Health Care Management Science (2021) 24:460–481

https://doi.org/10.1007/s10729-020-09527-z

Stochastic programming for outpatient scheduling with flexible

inpatient exam accommodation
Yifei Sun 1 & Usha Nandini Raghavan 2 & Vikrant Vaze 1 & Christopher S Hall 2 & Patricia Doyle 3 &
Stacey Sullivan Richard 3 & Christoph Wald 3

Received: 10 September 2019 / Accepted: 21 October 2020 / Published online: 4 January 2021
# Springer Science+Business Media, LLC, part of Springer Nature 2021

Abstract
This study is concerned with the determination of an optimal appointment schedule in an outpatient-inpatient hospital system
where the inpatient exams can be cancelled based on certain rules while the outpatient exams cannot be cancelled. Stochastic
programming models were formulated and solved to tackle the stochasticity in the procedure durations and patient arrival
patterns. The first model, a two-stage stochastic programming model, is formulated to optimize the slot size. The second model
further optimizes the inpatient block (IPB) placement and slot size simultaneously. A computational method is developed to solve
the second optimization problem. A case study is conducted using the data from Magnetic Resonance Imaging (MRI) centers of
Lahey Hospital and Medical Center (LHMC). The current schedule and the schedules obtained from the optimization models are
evaluated and compared using simulation based on FlexSim Healthcare. Results indicate that the overall weighted cost can be
reduced by 11.6% by optimizing the slot size and can be further reduced by an additional 12.6% by optimizing slot size and IPB
placement simultaneously. Three commonly used sequencing rules (IPBEG, OPBEG, and a variant of ALTER rule) were also
evaluated. The results showed that when optimization tools are not available, ALTER variant which evenly distributes the IPBs
across the day has the best performance. Sensitivity analysis of weights for patient waiting time, machine idle time and exam
cancellations further supports the superiority of ALTER variant sequencing rules compared to the other sequencing methods. A
Pareto frontier was also developed and presented between patient waiting time and machine idle time to enable medical centers
with different priorities to obtain solutions that accurately reflect their respective optimal tradeoffs. An extended optimization
model was also developed to incorporate the emergency patient arrivals. The optimal schedules from the extended model show
only minor differences compared to those from the original model, thus proving the robustness of the scheduling solutions
obtained from our optimal models against the impacts of emergency patient arrivals.

Highlights
& Timestamped operational data was analyzed to identify sources of uncertainty and delays.
& Stochastic programming models were developed to opti-
mize slot size and inpatient block placement.
& A case study showed that the optimized schedules can
reduce overall costs by 23%.
& Distributing inpatient and outpatient slots evenly through-
out the day provides the best performance.
& A Pareto frontier was developed to allow practitioners to
choose their own best tradeoffs between multiple objectives.

Keywords Outpatient scheduling . Stochastic programming . Discrete-event simulation . Inpatient exam cancellation .
Appointment scheduling/sequencing . Operations research

* Yifei Sun 2
Philips Healthcare, Cambridge, MA, USA
yifei.sun.th@dartmouth.edu 3
Lahey Hospital and Medical Center, Burlington, MA, USA

1
Thayer School of Engineering, Dartmouth College, College, 14
Engineering Dr, Hanover, NH 03755, USA
Stochastic programming for outpatient scheduling with flexible inpatient exam accommodation
1 Introduction
Hospitals in the US are continually trying to find more effi-
cient ways to manage their resources and improve workflows
in an effort to control costs while maintaining or expanding
patient access to care. One main factor that impacts workflow
efficiency is patient scheduling. Patient scheduling involves
determination of the start time (appointment time), duration,
end time, and resources required to provide services to pa-
tients [1]. Existing studies have shown that long waiting times
caused by, among other factors, poor scheduling and execu-
tion is a “constant and significant” contributing factor to pa-
tient dissatisfaction [18, 28, 32]. Patient scheduling is compli-
cated because of the variability in procedure durations, patient
arrival patterns, patient preferences for appointment times,
availability of resources, variability in exam lengths based
on patient-related factors, and the presence of cancellations
and no-shows.
Our work presented in this paper is motivated by the need
to address the real-world problem of long patient waiting
times observed in the outpatient-inpatient hospital systems,
such as the MRI (Magnetic Resonance Imaging) centers of
Lahey Hospital and Medical Center (LHMC). LHMC is a
mid-sized, tertiary care hospital of an Integrated Care
Delivery Network (IDN) located in Burlington, MA. On a
typical weekday, outpatients wait an average of 54 min from
arrival at the facility to the beginning of their exam. One factor
complicating the scheduling problem is that the procedure
durations and the patient arrival patterns both have a consid-
erable degree of uncertainty. Another complicating factor is
that the hospital appointment system consolidates multiple
classes of patients (namely, inpatients, outpatients, and emer-
gency patients), each with their own specific clinical require-
ments given their different levels of acuity. Figure 1 is an
example of the patient scheduling system currently followed
at LHMC. Patients are scheduled in advance at equally spaced
time intervals referred to as slots. The slot size, i.e. the sched-
uled appointment duration, is pre-set at either 45 min or
60 min. When a patient is scheduled for an MRI procedure,
they are given an appointment time and are asked to arrive
30 min in advance of that time to ensure sufficient time for
MRI safety screening and procedure preparation. The differ-
ent colors in Fig. 1 represent slots that are used to schedule
patients of different classes. Most inpatients are scheduled
between 12am and 6am (i.e., during the 6-h night shift), and
all outpatients are scheduled between 6am and 12am (i.e.,
during the 18-h day shift). Day shift appointments fall under
Fig. 1 Current patient appointment schedule for one MRI machine with a 60-min slot size. The red slots represent the IPBs, while the green ones are the
outpatient slots
461
one of the following two categories: (a) standard outpatient
slots (green colored slots in Fig. 1) which are available for
scheduling outpatients in advance, and (b) inpatient blocks
(IPBs) (red colored slots in Fig. 1 that are not open for
advanced scheduling). IPBs serve multiple functions. First,
they can accommodate STAT inpatient exam requests (de-
fined as requests for inpatients that need immediate attention)
and emergency room patients, i.e. patients that must be seen
on a short notice due to medical emergencies. Second, based
on availability, they can be used to accommodate non-
emergency inpatients as per the requests from radiologists
and/or the referring physician base. Finally, they can be used
as time buffers if previous exams are running late; in such
cases the inpatient exam in such a slot will be postponed to
the night shift and the exam for the next regularly scheduled
patient will be performed instead. This flexible use of IPBs,
common at many outpatient-inpatient hospital systems such
as LHMC, while beneficial in practice, introduces a signifi-
cant amount of complexity in patient scheduling optimization.
In Sect. 5, we will take into account only the second and third
above-mentioned functions of IPBs and disregard STAT in-
patient requests and emergency patients because they are only
a small fraction of all the patients whose exams are performed
in this modality. Then, in Sect. 9, we extend our optimization
models to additionally incorporate emergency patient arrivals.
This paper focuses on the scenario of a hospital-based MRI
department providing services to both inpatients and outpa-
tients as opposed to an independent testing facility focused
solely on outpatient services. This paper outlines an end-to-
end process of resolving real-world healthcare operations
workflow challenges associated with such hospital-based
MRI departments, ranging from data analysis, identification
of the most relevant decision variables and sources of uncer-
tainty, development of a sophisticated optimization approach,
to demonstration of the superiority of the optimization solu-
tion via a simulation-based evaluation. Finally, we present a
real-world implementation of some of the recommendations
emerging from this analysis. Specifically, we first provide a
thorough analysis of the causes of long patient waiting times
by analyzing patient arrival patterns and procedure durations.
We find that, while the early arrivals of patients do contribute
to long patient waiting times, the sub-optimal slot sizes are
shown to further increase the waiting times significantly.
Secondly, we develop a stochastic programming model to
build a patient scheduling template, such as the one shown
in Fig. 1, which allows flexibility to accommodate inpatients
by adjusting slot sizes and the placement of IPBs. Inpatient
462
exam accommodations in this approach are rule-based: the
day shift exam will be rescheduled to the night shift if, during
the day shift, the start time of the inpatient exam is behind
schedule by a certain threshold amount of time. When focus-
ing only on the day shift, this flexible rescheduling of inpatient
exams from day shift to night shift amounts to simply a can-
cellation. This is a common practice used by radiology depart-
ments, such as the one at LHMC, with a combined inpatient/
outpatient patient base, resulting in greater scheduling flexi-
bility. In this paper, we do not attempt to modify this practice;
instead, we optimize the patient scheduling template given a
predefined inpatient exam “cancellation” rule.
Our focus is on optimizing the appointment schedule by
explicitly accounting for such flexible inpatient cancellation
practices. The goal is the minimization of the total cost of
outpatient waiting time, radiology equipment idle time, day
shift staff overtime, and the number of inpatient exam cancel-
lations during the day shift. The waiting time in this cost
function is restricted to only one class of patients, namely
outpatients. This is because, outpatients are the only ones
who are given an appointment in advance and it comes with
an implicit guarantee of providing “timely” service, which is
strongly linked to patient satisfaction. Inpatients, on the other
hand, are already physically present in the hospital so that they
can be held in their rooms before the exam starts.
Inpatient accommodation, such as the one done at LHMC,
is a common practice in many hospitals. According to market
research report by IMV Medical Information Division [11],
17.7 million MRI procedures were performed in hospitals in
the US in 2017, as opposed to 18 million performed in non-
hospital facilities. With such a high proportion of MRI proce-
dures done in hospitals, they typically engage in strategies that
can accommodate a mix of outpatients and inpatients. In par-
ticular, mid-sized hospitals commonly use an inpatient accom-
modation strategy, such as the one at LHMC, at some or all of
their MRI machines.
There are two major types of decisions to be made when
developing the optimal outpatient scheduling template, while
explicitly accounting for the policy of flexible inpatient exam
cancellations. First and foremost, the size of each exam slot
needs to be decided. The second decision is related to the
placement of the inpatient blocks (IPBs) within the scheduling
template. From a practitioner’s standpoint, the slot size deci-
sions are the relatively easier ones to modify. Therefore, in our
Model 1, we focus on the problem of optimizing the slot sizes
while holding the IPB placement unchanged. Then, in our
Model 2, we expand the problem scope by simultaneously
optimizing both decisions. In both models, we explicitly ac-
count for the complexities introduced by the practice of flex-
ible inpatient exam cancellation.
To ensure the robustness of the schedule in the face of the
stochasticity in the procedure durations and patient arrival
patterns, we use a stochastic programming approach to model
Sun Y. et al.
and solve the scheduling problem. We then evaluate the opti-
mization results using a simulation software called FlexSim
Healthcare [29], to demonstrate the effectiveness of the
schedules generated by our optimization approach. The sim-
ulation approach allows modeling of several additional real-
world complexities that are difficult to incorporate in the sto-
chastic programming formulation, thus allowing a more com-
prehensive and independent evaluation of our optimization
approach and its underlying assumptions.
A majority of the previous literature on outpatient schedul-
ing has focused on only one class of patients (namely outpa-
tients) while some of the more recent literature has analyzed
the impact of interruptions on outpatient scheduling due to the
emergency patients. To the best of our knowledge, no research
study in the existing operations research literature to date has
explored optimal outpatient scheduling with flexible
cancellation/accommodation of inpatient exams. Among the
previous studies that took into consideration different patient
classes, many used rule-based and heuristic-based approaches,
which were evaluated using simulation. In this paper, we use
stochastic programming to handle uncertainty in patient arriv-
al patterns and exam durations, and evaluate the results using a
simulation.
The rest of this paper is organized as follows: Sect. 2 re-
views the relevant literature on patient scheduling and iden-
tifies the contributions of this paper to the healthcare schedul-
ing literature. Section 3 provides an overview of the typical
baseline MRI workflow motivating this research. Section 4
presents a brief analysis of the hospital workflow data.
Section 5 presents the two optimization models. Section 6
presents the corresponding solutions and results. Section 7
provides comparisons with simpler heuristic-based sequenc-
ing approaches to deal with situations in which sophisticated
optimization tools are not available for optimizing IPB place-
ment decisions. Section 8 presents a sensitivity analysis of
weights for outpatient waiting time, machine idle time, and
the number of exam cancellations, as well as the Pareto
Frontier between patient waiting time and machine idle time,
in order to generalize our conclusions to decision-makers with
different priorities. Section 9 extends the optimization model
in Sect. 5 to additionally incorporate emergency patient ar-
rivals and demonstrates the robustness of our main findings
to the different ways of capturing the effects of the extra un-
certainty added by the emergency patient arrivals. Section 10
concludes the paper.
2 Literature review
There is a substantial body of literature on outpatient sched-
uling under uncertainty. Queuing theory, stochastic program-
ming, and simulation are the most commonly used methodol-
ogies. Early research studies used the analytical methods in
Stochastic programming for outpatient scheduling with flexible inpatient exam accommodation
queuing theory, assuming procedure durations to be exponen-
tial or normally distributed, and concluded that the optimal
schedule is “dome-shaped” ([17, 27, 31, 33]). However, the
limitations on the choice of distributions negatively impact the
reliability and generalizability of the results. In the past few
decades, discrete event simulation methods have been widely
used in the context of patient scheduling under uncertainty
using mature simulation software like FlexSim and Arena
([15, 16, [20–22]). Compared to the queuing theoretic
methods, simulation methods require fewer restrictions on
the distributions of procedure durations and patient arrival
patterns, and hence are able to better approximate reality.
However, due to its inability to find optimal solutions, the role
of the simulation software has mostly been confined to eval-
uating the results of different appointment and sequencing
rules.
The stochastic programming method is widely used to
tackle the randomness in procedure durations and patient ar-
rival patterns. It provides a framework for modeling optimi-
zation problems under uncertainty. In the first stage of such
problems, scheduling decisions must be made before the
values of uncertain variables are realized. In single-stage sto-
chastic programming, the expected costs of first-stage deci-
sions are directly minimized across second-stage uncertainty
scenarios. In contrast, two-stage stochastic programming ad-
ditionally includes second stage decisions (known as re-
course), which are made after the uncertainty realization.
Two-stage stochastic linear programming is commonly used
in patient scheduling problems where the uncertain second-
stage values only become known after the first-stage variables
are decided.
Single-stage stochastic programming is used by Begen and
Queyranne [2] to make appointment scheduling decisions
without recourse. Two-stage stochastic programming has
been used to formulate the appointment scheduling problem,
with appointment time decisions as the first-stage variables,
and patient waiting times and operating room idle times as the
second-stage variables. Denton and Gupta [9] developed a
two-stage stochastic linear program assuming continuous pro-
cedure durations and a pre-determined appointment sequence.
Their stochastic programming framework minimized the
weighted sum of the costs of patient waiting times, doctors’
idle times and doctors’ overtimes. They developed a
sequential-bounding algorithm to solve small instances and a
heuristic for larger instances. The aforementioned study by
Begen and Queyranne [2] presented an optimization frame-
work and developed an algorithm based on discrete procedure
durations, which solved their problem instances in polynomial
time. These studies typically assumed the patient arrival pat-
tern to be deterministic and appointment durations to be sto-
chastic. Berg et al. [4] developed a two-stage stochastic
mixed-integer programming method to optimize the booking
and appointment times, maximizing the profit. In their study,
463
the optimal booking, sequencing, and scheduling decisions
were made iteratively considering patient no-shows and ran-
dom procedure durations. Methodologically, a widely
adopted method to solve stochastic programming formula-
tions is sample average approximation (SAA) [1, 19], applied
by Begen et al. [3], Ge et al. [13], and Mancilla and Storer
[26]. All these studies focused only on outpatients while
sometimes adding extensions like patient no-shows, cancella-
tions, and interruptions. The impact of inpatient procedures is
not well-studied, and the integration of flexible inpatient
scheduling and outpatient scheduling has not been achieved
in the current literature. Bridging this gap is an important
contribution of our paper to the healthcare scheduling
literature.
The literature focusing on multi-class patient scheduling
typically uses simulation to evaluate different scheduling
and sequencing rules. Cayirli et al. [7] compare the impact
of patient classification on appointment scheduling by com-
paring the results of applying patient classification only to
patient sequencing and to both patient sequencing and sched-
uling interval adjustment. Similarly, Bhattacharjee and Ray
[5] evaluate the combination of different sequencing rules
(e.g., IPBEG: scheduling all inpatients before outpatients,
OPBEG: scheduling all outpatients before inpatients) and
scheduling rules (e.g., IBFI: scheduling one patient in each
fixed-length block, 2BEG: scheduling two patients in the first
block, but one each in the others). They also conducted a case
study for MRI scanning rooms in a multi-specialty hospital in
India using simulation. Patrick and Puterman [30] categorized
patients into high-priority inpatients and low-priority outpa-
tients. They assumed that there is a pool of on-call outpatients
and non-emergency inpatients who can be moved to the next
day. However, their methods and findings aren’t applicable in
our setting, because outpatients in our case are scheduled
ahead of time and once their schedule is set, it is relatively
inflexible without incurring significant patient dissatisfaction.
Additionally, from a methodological standpoint, these studies
used simulation to evaluate the scheduling and sequencing
rules, whose results may not be optimal.
In recent literature, simulation-based optimization methods
have provided promising results. While simulation allows ac-
curate evaluations of different solutions, optimization can gen-
erate potential solutions which are likely to improve the results
based on prior simulation outputs. Most simulation software
platforms, like Arena and FlexSim, also incorporate optimiza-
tion tools, e.g., OptQuest, to help users make better decisions
[25]. Klassen and Yoogalingam [23] applied a simulation-
based optimization method to explore different combinations
of scheduling rules in order to mitigate the impact of late
arrivals of patients. This study concluded that the combination
of variable-length intervals and block scheduling works better
than the traditional dome-shaped or plateau dome rules.
Klassen and Yoogalingam [24] further examined the benefits
464
of adding mid-level service providers (MLSPs) to a single-
physician outpatient office. Multi-stage appointment schedul-
ing rules were also developed using simulation-based optimi-
zation. In both these studies, the authors used linear combina-
tions of prior solutions to generate new solutions. As summa-
rized by Fu [12], the commonly used search methods are
stochastic approximation, response surface, sample path, and
random search. The first three methods work well with opti-
mizing continuous variables while random search is the only
one that is relevant for the combinatorial optimization prob-
lems such as the ones dealt with in our research.
In our study, since we optimize slot size and IPB place-
ment simultaneously, the combinatorial nature of the IPB
placement variables restricts the application of most of the
commonly used simulation-based optimization methods to
our model. Even with the random search method, the
stochasticity and large choice set make it computationally
expensive to achieve robust results using random search.
Therefore, we decided to first formulate the problem into a
stochastic programming model capable of handling such un-
certainty, and subsequently used simulation to evaluate its
results, instead of attempting to perform a simulation-based
optimization exercise.
In this paper, we construct and solve a stochastic program-
ming model to optimize the sequencing and scheduling con-
sidering flexible cancellation of inpatient exams. This topic is
not studied in the literature on outpatient scheduling.
Moreover, the studies on the multi-class patient settings with
hospital-determined flexible cancellations have not developed
an optimization approach. The models and methods devel-
oped in this paper address these gaps and are tested using
detailed real-world datasets from a mid-sized outpatient-inpa-
tient MRI department.
3 Case study background: MRI workflow
at LHMC
LHMC provides magnetic resonance (MR) based imaging
services at three different locations. The largest operation is
located at the main campus in Burlington, MA and the case
study in this paper is focused on the data from the imaging
workflow at this Burlington campus. At this facility, three
individual MRI machines (different brands, ranging 4–
16 years since installation) perform approximately 17,000
MRI procedures every year. We denote the three machines
as MR2, MR3, and MR4, a naming convention used in the
LHMC practice. The majority of the procedures can be per-
formed using any of the three MRI machines, but differences
in capability exist. Prostate procedures, for instance, are re-
quired to be done on MR3 due to its bigger room size and
specific coil types used. MR3 is a 3T (3-Tesla) MRI machine
used for some exams with specific higher signal-to-noise ratio
Sun Y. et al.
requirements. This can lead to specific protocolling requests
by radiologists for the use of MR3 for specific exams. A
significant majority of the procedures is performed on week-
days (approximately 12,000 procedures) and a significant ma-
jority of the outpatient procedures is performed during the day
shift (between 6am and 12am). This results in approximately
49 daily procedures being performed on all three machines in
total (during the day shift). More than 123 different types of
imaging procedures are performed throughout the year. In an
attempt to handle this high demand, the MRI department uses
a fixed 45-min slot size for MR2 and MR4, and a fixed 60-min
slot size for MR3. However, under this somewhat restrictive
scheduling approach, the department suffers from long patient
waiting times, with an average outpatient waiting time of
54 min. A practical approach for solving this challenge is to
identify the causes of the long waiting times and to improve
the patient schedule by combining optimization and simula-
tion modeling techniques.
Figure 2 shows the workflow of an outpatient in the MRI
room, with blue blocks representing key actors, rectangles
representing different processes, and diamonds representing
decision points. Outpatient appointments are booked by a
scheduler in advance of the exam date at the request of refer-
ring primary care and specialty physicians. Patients are sched-
uled for an exam on a certain MRI machine at a specific time
on a specific date. The patients are asked to arrive 30 min
before the appointment time, check in at the reception desk,
and wait until the previous exam is finished. Typically, two
technologists (Technologist 1 and Technologist 2) are
assigned to work on each MRI machine. When Technologist
2 estimates that approximately 10 min of scanning time re-
main of the currently ongoing exam, then Technologist 1
starts preparation of the next patient. Exam preparation can
include verification of patient information, the insertion of an
intravenous line if the procedure requires it, and educating the
patient about the procedure.
Inpatients are also scheduled in advance, but unlike outpa-
tients, the lead time to scheduling an inpatient is much smaller.
Outpatients are scheduled by a scheduler at least 2 days in
advance. In contrast, an inpatient is scheduled by the technol-
ogists depending on how far along or behind they are with the
patient queue. If the procedures are running behind schedule
by a certain threshold amount, which in the case of LHMC is
15 min later than the appointment time, the technologists will
cancel the original inpatient exams and make use of IPBs to
continue to work on outpatients who have already arrived.
But, when the procedures are running close to the scheduled
durations, the technologists examine inpatient orders and re-
quest the attending nurse and/or transporting person to bring
the inpatient from their room to the imaging area to perform
the procedure. This inpatient scheduling typically happens at
least one slot in advance.
Stochastic programming for outpatient scheduling with flexible inpatient exam accommodation 465

Ordering Physician Receponist Paent Technologist 1

Place order Appointment made Paent Arrives

Check in

Technologist 2
<10 min
Wait in the
before no
waing
previous exam
room
end me?
yes Get changed in the Prepare paent for
changing room exam

Perform Get into the exam

Help paent get
exam room and get
into exam room
scanned
Exam geng
late & next yes Cancel next
paent is inpaent exam
inpaent?
no

Finish
paperwork
Get out of exam
Help paent get out
room with help of
of exam room
Technologist

Change
clothes Clean exam
room
Paent
leaves

Fig. 2 Workflow flowchart

All procedures, irrespective of patient class, require an or-
der request from a physician indicating the reason for the
exam and how soon the procedure needs to be performed
(e.g., immediately, within 4–6 h, or within 12 h). While the
data we obtained is able to discriminate a STAT request from
a routine one, it does not provide detailed information on
whether the STAT requests should be completed immediately,
or within 4–6 h, or within 12 h. From the data, we see that
about 12% of the procedures performed are STAT requests.
Given an average of 49 procedures performed in a day, this
translates into approximately six patients in a day with a
STAT request. Moreover, based on our interviews of technol-
ogists and managers at LHMC, we found that only a small
percentage of these STAT requests actually requires immedi-
ate attention and execution of the imaging exam. In our ob-
servations of the native workflow, we noticed that most pro-
cedures are performed on MRI machines where the patients
were originally scheduled for appointments.
Based on this workflow analysis, we make the following
three modeling assumptions. First, the slot sizes are held fixed
per MRI machine. Second, only two classes of patients (name-
ly, inpatients and outpatients) are modeled, because
emergency patients are “disruptors” in MR and our goal is
to optimize a typical patient schedule as opposed to optimiz-
ing disruption recovery within the workflow. Finally, even
though sometimes patients end up being switched to different
MRI machines than where they were originally scheduled, we
do not model this real-world observation. This is because it
happens intermittently and the complexity of modeling this
part of the workflow outweighs its effect on patient waiting
times. Hence, for the three different MRI machines, we devel-
op three separate optimal patient schedules independently of
each other.
4 Problem identification and data analysis
LHMC’s Radiology Information System (“Radiant” RIS)
supported by Epic Electronic Medical Record software appli-
cation [10] tracks every radiology transaction a patient has
with the radiology department. It collects timestamped data
on the patient appointment, patient arrival, performed imaging
procedure, machine, and the start and end time of the exam.
For our analysis, we collected data on all MRI exams
466
performed during the five-month time period between and
including January 2018 and May 2018. We used the
timestamped information to derive patient waiting times, pa-
tient arrival patterns and procedure durations. We focus on the
weekday schedule from 6am to 12am, where most outpatients
are scheduled.
The waiting time of an outpatient is defined as the duration
from the time when the patient arrives up to the time when the
imaging exam for that patient begins, i.e., the actual time that a
patient waits after arrival. While the hospital expects patients
to wait 30 min or less (as previously noted, the patients are
asked to arrive 30 min in advance of their appointment), the
current waiting time is 54 min on average. In particular, as can
be seen in Table 1, only 24.13% of the patients wait 30 min or
less, 40.69% wait between 30 and 60 min, and 35.18% wait
more than an hour. From Fig. 3, in which the red line repre-
sents the 30-min threshold, it is clear that a significant fraction
of the patients waits longer than the hospital expects, with
some patients waiting more than 2 h.
The long waiting times can be caused by the uncertainty in
two factors: patient arrival patterns and procedure durations.
Patients who arrive more than 30 min in advance of their
appointment time can inflate the average waiting time; on
the other hand, patients who arrive late and cause delays in
the workflow will adversely affect waiting times for subse-
quent patients too. Table 2 shows that a majority of the pa-
tients (70%) arrive earlier than the expected 30 min in advance
of the appointment time. Also noteworthy is that only 3% of
patients arrive later than the appointment time.
As shown in Table 3, the long patient waiting times at
LHMC is a systemic issue caused by factors beyond just the
inflated average waiting time of early arriving patients. We
notice that over 60% of the procedures begin later than the
appointment time and over 16% of the procedures begin more
than 30 min after the appointment time (even though only
about 3% patients arrive later than the appointment time).
Table 4 shows the summary statistics on the procedure
durations for the three MRI machines. We can conclude that
the slot sizes of 45 min on MR2 and MR4, and the slot size of
60 min on MR3, currently in use at LHMC, are sub-optimal.
Mean procedure durations on MR2 (49 min) and MR4
(57 min) exceed their slot sizes while the mean procedure
duration of 52 min (with a median of 45 min) on MR3 is
below its allocated slot size. These findings show that the time
slots do not align with the procedure durations and could be
Table 1 Outpatient waiting times
Waiting time <30 min 30–60 min 60–90 min >90 min Total
Frequency 930 1568 869 487 3854
Percentage 24.13% 40.69% 22.54% 12.64% 100.00%
Sun Y. et al.
improved. On the one hand, when procedure durations exceed
slot sizes, it can result in patients waiting longer and its effects
propagating throughout the day. On the other hand, when
procedure durations are lower than slot sizes, it can lead to
unnecessary machine idle times.
In light of this understanding of the inconsistency between
procedure duration and slot size on each MRI machine, we
examined the procedure durations for the 10 most common
types of procedures (of the total 123 types of procedures) to
see which procedures have durations exceeding the slot size
(see Table 5). It is important to note that, since some proce-
dures on MR2 and MR4 require double slots, in those cases
we compare the actual procedure duration to 90 min instead of
45 min of slot size. As we can see from Table 5, the duration
of over 73% of the “Brain WWO” (here “WWO” stands for
“with and without contrast”) exams – the most common type
of procedure – exceeds the slot size, and “MRCP” (“Magnetic
Resonance Cholangiopancreatography”) has the largest pro-
portion (83.08%) of exams exceeding its slot size. With a
significant number of procedure durations exceeding the cor-
responding slot sizes, the patient waiting time, especially for
those scheduled later in the day, is likely to be long.
Then we examined the average procedure durations for
different procedure types on different machines. Figure 4 re-
veals that two of these top 10 procedures, namely, “Prostate
WWO” and “Breast WWO”, are done only on certain ma-
chines. Though MR3 has a 60-min slot size, the procedure
duration for the same procedure on MR3 (marked in red) is
not necessarily always longer than those on MR2 (blue) and
MR4 (grey). Figure 4 also shows that for many types of pro-
cedures (e.g., “MRCP”, “Cervical Spine WO”, “Breast
WWO”, etc.), MR4 has the longest procedure duration among
the three machines. This further indicates that the slot sizes are
inconsistent with procedure durations.
By analyzing both patient arrival patterns and procedure
durations on each machine for the ten most common proce-
dures, it is clear that although patients tend to arrive earlier
than asked, the mismatch between procedure durations and
slot sizes does increase patient waiting times. Figure 5 shows
a clear growing trend in patient waiting times across the day
(as marked by the red line).
5 Models
For each machine, we consider a single server system where
two types of customers are served in a certain order. Both the
patient arrival patterns and service durations are stochastic.
The cancellation of one type of customers (inpatients) is
rule-based which means that if their service starts a certain
amount of time later than the appointment time, that service
will be canceled. The service for the other type of customers
(outpatients) cannot be canceled. While different days of the
Stochastic programming for outpatient scheduling with flexible inpatient exam accommodation
Fig. 3 Histogram of outpatient waiting times
week have different IPB placements and also different number
of IPBs, requiring them to be modeled differently, the hospital
requires the slot sizes to be identical across all weekdays. As a
result, the five problems associated with the five weekdays are
coupled and need to be solved jointly using a single integrated
optimization formulation. In Model 1 (presented in Sect. 5.1),
we optimize the slot size alone given a certain IPB placement.
In Model 2 (presented in Sect. 5.3), we determine the optimal
values of IPB placement and slot size, simultaneously.
5.1 Model 1: Slot size optimization
Model 1 decides the optimal slot size for each MRI machine
while fixing the IPB placement as per the hospital’s current
schedule, and taking the practice of flexible inpatient cancel-
lations into account.
This model is a two-stage stochastic programming model,
with the first stage deciding the slot size and the second stage
deciding waiting times, idle times, overtimes and cancella-
tions. The slot size decisions in the first stage are the only true
decision variables. The second stage decides the values of
waiting times, idle times, overtimes and cancellations based
on the first-stage decisions and the uncertainty realization. The
uncertainty comes from patient arrival patterns and procedure
durations, both of which are assumed to have independent
identical distributions regardless of the exam order. In order
Table 2 Outpatient arrival pattern
Earliness Late <30 min 30–60 min 60–90 min >90 min
Frequency 152 1357 2281 817 423
Percentage 3.02% 26.98% 45.35% 16.24% 8.41%
467
to estimate distributions, the LHMC data was fitted to
Gamma, Log-normal, Logistic, Normal, and Weibull distribu-
tions where necessary linear transformations were made to
ensure that all the data points are within the domain of a
specific distribution. After comparing the Akaike
Information Criterion (AIC) values [6] of the above distribu-
tions, we decided to use Logistic distribution to model patient
arrival patterns and Weibull distribution to model procedure
durations. Each scenario in the stochastic programming
model’s second stage uncertainty realization is one set of pa-
tient arrival patterns and procedure durations generated from
the aforementioned distributions.
Sets
J ¼ f1; …; J g Set of slots in a day
S ¼ f1; …; S g Set of scenarios
D ¼ f1; …; Dg Set of days of the week
Parameters
Procj, d, s: Procedure duration of patient in slot j∈ J on day
d∈D in scenario s∈S
Fj, d, s: Arrival lateness of patient in slot j∈ J on day d∈D
in scenario s∈S with respect to the appointment time; a
positive (negative) value indicates a patient arriving after
(before) the appointment time
Ij, d: 1 if slot j∈ J on day d∈D serves an inpatient (i.e., is
an IPB), 0 otherwise
Cwt, Cid, Covt, Ccc: The cost coefficients for patient
waiting time (in minutes), machine idle time (in minutes),
overtime (in minutes) and the number of inpatient exam
cancellations respectively
Twk: The official working hours in a day for MRI room
468 Sun Y. et al.

Table 3 Time from scheduled appointment time to exam start time

Exam start time – scheduled appointment time <−30 min −30 to 15 min −15 to 0 min 0 to 15 min 15 to 30 min >30 min

Frequency 257 341 911 1041 667 629

Percentage 6.68% 8.87% 23.69% 27.07% 17.34% 16.35%

Tprep: The preparation time for patient to get ready for Model
exams

Tlate: The delay threshold after the appointment start time Min C wt *E½TWO þ C id *E ½ID þ C ovt *E ∑ OV d
that will lead to inpatient exam cancellation d∈D
" #
k: Minimum increment in slot size (minute)
E ½TWI 
Smin, Smax: The lower/upper threshold for the number of þ þ C cc *E ∑ y j;d ð1Þ
M d∈D; j∈ J
k-minute increments constituting each slot
M: A large positive constant number
First-stage constraints
5.2 Decision variables s:t: G j ¼ G j−1 þ k*x∀ j∈ Jnf1g ð2Þ
G1 ¼ 0 ð3Þ
First-stage decision variable
x: Number of k-minute increments per slot S min ≤ x ≤ S max ð4Þ
x∈ℤ þ ð5Þ

Second-stage decision variables

yj, d, s: 1 if the exam for patient in slot j∈ J on day d∈D in Second-stage constraints
scenario s∈S is canceled, 0 otherwise    
TWOs ≥ ∑d∈D; j∈ J 1−I j;d * B j;d;s −A j;d;s ∀s∈S ð6Þ
 
T WI s ≥ ∑d∈D; j∈ J I j;d * B j;d;s −A j;d;s ∀s∈S ð7Þ
Auxiliary variables  
TWOs: Total waiting time for all outpatients in a week in IDs ≥∑d∈D; j∈ J B j;d;s −E j−1;d;s ∀s∈S ð8Þ
scenario s∈S OV d;s ≥ E J ;d;s −60*T wk ∀s∈S; d∈D ð9Þ
TWIs: Total waiting time for all inpatients in a week in
scenario s∈S A j;d;s ¼ G j þ F j;d;s ∀s∈S; d∈D; j∈J ð10Þ
IDs: Total machine idle time in a week in scenario s∈S B j;d;s ≥ A j;d;s þ T prep ∀s∈S; d∈D; j∈ J ð11Þ
OVd, s: Overtime on day d∈D in scenario s∈S
Aj, d, s: Arrival time of patient in slot j∈ J on day d∈D in B j;d;s ≥E j−1;d;s ∀s∈S; d∈D; j∈ J ð12Þ
scenario s∈S E 0;d;s ¼ 0∀d∈D; s∈S ð13Þ
Bj, d, s: Exam start time of patient in slot j∈ J on day d∈D  
I j;d * B j;d;s −G j ≤ T late þ M *y j;d;s ∀s∈S; d∈D; j∈ J ð14Þ
in scenario s∈S
Gj: Appointment time of patient in slot j∈ J y j;d;s ≤ I j;d ∀s∈S; d∈D; j∈ J ð15Þ
Ej, d, s: Exam end time of patient in slot j∈ J on day d∈D  
in scenario s∈S E j;d;s ¼ B j;d;s þ 1−y j;d;s *Proc j;d;s ∀s∈S; d∈D; j∈ J ð16Þ

y j;d;s ∈f0; 1g∀s∈S; d∈D; j∈ J ð17Þ

Table 4 Procedure durations and waiting times on different machines TWOs ; TWI s ; IDs ≥ 0∀s∈S ð18Þ

Machine MR2 MR3 MR4

B j;d;s ; E j;d;s ≥ 0∀s∈S; d∈D; j∈ J ð19Þ
G j ≥ 0∀ j∈ J ð20Þ
Mean procedure durations (min) 49 52 57
Mean waiting time (min) 54 51 55 OV d;s ≥ 0∀s∈S; d∈D ð21Þ
Median procedure time (min) 47 45 49
The objective function seeks to minimize the weighted sum
Median waiting time (min) 47 45 48
of the expected values of outpatient waiting time, machine idle
Slot size (min) 45 60 45
time, overtime and penalty for canceling inpatient exams. For
Stochastic programming for outpatient scheduling with flexible inpatient exam accommodation 469

Table 5 Procedure durations for top 10 most frequent procedures

Procedure Procedure duration within the slot size Procedure duration exceeding the slot size

Frequency Percentage Frequency Percentage

Brain WWO 227 26.71% 623 73.29%

Abdomen WWO 360 54.05% 306 45.95%
Lumbar spine 326 83.38% 65 16.62%
Brain WO 202 77.99% 57 22.01%
Prostate WWO (90 min) 199 78.97% 53 21.03%
Cervical spine WO 173 77.58% 50 22.42%
MRCP 33 16.92% 162 83.08%
Breast WWO (90 min) 85 63.91% 48 36.09%
Cervical spine WWO 26 22.61% 89 77.39%
Knee left WO 77 69.37% 34 30.63%

MRCP Magnetic Resonance Cholangiopancreatography, WWO With Or Without Contrast, WO Without Contrast

technical reasons described later in this section, the total inpa-
tient waiting time is also added to the objective function to
correctly define the operational workflow, and the small coef-
ficient (1/M) of this term guarantees that this term will have no
impact on the optimality of the resulting solution.
Constraints (2), (3), (4) and (5) are first-stage constraints,
which are directly related to slot size decisions. Constraints (2)
and (3) calculate the appointment time. Constraints (4) and (5)
together define the permissible set of values for the feasible
slot sizes. Constraints (6)–(21) are second-stage constraints
defining the patient waiting time, machine idle time, worker
overtime and inpatient cancellations. Constraints (6), (7), (8),
and (9) define the total outpatient waiting time, inpatient
waiting time, machine idle time, and overtime, respectively,
for each scenario. Constraint (10) gives the arrival time of
each patient. Constraints (11) and (12) ensure that the exam
starts after the current patient arrives and is prepared for the
exam, and also after the previous exam finishes. Constraint
(13) defines the exam end time for an imaginary “Patient 0”,
so that the real first patient’s exam start time will not be earlier
than time 0 (as in Constraints (12)), and also to ensure that the
machine idle time before the first patient is correctly defined
(as in Constraints (8)). Constraints (14), (15), and (16) simu-
late flexible inpatient cancellation if the exam is more than
Tlate minutes behind schedule. In particular, Constraints (14)
ensures that the inpatient exams that fail to start by Tlate mi-
nutes past the appointment time are canceled. Constraints (15)
ensure that no outpatient exams are canceled. Constraints (16)
set the exam end time equal to the sum of the exam start time
and the procedure duration for the non-canceled exams, and
equal to the exam start time for the canceled exams.
Constraints (17) ensure that the cancellation variables are bi-
nary. Constraints (18)–(21) ensure the non-negativity of the
auxiliary variables.
When formulating the optimization model without includ-
ing inpatient waiting time in the objective function, the gen-
erated solution sometimes has invalid inpatient exam start
times. The patient exam start time is constrained by
Constraints (11) and (12) to be no earlier than the later of
the two entities: previous patient’s exam end time and the time

Fig. 4 Average procedure 120

durations for top 10 procedures
on different machines 100
80
60
40
20
0

MR2 MR3 MR4

470 Sun Y. et al.

Fig. 5 Change in waiting times 80

and procedure durations across 70
the day
60

Time (min)
50
40
30
20
Waing Time (min) Procedure Duraon (min)
10
0
6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23
Hour of the Day

when the current patient’s preparation is complete. For outpa-
tients, the inclusion of outpatient waiting time in the objective
function ensures that at optimality, each outpatient exam starts
as soon as the previous exam is finished and the patient is
prepared, whichever happens later. However, this is not guar-
anteed for inpatients and some of the optimal solutions for this
formulation may have neither of the Constraints (11) and (12)
tight. In practice, however, the next exam should start as soon
as that machine and the patient are both ready. In order to
eliminate this discrepancy between the model and practice,
we add the inpatient waiting time to the objective function.
By giving it a negligibly small cost coefficient, we ensure that
this term does not reduce the solution quality in terms of the
original objective function but allows us to pick correctly
among the multiple optimal solutions of the original problem
formulation.
5.3 Model 2: Integrated slot size and IPB placement
optimization
While Model 1 determines the optimal slot size for a
predetermined IPB placement, Model 2 calculates the optimal
values of slot size and IPB placement at the same time.
5.4 Extra notation
Parameters
NIPBd: Number of IPBs on day d∈D
5.5 Decision variables
First-stage decision variable
zj, d: 1 if the slot j∈ J on day d∈D is an IPB, 0 otherwise
Auxiliary variables
A′j, d, s: Auxiliary variable representing the product of Aj,
d, s and zj, d for slot j∈ J on day d∈D in scenario s∈S
B′j, d, s: Auxiliary variable representing the product of Bj,
d, s and zj, d for slot j∈ J on day d∈D in scenario s∈S
A new first-stage decision variable, zj, d, is created as a
binary variable indicating whether block j is an inpatient block
on day d. The objective function is the same as that for Model
1 (Expression 1). However, since Ij, d, which was a constant in
Model 1 Constraints (6), (7), (14) and (15), has now become a
decision variable zj, d in Model 2, the multiplication of zj, d and
Bj, d, s as well as zj, d and Aj, d, s will introduce nonlinearities
into the model. Therefore two additional auxiliary variables,
0 0
B j;d;s , representing Bj, d, s ∗ zj, d, and A j;d;s , representing Aj, d,
s ∗ zj, d, are introduced to linearize the model. Constraints (23)
to (26) correspond to Constraints (2) to (5), respectively, in
0
Model 1. Constraints (27) to (32) ensure that B j;d;s ¼ B j;d;s *
0
z j;d and A j;d;s ¼ A j;d;s *z j;d . Constraints (33) are the linearized
versions of Constraints (14). Constraints (34) correspond to
Constraints (15) in Model 1. Constraints (35) require the num-
ber of IPBs in a single day to be equal to the number of IPBs in
the current schedule. Constraints (36) ensure that the IPB
placement decision variables are binary. Constraints (37),
(38), (39) and (40) respectively define the total outpatient
waiting time, inpatient waiting time, machine idle time and
overtime. Constraints (41) to (46) are identical to Constraints
(10)–(13) and (16)–(17) in Model 1. Constraints (47) to (50)
ensure the non-negativity of the auxiliary decision variables.


Min C wt *E½TWO þ C id *E ½ID þ C ovt *E ∑ OV d
d∈D
" #
E ½TWI 
þ þ C cc *E ∑ y j;d ð22Þ
M d∈D; j∈ J
First-Stage Constraints:
s:t: G j ¼ G j−1 þ 5*x∀ j∈ Jnf1g ð23Þ
G1 ¼ 0 ð24Þ
S min ≤ x ≤ S max ð25Þ
Stochastic programming for outpatient scheduling with flexible inpatient exam accommodation 471

x∈ℤ þ ð26Þ given machine to be the same across all days of week. To
0
 
þ M 1−z j;d ∀s∈S; d∈D; j∈ J
j;d;s ≤ B j;d;s ð27Þ
B ensure that the results remain amenable to practical implemen-
  tation, we too constrained the slot sizes for a given machine to
B j;d;s ≤B0 j;d;s þ M 1−z j;d ∀s∈S; d∈D; j∈ J ð28Þ be the same across all days of the week. All exams are sched-
 
A0 j;d;s ≤ A j;d;s þ M 1−z j;d ∀s∈S; d∈D; j∈ J ð29Þ uled sequentially from 6am. IPBs are optimized in Model 2. In
  Model 1, the sequencing of inpatient and outpatient slots is
A j;d;s ≤A0 j;d;s þ M 1−z j;d ∀s∈S; d∈D; j∈ J ð30Þ held constant as per the hospital’s current schedule, which in
B0 j;d;s ≤ z j;d *M ∀s∈S; d∈D; j∈ J ð31Þ turn fixes the IPB placement. We allow changing the slot sizes
in multiples of 5 min to remain consistent with practice. As
0
A j;d;s ≤ z j;d *M ∀s∈S; d∈D; j∈ J ð32Þ shown in Sect. 4, the long waiting times were caused in many
   
B j;d;s −G j − 1−z j;d *M ≤ T late cases because of the slot sizes being too small for the exam. In
order to keep outpatient waiting times under control, we set
þ M*y j;d;s ∀s∈S; d∈D; j∈ J ð33Þ the lower bound on the candidate slot sizes to 45 min; in other
y j;d;s ≤ z j;d ∀s∈S; d∈D; j∈ J ð34Þ words, Smin = 9. We do not need to consider slot sizes smaller
than 45 min because, as shown in Table 4 in Sect. 4, the mean
∑ j∈ J z j;d ¼ NIPBd ∀d∈D ð35Þ procedure time for each machine is already larger than 45 min.
z j;d ∈f0; 1g∀d∈D; j∈ J ð36Þ During the day-shift (6am to 12am) length of 18 h, the max-
imum allowable time per exam equals 18*60/17 = 63.5 min.
Second-Stage Constraints: Hence the candidate slot sizes with a duration of 70 min and
 0
 longer do not need to be considered; in other words, Smin=13.
TWOs ≥ ∑d∈D; j∈ J B j;d;s −A j;d;s þ A j;d;s −B0 j;d;s ∀s∈S ð37Þ This implies that our list of candidate slot sizes includes 45,
 0
 50, 55, 60, and 65 min.
TWI s ≥ ∑d∈D; j∈ J B0 j;d;s −A j;d;s ∀s∈S ð38Þ Table 6 shows the values used for the model parameters.
  The choices regarding some of these cost coefficients were
IDs ≥ ∑d∈D; j∈ J B j;d;s −E j−1;d;s ∀s∈S ð39Þ made based on expert opinions. At LHMC, an MRI machine
OV d;s ≥ E J ;d;s −60*T wk ∀s∈S; d∈D ð40Þ remaining idle is considered about twice as expensive as a
patient waiting for the same amount of time, which is reflected
A j;d;s ¼ G j þ F j;d;s ∀s∈S; d∈D; j∈ J ð41Þ in the relative values of cost coefficients Cwt and Cid (Table 6).
B j;d;s ≥A j;d;s þ T prep ∀s∈S; d∈D; j∈ J ð42Þ In cases where day shift overtime occurs, the technicians from
the day shift need to finish the current exams before handing it
B j;d;s ≥E j−1;d;s ∀s∈S; d∈D; j∈ J ð43Þ
over to the night shift staff. Thus, the overtime cost coefficient
E 0;d;s ¼ 0 ∀d∈D; s∈S ð44Þ (Covt) is determined based on the technicians’ wages. Due to
  the limited number of technicians in the night shift, the image
E j;d;s ¼ B j;d;s þ 1−y j;d;s *Proc j;d;s ∀s∈S; d∈D; j∈ J ð45Þ quality is significantly worse for inpatients in night shift than
y j;d;s ∈f0; 1g ∀s∈S; d∈D; j∈ J ð46Þ in day shift, which sometimes results in requiring additional
exams. Therefore, the cost coefficient for inpatient exam can-
TWOs ; TWI s ; IDs ≥ 0∀s∈S ð47Þ cellation (Ccc) is calculated based on this expected cost of
B j;d;s ; E j;d;s ≥ 0 ∀s∈S; d∈D; j∈ J ð48Þ additional exams. Twk is set at 18 h because we wish to opti-
mize for the day shift which is the time between 6am and
G j ≥ 0∀ j∈ J ð49Þ 12am. In practice, Tlate, can vary by technologist, but 15 min
OV d;s ≥ 0∀s∈S; d∈D ð50Þ was found to be a good approximation. This implies that if the
prior procedure runs late and extends into an IPB by more than
15 min, then the inpatient exam in that IPB is canceled. As
mentioned in the previous paragraph, Smin and Smax, reflecting
6 Computational experiments and results the minimum and maximum possible slot sizes, are set to 45
and 65 min respectively. Proc j;d;s ∀ j∈ J; d∈D; s∈S and F j;d;s ∀
Since the IPB placement and number of IPBs are different j∈ J; d∈D; s∈S are simulated via Monte-Carlo Simulations
across different days of the week, we jointly optimize the from the distributions fitted to the data. I j;d ∀ j∈ J; d∈D values
weeklong schedule. A total of 17 exams, including both inpa- are assigned according to the current IPB placement. In Model
tient and outpatient exams, are scheduled from 6am to 12am 2, IPB placements are optimized while keeping the number of
for each machine per day from Monday to Friday, resulting in IPBs for each day at the same level as in the current schedule.
a total of 85 exams per week per machine during the day shift. The numbers of IPBs are 5, 6, 5, 2, and 7 from Monday to
The current practice at LHMC requires the slot sizes for a Friday respectively, for MR2. The numbers of IPBs are 5, 5, 4,
472 Sun Y. et al.

Table 6 Parameter values used in the optimization models

Parameter Cwt Cid Covt Ccc Twk Tprep Tlate M Smin Smax N_scenario

Value 8.75 16 1.5 50 18 10 15 10,000 9 13 80

6, and 6 from Monday to Friday respectively, for MR4. The
number of IPBs is 6 for each weekday for MR3.
All results in Sect. 6 are based on these parameter values. In
Sect. 8, we test the robustness and sensitivity of our model
results to variations in some of these parameters. Optimization
Model 1 is solved using the “GLPK” optimizer Version 4.65
[14] while Model 2 is solved using a numerical method. A
dual-core Intel i5-X6300 CPU with 8GB RAM and Windows
10 as the operating system was used for all computational
experiments.
6.1 Model 1 results
As mentioned in Sect. 2, Sample Average Approximation
(SAA) is one of the most widely used methods for solving
stochastic programming problems. All of the computational
results in this section are obtained using the SAA method. The
number of scenarios (N_scenario) is set to 80, which was
found to provide a good balance between the competing goals
of ensuring stability of the numerical results and avoiding the
run-times becoming too large. The runtime for Model 1 using
GLPK was found to be 10 min on average. The results pre-
sented in Table 7 give optimal slot sizes with the current IPB
placement. As can be seen, the optimal slot size is 50 min for
MR2, 50 min for MR3, and 55 min for MR4, which means the
current slot sizes for MR3 (60 min) and MR4 (45 min) are far
from optimal, while the current slot size for MR2 (45 min) is
somewhat closer to optimal. The average waiting time for
each outpatient ranges from 33 to 38 min, a decrease of
18 min on average compared to the current practice. The last
two columns list the total costs of the current and the optimal
schedules, respectively, for each MR machine. By optimizing
slot size, we are able to reduce the total cost by 9%, 16%, and
16% for MR2, MR3, and MR4 respectively.
We also examine the changes in the optimal slot sizes if
allowed to vary with the day of the week. For this analysis,
MR4 was used as an example, and the results are presented in
Table 8. The optimal slot size is found to be somewhat var-
iable across the week, due to the differing IPB placements.
Monday, Tuesday, Thursday, and Friday still have an opti-
mal slot size of 55 min, while Wednesday has an optimal slot
size of 60 min. Compared to the total costs under the current
schedule, which are listed in the second-last column, we are
able to reduce the total weekly cost by 17% in the optimal
schedule (costs presented in the last column), a slight addi-
tional improvement relative to the 16% increase in Table 7. It
also shows that with fewer IPBs in a day, equivalent to hav-
ing fewer buffers between the outpatient exams, the optimal
slot size increases to compensate for the reduced buffers.
This result is directionally consistent with our intuition.
6.2 Model 2 results
When solving Model 2 using SAA on GLPK, we were faced
with very long runtimes. It takes the optimizer more than
10 h to solve the problem. Therefore, we implemented a
numerical approach by enumerating all the combinations of
IPB placement and slot sizes, and then computing the second
stage decision variables for each combination using the
GLPK optimization solver. The number of IPBs per week-
day in the current schedule ranges from 2 to 7. Therefore, the
largest number of IPB placement solutions is C(17, 7) =
19,448 (i.e., the number of combinations of seven items cho-
sen from a set of 17 items). For each combination of IPB
placement and slot size, the expected costs were evaluated by
averaging across all scenarios. For Model 2, the number of
evaluated scenarios was increased to 500 (from 80 for Model
1) to ensure robustness of the results. The runtime for this
numerical method was 245 min on average. As expected, the
runtime varied considerably with the number of IPBs, rang-
ing from 51 to 456 min.
The results presented in Table 9 show that the optimal slot
size when optimizing IPB placement and slot size simulta-
neously is smaller, by 5 min each, than when optimizing only

Table 7 Results from optimizing slot size with current IPB placement and requiring the same slot sizes across the week

Machine Slot Waiting time Idle time Canceled Overtime Total cost for current Total cost for optimal
size schedule schedule

(Min) (Min per patient) (Min per day) (Number per day) (Min per day) ($ per day) ($ per day)
MR2 50 36 132 1.48 0 6466 5879
MR3 50 33 127 1.80 0 6235 5240
MR4 55 38 128 2.06 0 7167 6003
Stochastic programming for outpatient scheduling with flexible inpatient exam accommodation 473

Table 8 Results from optimizing slot size with current IPB placement and allowing for different slot sizes across the week (for MR4)

Machine Day of Number of Slot IPB Waiting time Idle time Canceled Total cost for Total cost for
week IPBs size placement current schedule optimal schedule

(Min) (Min per patient) (Min per day) (Number per day) ($ per day) ($ per day)
MR4 Mon 5 55 7 8 14 16 36 128 2.04 7095 5848
17
Tue 5 55 5 6 7 8 17 40 130 1.91 7301 6210
Wed 4 60 5 6 16 17 33 164 1.25 8364 6327
Thu 6 55 5 6 7 8 16 37 133 2.27 6538 5706
17
Fri 6 55 5 6 7 8 16 37 133 2.27 6538 5706
17

for slot size, as presented in Table 7. Two important observa-
tions are that (1) the IPB placements are, for the most part,
evenly distributed across the 17 slots, and (2) the average
number of canceled exams is higher, in all cases, than in
Model 1’s optimal solutions. However, in practice, some
STAT inpatients may need to be treated within the 4 or 6 h
after the order is placed; so, hospital prefers to be able to treat
at least two inpatients each day. In the last column of Table 9,
the probabilities of fewer than 2 inpatients being treated are
presented. The probability is very high for MR2 on Thursday
with only 2 IPBs, while the probabilities for all days on MR4
are over 10%. To limit the number of inpatient exam cancel-
lations, another constraint is added requiring that the proba-
bility of fewer than 2 inpatient exams being performed should
be less than or equal to 5%. If the slot sizes are the same across
the week, with this new constraint the optimal slot size will be
45 min for MR2, 45 min for MR3 and 55 min for MR4, as
shown in Table 10. Since there are only two IPBs on Thursday
for MR2, there is no feasible solution for any slot size when
restricting the probability of performing at least two inpatient
exams to be at most 5%. Thus, the optimal slot size for MR2
was determined by minimizing the total cost for all the other
days of the week.
Optimization models have potential limitations. The
models simplify patient activities, patient movements from
one room to another, the interactions among medical staff,
and the use of hospital facilities. In order to provide practical
evaluation of the impact of the optimization outputs, we used
FlexSim Healthcare [29] to develop a simulation model of the
MRI room workflow in the Department of Radiology to

Table 9 Results for optimal slot size and IPB placement requiring the same slot size for each day of the week

Machine Day of Number of Slot IPB Waiting Canceled Prob (<2 inpatients Total cost for current Total cost for optimal
week IPBs size placement time treated) schedule schedule
(Min) (Min per (Number ($ per day) ($ per day)
Patient) per day)

MR2 Mon 5 45 3 6 9 12 16 32 2.51 0.16 6488 5125

Tue 6 45 3 6 9 12 14 31 2.78 0.07 5534 4765
17
Wed 5 45 3 6 9 12 16 32 2.51 0.16 6488 5125
Thu 2 45 6 11 44 1.3 0.87 8182 6961
Fri 7 45 3 5 7 9 12 28 2.96 0.01 5637 4472
14 16
MR3 Mon–Fri 6 45 4 6 8 11 13 30 2.61 0.04 6235 4582
15
MR4 Mon 5 50 4 8 11 13 33 2.79 0.22 7095 5246
16
Tue 5 50 4 8 11 13 33 2.79 0.22 7301 5246
16
Wed 4 50 4 6 9 14 36 2.22 0.41 8364 5753
Thu 6 50 3 5 8 10 13 30 3.02 0.12 6538 4896
15
Fri 6 50 3 5 8 10 13 30 3.02 0.12 6538 4896
15
474 Sun Y. et al.

Table 10 Results for optimal slot size and IPB placement with the probability of fewer than two inpatients treated being at most 5% and requiring the
same slot size for each day of the week

Machine Day of Number of Slot IPB Waiting Canceled Prob (<2 inpatients Total cost for current Total cost for optimal
week IPBs size placement time treated) schedule schedule
(Min) (Min per (Number ($ per day) ($ per day)
patient) per day)

MR2 Mon 5 45 4 7 8 11 12 35 2.06 0.05 6488 5387

Tue 6 45 3 4 7 10 13 31 2.71 0.04 5534 4807
16
Wed 5 45 4 7 8 11 12 35 2.06 0.05 6488 5387
Thu 2 NA NA NA NA NA 8182 NA
Fri 7 45 3 5 7 9 12 28 2.96 0.01 5637 4472
14 16
MR3 Mon–Fri 6 45 4 6 8 11 13 30 2.61 0.04 6235 4582
15
MR4 Mon 5 55 1 4 7 11 14 30 1.87 0.05 7095 5468
Tue 5 55 1 4 7 11 14 30 1.87 0.05 7301 5468
Wed 4 55 1 2 4 10 39 1.23 0.04 8364 6441
Thu 6 55 2 5 8 12 14 27 2.43 0.02 6538 5069
17
Fri 6 55 2 5 8 12 14 27 2.43 0.02 6538 5069
17

model the activities of patients from their arrival in the depart-
ment to their discharge from the system after finishing the
exam. This model aims to evaluate the waiting time, idle time,
overtime and cancellations in the MRI rooms under different
slot sizes and IPB placements. FlexSim Healthcare simulation
tool enables us to set detailed patient activities, incorporate the
floor plan of the hospital environment, coordinate technicians
in the exam room, simulate the use of changing rooms and
other facilities. The software also allows for customized code,
which enabled us to model the rule-based inpatient exam
cancellation.
First, we tested the simulation model with the current slot
size, current IPB placement, and current patient arrival pattern
to validate model parameters. Comparing the simulation re-
sults to the actual data showed that the model captures the
main features of the actual workflow and is an accurate repre-
sentation of it. In particular, the average outpatient waiting
time was found to be 57 min, which is close to the actual
waiting time of 54 min in practice. Additionally, as shown
in Fig. 6, the increasing trend in patient waiting times during
the day is consistent with the trend shown in Fig. 5 in Sect. 4.
Figure 6 shows that the waiting times in simulation and reality
track each other closely throughout the day, thus validating
the accuracy of the simulation model.
Next, the results from the various optimization runs with
the same slot size across the week are evaluated using this
simulation model and compared to the current timetable. As
shown in Table 11, the total cost for all three machines in a
week decreases by 11.6% if we use the output of the model
that optimizes slot sizes alone, and it further decreases by an

Fig. 6 Change in average

Outpaent Waing Time in Simulaon and Real Data
outpatient waiting time across the
120
day in the simulation (red) and
real data (grey) 100
Waing me (min)

80

60

40

20

0
6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22
Time of the day (hour)

Real Data Simulaon

Stochastic programming for outpatient scheduling with flexible inpatient exam accommodation 475

Table 11 Simulation results with current timetable and the timetables obtained from model 1 and model 2 with the same slot sizes across the week

Timetable Machine Waiting time Idle time Total cost for all machines Change of total cost

Simulation Optimization Simulation Optimization Simulation Optimization Simulation Optimization

Current timetable MR2 68 48 102 82 124,760 99,340 NA NA

MR3 34 24 255 244
MR4 67 58 85 55
Model 1 optimal MR2 48 36 153 132 110,259 85,610 12% 14%
MR3 43 33 170 127
MR4 45 38 170 128
Model 2 optimal MR2 43 35 136 99 96,312 78,660 23% 21%
MR3 31 30 153 97
MR4 35 31 187 140

additional 12.6% if we use the output of the model that opti-
mizes both slot sizes and IPB placement simultaneously. The
simulation results are also compared with the results obtained
directly by running the optimization models in Table 11, for
the current timetable as well as for the Model 1 and Model 2
solutions. Specifically, the results for the Current Timetable
from the Optimization model are calculated using the numer-
ical approach in which we set the slot time and IPB placement
to be the same as the current timetable. The waiting time,
machine idle time, and total costs are smaller in the optimiza-
tion results than in simulation results for all the cases. This
phenomenon can be explained by the fact that the simulation
model allows a more detailed depiction of the use of changing
room, patient movement from one room to the other and the
coordination among medical staff. Nevertheless, the change of
total cost is very consistent between simulation results and
optimization results, which shows the robustness of the sched-
ule derived from optimization model.
7 Sequencing rules analysis
In Sect. 6, we obtained the optimal IPB placement using sto-
chastic programming methods. However, when optimization
tools are not available, rule-based sequencing methods are
widely used due to their simplicity. In this section, we com-
pare the performances of different sequencing rules (e.g.,
IPBEG) to each other and to the optimal sequencing provided
by the stochastic programming approach, under fixed slot
sizes. The goal is to identify the most adequate sequencing
rules that can be used for deciding IPB placement to replace
stochastic programming with minimal loss of optimality.
We first examine several sequencing rules and compare
them to the optimal sequences with the lowest total cost, on
MR4 with a 55-min slot size. These results reported in
Table 12 are computed without imposing the additional con-
straints restricting the minimum number of treated inpatients
and hence are slightly different from those reported in
Table 10. We chose three commonly used sequencing rules
as benchmarks: (1) IPBEG (inpatient exams first, then outpa-
tient exams), (2) OPBEG (outpatient exams first, then inpa-
tient exams), and (3) a variant of the sequencing rule called
ALTER. ALTER was defined in Bhattacharjee and Ray [5] as
“… scheduling inpatient exams and outpatient exams alterna-
tively. If the number of a particular class of scheduled patients
exceeds the other one, the excess of that class is scheduled at
the end …”. In our problem setting, since more outpatient
exams are scheduled than inpatient exams during the day,
we use a simpler variant of the ALTER rule by placing inpa-
tient exams evenly across the day.
As shown in Table 12, even with the same slot size, differ-
ent sequencing rules will give very different total costs and
waiting times. The IPBEG and OPBEG sequencing rules have
significantly worse performances compared to the “Optimal”
sequences (defined as the sequences obtained from running
the Optimization Model 2) and also compared to the ALTER
variant, in terms of total costs and waiting times. However,
more inpatients are treated with IPBEG and OPBEG rules.
The ALTER variant gives a near-optimal solution in terms
of the total expected cost minimization. The sequences gener-
ated by the “Optimal” solution also resemble the ones gener-
ated by the ALTER variant, in that they distribute the IPBs
evenly across the day. To conclude, if optimization tools are
not available, then using ALTER variant sequencing rule, in
general, gives a better performance than IPBEG and OPBEG.
8 Sensitivity analysis
In order to generalize our conclusions to decision makers with
different priorities, in this section we perform sensitivity anal-
ysis of weights for outpatient waiting time, machine idle time,
and exam cancellations.
In Table 13, we demonstrate the impacts of applying dif-
ferent combinations of weights for waiting time, machine idle
time and inpatient exam cancellations using Model 2. Because
476 Sun Y. et al.

Table 12 Results for different sequencing rules, and the “Optimal” sequences (defined as the sequences obtained from optimization model 2) on MR4
with 55-min time slot and different number of IPBs

Sequencing rule Number of IPBs IPB placement Waiting time Idle time Canceled Overtime Total cost
(Min per patient) (Min per day) (Number per day) (Min per day) ($ per day)

IPBEG 4 1234 52 120 0.87 1.69 7833

5 12345 48 120 1.06 0.71 7054
6 123456 45 139 1.30 1.06 6937
OPBEG 4 14 15 16 17 48 101 1.50 0 7141
5 13 14 15 16 17 50 105 1.78 0 7060
6 12 13 14 15 16 17 48 123 1.90 0 6681
ALTER variant 4 1 5 9 13 34 128 1.67 0.55 6036
5 1 4 7 10 13 30 150 2.09 0 5669
6 1 4 7 10 13 16 29 142 2.35 0 5165
Optimal sequence 4 5 8 12 15 30 137 1.78 0.01 5718
5 4 7 10 12 15 29 142 2.08 0.1 5423
6 2 5 8 12 14 17 27 146 2.43 0.02 5069

overtime durations, which in our results are usually 0 min (or
small positive values) despite the small weights assigned to
them, are not big contributors to the objective function, we fix
the weight of overtime to 0. We consider various ratios of the
weights of waiting time and idle time, namely 1:1, 1:2, 1:3,
2:1, and 3:1, as well as various ratios of the weight of the
number of exam cancellations to the sum of the weights of
the other two, from 2:3 to 9:1. We present the optimal slot
sizes and IPB placements, as well as the average waiting
times, idle times and the number of cancellations in
Table 13. In these optimal results, the IPB blocks are still
found to be evenly distributed across the day for all the com-
binations of weights, similar to the ALTER variant sequenc-
ing rule discussed in Sect. 7. However, the IPB placements
differed with different ratios of weights for waiting time and
cancellations. If we fix the ratio of weights for waiting time
and idle time to 1:1 and progressively reduce the weights of
exam cancellation (e.g., rows 1, 5, 11, and 14 of Table 13), the
IPB placement shifts to later in the day. All of these IPB
placements can be interpreted as variants of the ALTER se-
quencing rule. If exam cancellations are more costly, then we
should apply the ALTER variant sequencing rule in which the

Table 13 Optimization results from sensitivity analysis to objective function weights of patient waiting time, machine idle time and cancellations for
MR4 with 6 IPBs across the day

Row Ratio of weights for waiting time: idle time: exam Slot IPB Waiting time Idle time Canceled
number cancellation size placement
(Min) (Min per (Min per (Number per
patient) day) day)

1 5%:5%:90% 55 2 4 7 9 11 15 27 154 2.17

2 5%:10%:85% 45 2 5 8 10 12 15 35 82 3.53
3 5%:15%:80% 45 3 6 9 11 13 15 35 77 3.49
4 10%:5%:85% 60 2 5 7 10 12 15 23 203 1.92
5 10%:10%:80% 55 3 5 7 10 12 15 26 161 2.43
6 10%:20%:70% 45 3 6 9 10 12 15 36 72 3.49
7 10%:30%:60% 45 3 5 7 10 14 16 36 69 3.67
8 15%:5%:80% 65 1 4 7 9 14 16 21 263 1.41
9 15%:30%:55% 45 2 5 8 11 13 16 36 72 3.66
10 20%:10%:70% 65 1 3 5 8 12 16 21 259 1.44
11 20%:20%:60% 50 3 5 8 11 14 16 30 110 3.04
12 30%:10%:60% 65 1 4 6 8 11 15 21 261 1.46
13 30%:15%:55% 65 1 3 6 8 12 15 21 257 1.33
14 30%:30%:40% 50 4 7 9 11 13 16 30 119 2.97
Stochastic programming for outpatient scheduling with flexible inpatient exam accommodation
first IPB starts early, so the probability of them being canceled
will be lowered under the same slot size. On the other hand, if
the patient waiting time is more costly, we should use the
ALTER variant sequencing rule in which the first IPB starts
later, so that the function of IPBs as a buffer for outpatient
exams can be better utilized.
We further analyze the impact of the change in the ratio
between the weights of patient waiting time and machine idle
time. When the ratio of the weights of waiting time and idle
time is 1:2 or 1:3, the optimal slot sizes are always 45 min
(rows 2, 3, 6, 7, and 9 of Table 13), which is the lowest
possible value in our choice set. The waiting time is on aver-
age 35 min for a ratio of 5%:15% (row 3 of Table 13) com-
pared to 21 min for a ratio of 15%:5% (row 8 of Table 13).
This is compensated by an impact on idle times that is
directionally exactly the opposite (77 min vs. 263 min). It
shows how the different weights change our optimal solution
by sacrificing patient waiting time to lower the machine idle
time and vice versa.
Finally, we analyze how the weight of the number of exam
cancellations affects our optimal slot sizes. When the ratio of
the weights of waiting time and idle time is 1:1 (rows 1, 5, 11,
and 14 of Table 13), the slot size increases with the weight of
the number of exam cancellations from 50 min for the ratio of
30%:30%:40% in row 14 of Table 13 to 55 min for the ratio of
5%:5%:90% in row 1 of Table 13. Accordingly, a comparison
of row 14 and row 1 of Table 13 shows that the average idle
time increases, while the average waiting time and the average
number of cancellations decrease with the weight of exam
cancellation. That happens because the larger slot size de-
creases the probability of the exam getting delayed, leading
to a decrease in both the number of cancellations and patient
waiting time while increasing the machine idle time. Note,
however, that these patterns are not completely monotonic
across rows 1, 5, 11 and 14, due to the discrete nature of the
allowable slot sizes.
Due to the inherently multi-objective nature of the
problem, different medical centers may have different
priorities when it comes to the optimal tradeoff between
patient waiting time and machine idle time. Therefore,
we provide the Pareto frontier using NSGA-II (Fast
Non-dominated Sorting Genetic Algorithm) method de-
veloped by Deb et al. [8], which is known to be compu-
tationally efficient. We implement their algorithm (Sect.
3 in Deb et al. [8]) in Python with a runtime of 11.6 h.
We only examine the solutions in which the probability
of fewer than 2 inpatients being treated is less than or
equal to 5%. The patient waiting time and machine idle
time for each solution were compared with all the other
solutions. Since the worker overtime is positively associ-
ated with machine idle time, we only focus on two major
objectives: patient waiting time and machine idle time.
477
Interestingly, as shown in Fig. 7, the solutions with the same
slot size tend to cluster together. The idle time increases with slot
size while patient waiting time shows the opposite trend, as ex-
pected. When the slot size is small, the IPB placement has greater
impact on patient waiting time. The waiting time ranges from
40 min to more than 80 min by changing the IPB placement when
the slot size is 45 min. However, the idle time doesn’t change as
much when the slot size is small. By drawing and analyzing this
frontier, medical centers can choose scheduling solutions based
on their own priorities regarding the tradeoff between multiple
objectives, such as patient waiting time and machine idle time.
9 Extended model: Emergency patient arrivals
Even though the number of emergency patient exams is small
as a fraction of the total number of exams conducted at
LHMC, emergency patients have a disruptive effect on non-
emergency patient workflow due to the unpredictability and
urgency associated with emergency patient exams. Therefore,
we extended our models to additionally incorporate emergen-
cy patient arrivals. Specifically, we assumed that the emergen-
cy patients will have a non-preemptive priority, that is, as soon
as an emergency patient comes in, that patient will be assigned
to a machine and will get an MRI exam right after the current
exam is finished. If multiple emergency patients arrive during
an exam, their exams are performed on a first-come-first-
served basis.
The revised and added parameters, variables and con-
straints required for the extended model are as presented next.
Except for the idle time constraints – Constraints (51), all the
other constraints presented below are newly added constraints
for the extended model. These parameters, variables, and con-
straints can be integrated directly into both Optimization
Model 1 and Model 2 by adding these constraints and revising
the idle time constraints. Note that all new variables and con-
straints being added are second-stage variables and
constraints.
Sets
K ¼ f1; …; K g: Set of emergency patients in a day, in
increasing order of arrival times
Parameters
B0, d, s: Exam begin time for an imaginary patient 0 on
day d∈D in scenario s∈S
ProcEk, d, s: Procedure duration of emergency patient k∈k
on day d∈D in scenario s∈S
ETk, d, s: The arrival time of emergency patient k∈k on
day d∈D in scenario s∈S
478
Slot size: 65 min
Slot size: 60 min
Slot size: 55 min
Fig. 7 Pareto frontier for patient waiting time and machine idle time
Second-stage decision variables
mj, k, d, s: 1 if the exam of emergency patient k∈K is
performed after the non-emergency patient in slot
j ∈ {1, …, J}, but before the next (if any) non-
emergency patient on day d∈D in scenario s∈S, 0 other-
wise. m0, k, d, s equals 1 if the exam of emergency patient
k∈K is performed before the first non-emergency patient,
0 otherwise.
BEk, d, s: Exam start time of emergency patient k∈K on
day d∈D in scenario s∈S
EEk, d, s: Exam end time of emergency patient k∈K on
day d∈D in scenario s∈S
Second-Stage Constraints:
 
IDs ≥∑d∈D; j∈ J B j;d;s −E j−1;d;s −∑k∈K m j−1;k;d;s *ProcEk;d;s ∀s∈S
 
B j;d;s ≥EEk;d;s −M * 1−m j−1;k;d;s ∀s∈S; d∈D; j∈ J; k∈K ð52Þ
∑ j∈f0;…; J g m j;k;d;s ¼ 1∀s∈S; d∈D; k∈K
j−1
B j;d;s −ET k;d;s ≤M * ∑ m j0 ;k;d;s ∀s∈S; d∈D; j∈ J; k∈K
0 0
j ¼0
 
BEk;d;s ≥ E j;d;s −M * 1−m j;k;d;s ∀s∈S; d∈D; j∈f0; …; J g; k∈K
BEk;d;s ≥ ET k;d;s þ T prep ∀s∈S; d∈D; k∈K
BEk;d;s ≥ EEk−1;d;s ∀s∈S; d∈D; k∈Knf1g
EEk;d;s ¼ BE k;d;s þ ProcEk;d;s ∀s∈S; d∈D; k∈K
m j;k;d;s ∈f0; 1g ∀s∈S; d∈D; j∈f0; …; J g; k∈K
Sun Y. et al.
Slot size: 45 min
Slot size: 50 min
BEk;d;s ; EEk;d;s ≥ 0 ∀s∈S; d∈D; k∈K ð60Þ
Constraints (51), which replace the idle time definition
constraints in Model 1 (Constraints (8)) and in Model 2
(Constraints (39)), ensure that the machine idle time between
two consecutive non-emergency patient exams excludes the
procedure duration of emergency patients. Constraints (52)
make sure that the non-emergency patient exam does not start
before the end time of the emergency patient exam performed
before it. Constraints (53)–(54) define the binary variable mj, k,
d, s to be 1 if the exam for emergency patient k∈K is performed
after non-emergency patient in slot j∈ J and before the non-
emergency patient (if any) in slot j + 1, 0 otherwise. In partic-
ular, Constraints (53) ensure that every emergency patient
undergoes exactly one exam. Constraints (54) ensure that mj,
k, d, s equals 1 when the emergency patient arrival time is
between the actual start times of two consecutive non-
ð51Þ
emergency exams. To be more specific, when Bj, d, s − ETk,
d, s > 0, which means the emergency patient k arrives before
the exam start time of non-emergency patient in slot j, the left-
ð53Þ
hand side of Constraints (54) will be positive. It will enforce
j−1
ð54Þ ∑ m j0 ;k;d;s to be 1 which guarantees that the exam for emer-
j ¼0
gency patient k is performed before non-emergency patient in
slot j. Constraints (53)–(54) combined with the objective func-
ð55Þ tion of the model further ensure that mj − 1, k, d, s = 1 for the
ð56Þ smallest j value such that Bj, d, s − ETk, d, s can be positive.
When the actual exam start time can be earlier than the emer-
ð57Þ
gency patient arrival time, the objective function, which min-
ð58Þ imizes the non-emergency patient waiting time, machine idle
ð59Þ time and the number of inpatient cancellations, also prevents
the situation where the non-emergency patient’s exam start
Stochastic programming for outpatient scheduling with flexible inpatient exam accommodation 479

Fig. 8 Average number of

emergency patient arrivals for
each hour across the day

time is postponed waiting for an emergency patient.
Therefore, Constraints (53)–(54) guarantee that the emergen-
cy patient exam is performed immediately after the current
exam.
Constraints (55)–(58) define the exam start time and end
time for emergency patients. In particular, Constraints (55)
ensure that the exam start time is after the exam end time of
the previous non-emergency patient. Constraints (56) make
sure that the patient gets prepared before the exam starts.
Constraints (57) guarantee that the start time of an emergency
patient is not before the end time of the exam of the previous
emergency patient. Constraints (58) define the exam end time
to be the sum of the exam start time and the procedure dura-
tion of an emergency patient. Constraints (59) ensure that mj, k,
d, s variables are binary. Constraints (60) are the non-
negativity constraints.
To tackle the variability in emergency patient volumes
across different scenarios, we set K to be the largest number
of emergency patients across all scenarios and all days of the
week. For the scenarios where the number of emergency pa-
tients is less than K, we assign a large positive value (but
smaller than M) to the arrival times of all remaining
(imaginary) patients so that these imaginary emergency pa-
tients will have no impact on the operations of non-
emergency patients.
By adding these constraints to Model 1 and Model 2 in the
Sect. 5, we are able to optimize the slot size and IPB place-
ment considering the impact of emergency patient arrivals.
In our case study, most of the emergency patients are
assigned to have their exams performed on MR3 due to its
larger room size and higher image quality. Therefore, we ap-
ply the extended models to MR3 machine. The arrival times
and procedure durations of the emergency patients are gener-
ated using the arrival time distribution and procedure duration
distribution extracted from the real-world data.
Figure 8 demonstrates the emergency patient arrival pattern
across the day. The majority of emergency patients comes in
the afternoon, especially after 4pm. In order to generate the
emergency patient arrival times for the optimization model,
we first generate the numbers of emergency patients arriving
at each hour of the day using Poisson distribution. Then, the
exact arrival time in that hour is randomly generated using
Uniform distribution.
The results for the extended versions of both optimization
models, Model 1 and Model 2, are presented in Table 14. We
found that the solutions for both models are very similar com-
pared to the original solutions presented in Tables 7 and 10 in
Sect. 6. The only differences occur in Model 2 solutions where
the slot size changes from 45 to 50 min and IPB placement
changes slightly from 4, 6, 8, 11, 13, 16 to 4, 6, 8, 11, 13, 15.
Under the same timetable, the waiting time is usually 29%
higher while the idle time is 25% lower when explicitly

Table 14 Results for the current timetable, model 1, and model 2, with and without accounting for emergency patient arrivals for MR3 with same
schedule across the week

Approach Timetable Slot size IPB Waiting time Idle time Total cost

With emergency patients Current timetable 60 8 9 14 15 16 17 31 199 6244

Model 1 timetable 50 8 9 14 15 16 17 41 100 5691
Model 2 timetable 50 4 6 8 11 13 16 33 116 5163
Without emergency patients Current timetable 60 8 9 14 15 16 17 24 243 6235
Model 1 timetable 50 8 9 14 15 16 17 33 127 5240
Model 2 timetable 45 4 6 8 11 13 15 30 97 4582
480
accounting for emergency patients compared to the original
results. Even though the waiting times and idle times deviate
from the original results, the minor changes in optimal sched-
ules themselves show the robustness of the original results to
the impacts of different ways of modeling the emergency pa-
tient arrivals.
10 Conclusion
This paper addresses the multi-class patient appointment
scheduling problem where the exams of one class of patients
are more likely to get cancelled/rescheduled than another. It
provides useful tools and several insights into multi-class pa-
tient scheduling and contributes to the healthcare scheduling
literature by effectively addressing, for the first time, a com-
monly used inpatient accommodation strategy at mid-sized
hospitals.
First, stochastic programming models are formulated for
patient scheduling under flexible inpatient exam accommoda-
tion. Inpatient exam accommodation and cancellation are
common among mid-sized hospitals where inpatient and out-
patient exams are scheduled in the same department. Multi-
class patient scheduling problems are not well investigated
using stochastic programming in the previous literature. In this
paper, we provided optimization models to incorporate flexi-
ble inpatient accommodations. We also extended the model to
explicitly account for the emergency patients. The simulation
results show that, by optimizing slot sizes, we are able to
reduce the total cost per week by around 11.6%. If optimizing
slot size and IPB placement simultaneously, we can further
reduce the total cost per week by an additional 12.6%. The
MR modality manager in our case study decided to change the
slot size from 45 to 60 min for MR4 in practice, as recom-
mended by us based on some of our results in Table 8.
Depending on the outcome of this initial change, additional
changes recommended based on the research presented in this
paper are likely to be implemented in near future. Multi-
objective methods have also been deployed to provide a
Pareto frontier of patient waiting time and machine idle time,
enabling the methods to be generalized to other medical cen-
ters where these tradeoff priorities may be somewhat different.
Second, ALTER variant sequencing rule was found to pro-
vide the best performance when the optimization tools are not
available. Due to the lack of optimization resources, many
hospitals deploy commonly used sequencing rules like
IPBEG, OPBEG, and ALTER for patient scheduling. When
considering the inpatient accommodation, solutions from op-
timization methods were found to employ similar IPB place-
ment as an ALTER variant sequencing rule, which evenly
distributes the IPBs across the day. Moreover, the perfor-
mances of IPBEG, OPBEG, and the ALTER variant were
evaluated supporting the superiority of ALTER variant
Sun Y. et al.
sequencing rule in terms of total cost and average patient
waiting times as well.
Third, we found that even though the emergency patients
do exert a disruptive impact on the normal routine of a radi-
ology department, they had little impact on the schedule opti-
mization model’s solution. The results showed that under the
same timetable, both waiting time and machine idle time de-
viate more than 25% due to the disruptions caused by the
emergency patients. However, the scheduling strategies them-
selves changed little when explicitly accounting for the emer-
gency patient visits. It shows the robustness of the proposed
solutions and methods, especially since the emergency pa-
tients constitute a relatively small fraction of the total number
of performed exams.
There are also some important limitations of the optimiza-
tion analysis in this paper, though many of these are partly
overcome via the simulation analysis. In particular, the opti-
mization model only solves a relaxed version of the actual
problem by simplifying patient activities, patient movements
from one room to another, the interactions among medical
staff, and the use of hospital facilities. It simplifies the coor-
dination among different machines and technologists. Patients
of different emergency levels are also not taken into account
explicitly. Future research studies may be able to expand on
our research by addressing some of these limitations by more
sophisticated stochastic programming models, robust optimi-
zation models, or simulation-based optimization methods.
References
1. Ahmadi-Javid A, Jalali Z, Klassen KJ (2017) Outpatient appoint-
ment systems in healthcare: a review of optimization studies. Eur J
Oper Res 258(1):3–34. https://doi.org/10.1016/j.ejor.2016.06.064
2. Begen MA, Queyranne M (2011) Appointment scheduling with
discrete random durations. Math Oper Res 36(2):240–257. https://
doi.org/10.1287/moor.1110.0489
3. Begen MA, Levi R, Queyranne M (2012) Technical note – a
sampling-based approach to appointment scheduling. Operations
Research 60(3):675–681 Retrieved from JSTOR
4. Berg B, Denton B, Erdogan S, Rohleder T, Huschka T (2014)
Optimal booking and scheduling in outpatient procedure centers.
Retrieved from https://www.sciencedirect.com/science/article/pii/
S0305054814000987. Accessed 29 Oct 2020.
5. Bhattacharjee P, Ray PK (2016) Simulation modelling and analysis
of appointment system performance for multiple classes of patients
in a hospital: a case study. Operations Research for Health Care 8:
71–84. https://doi.org/10.1016/j.orhc.2015.07.005
6. Burnham KP, Anderson DR (2002) Model selection and
multimodel inference: a practical information-theoretic approach,
2nd edn. Springer-Verlag, New York
7. Cayirli T, Veral E, Rosen H (2008) Assessment of patient classifi-
cation in appointment system design. Prod Oper Manag 17(3):338–
353. https://doi.org/10.3401/poms.1080.0031
8. Deb K, Pratap A, Agarwal S, Meyarivan T (2002) A fast and elitist
multiobjective genetic algorithm: NSGA-II. IEEE Trans Evol
Comput 6(2):182–197
Stochastic programming for outpatient scheduling with flexible inpatient exam accommodation
9. Denton B, Gupta D (2003) A sequential bounding approach for
optimal appointment scheduling. IIE Trans 35(11):1003–1016.
https://doi.org/10.1080/07408170304395
10. Epic (n.d.). https://www.epic.com/
11. Forest, W (2018) MRI scan volume drops in 2017, but new pur-
chases planned. https://www.auntminnie.com/index.aspx?sec=
ser&sub=def&pag=dis&ItemID=119720
12. Fu MC (2002) Feature article: optimization for simulation: theory
vs. practice. INFORMS J Comput 14(3):192–215. https://doi.org/
10.1287/ijoc.14.3.192.113
13. Ge D, Wan G, Wang Z, Zhang J (2013) A note on appointment
scheduling with piecewise linear cost functions. Math Oper Res
39(4):1244–1251. https://doi.org/10.1287/moor.2013.0631
14. GLPK version 4.65. (2018). Retrieved from https://www.gnu.org/
software/glpk/
15. Ho C-J, Lau H-S (1992) Minimizing total cost in scheduling out-
patient appointments. Manag Sci 38(12):1750–1764. https://doi.
org/10.1287/mnsc.38.12.1750
16. Ho C-J, Lau H-S (1999) Evaluating the impact of operating condi-
tions on the performance of appointment scheduling rules in service
systems. Eur J Oper Res 112(3):542–553. https://doi.org/10.1016/
S0377-2217(97)00393-7
17. Jansson B (1966) Choosing a good appointment system – a study of
queues of the type (D, M, 1). Oper Res 14:292–312. https://doi.org/
10.1287/opre.14.2.292
18. Katre AN (2014) Assessment of the correlation between appoint-
ment scheduling and patient satisfaction in a pediatric dental setup.
Int J Dent 2014:1–7. https://doi.org/10.1155/2014/453237
19. Kim, S, Pasupathy, R, and Henderson, SG (2015) A guide to sam-
ple average approximation. In: Fu MC (ed) Handbook of simulation
optimization. https://doi.org/10.1007/978-1-4939-1384-8_8, (pp.
207–243)
20. Klassen KJ, Rohleder TR (1996) Scheduling outpatient appoint-
ments in a dynamic environment. J Oper Manag 14(2):83–101.
https://doi.org/10.1016/0272-6963(95)00044-5
21. Klassen KJ, Rohleder TR (2004) Outpatient appointment schedul-
ing with urgent clients in a dynamic, multi-period environment. Int
J Serv Ind Manag 15(2):167–186. https://doi.org/10.1108/
09564230410532493
22. Klassen KJ, Yoogalingam R (2009) Improving performance in out-
patient appointment services with a simulation optimization
481
approach. Prod Oper Manag 18(4):447–458. https://doi.org/10.
1111/j.1937-5956.2009.01021.x
23. Klassen KJ, Yoogalingam R (2014) Strategies for appointment pol-
icy design with patient unpunctuality. Decis Sci 45:881–911.
https://doi.org/10.1111/deci.12091
24. Klassen KJ, Yoogalingam R (2019) Appointment scheduling in
multi-stage outpatient clinics. Health Care Manag Sci 22:229–
244. https://doi.org/10.1007/s10729-018-9434-x
25. Lal TM, Roh T and Huschka T (2015) Simulation based optimiza-
tion: applications in healthcare. 2015 winter simulation conference
(WSC), pp. 1261–1271
26. Mancilla C, Storer R (2012) A sample average approximation ap-
proach to stochastic appointment sequencing and scheduling. IIE
Trans 44(8):655–670. https://doi.org/10.1080/0740817X.2011.
635174
27. Mercer A (1960) A queueing problem in which the arrival times of
the customers are scheduled. J R Stat Soc Series B (Methodol)
22(1):108–113 Retrieved from JSTOR
28. Michael M, Schaffer SD, Egan PL, Little BB, Pritchard PS (2013)
Improving wait times and patient satisfaction in primary care. J
Healthc Qual 35(2):50–60. https://doi.org/10.1111/jhq.12004
29. Nordgren WB (2003) Flexsim simulation environment, published
in the proceedings of winter simulation conference. IEEE, Phoenix
30. Patrick J, Puterman ML (2007) Improving resource utilization for
diagnostic services through flexible inpatient scheduling: a method
for improving resource utilization. J Oper Res Soc 58(2):235–245.
https://doi.org/10.1057/palgrave.jors.2602242
31. Sabrai F, Daganzo CF (1989) Approximate expressions for queue-
ing systems with scheduled arrivals and established service order.
Transp Sci 23(3):159–165 Retrieved from JSTOR
32. Sun, J, Lin, Q, Zhao, P, Zhang, Q, Xu, K, Chen, H, Hu, CJ, Stuntz,
M, Li, Hong, and Liu, Y (2017) Reducing waiting time and raising
outpatient satisfaction in a Chinese public tertiary general hospital-
an interrupted time series study. BMC Publ Health 17. https://doi.
org/10.1186/s12889-017-4667-z
33. Wang PP (1997) Optimally scheduling N customer arrival times for
a single-server system. Comput Oper Res 24(8):703–716. https://
doi.org/10.1016/S0305-0548(96)00093-7
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