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Procedia Computer Science 200 (2022) 1674–1684

International Conference on Industry 4.0 and Smart Manufacturing

3rdInternational
InternationalConference
ConferenceononIndustry
Industry4.0
4.0and
andSmart
SmartManufacturing
Manufacturing
Process optimization in the hospital environment: a systematic
Process optimization
review of theinliterature
the hospital
andenvironment: a systematic
results’ analysis
review of the literature and results’ analysis
Eleonora Bottania, Barbara Bigliardib, Beatrice Franchic
Eleonora Bottania, Barbara Bigliardib, Beatrice Franchic
a
Department of Engineering and Architecture, University of Parma, Viale delle Scienze 181/A, 43124 Parma, Italy
abDepartment of
Department of Engineering
Engineering and
and Architecture,
Architecture, University
University of
of Parma,
Parma, Viale
Viale delle
delle Scienze
Scienze 181/A,
181/A, 43124
43124 Parma, Italy
Parma, Italy
bcDepartment of Engineering and Architecture, University of Parma, Viale delle Scienze 181/A, 43124 Parma, Italy
Department of Engineering and Architecture, University of Parma, Viale delle Scienze 181/A, 43124 Parma, Italy
c
Department of Engineering and Architecture, University of Parma, Viale delle Scienze 181/A, 43124 Parma, Italy

Abstract
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Keywords: helthcare management; operating room; process optimization; review.
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Keywords: helthcare management; operating room; process optimization; review.

1. Introduction
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1877-0509 © 2022 The Authors. Published by ELSEVIER B.V.
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Peer-review under responsibility of the scientific committee of the 3rd International Conference on Industry 4.0 and Smart Manufacturing

1877-0509 © 2022 The Authors. Published by Elsevier B.V.

This is an open access article under the CC BY-NC-ND license (https://creativecommons.org/licenses/by-nc-nd/4.0)
Peer-review under responsibility of the scientific committee of the 3rd International Conference on Industry 4.0 and Smart Manufacturing
10.1016/j.procs.2022.01.368
 Eleonora Bottani et al. / Procedia Computer Science 200 (2022) 1674–1684 1675
2 Author name / Procedia Computer Science 00 (2019) 000–000

a public-private interface that raises employment and growth [2]. In line with this, in the last few decades many
healthcare organizations (i.e. hospitals) have been requested to increase their efficiency and to do more with less
resources; however, the key point is that this increased efficiency is not to be achieved at the expenses of the quality
and quantity of services delivered to patients [3]. This is why some principles and tools, typically used in the private
(industrial) field, started being applied also to the healthcare sector, and their usage became even more important with
the advent of COVID-19 pandemics, that exacerbated the need for doing more with the available resources [4].
Examples of approaches and tools originating in the industrial field and exported to the healthcare one include lean
thinking [5], agile management [4], deep learning [6], business process reengineering [7], and simulation [8]. Almost
all these approaches and tools proved to be effective in improving the performance level of healthcare organizations.
In many hospitals, operating rooms (ORs) consume the largest amount of human resources, materials, and facilities.
On average, approximately 40% of a hospital’s total expenses can be ascribed to the activity of its ORs [9]. At the
same time, however, ORs contribute the majority of revenues in most hospitals. Therefore, ensuring high quality of
health care while trying to reduce the cost of ORs is one of the most challenging issues for hospitals.
In line with these considerations, this study presents a review of the technical tools discussed in literature for
optimizing the efficiency of hospitals in general, and of ORs in particular, in the attempt to categorize them and
highlight the primary performance metrics these tools allow to improve. The chosen research methodology for
accomplishing the stated aim is the systematic literature review, carried out on an appropriate sample of paper retrieved
from the scientific databases. To be best of the authors’ knowledge, there are only two papers that have dealt with
carrying out a review about the optimization of healthcare processes, i.e. [10] and [11]. The former study [10] has
provided a systematic review of hospital bed management research and evaluated a range of problem definitions,
measurement metrics, and decision support techniques in the studies reviewed. Abe [11], instead, has reviewed the
body of literature on operations research methods applied to hospital operations. Our study differs from the previous
reviews in that it is focused on engineering tools applied to healthcare management and has a clear orientation towards
the potentials of these tools when applied in practice.
The remainder of the paper is organized as follows. Section 2 details the procedure followed for creating the sample
of relevant studies and to analyze them. Section 3 proposes the main results of the review and section 4 discusses their
practical implications for healthcare organizations. Section 5 concludes and delineates the future steps of the research.

2. Methodology

2.1. Sample creation

The sample of papers relevant to the present study has been derived from the Scopus database*, which was chosen
as it ensures a wide coverage of various scientific areas, such as social sciences, engineering, and medicine, these
latter being particularly relevant for the purpose of this study. Several queries were set, using two groups of keywords:
• Group 1 includes terms relating to the process optimization area, e.g. “optimization”, “process
optimization”, and “simulation”;
• Group 2 includes terms relating to the context of analysis, such as “hospital” or “healthcare”.
These two groups were combined using the OR operator for terms belonging to the same group and the AND
operator for combining terms taken from different groups. The publication language was set at “English”.
The various queries made with these terms led to a total of 119 papers (excluding duplicated studies), whose
relevant data were extracted from Scopus in the form of a .csv file, using the export function; the key data extracted
are: the paper metadata (authors, title, year of publication, source title, DOI and keywords), the paper type, and the
number of citations. Papers for which the author’s name was not recorded on Scopus (i.e., that returned [No author
name available] in the author’s name field) were excluded, as they typically are not research papers but rather prefaces
to conferences; this process led to 11 documents to be removed from the sample. As a further step, the 108 remaining

*https://www.scopus.com/search/form.uri?display=basic#basic
1676 Eleonora Bottani et al. / Procedia Computer Science 200 (2022) 1674–1684
Author name / Procedia Computer Science 00 (2019) 000–000 3

papers were all evaluated for consistency with the stated aim of the research, by reading the full text. The papers that
were found to be of particular interest in this regard are 44 and were taken as the final sample for this review.

2.2. Descriptive statistics

Some descriptive statistics were made on the 44 documents retained, with the purpose of delineating the trend of
research in the field of technical tools available for optimizing the efficiency of hospitals. These statistics include the
number of publications per year, the top-journals and the distribution of papers among conferences and journals.

2.3. Classification framework

For classification purpose, the following additional information were retrieved from the papers reviewed:
• The specific area of the healthcare facility on which the paper focused. Examples of possible areas include the
OR, the whole hospital, or a clinic;
• The approach/methodology applied (e.g., simulation, linear programming…);
• The main theme of the paper;
• The key performance indicators used for evaluating the efficiency of the hospital.
The above data were used for deepening the analysis of the sample of papers and to derive some further insights
for practical application of the methodologies identified.

3. Papers overview: descriptive statistics

The distribution of the studies reviewed in time is shown in Table 1. As can be seen from this table, 17 of the paper
retrieved (39%) were conference papers, while most of the papers (27 out of 44, 61%) are journal articles. Although
no boundaries were set for the publication year, results show that only one paper (i.e. the pioneering study by Weiss,
[30]) was published before 2006; besides this document, the remaining literature started being published on that year,
with an average rate of 1 to 3 papers per year up to 2013. The publication rate has slightly increased in the last years,
as demonstrated by the peaks of 6 and 5 papers per year published in 2014 and 2018. This could be the (logical)
consequence of the diffusion of Industry 4.0 technologies, such as big data, Internet of things or could computing, that
of course can enhance the potentials for process optimization in any industrial field.

Table 1: distribution of papers in time.

Year
Paper type 1990 2006 2007 2009 2010 2011 2012 2013 2014 2015 2016 2017 2018 2019 2020 2021 Total
Article 1 1 1 1 1 3 4 3 3 3 2 3 1 27
Conference paper 1 2 1 1 1 2 1 3 1 2 2 17
Total 1 1 3 2 1 2 2 2 6 4 3 4 5 4 3 1 44

Among the most prominent publication outlets, Computers & Industrial Engineering appears as the journal that
published the highest number of studies (4 papers); this result is consonant with the nature of the journal, which
focuses on engineering applications in various fields. Making a classification of the most prominent conferences is
not immediate, as the number of papers published in each conference is generally limited to one or two; the only
conference that published 3 papers is the IEEE International Conference on Automation Science and Engineering.
This latter is classified in the engineering field as well, with a specialization in electronic and electrical engineering.
 Eleonora Bottani et al. / Procedia Computer Science 200 (2022) 1674–1684 1677
4 Author name / Procedia Computer Science 00 (2019) 000–000

4. Detailed analysis

4.1. Papers categorization

In terms of the area of the hospital taken into account by the studies reviewed, ORs are by far the most investigated
context, with 31 studies (>70% of the sample), followed by the whole hospital structure, evaluated in 10 studies
(22.7% of the sample). One study only has targeted the context of clinics, while the remaining two studies are about
the emergency room (ER). These results are in line with the previous consideration about the cost of ORs, which
forms an important part of the total cost of the structure and justifies the attention paid to this specific area of the
hospital. Table 2 indicates the study context for each paper examined.

Table 2: study context of the papers.

Paper Study context Paper Study context Paper Study context Paper Study context Paper Study context
[10] Hospital [19] Operating room [28] Operating room [37] Operating room [46] Hospital
[11] Hospital [20] Operating room [29] Operating room [38] Operating room [47] Hospital
[12] Operating room [21] Hospital [30] Operating room [39] Operating room [48] Hospital
[13] Operating room [22] Operating room [31] Operating room [40] Operating room [49] Clinic
[14] Operating room [23] Operating room [32] Operating room [41] Operating room [50] Emergency room
[15] Operating room [24] Hospital [33] Operating room [42] Operating room [51] Hospital
[16] Operating room [25] Operating room [34] Operating room [43] Operating room [52] Emergency room
[17] Operating room [26] Operating room [35] Operating room [44] Operating room [53] Hospital
[18] Operating room [27] Operating room [36] Operating room [45] Hospital

4.2. Approach/methodology applied

Looking at the approach/methodology used, most of the studies reviewed make use of a hybrid approach,
integrating various engineering tools with the purpose of either evaluating or optimizing the performance of the system
under examination. To be more precise, focusing on the single techniques, 35 studies (79.5% of the sample) have
applied simulation to the analysis and optimization of healthcare processes. Most of these studies have targeted the
optimization of ORs (24 out of 35). Linear programming models have been found in 17 studies (38.6% of the sample),
while heuristic/metaheuristic models appeared in 12 studies (27.2% of the sample). Other approaches, used less
frequently, include analytical models (5 studies, 11.3% of the sample) or statistical process control (SPC) techniques
(2 studies, 4.5% of the sample); nine studies made instead use of approaches that cannot be easily classified in the
previous categories.
In addition, researchers have typically applied more than one approach/method for process optimization. In this
respect, the most recurring combination of techniques consists in simulation coupled with linear programming (16
studies, 36.3% of the sample), followed by simulation and heuristic/metaheuristic models (10 studies, 22.7% of the
sample). The combined usage of various approaches is a possible consequence of the complexity of the problems
under examination in the various studies.

4.3. Macro-themes

The sample of articles obtained following the procedure described above was classified according to the macro-
theme covered by the authors. Indeed, a first consideration that emerged from the studies reviewed is that the trend is
to use simulation and optimization approaches as key techniques for process improvement. With the aim of delineating
the tools actually available for optimization purpose in this context and the goal of the optimization, five main themes
were identified:
• the scheduling of surgical procedures in ORs and the scheduling of patients (e.g. appointments scheduling);
• the planning of ORs, intended to create efficient surgical programs for patients;
• the evaluation of the ORs’ performance, through the construction of analytical models or through simulation
analysis, with the ultimate aim to evaluate their performance;
1678 Eleonora Bottani et al. / Procedia Computer Science 200 (2022) 1674–1684
Author name / Procedia Computer Science 00 (2019) 000–000 5

• the tracking of patients passing through hospital facilities and data collection through the implementation of radio
frequency identification (RFID) systems;
• the simulation of the hospital flows, used as a support tool in decision-making processes when new processes
have to be implemented.
These five themes will be described in detail in the sub-paragraphs that follow.

4.3.1. Planning of procedures and patients

The issue of scheduling procedures and patients in the OR has been addressed using different approaches. In
particular, the typical surgical scheduling problem aims to define the time and room in which a series of surgical
interventions must be performed.
Zhang et al. [12] have addressed the problem of planning a series of surgeries scheduled on a given day and
characterized by a random duration. A “promised surgery start time” determined at the beginning of the day is
suggested in order to free surgeons from endless waiting. Xiang et al. [13], on the other hand, looked at the similarities
between the programming of the surgery in the OR and a flexible job shop scheduling problem (FJSSP) with multiple
resources in production, and proposed an ant colony optimization (ACO) approach to efficiently solve the scheduling
of surgical interventions based on the knowledge acquired in the FJSSP area. Again with regard to the surgery
scheduling, Diaz-Lopez et al. [14] have proposed a simulation-optimization technique to solve the stochastic version
of the surgical programming problem. Instead of generating a solution for each problem instance, the proposed
technique generates a set of various feasible solutions, among which the hospital can select the one to implement. The
proposed approach implies that the surgical time can be modelled using the typical probability density functions.
Hence, these functions are used to generate a set of data corresponding to different percentiles of surgical time. Next,
for each percentile, the deterministic version of the problem is solved using a Greedy Randomized Adaptive Search
Procedure (GRASP). Therefore, there are as many solutions for one instance as test percentiles chosen. Finally,
through the Monte Carlo simulation, the authors determine the confidence intervals for three indicators: i) percentage
of usage of the rooms; ii) percentage of delayed interventions; and iii) average delay time of an intervention. As a
final outcome, the proposed technique quantifies the impact of a high utilization rate on the service level. Marwa et
al. [15], instead, have taken into consideration an intervention planning problem that integrates the three phases of the
intervention. The results obtained show the superiority of the coupled optimization-simulation approach to maximize
the utilization of the OR and reduce the maximum completion time within an OR. Heider et al. [16] have proposed a
mixed-integer quadratic model that optimizes the tactical surgery schedule to balance the expected day-to-day
occupancy of the scheduled patients in the surgical intensive care unit (ICU).
Saadouli et al. [17] have studied the problem of scheduling elective surgery patients in an orthopedic surgery
department. Two types of resources are considered: OR and recovery beds (RB). The problem lies in optimizing the
assignment of surgeries to ORs and planning recoveries to avoid them in the OR when a bed is not available in the
recovery room. Bam et al. [18], on the other hand, have focused on planning one-day hospital elective surgeries,
considering surgeons, ORs, and post-anaesthesia care unit (PACU). Xiao & Yoogalingam [19], instead, have
developed a flexible model of an OR system where elective patients and emergency patients, who arrive randomly,
are scheduled in the same OR. Saadouli et al. [20] have proposed two stochastic mixed-integer linear programming
(MILP) models that take into account the stochastic aspect of the surgery duration. Once the set of operations to be
carried out in a week are selected, at the operational level they determine the day and room to which the operations
are to be assigned and the relating order. As patients are typically asked to come to the hospital in the morning, the
best scheduling is the one that minimizes the patients waiting time. In the study by Kühn et al. [21], there is a
description of possible developments toward automatically optimizing scheduling of patients, reducing processing
time and optimizing resource usage in a cancer centre using genetic algorithms.
The study by Abedini et al. [22] has developed a block minimization model to reduce the number of blocks between
two consecutive phases. To avoid blocking, the number of patients in each stage should not exceed the number of
beds in the same stage. Fei et al. [23], instead, have dealt with classifying patients who pass through the OR in groups
with homogeneous trajectories. In general, the trajectories of patients passing through the OR consist of three phases:
the preoperative phase, the peri-operative phase and the post-operative phase. Finally, Tamburis [24] aims at
describing an original approach to link process mining techniques and Discrete Event Simulation (DES) modeling,
via the implementation of ProM6 framework, in a hospital-based scenario.
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4.3.2. Programming of ORs

Su et al. [25] have taken into account the problem of determining the optimal planning of the ORs as a flexible job
shop planning (FJSP) problem. Molina-Pariente et al. [26], instead, have addressed the problem of planning the ORs
at the level of offline operative decision. The authors focus on the problem of early OR scheduling including also
stochastic considerations.
Saremi et al. [27] have addressed the appointment scheduling of outpatient surgeries in a multistage OR department
with stochastic service times serving multiple patient types. Cappanera et al. [28] have compared three different
scheduling policies in the master surgical scheduling context with respect to three performance criteria: 1) efficiency,
i.e. the capability of scheduling a large number of surgeries; 2) balancing, i.e. the capability of distributing the
workload fairly among the resources involved in surgical activities; and 3) robustness, i.e. the capability to prevent
schedule disruptions caused by variability of surgical time and length of stay. Erekat et al. [29] have instead carried
out a study in which four different traditional data mining techniques are used to predict cancellations and create
efficient surgical programs for patients. Weiss [30] has also addressed a number of scheduling problems that are often
faced in a hospital’s OR. Gunna et al. [31] have proposed an optimization model which returns an OR schedule that
maximizes patient flow and benefit at a fixed level of risk using portfolio selection. Zheng et al. [32] have proposed a
simulation model of ORs in a large hospital using a simulation platform - SIMIO. Zhang & Xie [33] have dealt with
appointments scheduling (AS) for a sequence of surgeries with random durations served by multiple OR (Multi-OR).
Zhang et al. [34] have addressed the problem of surgery appointment sequencing and scheduling of Multi-OR for a
given day with random surgery durations. M'Hallah & Al-Roomi [35] have evaluated the stochastic off-line planning
and on-line scheduling of OR at operational level.
Lamiri et al. [36] have proposed several optimization methods and compared them when used for elective surgery
planning when the OR capacity is shared by elective and emergency surgery. The same authors [37] have also
addressed OR planning problems with elective and emergency surgery demands.
Baumgart et al. [38] have proposed several strategies that optimize patient throughput by redesigning the
perioperative processes.
Finally, in the study by Mousavi et al. [39] optimization problems are introduced to determine the optimal number
and sensors in a hospital OR. Sensors allow for continuous measurement of air quality, thus helping to regulate
ventilation rates by creating an intelligent system with reduced energy consumption. Various optimization problems
are formulated to find the optimal position and sensors to minimize the expected detection time.

4.3.3. Evaluation of the performance of operating rooms (ORs)

The focus of scientific papers falling into this category is on evaluating the OR performance, through the
construction of analytical models or simulation analysis.
A very interesting case is the one suggested by Wang et al. [40]. The goal of this work is to use DES to evaluate
real-world performance of distributed operating room scheduling (DORS), a collaborative and multi-hospital OR
programming approach based on a deterministic integer programming (IP) model. Zeng et al. [41], instead, have
introduced an analytic model to evaluate the performance of OR programs in an orthopedic surgery department.
Wang et al. [42] have proposed an algorithm that estimates the mean effective process time and its coefficient of
variation. The algorithm therefore quantifies the patient flow variability. When the parameters are identified, a takt-
time approach gives a solution that minimizes the variability in production rates and workload.
The contribution by Zeng et al. [43] is an aggregation method for approximating an OR idle time and patient
waiting time for a surgical sequence data.
In the study of Abedini et al. [44], stochastic bi-level optimization models were formulated to optimize total cost
and throughput of ORs under the presence of uncertainties in patient arrivals and case times. The work by Xu et al.
[45], instead, brings out the outpatient OR process upswing plan and establishes simulation models; then, this paper
puts forward the total cost objective function of outpatient ORs, and uses FlexSim for Healthcare to solve a case with
the model above, and then analyzes the system indicators and costs, and finally determines the most rational model.
Finally, Aringhieri & Duma [46] have focused their attention on the analysis of a surgical Clinical Pathway (CP)
from a patient-centered point of view in order to optimize the most critical resources of a surgical CP and to evaluate
the impact of the optimization with respect to a set of patient and facility centered indices.
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Author name / Procedia Computer Science 00 (2019) 000–000 7

4.3.4. RFID to support process optimization

The targeted objectives for adopting RFID in the hospital field can be different and include:

• improving the safety and quality of care provided to the patient;

• improving the quality of hospital processes, such as the process of delivery of clean linen to the wards;
• improving the process visibility;
• using the data obtained from RFID reads for tactical and strategic purposes, such as the redesign of processes.

Boginski et al. [47] have built a simulation model of operations and resource utilization in a hospital. The inputs
for the model were derived from data recorded over daily periods from RFID devices connected to hospital resources.
A simulation model was created in ARENA to study the patient flow in the hospital and identify potential sources and
locations of delays associated with the use of the equipment. Also Amini et al. [48] have explored the potential value
of RFID data for tactical and strategic purposes and the redesign of processes within supply chain through the
deployment of simulation modelling and analysis.
Another interesting study has been provided by Lin & Padman [49], who have analysed the care delivery process
in ambulatory care using time and location stamped data collected via RFID-enabled badges worn by patients,
clinicians, and staff as they complete each clinic visit.
The study by Deryahanoglu & Kocaoglu [50], instead, aimed at improving patient safety and quality with
sustainable tracking system. A real-time warning mechanism is created by determining the number of optimum
medical staff due to RFID technology. As a result, length of stay of the patients will be reduced and patient satisfaction
will be increased.
Lastly, Shim et al. [51] have considered the deployment of an RFID system to improve the linens delivery and
tracking process.

4.3.5. Simulation of hospital flows

The scientific publications belonging to this category are two studies that have used simulation for testing the
effects produced by managerial decisions before they are implemented, mainly in terms of flows and allocation of
hospital resources.
In particular, Sulis & Di Leva [52] have developed an application of simulation in the Business Process
Management (BPM) area. The discipline includes modelling to facilitate the optimization of business processes. By
comparing real and simulated process indicators, the support systems provide effective and efficient performance
analysis.
Thorwarth et al. [53], instead, have demonstrated how an analytic representation of complex DES models can be
developed in order to facilitate prompt yet effective solutions for decision makers. This analytical representation
provides a brief overview of the simulation results by using the staff scheduling and nurses’ utilization approaches.

4.4. Key performance indicators

This section analyzes the outputs measured as key performance indicators (KPIs) of the optimization process in
each of the studies described before, with the aim of identifying the parameters of greatest interest among authors and
relate them to the type of process studied. Starting from the consideration that the KPIs of interest for the authors were
of different species, we preliminarily tried to classify them on the basis of their type, attempting to group them into
homogeneous categories. This proposed classification has identified four types of KPIs:

• Time indicators, which measure aspects related to the duration of the process or to the patient’s expectations;
their ultimate aim is to reduce inefficiencies related to waste of time;
• Usage indicators, mostly referring to the use of resources, such as beds, nurses, surgeons and ORs, within the
different processes observed;
• Cost indicators, i.e. economic measures relating to the hospital and its facilities;
• Other indicators, i.e. all those indices that do not fall into the previous categories.
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8 Author name / Procedia Computer Science 00 (2019) 000–000

In the table below, the main indicators have been collected and listed, based on the previous classification.

Table 3. KPI classification.

Time indicators Usage indicators Cost indicators Other indicators

Overtime [15]-[18]-[19]-[28]-
[29]-[40]-[42]-[44]
Waiting time [14]-[17]-[19]-
[21]-[27]-[29]-[30]-[41]-[42]-
[43]-[45]-[46]-[47]-[48]-[49]-
[50]
Expectation rate [14]
Employment rate [14]
Makespan [13]-[15]-[17]
Door-To-Doctor Time [52]
Lenght of Stay [50]- [52]
Surgery time [43]-[48]
Average time spent on the
waiting list by patients [46]
Inter-arrival time of patient [53]
Downtime [19]-[30]-[41]-[43]-
[44]
Use of the OR [19]- Cost of not using the OR [12]- Number of cancellation [27]-[40]-[46]
[28]-[29]-[38]-[40]-[45] [33]-[34]
Use of resources/staff Cost for overtime in the OR Personal number available [53]
[32]-[38]-[53] [12]-[37]
Coefficient of variation Cost of waiting for the Patient trajectories [23]
in working hours [13] surgeon [12]- [33]- [34]
Capacity of use [25]- Average cost of each strategy Number of surgeries scheduled [20]-[28]-[36]
[35]-[50] [12]
Use of the bed [16]- Total cost [33]- [34]- [40]- Bed overbooking [28]
[28] [44]
Impact of workload and surgical structure
Tail average length [45]-[46]
Average number of surgical interventions per
day [29]
Average percentage of achievement of selected
interventions' list [31]-[44]
Rate of blocks [22]
Relative Deviation Index [26]

The studies typically do not limit the evaluation to just one of these KPIs; conversely, in many cases various types
of KPIs are discussed in the same study. Hence, this classification was made with the primary aim to clarify the
different nature of the KPIs used. In the attempt to provide an idea of what can be learned from this analysis, what can
be said is that the indicators relating to time and use appear most frequently in the studies reviewed.
Among the time indicators, the indices relating to “waiting time”, “overtime” and “downtime” have been taken up
several times by the authors. The waiting time, defined as the time spent by patients waiting before receiving a
treatment, is measured as the ratio of the total waiting time to the total of surgeries and was evaluated in 16 of the
studies reviewed (36% of the total sample). The overtime, i.e. the index that records the additional time required
besides the standard working hours, was taken into account in 8 of the 44 papers examined and, therefore, it is present
in 18% of cases. What was still observed, then, with respect to measurement of overtime, is that this indicator has
sometimes been used in relation to the working hours of the hospital staff (for example, doctors and nurses) but, in
most of the cases, it was related to the extraordinary opening time of the OR itself.
Finally, the downtime, i.e. the unproductive time of ORs, was reported in 5 studies of our sample. A more concise
representation of these indexes and their usage is shown in the graph below.

Graph. 1. Time indicators diffusion.

Among the indicators of usage, the most frequently observed is the measurement of the OR utilization, calculated
as the ratio between the total OR time used (excluding turnover and waiting time for downstream unit) and the time
scheduled for the usage of the OR. Very interestingly, from the point of view of the resource usage, the presence of a
coefficient of variation of the working time was observed, although in one paper only [13]. This indicator is defined
as the ratio of the standard deviation of the working time to the mean and it is used to evaluate the balance of resource
utilization.
1682 Eleonora Bottani et al. / Procedia Computer Science 200 (2022) 1674–1684
Author name / Procedia Computer Science 00 (2019) 000–000 9

5. Conclusions

This paper has provided an overview of the usage of engineering tools and approaches to the evaluation and
improvement of the process performance in the healthcare context. Through an analysis of a sample of 44 relevant
studies, retrieved from the Scopus database, the main tools have been mapped and their application to the healthcare
context investigated in detail.
A sort of parallel can also be drawn between the use of RFID in the healthcare field and the use of RFID in the
industrial environment. The industrial sector has influenced the hospital sector in the following fields of application:
access control; traceability of personnel, patients, drugs and medical instruments; control of drug administration;
laundry; asset and inventory management. A critical aspect both environments have had to contend with is the data
privacy; in recent years, however, there have been several studies that have addressed this problem by managing
privacy and security issues in RFID systems.
From the analyses made, it emerged that the most widely used tools for process optimization in healthcare is
simulation, followed by linear programming models and heuristic/metaheuristic algorithms. Most of the studies
reviewed applied these techniques to the analysis of ORs, although some studies have targeted ERs, clinics or the
whole hospital. In terms of performance, time indexes are by far the most used indicators for evaluating the ORs or
the hospital, followed by usage indicators.
Overall, from these outcomes it can be easily deduced that the problem of process optimization in healthcare
environments is attracting the attention of several researchers and that engineering tools seem to be interesting means
for investigating this problem. ORs have attracted a particular attention compared to other areas of a hospital, probably
because they are responsible for most of the costs of a healthcare facility. Future research activities, which form part
of our ongoing research, will be directed towards the development of an engineering tool for optimizing the processes
of a real healthcare facility, to evaluate the effectiveness of the approaches emerged from the analysis carried out in
this paper.

Acknowledgements

This research has financially been supported by the Programme “FIL-Quota Incentivante” of University of Parma
and co-sponsored by Fondazione Cariparma.

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