Operating Rooms (ORs) Scheduling

ORs are one of the most precious and costly resources in a hospital, accounting for over
40% of both the hospitals revenue and cost according to the Health Care Financial
Management Association. It is thus crucial to optimise the scheduling of ORs in order to
ensure maximal efficiency by maximising OR utilization and minimising the waiting time of
patients.
The problems and decisions associated with ORs scheduling is threefold: (1) Case-mix
problem (CMP), (2) Time block problem (TBP) and (3) Surgery scheduling problem (SSP).

The case-mix problem (CMP)

The CMP refers to the process of determining the OR time allocated to each surgical team.
For simple illustration, we assume that there is currently only 1 OR which is operational for 8
hours a day, 5 days a week. If there are 5 surgical teams, then the CMP is concerned with
how this 40 hours of OR time can be distributed among these 5 teams. A sample allocation
is shown in the figure below.
Surgical team
Team 1
Team 2
Team 3
Team 4
Team 5

Allocated hours (40 available hours)

12
10
10
4
4

The actual decision behind the CMP is determined through a simulation software. The
objective function that different hospital works towards is different. Some hospitals focus
more on the ultimate aim of improving OR utilisation, while others emphasize more on the
cost and revenue aspect. Since different team might specialise in different surgeries, the
revenue and cost associated will also be different.

The time block problem (TBP): Block scheduling

After the allocation of OR time, the TBP is concerned with how the OR time is distributed
across a time period (usually a week).The primary strategy adopted here is block
scheduling: the construction of predetermined time blocks, and then assigning teams to
these time blocks such that they achieve their total allocated hours. The decisions to be
made here include determining the optimal number of blocks, the length of each block, and
which team to assign to each block. Extending from the example in the CMP, an illustration
is shown in the figure below.
Mon
0800 0900
0900 1000
1000 1100
1100 1200
1200 1300
1300 1400
1400 1500
1500 1600
1600 1700

Tues

Wed

Thurs

Fri

T5

T1

T1
T1

T4
T3

T2

T1
T3

T3

T2

T2
T3

The benefits of block scheduling include the reduction of setup time due to the possibility of
scheduling multiple similar surgeries in a single time block. This is under the assumption that
these surgeries would largely utilise the same equipment. Another upside to block
scheduling is the potential reduction in idle time. If a surgery took less time than expected,
then the subsequent patient can begin at an earlier time.
It is important to recognise that there also exists a possibility of a surgery ending much later
than estimated. In this case, under the structure of block scheduling, there might not be
enough time left in the block to accommodate the subsequent patient. This might mean the
cancellation of the surgery, thus postponing it to a much later date.
TBP Alternative: Open scheduling
An alternative strategy to block scheduling is open scheduling. As the name suggests, the
use of fixed block time is abolished, and no time slots can be reserved for a particular team.
Sometime before the week (usually a few months), the surgical teams are able to register
the time slot and date that they wish to take up, after confirming the availability of the patient.
This is done on a first-come-first-serve basis (FCFS) each team is free to register any time
slots which have not yet been taken up by another team. The teams are able to register any
number of hours they wish, allowing them to take into account the probability that the
surgery might end earlier or later. The total hours that they can take up is subjected to their
assigned hours from the CMP.
Open scheduling offers additional flexibility to the surgical teams. To further address the
shortcomings of the block scheduling strategy, below are various potential improvements
that could be made to the open scheduling approach.

Open scheduling improvement : Assign across a week rather than a single day
Instead of directly arriving at a final surgery date with the patient, it might prove to be more
efficient to the hospital if the team first confirms with the patient a week where the surgery
would be scheduled to take place. A month prior to the planned week, the hospital
operations team can then consolidate all the surgeries that are scheduled for that week and
then allocate the time block for each surgery. When this information is disseminated to the
teams, then the patient can be notified accordingly.
Mon
0800 0900
0900 1000
1000 1100
1100 1200
1200 1300
1300 1400
1400 1500
1500 1600
1600 1700

T1

T2

Tues

Wed

T4

Thurs

Fri

T5

T1

T1
T3
T4

T1
T3

T2

T2
T3

This modification helps to minimise the potential idle time that could result with open
scheduling. To illustrate, suppose that after rounds of registration, the only open time blocks
left are Monday 1600-1700 and Tuesday 1100-1200. If there exists an additional demand for
1 more surgery which is expected to take 2 hours, then it would be rejected as there are no
eligible time blocks. With the improvement proposed, the schedule above can be rearranged
such that there would be no more empty time blocks.

Open scheduling improvement: Mixed scheduling

This strategy draws from both block and open scheduling some time blocks are fixed,
while others are left open for registration. Fixed time blocks can be assigned to surgical
teams who are responsible for surgeries with a higher standard deviation in terms of time
needed. Some examples are more complex procedures such as heart and brain surgery.

The surgery scheduling problem (SSP)

This aspect of OR scheduling pans out in a 2-step process.
1. Assign each surgical case received by the team to a time block.
2. In the case where multiple surgeries are allocated to a single time block, the
sequence is determined.
To resolve step 1, the cases will be assigned on a FCFS basis to the earliest time slot that
both the team and the patient are available.
For step 2, traditional scheduling rules will be employed. This includes shortest processing
time (SPT), longest processing time (LPT) and longest waiting time (LWT). The effectiveness
of each rule differs from hospital to hospital, based on circumstantial factors as well as the
objective function(s) defined. The optimal rule to adopt can be derived from multiple
simulation runs in conjunction with linear programming.

Emergency department (ED) overcrowding due to boarding

This is a widespread and persistent issue that plagues most hospitals. The result is support
staff not being able to keep up with physicians and nurses having less time to focus on
individual patients. Mortality rates have also been shown to increase when the ratio of
nurses per patient decreases, while patients held in the ED until inpatient beds are freed up
have higher rates of morbidity and mortality.
Various improvements and practices have been implemented, but most of them focuses on
treating the symptoms of overcrowding rather than the causes. Some common solutions
undertaken include the construction of new facilities and the hiring of additional staff. These
simplistic measures often come with costs that very much eclipse the benefits that it can
bring. The root cause of ED overcrowding has been traced to the phenomenon of boarding
the practice of holding patients in the ED after they have been admitted to the hospital
because they are no inpatient beds available. The following improvements will thus serve to
minimize the effects of boarding.
http://www.commonwealthfund.org/publications/newsletters/quality-matters/2013/octobernovember/in-focus-improving-patient-flow
Moving the patients out of the ED
Patients can be moved out of the ED into common areas such as the cafeteria, conference
rooms or even hallways. The basis is that if each individual hospitals units share the burden
of caring for these patients, then the toll will be eased on the ED department. The personnel
at the ED department can then turn their focus on more pressing issues and divert their
attention towards the patients in dire needs.
Bedside registration
Many EDs seek to triage first, then register, and finally place patients in beds. If an empty
bed is available when the patient is first admitted to the ED, then the triage can be bypassed
altogether. This reduces the additional waiting time that could result from the traditional
process. A quick pre-registration procedure is required to support this solution, where a
simple set of identifiers is used to register the patients into the hospital electronic system.

Payment immediately after booking

This solution proposes that after making an appointment with the doctor, a patient has to go
to the counter immediately to pay his medical fees. He will be issued a ticket after payment,
and then return the ticket to the corresponding department to confirm his appointment.