the master’s degree in
nursing administration from Edgewood College,
Madison.
She has been with UW Health, Madison, since
1995, where she has been leading performance
improvement and systems design since 2003. She
is currently the Vice President of Clinical Joint
Ventures, UW Health. She has over 25 years of
ambulatory health care experience which includes
direct patient care, clinic management and new program, and facility design.
She led the development of the UW Health Digestive Health Center,
Madison, where she currently leads the enterprise-wide redesign of UW Health
Behavioral Health Services.
Lauren Fiedler received the bachelor’s and mas-
ter’s degrees in industrial and systems engineering
from the University of Wisconsin (UW), Madison,
WI, USA.
She is a Senior Health Systems Engineer with the
UW Health, Madison. She has been with UW Health
since 2008, where she leads and manages system-
wide improvement initiatives focused on strategy
and redesign. She served as a Lead Project Manager
for the design and start-up of the UW Health
Digestive Health Center, Madison, where she is cur-
rently managing the enterprise-wide redesign of UW Health Behavioral Health
Services. She has held prior industrial engineering positions in the manu-
facturing industry with Nestle, Vevey, Switzerland, and Alcoa, New York,
NY, USA.
Ms. Fiedler is a member of the Institute of Industrial Engineers.

Carol Hassemer received the B.S. degree in med-

ical microbiology and the M.A. degree in business
of healthcare administration, both from University
of Wisconsin (UW), Madison, WI, USA.
She is the Director of Clinic Operations/Medical
Imaging with the University of Wisconsin Medical
Foundation, Middleton, WI, USA. She is account-
able for all the department’s seven operational pro-
grams, including breast imaging for which over
16 000 screening mammograms are collectively per-
formed annually at five locations. The department
has a commitment to continuous process improvement and being patient
focused, and appreciates the collaboration with the Department of Industrial
Engineering, UW, Madison.