OPERATING ROOM ALLOCATION USING MIXED

INTEGER PROGRAMMING(MIP)

Seminar Report

Submitted in partial fulfillment of the requirements for the award of the

degree of

Master of Technology
in
Industrial Engineering and Management

by

KAILAS SREE CHANDRAN (Roll No.: M100447ME)

Department of Mechanical Engineering

NATIONAL INSTITUTE OF TECHNOLOGY CALICUT
November 2010
 CERTIFICATE

This is to certify that the report entitled “OPERATING ROOM

ALLOCATION USING MIXED INTEGER PROGRAMMING(MIP)” is a
bonafide record of the Seminar presented by KAILAS SREE CHANDRAN
(Roll No.: M100447ME), in partial fulfilment of the requirements for the award
of the degree of Master of Technology in Industrial Engineering and
Technology from National Institute of Technology Calicut.

Dr. R. Sridharan
Faculty-in-Charge
(MEA692- Seminar)
Dept. of Mechanical Engineering

Dr. S. Jayaraj
Professor & Head
Dept. of Mechanical Engineering

Place : NIT Calicut

Date :
 ACKNOWLEDGEMENT

I am deeply indebted to my guide Dr. R. Sridharan, Professor, Department of Mechanical

Engineering, for his invaluable guidance, consistent encouragement and suggestions
throughout the course of the work.

I wish to express my sincere thanks to Dr. S. Jayaraj, Professor and Head, Department of
Mechanical Engineering, for providing the necessary facilities to carry out this work.

Last but not the least, I extend hearty thanks to all our teachers whose constant support
and encouragement helped me to complete this seminar in time.

KAILAS SREE CHANDRAN

 ABSTRACT
In most hospitals, the waiting period for surgeries are high and efforts
made in the efficient utilization of resources can prove to be productive in long
term. The aim of this seminar is to present a model which can optimally allocate
the Operating Rooms of the hospital and to minimize the total length of stay of
patient. The model is a mixed integer programming (MIP) methodology which
determines a weekly operating room(OR) allocation template that minimizes
patient’s cost measured as their length of stay. A number of patient type priority
(e.g., emergency over inpatient) and clinical constraints (e.g., maximum number
of hours allocated to each specialty, surgeon and staff availability) are included in
the formulation. The optimal solution from the analytical model is entered into a
simulation model that captures some of the randomness of the processes (e.g.,
surgery time, demand and arrival time). The simulation model outputs the average
length of stay for each specialty and the room utilization. On a case example of a
Los Angeles County Hospital, how the reduction in hospital length of stay
pertaining to surgery is shown. A proposal for a new constraint which takes into
account the Post-Operative Care(POC) capacity is also explained.
 CONTENTS

List of Symbols ii
List of Tables iii

1. Introduction 1
1.1. Introduction 1
1.2. Problem Background 1
1.3. Objective of the Model 3
1.4. Outline of the Report 3

2. Literature Review 4
2.1. Literature Review 4

3. Modeling 5
3.1. Problem Identification 5
3.2. Problem Formulation 6
3.3. Notations 6
3.4. Assumptions 7
3.5. Decision Variables 8
3.6. Objective Function 9
3.7. Constraints 10
3.8. Simulation Modelling 12
3.9. Proposal: Post-Operative Care Beds Capacity Constraint 13

4. Case study 14
4.1. Description 14
4.2. Solving the Model and Results 14

5. Conclusion and Scope for Future Works 17

5.1. Conclusion 17
5.2. Scope for Future Works 17

References 18
 LIST OF SYMBOLS

θ: Penalty rate for “unmet” demand.

β: Penalty rate for undersupply of OR hours to a specialty.

h: Total amount of idle time of all non-emergency OR’s.

i: Index for room type.

j: Index for medical specialty.

k, l: Indices for days.

s: Amount of staffed hours per day.

D: Set of days.

I: Set of room types.

J: Set of medical specialties.

Subscripts

ρkl: The number of days delayed if a surgery is postponed from day k to day l.

ai: number of operating rooms of type i.

bjk: The amount of idle time of the OR allocated to specialty j on day k.

cjk: The maximum number of operating rooms that specialty j can utilize on day k.

ejk: Emergency patients’ surgery demand for specialty j on day k, (hours).

ojk: Non-emergency patients’ surgery demand for specialty j on day k, (hours).

pj: Oversupply of OR hours to specialty j.

qj: Undersupply of OR hours to specialty j.

ujk: Specialty j’s unmet non-emergency demand on day k.

xijk: The number of operating rooms of type i allocated to specialty j on day k.

yjk: Amount of the emergency OR’s staffed hours allocated to specialty j on day k.

zjkl: Specialty j’s non-emergency demand postponed from day k to day l.

ii
 LIST OF TABLES
4.1 OR capacity allocated to each specialty per week 15
4.2 Summary of simulation results for different 𝛽 s 16
4.3 Performance(simulation results) summary with the original demand 16

iii
 CHAPTER 1
INTRODUCTION

1.1 INTRODUCTION

Surgery is an important activity in most hospitals and clinics since it is

estimated to generate around two thirds of hospital revenues. On the other hand, it
accounts for approximately 40% of hospital resource costs, including the costs of
personnel (surgeons, anaesthetists, nurses, etc.) and facilities (operating rooms,
intensive care beds, etc.). Surgery takes place in a context of challenging trends
such as heavy expenditure on health care, increasing rates in health care costs, and
rising surgery demand due to aging populations and technological advances that
have broadened the scope of surgical interventions. In this context, hospital
management is subject to ever mounting pressures to control surgical costs while
ensuring quality of care for surgical patients in a timely manner. A successful cost
containment strategy must integrate decision-making at all levels: strategic,
tactical, and operational. At the operational level, one of the main problems is
surgical case scheduling.

In many hospitals, a large percentage of patients undergo some type of

surgery when admitted or during their stay in a hospital. To reduce a patient‟s
length of stay and also for the sake of the patient‟s health, it is ideal that a surgery
is performed as soon as it is requested or judged to be needed. However, it is
common in a hospital that patients have to wait in Bed for their surgery for a
couple of days or sometimes a longer time (especially in public hospitals).

In a Hospital environment, significant amount of time and resource is

allocated for the working of operating theatres. This is made more complicated by
the demand being uncertain. If optimum allocation strategies are devised, then
worthy savings in time and there by resources can be achieved.

1.2 PROBLEM BACKGROUND

In many hospitals, surgery planning and scheduling is carried out as

follows or in a similar fashion. At the beginning of each week or each month,
the surgery planning office or a similar unit of the hospital builds an Operating

1
Room(OR) allocation template, or so-called weekly "Block Time Schedule",
which allocates blocks of OR capacity to emergency surgery and various
specialties‟ non-emergency surgery. Oftentimes, each block of OR capacity is one
day of staffed hours of an operating room.

Before each working day, the doctors determine which inpatients in their
specialty will have surgery performed on the following day. When making these
decisions, they usually first accommodate outpatient surgeries scheduled for the
next day because these have been previously scheduled many days in advance.
Also, they take into account the number of blocks/rooms allocated to their
specialty on that day, and the order and degree of urgency of all the active
inpatients' surgery requests.

During a working day, surgeons try to finish as many scheduled surgeries

as possible, in a predetermined order. In addition, emergency surgery demand
arises almost every day, and surgeons try to operate upon these emergency
patients as soon as possible because of their critical condition. Usually, they are
sent into the emergency OR immediately, as long as it is available. If the
emergency OR is busy when needed, the emergency patient is operated in one of
the non-emergency rooms allotted to the particular specialty in which the patient
or the needed surgery belongs. As a result, some scheduled inpatient and
outpatient surgeries may have to be postponed to a later date or rescheduled.
Also, surgeries scheduled for the afternoon may not be performed because they
are too much behind schedule, and they cannot be completed within the staffed
hours if started.

Though there may be some real-time adjustments to the Block Time

Schedule (i.e., one specialty‟s surgery is performed in an OR allocated to another
specialty or occasionally some non-emergency surgery in the emergency OR)
during the working days, surgeons do follow it as much as possible, because each
specialty may require special medical equipment or prior preparations in the OR,
and any change to the schedule may cause confusion in the daily work and take an
extra amount of setup or switching time. Therefore, the quality of the OR
allocation template is crucial to any operational performance measure pertaining
to surgery, including the inpatients' in-hospital cost or length of stay.
2
1.3 OBJECTIVE OF THE MODEL

Public hospitals are non-profit organizations, and their prime operational

objective is to provide medical services to their patients at a reasonable cost. In
such an environment, a significant amount of time and resources are invested in
operating theatres. If optimum allocation strategies are devised for the same,
worthy savings can be achieved. For the study, a hospital with a certain number of
operating theatres and specialties has been considered. With the given conditions,
the allocation strategy could be bettered so that the time the patient stays at
hospital is minimized. The objective of the model is to optimally allocate the
Operating Rooms(OR) of the hospital to different medical specialties based on
surgery demand and to minimize the total length of stay of patient (Zhang B,
2009).

1.4 OUTLINE OF THE REPORT

The report starts with the literature review of various surgery planning journals
and relate them to this work. Then the model is explained with its assumptions,
objective function and its constraints. Modelling of simulation is also explained
and a proposal for a new constraint in the model, i.e. Post-Operative care beds
capacity constraint is explained. Then a case study is conducted and results are
presented which shows the template from the model is performing better than the
original allocation template. Finally scope for future works is explained.

3
 CHAPTER 2
LITERATURE REVIEW

2.1 LITERATURE REVIEW

The main approaches that have been adopted for surgery planning are
mathematical programming (Ogulata 2003, Blake 2002, Ozkarahan 2000), and
simulation (Dexter 1999). Mathematical programming (especially, integer or
mixed integer programming) models have shown to be useful in capacity planning
or resource allocation in many systems, including in the healthcare setting; while
valid simulation models are useful in estimating the actual performance of a
planning solution beforehand. Here the methodology consists of both
approaches.

As for the objective, much research has aimed at maximizing OR

utilization, due to its high operational cost (Dexter and Traub, 2002, Ozkarahan
2000). However, at hospitals with fixed or nearly fixed annual budgets, allocating
OR time based on utilization can adversely affect the hospital financially, and
suggested considering not only OR time but also the resulting use of hospital beds.
In line with this idea, there have recently been some studies on the impact of
surgery schedules on the use of the other resources in hospitals. One
distinguishing characteristic of this work is the focus on minimizing inpatients‟
length of stay waiting for surgery, resulting from the block time schedule.

More and more attention has been paid to managing uncertainty in surgery
planning and scheduling and improving the punctuality of the schedule realized.
Giving incentives to hospital workers to improve their on-time performance is
crucial to reducing delays in surgery or other health services, and the punctuality
of the first service of the day has a significant impact on subsequent
services(Lapierre 1999). The actual surgery demand tends to be higher than
recorded or forecasted, while the supply of OR resources often suffers such
uncertainties as staffing or equipment shortages, which has an effect equivalent to
the former.

4
 CHAPTER 3
MODELING

3.1 PROBLEM IDENTIFICATION

The public health care sector is severely strained with the ever increasing
population .The hospitals are unable to cope up with the increasing demands of
the teeming millions as the resources and facilities available for satisfying the
demand are limited .This has resulted in long serpentine queues which cripples the
health sector reforms and initiatives. Operating rooms are considered among the
most costly hospital facilities and it often becomes a bottleneck in the hospital.
The efficient management of the operating theatres will therefore result in an
improved performance of the hospital as a whole as it is highly interrelated with
the other facilities.

An unnecessarily long length of stay(LOS) for inpatients is one of the

common issues in the hospitals. A high LOS is due to inefficient scheduling
procedures used in surgical and ancillary services, since most inpatients require
one or both of these during their stay at the hospital. In most hospitals, a large
percentage of inpatients undergo some type of surgery during their stay in a
hospital. To reduce inpatient length of stay and also from the patient‟s health point
of view, it is ideal that a surgery is performed as soon as it is requested. However,
in reality, inpatients may need to wait in bed for their surgery for a day or two or
even longer (especially in public hospitals). Outpatients also may not always
undergo their surgery on schedule, although this is not directly counted in the
hospital‟s expenditures. Thus, it is of great interest to hospital administrators to
reduce inpatients' LOS. There are many possible reasons for delays. For example,
a patient who is considered to need surgery immediately might be given
preference over another patient who has been waiting for a week, and has a
scheduled surgery. Or, a hospital may face a situation where a large number of
emergency patients needing surgery use up most of the available Operating Room
capacity(Zhang B, 2009). As a result, the delayed inpatients stay in the hospital
longer, incurring higher non-reimbursable costs for the hospital and the delayed
outpatients may remain in a long outpatient queue (often in the form of a waiting

5
list) waiting for surgery and also continue to “compete” for operating room
capacity with inpatients, affecting LOS indirectly. Thus the unnecessarily long
length of stay in the hospital due to the inefficient scheduling procedure is the
problem which needs immediate attention .This can be solved by developing an
efficient scheduling procedure using the operations research technique.

3.2 PROBLEM FORMULATION

The mixed integer linear programming technique is used to solve the

problem of operating room scheduling. The model determines an allocation
template and each specialty‟s weekly OR time (uniquely determined by the
template) based on the objective of minimizing inpatients‟ length of stay in the
hospital. Based on the study conducted on the operating theatre systems the
various constraints are also identified. The mixed integer programming method is
adopted as some of the decision variables are constrained to take integer
values(Zhang B, 2009).

The decision variables identified to be analysed in the system includes

• Number of Operating Rooms of a particular type allocated to a specialty on

any day.
• Amount of Emergency OR‟s staffed hours allocated to a specialty on any day.
• A Specialty‟s postponed non-emergency demand from a day to another.
• A Specialty‟s unmet non-emergency demand on any day.
• Amount of idle time of the OR allocated to a specialty on a day.
• Total amount of idle time of all non-emergency OR‟s.
• Oversupply of OR hours to a specialty relative to its desired level.
• Undersupply of OR hours to a specialty relative to its desired level.

3.3 NOTATIONS

I: set of room types.

J: set of medical specialties.
D: set of days.
i: index for room type. A room can be considered a different type due to its
location or special medical equipment.
6
j: index for medical specialty.
k, l: indices for days.
s: amount of staffed hours per day.
ai: number of operating rooms of type i.
ejk: emergency patients‟ surgery demand for specialty j on day k, measured in
hours.
ojk: non-emergency patients‟ (including inpatients‟ and outpatients‟) surgery
demand for specialty j on day k, measured in hours.
cjk: the maximum number of operating rooms that specialty j can utilize on day k,
determined by the number of surgeons and the amount of equipment or any other
necessary medical resources that each specialty has.
ρkl: the number of days delayed if a surgery is postponed from day k to day l.
θ: the equivalent number of days delayed if some surgery demand is not met in
the model (or the penalty rate for “unmet” demand).
β: the penalty rate for undersupply of OR hours to a specialty, relative to a desired
level determined by the percentage of total non-emergency surgery demand for
each specialty. Inclusion of this penalty term in the objective function serves the
purpose of smoothing the OR capacity. The β value should be much smaller than
θ.

3.4 ASSUMPTIONS

1. The number of working days can be defined by the end user subject to the
maximum of a 7 workdays.
2. Staffed hours can also be given by the user. Overtime work is not
modelled.
3. The demand pattern for a week is known beforehand. The model does not
account for the uncertainty in the demand.
4. Emergency capacity for each day is user defined.
5. Only weekdays' surgery demand is considered in the model. However,
patients' stay in the hospital on Saturdays and Sundays does incur cost just
like on weekdays. Therefore,

7
 7
ρkl = { (3.1)
7

Note that if k = l or k > l, day l represents a weekday following the week

for day k.
6. The surgery demand is measured by the amount of OR hours. For
example, if specialty j, on average, has 2 emergency patients who need
surgery on Wednesday and the average length of this specialty's
emergency surgery is 1.6 hours, then the surgery demand of specialty j's
emergency patients on Wednesday or ej3 is 3.2 hours.
7. Inpatients' in-hospital cost is incurred by the delay in meeting surgery
demand. Because surgery demand is measured in OR hours, inpatients' in-
hospital cost or length of stay is measured by "OR hours × days". It is
obtained by multiplying the postponed demand volume (i.e. the amount of
OR hours postponed) by the number of days between the day that amount
of demand arises and the day it is met.
8. All emergency surgery demand must be met on the day it arises. Non-
emergency or inpatients' and outpatients' surgery demand can be delayed.
9. If some non-emergency patients' surgery demand cannot be met on the
requested day, it can be met on the remaining days of the current week, on
any day in the following week, or become unmet (equivalent to being met
θ days late).
10. Each specialty performs their non-emergency surgeries only in the non-
emergency OR(s) allocated to them.
11. Each specialty can perform their emergency surgeries either in the
emergency OR or in the non-emergency OR(s) allocated to them.
12. Specialty j is at most allocated cjk ORs on day k.
13. Post-Operative Care capacity(in the proposal).

3.5 DECISION VARIABLES

xijk: the number of operating rooms of type i allocated to specialty j on day k. The
entire set of xijk‟s determines the allocation template.

8
yjk: the amount of the emergency OR‟s staffed hours allocated to specialty j on
day k.

zjkl: specialty j‟s non-emergency demand postponed from day k to day l.

ujk: specialty j‟s unmet non-emergency demand on day k.

bjk: the amount of idle time of the OR allocated to specialty j on day k.

h: the total amount of idle time of all non-emergency OR‟s.

pj: oversupply of OR hours to specialty j, relative to its desired level.

qj: undersupply of OR hours to specialty j, relative to its desired level.

3.6 OBJECTIVE FUNCTION

The objective function aims at minimising the patient‟s length of stay in

the hospital. In order to represent the patient‟s length of stay in the hospital three
penalty terms are identified. The objective function of the formulation consists of
three cost or penalty terms. The first two represent the inpatients‟ length of stay
caused by the delay in meeting surgery demand within one cycle (or for up to 7
days) and by “unmet” demand, respectively. The third term represents the total
penalty caused by the undersupply of OR hours to each specialty, relative to its
desired level determined by the percentage of total non-emergency surgery
demand for each specialty. This penalty term is less dominant, considering our
practical objective of minimizing inpatients‟ length of stay waiting for their
surgery; yet inclusion of this term is useful in determining, among solutions
yielding the same or similar sum of the first two terms or total length of stay, the
one that leads to the most reasonable allocation of the non-emergency OR idle
time (in the sense that the larger non-emergency surgery demand a specialty has,
the more non-emergency OR idle time it tends to occupy) and thus would perform
the best when subject to actual demand and time uncertainty(Zhang B, 2009).

Minimize ∑ ∑(𝜌 ∑ 𝑧𝑗 ) 𝜃 ∑ ∑ 𝑢𝑗 𝛽 ∑ 𝑞𝑗 (3 2)

9
3.7 CONSTRAINTS

The number of operating rooms available for each of the speciality for a
particular day (both emergency and non-emergency operating rooms) represents
the main „resources‟ constraint. The amount of available OR hours and the total
idle time are the other resource constraint identified. Also the model should make
sure that the emergency demand for a day should be met whereas the non-
emergency demand can be postponed or delayed indefinitely(Zhang B, 2009).

∑𝑥 𝑗 𝑎i ∀ (3 3)

𝑠∑𝑥 ≥ 𝑒jk 𝑦jk ∑𝑧 ∀𝑗 (3 4)

𝑗 𝑗

𝑠∑𝑥 𝑗 (𝑒jk 𝑦jk ∑ 𝑧𝑗 ) 𝑏jk ∑ 𝑧𝑗 𝑢jk 𝑜jk ∀𝑗 (3 5)

ℎ ∑ ∑ 𝑏𝑗 (3 6)

ℎ∑ 𝑜
∑𝑏 𝑝 𝑞 ∀𝑗 (3 7)
∑ ∑ 𝑜

∑ 𝑦𝑗 ≤ 𝑠 ∀ (3 8)

∑𝑥 ≤𝑐 ∀𝑗 (3 9)

𝑦jk ≤ 𝑒jk ∀𝑗 (3 10)

𝑥ijk 𝑦jk 𝑧jkl 𝑢jk 𝑏jk ℎ 𝑝 𝑞 ≥ 0 ∀ 𝑗 (3 11)

𝑥ijk Integer, ∀ 𝑗 (3 12)

10
 All the decision variables can take only positive values. The decision
variable representing the number of operating rooms can take only positive
integral values.

 Constraint-1, Eq. (3.3) guarantees that all the operating rooms are
allocated to some specialty each day.
 Constraint-2, Eq. (3.4) ensures that on any day each specialty has at least
the OR capacity to meet the non-emergency demand decided to be
postponed to that day.
 Constraint-3, Eq. (3.5) states that specialty j's non-emergency surgery
demand on day k must be met either on that day, some remaining day in
the current week, some day in the next week, or unmet (that is, met θ days
late).
 Constraint-4, Eq. (3.6) defines h as the sum of idle hours of all the non-
emergency ORs over one week.
 Constraint-5, Eq. (3.7) defines pj and qj, respectively, as the oversupply
and undersupply of non-emergency OR (idle) time to specialty j, relative
to a desired level determined by the percentage of total non-emergency
surgery demand for specialty j. More specifically, given the weekly total
of non-emergency OR idle hours, it is desired that each specialty occupies
the amount proportional to its share of the total non-emergency surgery
demand; pj and qj represent the difference between the actual allocation
and the desired level for specialty j.
 Constraint-6, Eq. (3.8) guarantees that at most s hours of emergency
demand is met in the emergency OR each day.
 Constraint-7, Eq. (3.9) ensures that specialty j is at most allocated cjk ORs
on day k.
 Constraint-8, Eq. (3.10) guarantees that the daily emergency OR capacity
allocated to each specialty does not exceed their emergency demand.
 Constraint-9, Eq. (3.11) is the non-negativity constraint on all the decision
variables.
 Constraint-10, Eq. (3.12) defines each xijk variable to be an integer.

11
3.8 SIMULATION MODELING

In reality, OR capacity and surgery demand are stochastic and/or

dynamic. Also, surgery demand is discrete in nature or measured by the number
of surgeries, instead of by hours as assumed in our MIP model. The degree in
which the randomness and discreteness of the variables impacts the optimality of
the template determined by the analytical model depends on the specific data or
the problem instance under consideration. Therefore, after obtaining the template
from the MIP model, a simulation model is used to assess the quality of the
template generated by the MIP. Also, since the MIP model strives to enhance the
robustness of the template by smoothing the OR capacity, the smoothing constant
or specifically the 𝛽 value be determined by testing in the simulation model
the templates resulting from different 𝛽 values(Zhang B, 2009).

The following features are included in the surgery simulation model.

 Each specialty has two queues waiting for surgery: inpatients and
outpatients. There is a single queue of all emergency patients who need
surgery. All ORs are modelled as servers in the queuing system and the
number of non-emergency ORs available to each specialty changes
throughout the week as determined by the template.
 All types of patient arrivals are modelled as renewal processes.
 Each specialty's inpatient, outpatient, and emergency patients‟ surgery
lengths are random variables fit from historical data. Pre-surgery set-up
time and post-surgery OR cleaning time, if significant, is also added to the
model (Spangler 2004).
 Emergency surgeries are performed in the emergency OR immediately as
long as it is available. If not, they are performed in an available non-
emergency OR allocated to that specialty. If no non-emergency OR of
the needed specialty is currently available, emergency patients wait
until the emergency OR or one of the respective specialty‟s non-
emergency OR becomes available. Each specialty‟s non-emergency
surgeries are only performed in the non-emergency OR(s) allocated to
them.

12
  Emergency patients have the highest priority to be served, then outpatients,
and lastly inpatients.
 In the case of inpatient surgeries, the simulation model has an “end-of-
shift” protocol. If there are 90 minutes or less remaining for the end of the
shift, then a search is done through each specialty‟s inpatient queue
(assuming that all of them have been prepped) to determine which patient
has a surgery time less than or equal to the remaining time before the
shift ends. If such a patient can be found, then he/she goes into surgery. If
not, the room remains unoccupied till the end of the shift.

3.9 PROPOSAL: POST-OPERATIVE CARE BEDS CAPACITY

CONSTRAINT

A new constraint taking into consideration the number of beds available in

post-operative care has been introduced.

𝑂 ∑𝑍 𝑢 ≤ 𝑃𝑂𝐶 ℎ𝑜𝑢𝑟𝑠 ∀𝑗 (3 13)

𝑗 𝑗 𝑗

Constraint-11, Eq. (3.13) states that the sum of the total non-emergency
demand and the demand that has been postponed to day k from l minus the non-
emergency demand that has been postponed from day k for a specialty j must be
less than or equal to the number of hours available on post-operative care.

13
 CHAPTER 4
CASESTUDY

4.1 DESCRIPTION

The Los Angeles County (LAC) General Hospital is used as a case study
to demonstrate the modelling approaches(excluding the proposed constraint).
LAC General Hospital is a large urban health centre serving a largely poor
population. It is also the trauma centre for central Los Angeles, with the
busiest emergency department, measured in admissions. Approximately 85% of
the patients admitted to beds in the hospital enter through the emergency
department.

4.2 SOLVING THE MODEL AND RESULTS

At the time of this analysis, Los Angeles County General Hospital was
using 19 operating rooms with 16 specialties and 1 emergency OR. The capacity
data and January 2005‟s demand data was fed into the MIP model and used
CPLEX 9.0 with default settings to solve the problem on a 3.2 GHz CPU with
2GB RAM.

Four different values (0, 0.5, 0.75, 1) of the smoothing constant (𝛽), and
the solver gave an optimal solution or a close-to-optimal solution in less than 2
hours of CPU time for all four scenarios. The weekly OR capacity allocations
for the actual template followed in January 2005 and for the four templates
determined by the MIP model (with different 𝛽 values) are shown in Table 4.1.

Template i: Actual Allocation

Template ii: Determined by MIP Model 𝛽 = 0
Template iii: Determined by MIP Model 𝛽 = 0.5
Template iv: Determined by MIP Model 𝛽 = 0.75
Template v: Determined by MIP Model 𝛽 = 1

In order to evaluate the different templates, a simulation analysis was

performed based on the features discussed in Section 3.8. AweSim! Version 3.0
(Pritsker and O‟Reilly, 1999) was used as the simulation software. In order to

14
develop the surgery simulation model, the operating room process of LAC
General Hospital was closely observed over a number of days. Furthermore, four
months of data from the hospital‟s information system was requested. The data
included admit date, discharge date, surgery start date and time, surgery end date
and time. Based on the data analysis, the emergency patient and inpatient
demands for each specialty were assumed to follow a stationary Poisson
Process. That is, the inter-arrival times of requests were modelled as exponential
random variables with mean equal to the inverse of the average daily demand. For
outpatients the daily demand for each specialty does depend on the day of week.
Thus, the average demand for each day was computed for each specialty type. In
this case, the arrival process for outpatients was modelled as a non-stationary
Poisson Process with the arrival rate changing in each day. Furthermore, the
surgery times were assumed to be lognormal random variables with a
constant 30 minute cleaning time after surgery. Prior studies (Spangler, 2004),
and the data analysis for LAC General Hospital shows that the lognormal
distribution is a reasonable model(Zhang B, 2009).

Table 4.1: OR capacity allocated to each specialty per week

Unit: OR hour Template Template Template Template Template
i ii iii iv v
Emergency 40 40 40 40 40
Burns 32 32 32 32 24
Cardiac 48 40 40 40 40
Colorectal 24 40 32 24 24
Foregut 16 16 16 16 16
HNS 88 80 88 88 88
Neuro 40 40 40 40 40
Ortho 192 160 168 176 184
Trauma 8 24 24 24 24
Tumor 24 24 24 24 24
Urology 40 40 40 40 40
GSNTE 16 40 40 40 40
Plastics 24 24 24 24 24
Hepatobiliary 24 24 24 24 24
Ophthalmology 80 72 72 72 72
OMFS 32 32 32 32 32
Vascular 24 32 24 24 24

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 The simulation results based on running the model for 100 weeks with a
warm-up period of 10 weeks are shown in Table 4.2. Template v yields the
shortest inpatients‟ length of stay waiting for surgery and also the smallest
standard deviation of non-emergency OR utilization. Notice that the function of
inpatients‟ average wait with respect to 𝛽 does not necessarily have a convex
structure due to many complicating factors.

Table 4.2: Summary of simulation results for different 𝛽 s

Template ii iii iv v
𝛽 0 0.5 0.75 1
Inpatients‟ Average Wait (day) 1.64 1.81 1.90 1.54
Standard Deviation of Non-Emergency OR Utilizations 14.56 10.63 10.39 9.80

Table 4.3 provides summary comparison of output statistics between the actual
template (i) and the best template generated by the model (v). The inpatients‟ average
length of stay waiting for their surgery reduces from 1.86 days in the scenario of
using the actual hospital template to 1.54 days when using the model‟s template. Also,
the emergency patients‟ average wait reduces by nearly 18% and all the other
performance measures stay relatively equivalent.

Table 4.3: Performance(simulation results) summary with the original demand

Template i v
Emergency Patients Average Wait(day) 0.62 0.51
Emergency Operating Room Utilization (%) 48.35 47.28
Inpatients Average Wait(day) 1.86 1.54
Outpatients Average Wait(day) 0.34 0.33
Average Non-Emergency Operating Room Utilization (%) 63.39 65.91

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 CHAPTER 5
CONCLUSION AND SCOPE FOR FUTURE WORKS

5.1 CONCLUSION

The researches done in medical fields are focused on developing

advanced technologies in equipment arena and in developing cures for diseases.
Scheduling and optimal allocation of available resources is an area which deserves
a look in especially considering the paucity of resources seen nowadays.

A mixed integer programming model was developed to determine optimal

operating room allocation to each specialty. A simulation analysis was used to
assess the performance of the operating room template. The methodology was
illustrated on a case example of Los Angeles County General Hospital, and the
analysis showed that the average patient‟s waiting time for surgery could be
reduced with an efficient allocation of operating room time.

5.2 SCOPE FOR FUTURE WORKS

The templates generated by the optimization model could perform poorly

in practice when there are high variances associated with surgery length and
volatile patient arrival patterns since the optimization model does not account for
uncertainty in the problem parameters. Therefore, future research can focus on
incorporating uncertainty into the analytical model. Also, since the problem sizes
were relatively small the MIP could be solved to optimality or near-optimality in
the scenarios performed in this study. However, for larger problem sizes
specialized algorithms or heuristics may be necessary in order to solve the model.
Also the model could be expanded to take into account staff shifts at the hospital.

Further, the feasibility of the proposed „Post-Operative Care‟ constraint

can be determined by solving the model using CPLEX and the performance can
be analyzed by simulating the new model.

17
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