Determining the optimal capacity and occupancy rate in a hospital: A theoretical model using queuing theory and marginal cost analysis

We model the hospital as seeking to balance the costs to itself in providing care, as well as the societal cost of people waiting for care. We use queuing theory to show that the optimal capacity and the corresponding optimal occupancy rate are dependent on the marginal cost of expanding capacity, the marginal cost of waiting, and the rates of patient arrival and discharge. Therefore, a universal occupancy target is unfounded. As well, the model shows that increasing capacity to respond to increased patient influxes is inadequate, suggesting that the health care system must explore alternate responses to burgeoning patient populations.     

Specialty care single and multi-period location–allocation models within the Veterans Health Administration

Optimal location of specialty care services within any healthcare network is increasingly important for balancing costs, access to care, and patient-centeredness. Typical long-range planning efforts attempt to address a myriad of quantitative and qualitative issues, including within-network access within reasonable travel distances, space capacity constraints, costs, politics, and community commitments. To help inform these decisions, single and multi-period mathematical integer programs were developed that minimize total procedure, travel, non-coverage, and start-up costs to increase network capacity subject to access constraints. These models have been used to help the Veterans Health Administration (VHA) explore relationships and tradeoffs between costs, coverage, service location, and capacity and to inform larger strategic planning discussions. Results indicate significant opportunity to simultaneously reduce total cost, reduce total travel distances, and increase within-network access, the latter being linked to better care continuity and outcomes. An application to planning short and long-term sleep apnea care across the VHA New England integrated network, for example, produced 10–15% improvements in each performance measure. As an example of further insight provided by these analyses, most optimal solutions increase the amount of outside-network care, contrary to current trends and policies to reduce external referrals.     

Improving access to health facilities in Nouna district,Burkina Faso

The Nouna health district in Burkina Faso, has a population of approximately 275,000 people living in 281 villages, and is served by 25 health facilities, as of 2006. For many people, the time and effort required in traveling to a health facility, which may demand a journey of many kilometers over poor roads on foot, is a deterrent to seeking proper medical care. In this study we examine how access to health facilities in Nouna may be improved by considering the configuration of the road network in addition to the locations of the facilities. We model the situation as a facility location–network design problem and draw conclusions about how best to improve the physical access of the health facilities. Our model shows the extent to which access can be improved when the road network is considered along with facility locations, in contrast to facility locations considered alone.     

The ‘postcode lottery’ of the Italian public health bill analysed with the hierarchy Stochastic Multiobjective Acceptability Analysis

Over the last two decades, due to strong decentralization and widespread budget constraints, the Italian co-payment for health care has become a way to finance public health. This phenomenon has provoked a continuous increase of private costs of public health and an evident regional heterogeneity. As a result, a pervasive spatial inequality of access to public health care is becoming increasingly clear. The aim of this paper is to measure this inequality, mainly determined by the differences among regional co-payment prices. Access, equity, and needs are all part of the phenomenon ‘inequality of access’, and they are difficult to define and measure in health care. For this reason, most of the previously proposed measurement methods have inherent limitations and have prompted us to use an innovative approach focused exclusively on the supply side. In particular, we focus only on the cost of health benefits (co-payment). From a methodological perspective, we use a recent new version of the Stochastic Multiobjective Acceptability Analysis (SMAA), which is a methodology mainly used to build composite indicators of multidimensional phenomena out of the market. In order to deal with the hierarchical structure of the Italian health care system, we use the Hierarchy Stochastic Multiobjective Acceptability Analysis (HSMAA), which takes into account the uncertainty with respect to the weights assigned to the considered criteria, as in the standard SMAA, but also the uncertainty with respect to the weights assigned to the considered sub-criteria. Applying for the first time HSMAA to measure inequality allows us to create a unique index for each region and then to make a classification among them. The results show that, since there are different prices for the same health benefits among different regions, there are strong spatial inequalities in the cost of the Essential Levels of health care in Italy.     

Revolution, evolution, or status quo? Guidelines for efficiency measurement in health care

This paper discusses ways forward in terms of making efficiency measurement in the area of health care more useful. Options are discussed in terms of the potential introduction of guidelines for the undertaking of studies in this area, in order to make them more useful to policy makers and those involved in service delivery. The process of introducing such guidelines is discussed using the example of the development of guidelines in economic evaluation of health technologies. This presents two alternative ways forward—‘revolution’, the establishment of a panel to establish initial guidelines, or ‘evolution’—the more gradual development of such guidelines over time. The third alternative of ‘status quo’, representing the current state of play, is seen as the base case scenario. It is concluded that although we are quite a way on in terms of techniques and publications, perhaps revolution, followed by evolution is the way forward.     

Capacity planning in service operations: The case of hospital outpatient facilities

This paper presents models that may be used to balance service capacity and demand in situations in which demand is external and, therefore, is not fixed but may fluctuate in response to factors that include the waiting time imposed upon customers. Such situations are common in retailing, financial services, health services, and other service sector industries. An application is shown to a hospital outpatient facility.     

An integrated approach to measuring potential spatial access to health care services

In recent years there have been several attempts to develop quantitative measures of potential spatial access to health care services which, despite their limitations, offer many positive ideas that can perhaps be integrated into a logically consistent and generally acceptable index. It is in this vein that the current paper presents an integrated approach, drawing partially from past contributions, to measuring potential spatial access to health care services. The final access index is derived as the culmination of a series of individual measures, starting with an initial gravity formulation and progressing through successive stages as new elements, consistent with the definition and conceptualization of potential spatial access, are introduced. Application of the proposed index to the ambulatory medical care system of the Akron, Ohio SMSA, demonstrates the validity of the measure, and its suitability as a potential health care planning tool.     

Indicators for planning of health services: assessing impacts of social and health care factors on population health.

Community health planning requires identification of the level of access to care and factors which affect the differentials in use of health services. In formulating strategies or alternatives for planning, some assessment of the current level or patterns of health services must be made. It is this element of the planning process that is addressed in this paper. In this study sixty-five specifically designated areas (medical market areas) in the Province of Quebec, Canada were selected. The analysis was performed using data obtained from a large scale study of physicians' responses to the introduction of universal medical care insurance in Quebec. Our analysis offered an opportunity to observe the impact of Medicare on access to care for those thought to be underserved.     

工作研究在按摩椅组件装配方法改善中的应用

基于工作研究的原理和方法,对某健康产品有限公司按摩椅组件的装配方法进行了分析改善。首先对按摩椅组件的装配过程进行了流程程序分析,运用5W1H和ECRS方法,通过流程化改善减少了装配过程中的搬运和等待;其次对按摩椅组件的装配过程关键瓶颈工序进行了双手作业分析,通过合理摆放工具和物料,消除了作业浪费。通过对按摩椅组件装配过程的两次改善,装配产能提升了26.7%,单个工人的效率提高了42.9%。     

An Application of Rating Conjoint Analysis to Study the Importance of Quality-, Access- and Price-attributes to Health Care Consumers

Outside the health care sector, consumer preferences have been effectively studied using rating and ranking conjoint techniques. In the health care sector this technique has received less attention than its choice-based variant. Applications of rating and ranking method to health care issues are few. This paper presents an application of rating conjoint analysis to study the importance of quality, access and price to the health care consumers in Bulgaria. The paper first describes the rating conjoint method and its distinctive features compared to the choice-based and the ranking approach. The method is illustrated by the rating conjoint design applied in the study. Next, the impact of different quality-, access- and price-levels on the rating of physician profiles is analysed and the differences between the socio-demographic groups are examined. The results suggest that similar to other countries, the quality of care is a highly valued characteristic in Bulgaria, whereas access is perceived as less important. The considerable importance of patient payments further implies that Bulgarians are responsive to prices in the health care sector, especially the elderly, the village dwellers and the lowest income groups. The relevance of the results with regards to health policy and planning, as well as with regards to the methodology of rating conjoint analysis is discussed at the end of the paper.     

Waiting Time and Production Uncertainty in Medical Services

To focus on office waiting time, the behavior of a medical practice is analyzed under a perfectly competitive setting where office waiting time is the only choice variable in the short-run. The optimum waiting time is determined for both the certainty and the uncertainty cases. Comparative statics are drawn with respect to the opportunity cost of waiting time, physician fee, capacity, and standard deviation of waiting time. Empirical analysis of waiting time is made based on questionnaires distributed among physicians and patients. The results are consistent with the majority of the theoretical findings.     

Do health system reforms stand a chance?

While most major reforms of health systems fail, those that succeed are motivated by politicians' quest for reducing the health burden on their budget in response to a shift in voters' preferences away from public health. An Edgeworth box is used to depict their preferences, in addition to those of (potential) patients and health‐care providers. Politicians are found to severely constrain the area of mutual advantage, suggesting that only minor reforms are possible unless they promise to lower health‐care expenditure. An efficiency‐enhancing change that would enlarge the box and hence the area of mutual advantage would be to suppress the requirement imposed on health insurers to purchase domestically, rather than being free to directly import health‐care services and drugs.     

The potty parity problem: Towards gender equality at restrooms in business facilities

In business facilities such as theaters, restaurants, stadiums, and etc., anecdotal evidences suggest that waiting lines for women's restrooms are longer than those for men's. Respectively, there have been growing concerns on ensuring restrooms in business facilities to be equally convenient for both women and men. This issue not only relates to gender equality, but also relates to business performance, since restroom experience directly affects performance efficiency (e.g., revenues, repeat sales, asset turnover, service times, and etc.). Nonetheless, current codes and legislations for designing restrooms in business facilities are not based on objective analyses but on the survey of experts that may be male biased. In this study, we develop a quantitative model using queueing theory and simulations to evaluate the waiting time for restrooms. Using our model, we compare the waiting times between women and men to examine if the current codes and legislations provide equal access. Our analysis reveals that the current standard specified by the Uniform Plumbing Code (UPC) still fails to achieve equal access. The methods demonstrated in this study may serve as a basis for design of restrooms in business facilities and improve both gender equality and performance efficiency in business facilities.     

The effects of an online inquiry service on gatekeeping systems with heterogeneous patients

An online inquiry service (OIS) is an innovative service designed to make medical resources more accessible, especially in remote areas. An OIS provides patients with an alternative method of consulting a physician. This study develops a game-theoretical queueing model to examine the impact of OISs on gatekeeping systems. In such systems, patients are heterogeneous in terms of their travel costs. Here, we compare the performance of gatekeeping systems with and without an OIS. As such, we show that, owing to physicians’ reduced diagnostic ability when working online, an OIS reduces patients’ travel costs, increases the flow of patients to specialists, increases the total waiting time in the system, and decreases the total health surplus of patients. Moreover, we demonstrate that when patients are not sensitive to delays, introducing an OIS always reduces their total cost. These findings are consistent with the intuition that patients are better off when more options are available. Interestingly, when patients are sensitive to delays, introducing an OIS may increase their total cost. This paradoxical result occurs when patients’ sensitivity to delays is high, because those who consult a physician online impose negative externalities on the system by increasing the waiting cost in both the online and offline channels (which is proportional to patients’ delay sensitivity). Finally, we numerically illustrate that the benefit of introducing an OIS is non-monotonic in the system parameters; thus, caution is required when designing policies to regulate OISs.     

Health Care

A bstract . A broad rational national health care insurance policy for the United States , providing for universal financial access to health care for all citizens, has both "meaning" and "validity" in that it would address actual socioeconomic concerns and could be implemented. It is justified by theories of justice of Rawls and Donaldson as well as by Adam Smith's socioeconomic model. Social consensus in this area accepts the principle of solidarity that individual self-interests may be better served through collective action , especially if such action is tied to competitive rules. Health care, therefore, is evolving as a public or quasi public good. The basic question no longer is whether the U.S. should have universal health care insurance but what specific health care policy the country should adopt in order to strengthen the market system and to maximize social welfare as effectively as possible.     

Reliable design of a congested disaster relief network: A two-stage stochastic-robust optimization approach

The preparedness of humanitarian relief networks can be enhanced by pre-positioning resources in strategic locations and using them when disasters strike, a strategy that gives rise to a two-stage planning problem. This paper presents a novel two-stage stochastic-robust optimization approach for integrated planning of pre- and post-disaster positioning and allocation of relief resources, while taking into consideration the uncertainty about demand for relief services and disruptions in the relief facilities and the transportation network. The proposed approach enables planners to effectively use limited historical data and imperfect experts’ opinions to obtain robust solutions while avoiding the over-conservatism of classical robust optimization methods. The objective sought is to minimize the expected total time victims need to receive assistance, including both access time to facilities and waiting/service time in them. Congestion in relief facilities is accounted for by modeling them as queuing systems and penalizing waiting time. A decomposition method based on column-and-constraint generation is implemented to solve the problem, whereas the nonlinear terms corresponding to queuing in the second-stage problem are handled using a direct search procedure. Applicability of the proposed approach is demonstrated through a real case study and the numerical results are analyzed to draw managerial insights.     

Towards a real-time prediction of waiting times in emergency departments: A comparative analysis of machine learning techniques

Emergency Departments (EDs) can better manage activities and resources and anticipate overcrowding through accurate estimations of waiting times. However, the complex nature of EDs imposes a challenge on waiting time prediction. In this paper, we test various machine learning techniques, using predictive analytics, applied to two large datasets from real EDs. We evaluate the predictive ability of Lasso, Random Forest, Support Vector Regression, Artificial Neural Network, and the Ensemble Method, using different error metrics and computational times. To improve the prediction accuracy, new queue-based variables, that capture the current state of the ED, are defined as additional predictors. The results show that the Ensemble Method is the most effective at predicting waiting times. In terms of both accuracy and computational efficiency, Random Forest is a reasonable trade-off. The results have significant practical implications for EDs and hospitals, suggesting that a real-time performance monitoring system that supports operational decision-making is possible.     

Helping staff cope with change

Change seems to be the one constant in health care. This article examines how employees react to change and provides guidelines to help them and managers overcome barriers to change. These guidelines include providing support during change, using appropriate interventions, helping staff find the challenge in change, helping them find the stamina for change, and fostering teamwork.     

Competency evaluation

Evaluation of competency is a lot like competency itself: easy to talk about and difficult to pin down. There are no hard and fast guidelines, but evaluation will be an easier, if not easy, task if attention is given to (1) ensuring alignment with goals of the institution and patient care situation; (2) developing properly a valid and reliable form; (3) training of evaluators; and (4) choosing a reasonable timetable for re-evaluation.