a r t i c l e i n f o a b s t r a c t
Article history: Overcrowding of hospital wards is a wellknown and often revisited problem in the literature, yet it ap
Received 13 July 2016 pears in many different variations. In this study, we present a mathematical model to solve the problem
Accepted 18 January 2017
of ensuring sucient beds to hospital wards by redistributing beds that are already available to the hos
Available online 23 January 2017
pital. Patient ow is modeled using a homogeneous continuoustime Markov chain and optimization is
Keywords: conducted using a local search heuristic. Our model accounts for patient relocation, which has not been
OR in health services done analytically in literature with similar scope. The study objective is to ensure that patient occupancy
Queueing is reected by our Markov chain model, and that a local optimum can be derived within a reasonable
Markov chain runtime.
Stochastic optimization
Heuristics Using a Danish hospital as our case study, the Markov chain model is statistically found to reect occu
pancy of hospital beds by patients as a function of how hospital beds are distributed. Furthermore, our
heuristic is found to eciently derive the optimal solution. Applying our model to the hospital case, we
found that relocation of daily arrivals can be reduced by 11.7% by redistributing beds that are already
available to the hospital.
2017 Elsevier B.V. All rights reserved.
homogeneous continuoustime Markov chain, and optimize the mathematical programming elaborately, leaving this area rather
response using a local search heuristic. unexploited. In Pinto et al. (2014), a simulationoptimization
In Section 2 we present the specic problem of this study. In model is developed to analyze dynamic features of the sys
Section 3 our solution approach is presented, divided into two tem and nd the best conguration of beds. Moreover, Li et al.
parts. The rst part describes the Markov chain, we use to model (2009) applied a M/PH/c model from Gorunescu et al. (2002a) in a
patient ow behavior. The second part connects this Markov chain multiobjective goal programming model to reallocate beds.
model to a local search heuristic. Section 4 demonstrates the Two studies in the area of capacity balancing that are rather
usability of our solution approach for a specic hospital case, and similar to this paper, are uncovered (Cochran & Bharti, 2006;
tests on a number of different parameter settings are presented. Cochran & Roche, 2008). However, in case of overcrowding, none
Lastly, we present our conclusion in Section 5. of these studies modeled the effect of patients being relocated
to alternative locations. In this paper, we present an approach
1.1. Literature review to balance capacity in a system of queues, where patients are
relocated when capacity is insucient. To achieve this, we use a
Modeling and optimization of hospital bed utilization is a
homogeneous continuoustime Markov chain model.
recurrent topic dating back to Newsholme (1932). The specic
A range of studies, using Markov chains to model patient ow,
problem structure differs from one study to another, however,
have already been conducted (Bartolomeo, Trerotoli, Moretti, &
all focus on one of three major objectives: (1) testing scenarios Serio, 2008; Broyles, Cochran, & Montgomery, 2010; Deng, Deng,
(Akkerman & Knip, 2009; Goldman, Knappenberger, & Eller, 1968),
Deng, Liu, & Liu, 2015; Xie, Li, Swartz, & Dong, 2013; Zhang
(2) deriving the required number of beds for one or more wards
et al., 2013). As relevant examples, Broyles et al. (2010) predicts
(Gorunescu, McClean, & Millard, 20 02a; 20 02b; Green, 20 02; distribution and expected admissions, and Bartolomeo et al.
Harris, 1984; Pendergast & Vogel, 1988; Pinto, Cardoso de Campos,
(2008) determines the probabilities of readmission for two dif
Oliva Perpetuo, & Neves Marques Barbosa Ribeiro, 2014; Zeraati,
ferent patient categories. However, none of these exploit the
Zayeri, Babaee, Khanafshar, & Ramezanzadeh, 2005), or (3) balanc advantages of Markov chains, to model patient relocation, and
ing beds with demand (Cochran & Bharti, 2006; Cochran & Roche,
subsequently use these models to optimize the system.
2008; Li, Beullens, Jones, & Tamiz, 2009). In achieving these, two
methodological aspects are considered: (1) the methods used to
model the system in focus, and (2) the methods used to study and 2. Problem description
optimize the system.
Different approaches of modeling the system are known from In this study, we consider a Danish hospital where an organiza
the literature. These are usually either simulation (Goldman tional structure for patient relocation has been fully implemented.
et al., 1968; Harris, 1984; Zeraati et al., 2005), queueing theoretic That is, even though minor changes in the distribution of
approaches (Cochran & Roche, 2008; Gorunescu et al., 2002a; resources might take place on a daily basis, most actions to avoid
20 02b; Green, 20 02; Li et al., 2009; Pendergast & Vogel, 1988), overcrowding are performed using patient relocation. Any greater
or a mixture of these (Akkerman & Knip, 2009; Cochran & Bharti, changes in the distribution of resources are not practical if they
2006; Pinto et al., 2014). occur too frequently, and are thus considered more as a tactical
In Goldman et al. (1968), utilization and costs are tested for decision. Deciding on the best allocation of resources, is therefore
various bed allocation policies using a simulation model. Harris an important decision, as the result will affect how patients are
(1984), develops a simulation model to assist decision making in hospitalized, and the hereto related costs, through a period of
the area of operating theatre time tables and the resultant bed re several months.
quirements. Lastly, Zeraati et al. (2005), use a statistical simulation For this reason, the decision this study will focus upon, is
to estimate the number of required beds for an obstetrics ward. how resources should be allocated among the hospital wards.
In the area of queueing theoretic models, two studies by As hospitalizations are usually dependent on a range of different
Gorunescu et al. (20 02a; 20 02b) and Li et al. (20 09), exploit resources, we assume that one hospitalization can only take place
M/PH/c/N and M/PH/c models, to assess a mixture of patient ow. when one suciently staffed and equipped bed is available. That
Furthermore, Green (2002), use an M/M/s model to estimate bed is, we disregard the possibility that a hospitalization may in some
availability in different intensive care and obstetrics units, and instances take place without sucient staff or equipment. Thus, if
Pendergast and Vogel (1988), use clinical judgment and basic an entrance to a ward is restricted by the lack of resource units,
probability theory to derive future hospital bed requirements. we assume that an alternative ward always exists somewhere else.
Lastly, Cochran and Roche (2008), develops a queueing network We have found through interviews with hospital employees that
model that is implemented as a capacity balancing tool between this is a reasonable assumption.
different hospital units. Taking all of the above considerations into account, the overall
Exploiting the use of both simulation and queueing theory, goal of this study, is to develop a mathematical model that can be
Cochran and Bharti (2006) use queueing networks to assess the used to eciently minimize the number of rejections at preferred
ow between units of an obstetrics hospital, and dene utiliza wards, by changing the distribution of bed resources.
tion targets. A DiscreteEventSimulation model is then used to For the remaining of this paper, a patient hospitalization at
maximize the ow. A related approach is used in Akkerman and a preferred ward, will be denoted as a primary hospitalization. A
Knip (2009), where Markov chain theory and simulation is used patient relocation to an alternative ward, will be denoted as a
to evaluate a number of different management scenarios. This secondary hospitalization. In the same way, patient blocking at a
specic Markov chain model is found to produce useful insight preferred ward, is denoted a primary rejection, as well as patient
into the theoretical number of required beds, but a simulation blocking at the alternative ward is denoted a secondary rejection.
model is required to derive the amount of patient rejections.
The second methodological aspect that is considered in most 2.1. Dynamics of the system
studies, is studying and optimizing the system in focus. Naturally,
scenario testing is more straightforward, whereas bed requirement As mentioned above, wards have limited resources, and as a
or capacity balancing would suggest the application of a more result, arriving patients are relocated whenever resources have
elaborate approach. Here, we found only a few studies (Li et al., been depleted (no staffed and equipped beds are available). During
2009; Pinto et al., 2014) that exploit advantages of heuristic or such a relocation, patient characteristics are required to match
1154 A.R. Andersen et al. / European Journal of Operational Research 260 (2017) 11521163
presented for = 0.05, 0.01 and 0.001. f(M1 , M2 , . . . , MN1 ), with the derivative of B(Mi , i /i ) pre
Each of these settings were assessed by comparing the respec sented in (10) in the Appendices. The horizontal tangent plane
tive marginal distributions of that is, the distribution of how of f(M1 , M2 , . . . , MN1 ) can then be found from the system of
many beds are expected to be occupied for each ward. Obviously, equations: fM1 ( ) = 0 fM2 ( ) = 0 fMN1 ( ) = 0. We solve
the tails approach zero as the truncation is relaxed. However, the this, using the NewtonRaphson method.
algorithm only takes 69 seconds to nish for = 0.05, against Now, recall that the difference between (6) and (7), is the
1947 seconds for = 0.001. Additionally, in case we are only relocation of patients from fully occupied to free wards. Therefore,
interested in the blocking probabilities, we would be able to make as the probabilities p()ij from the CTMC model decrease, (6) ap
do with the largest truncation value given that we always end proaches (7). In other words, an optimal solution derived using
up with a CTMC model representation where U j = M j j I. (7) is likely close to the optimal solution using (6). To locate the
However, to gain a more generic use of our model, we nd it more optimal solution to the optimization problem (5a)(5c), an idea
appropriate to use = 0.01. would therefore be to slowly change the solution conguration,
starting with an initial guess derived from the estimate (7).
Let N(M) dene the neighborhood of the bed distribu
3.2. A heuristic optimization model
tion M, and still consider that MN = iI\{N} Mi , so now
In Section 3.1 we presented an approach to model the ward M = (M1 M2 . . . MN1 )T . Then, (M + ) N (M ), where
= 1
occupancy for N wards and correspondingly N patient types. We and the elements i {0, 1, 1}. This leads to a maximum neigh
now consider the number of beds, available to ward i, Mi , as a de borhood size of N (M ) = N 2 1 or O(N2 ). Hence, in case N = 3,
cision variable that may be adjusted to optimize the overall system N (M ) = 32 1 = 8 solutions.
performance. In general, we consider the following optimization Consider if M is the currently best known solution to (5a)(5c),
problem: then an idea would be to systematically check N(M ) for an even
better solution, and update M in case such a solution is found.
min. f (M ) (5a) This leads to the local search heuristic presented in Algorithm 2.
being occupied in ward i, with beds distributed as in M. In this 12: if f < f then
case, we would get some kind of measure for the total amount 13: f f Update values
of work recall when iB (M ) increases, so does the amount of 14: M M
relocated patients from ward i. However, the expression does not 15: N generateneigh(M ) Generate the new
incorporate the weight of patient types arriving with different neighborhood, again in random order
rates. So we insert i , to get (6), the total expected number of 16: j0
primary rejections. 17: end if
18: end if
f (M ) = i iB (M ) (6) 19: end while
iI 20:
Patient type 1
1.0
Patient type 2
0.8 Patient type 3
Arrivals pr. hour
0.6
0.4
0.2
0.0
Fig. 3. Empirical hourly arrival rate. Presented for each of the three patient types.
the function init() that, based on the NewtonRaphson method, thus also treatment type, giving us the opportunity to determine
takes an initial guess M0 . The raw output is most likely not preferred and alternative wards.
integral, so we round to the integer solution yielding the lowest
objective value. Next, the currently best known objective value, f ,
is calculated. 4.1.1. Arrival rates
Then, generateneigh() is used to generate a list of the entire Patient hospitalization data was used to derive hourly arrival
neighborhood. For larger cases, a probabilistic candidate list might rates for each of the three patient types, showing clear repetitive
be more appropriate, choosing a random fraction of the solutions patterns on a weekly scale of the hourly arrival rate. In Fig. 3, the
in N(M). Elements of the list should in any case be placed in empirical hourly arrival rates are presented for all patient types.
random order. As expected for nonacute wards, most patients are hospitalized
Due to the local progression of the heuristic, and a relatively during the daytime, whereas an almost negligible fraction of
long function evaluation time, we further introduce a list of patients arrive during the night. Further, the arrival rates seem to
banned solutions, C. As the heuristic can only move one step at a slightly decrease during the weekend, and regain its level starting
time, there will always be an overlap between the neighborhood Monday. The empirical average arrival rates were estimated to
of iteration k and k + 1. For this reason, we add all previously 1 = 5.42, 2 = 3.96, 3 = 2.52 patients per day, respectively.
evaluated solutions to a list (line 10, Algorithm 2), to ensure that
we do not spend time on evaluating a solution more than once.
4.1.2. Service rates
4. Implementation and results To derive service rates for each of the three patient types,
we calculated the Length of Stay (LOS) using the same patient
In this section, we directly implement the methods from hospitalization data, as was used to derive the arrival rates. Time
Section 3 to obtain an improved distribution of beds for a case dependency was checked on a daily level by deriving the average
hospital. In modeling the system behavior, we have limited our hourly LOS from time of arrival. Performing a graphical representa
scope to the hospitalization of patients to the medical area of the tion showed no signs of seasonality, neither did an estimate of the
hospital. More specically, we focus on patient ow in gastrology, autocorrelation function. Regarding loaddependency, we did not
pneumology, endocrinology and geriatrics, respectively. For the obtain sucient data to conrm nor reject such behavior. For the
case hospital, these areas make up three different wards and casehospital, capacity meetings are often held to ensure that pa
correspondingly three different patient types. tients are immediately relocated upon blocking. As a result, neither
In Section 4.1, we present the data obtained from the case LOS increase nor earlydischarge due to overcrowding is rarely the
hospital and statistically test our homogeneous continuoustime case. The overall distribution of LOS was investigated graphically,
Markov chain (CTMC) model. Next, Section 4.2 presents the where the patient type 1 and 2 distributions show close similarity
implementation of our solution approach. Lastly, we assess the to an exponential distribution (See Fig. 4). With a longer average
robustness of Algorithm 2, and investigate the solution behavior LOS, the patient type 3 distribution has probability mass that is
when the CTMC model parameters are adjusted. This is presented moved more to the right, quite similar to a gamma distribution.
in Section 4.3. Due to the similarities that was found between patient type 1
and 2, we tested their difference in mean LOS using a Wilcoxon
4.1. Case and data description ranksum test (WILCOXON, 1945). With a pvalue of 0.2105, we
found no signicant difference in mean LOS between the two pa
The patient ow was investigated through interviews with tient types. Fig. 4 suggests that there is no difference in statistical
hospital staff. Furthermore, we retrieved data from the period of distribution either. For patient type i {1, 2, 3}, the resulting ser
01052014 to 30042015 on patient arrival and discharge times. vice rate (1/LOSi = i ) was estimated based on an empirical aver
From this, we were able to categorize patients on diagnosis and age to 1 = 2 = 0.19 and 3 = 0.11 patients per day, respectively.
1158 A.R. Andersen et al. / European Journal of Operational Research 260 (2017) 11521163
0.15
Patient type 1
Patient type 2
Patient type 3
0.10
Density
0.05
0.00
0 4 8 12 16 20 24 28 32 36
Length of Stay (days)
Fig. 4. Empirical distribution of length of stay, measured in number of days. Presented for each of the three patient types.
Table 2 ing the timedependency of hourly arrival rate and discharge hour
Probability that patient type i {1, 2, 3} (Pi ), is relocated to ward j {1, 2, 3} (wi ),
into account might be necessary for purposes of accurately predict
in case ward i is blocked.
ing the occupancy for each specic hour of the week. However, as
Pi /w j 1 2 3 Other our aim is to derive a longterm allocation of beds for the hospital,
1 0.05 0.23 0.72
we consider the observed uctuations as negligible for this case.
2 0.10 0.27 0.63
3 0.06 0.00 0.94
4.1.5. Truncation of the CTMC
For practical reasons we are often required to truncate
the CTMC prior to implementation. We start this process by
4.1.3. Relocations rstly considering the data obtained from the casehospital. In
We investigated the secondary hospitalization options for each Section 4.1.2 we found that 1 = 2 ; hence the number of pa
of the three patient types. From data, we obtained the 80% most tients of type 1 and 2, can be contained in only two bins of the
common diagnoses for each patient type, and for each of these state space. In other words, w11 and w12 are merged into w121 ,
diagnoses, hospital staff identied the alternative locations they as well as w21 and w22 are merged into w122 . Moreover, from
would usually offer to these patients. This allowed us to draw a Table 2, we have that p( f1 , f2 , f3 )32 = 0 in all cases, so w32 can be
picture of how relocated patient are usually distributed. Here, we neglected. This results in the state representation:
found that patients have secondary hospitalization options both
within and outside the three wards; hence, in case of blocking, a w121 w13
fraction of patient will always be lost from the system. Moreover, s= w122 w23 , ( f1 , f2 , f3 ) S
we found that patients would usually have a third hospitalization w31 w33
options however, for this case, we found it reasonable to assume
Now we apply the truncation procedures described in
that a third hospitalization options is always situated outside the
Section 3.1.1. We use the truncation parameter = 0.01, as
system. The resulting relocation probabilities are presented in
proposed in Section 3.1.2. For the casehospital, the total number
Table 2, showing that a reasonably large fraction of patients has to
of beds = 74, so we calculate uij , Lj and Uj for any feasible value
be relocated elsewhere.
of M j {0, 1, . . . , (N 1 )} j J = {1, 2, 3}.
To illustrate the resulting truncation, the total state space
4.1.4. Other characteristics of the system size, S, for a nontruncated model with N = 3 wards, where
From the distinct uctuating arrival rate, one would naturally M1 = 27, M2 = 23 and M3 = 24 has S = 30, 876, 300, 000 states.
u
expect the level of hospitalized patients to be uctuating as well. The truncated model, with the same settings, has S = ( i 31 (U1
Fig. 5 shows the empirical probability of a patient being discharge u13 min{U3 i;u23 }
i max{L1 1; 0} + 1 ))(U2 L2 + 1 )( j=0 k=0
(U3 j
as function of hour of the week. As expected for nonacute pa
k max{L3 i j; 0} + 1 )) = 1, 358, 760 states a substantial
tients, discharges mainly occur on weekdays during the daytime,
reduction of the state space.
with a negligible number of patients discharged during the night.
Comparing with the arrival rates in Fig. 4, we notice that the
system is mainly active between 07:00 and 23:00. 4.1.6. Statistical testing of the CTMC
Observations from 14092015 to 31102015 were obtained We conducted a statistical test to assess the CTMC model
to investigate the timedependent behavior of ward occupancy in tness with observations on ward occupancy. To our knowledge,
the system. Fig. 6 shows the average number of occupied beds there exists no standard technique to test the tness of a CTMC
every 8th hour during the week. From here, we notice some time with a complexity as considered in this study. Thus in this section
dependent behavior as the occupancy is usually lower during the we present a heuristic approach that combines a simulation of
middle of the day. This behavior repeats on a daily basis, with a the CTMC behavior and compare this to hospital data on ward
small overall decrease during the weekend for wards 2 and 3. Tak occupancy.
A.R. Andersen et al. / European Journal of Operational Research 260 (2017) 11521163 1159
Patient type 1
0.10
Patient type 2
Patient type 3
0.08
Probability
0.06
0.04
0.02
0.00
Fig. 5. Empirical probability of a patient being discharged as function of hour of the week. Presented for each of the three wards.
Fig. 6. Empirical average number of occupied beds for each of the three wards. Observations were obtained for every 8th hour of the week.
To begin with, our nullhypothesis is that the observed values our CTMC model, we require a measure of how (8) relates to the
are generated by the CTMC process. If that is the case, we would model noise. For this reason, we introduce the simulated model
expect the observed frequency of occupied beds to be quite residual (9), where yij is the simulated frequency of i occupied
similar to the marginal distributions of for each ward. A stan beds in ward j. Thus, by replicating (9), we determine the distri
dard approach would be to test the observed frequencies against bution of noise that is expected by our CTMC model, and then
the corresponding expected frequencies from the CTMC using a compare our results from (8) hereto.
chisquared test. However, such as test would require each of the
z= (yi j ei j )2 / j (9)
observed values to be independent, which is not the case here.
jJ iI
Let j be the expected number of occupied beds from the
M j We implemented the simulation of the CTMC model as a Discrete
CTMC for ward j J, where J = {1, 2, 3}. Then j = k=0 k k j ,
EventSimulation using Matlab. Replications of (9) were con
where kj is the probability that ward j J has k occupied beds.
ducted n = 30, 0 0 0 times (Fig. 7).
Further, let oij and eij be the observed and expected frequency of i
A total of 432 (144 pr. ward) observations were obtained from
occupied beds in ward j. Then, we dene our test statistic as (8),
the period of 14092015 to 31102015. Using these, we calculated
T = (oi j ei j )2 / j (8) T = 0.45. A fraction of 32.03% simulated residuals, scoring higher
jJ iI
than T, were found. Thus, with a signicance level of = 0.05, we
accept the nullhypothesis.
where I = {0, 1, 2, . . . , M j } is the set of beds that can be occupied, The power of our test was evaluated by conducting a range of
and J = {1, 2, 3} the set of wards. In order to quantify the t of experiments where model parameters were adjusted until under
1160 A.R. Andersen et al. / European Journal of Operational Research 260 (2017) 11521163
4000
3000
Frequency
2000
1000
0
Table 5
Test parameters used to assess Algorithm 2. Parameters subject to change are pre
sented in bold font.
# 1 2 3 p13 p23
10
20
5
evaluations that are avoided as a result of the list of banned
0
40 solutions are presented in the second last column.
Giving the ve tests a closer look, we expect for Test 13 that
0
20 60 an increase in arrival rate results in a corresponding increase in
40 M2 allocated resources. This behavior is found for each of the three
60
80
tests, where resources are allocated to respond to the increased
M1 80 demand for primary hospitalizations.
Fig. 8. Complete enumeration of the search space for the current distribution of In Test 4 nothing was changed but the total amount of avail
beds. able beds . We conducted this test, to assess the potential
improvements caused by a relatively small increase in resources.
Table 4 We nd that, as more resources are available in the system,
The optimal solution compared to the current distribution of beds. Presented with additional surplus is created and the fractional distribution of
objective values, f(M), beds Mi and blocking probabilities iB . The product i iB
beds between the wards is more balanced. In the original hospital
shows the expected daily amount of primary rejections for each ward.
case, the optimal fractional distribution was 43.2%, 32.4% and
Ward Current Optimal 24.3% for ward 1, 2 and 3, respectively. In Test 4 with = 80, this
Mi iB i iB Mi iB i iB distribution changes to 42.5%, 31.3% and 26.3%. More importantly,
as all wards receive more bed resources, the objective value is
1 27 0.178 0.969 32 0.083 0.454
reduced correspondingly. Adding six additional beds yields a 38.9%
2 23 0.109 0.430 24 0.084 0.335
3 24 0.161 0.405 18 0.318 0.803 reduction in the number of primary rejections.
f(M) 1.804 1.592 Test 5 was conducted to assess the effect from relocation in the
system on the optimal solution. To emphasize, we increased the
demand for secondary hospitalizations in ward 3 substantially, by
maximizing p( f1 = 0 )13 and p( f2 = 0 )23 , keeping all other param
patients per day, the optimal solution yields a 11.77% reduction in
eters xed. Through these adjustments, we expect to increase the
number of primary rejections. We notice for the current case, the
distance from initial to optimal solution. Moreover, we clarify how
highest probability of ward blocking, iB , takes place in ward 1.
the optimal solution relates to a large probability of relocation
Unfortunately, we nd that patient type 1 has the highest arrival
within the system. Interestingly, it might seem natural to allocate
rate of 5.42 patients per day as well. Thus, it would be expected,
beds to the ward with an increased demand (ward 3), however
in order to minimize f(M), additional resources has to be pushed
the optimal solution reveals the objective value is minimized by
to ward 1 with a view to decrease 1B . Conversely, patient type
moving beds to wards 1 and 2, and avoiding relocation in the rst
3 has the lowest arrival rate of 2.52 patients per day, and with
place.
3B = 0.161, ward 3 is expected to reject 0.41 patients per day
0.56 patients fewer than for ward 1. Turning to the optimal solu
tion, we nd the probability of rejection has been vastly increased 4.3.1. Assessment of expected hospital changes
for ward 3, but decreased for both ward 1 and 2. Further, we nd For our last test, we consider a number of organizational
that maxiI {i iB } has been decreased from 0.969 to 0.803 patients changes planned to be introduced in the spring of 2016. Patients
of another organizational region are to be rerouted to the case
per day, and miniI {i iB } decreased from 0.405 to 0.335 patients
hospital. As a result, patient arrival rate is expected to increase.
per day.
Moreover, the case hospital are given additional resources to
cope with the increase in demand, and for the area of gastrology,
4.3. Case testing pneumology, endocrinology and geriatrics, available resources will
increase from 74 to 93 beds. Patient arrival rate of type 1 and 2
With a view to investigate the solution behavior of our are now expected at 9.84 and 3.44 patients per day, respectively.
heuristic, we conducted a series of tests with various parameter Just as previously, we generate the initial solution, starting
adjustments. The hospital is planning to introduce a number of with M0 = (27 23 )T . Rounding to the smallest estimated objective
organizational changes, with the result of increased patient arrival value, we set M = (56 20 )T and initial objective value f = 1.965.
rate, but additional overall bed capacity. Thus in our last test, we After 4 iterations we nd the new distribution of beds at M1 = 56,
demonstrate how our approach may be used as a tool to assess M2 = 21 and M3 = 16, with an objective value of f = 1.958 pa
future changes to the organization. tients per day. The total number of function evaluations is 9 with
We conducted a total of ve different basic tests, where patient an overall runtime of 961.35 seconds.
ow or available resources were changed. In Table 5 the param
eters that were subject to change are presented in bold font, the 5. Conclusion and future work
rest are from the hospital case.
The results for each of Test 15 are presented in Table 6, with With a view to optimizing the distribution of bed resources,
rstly the initial solution, then the optimal solution, and lastly we presented a solution approach consisting of two main compo
data on the heuristic progression. The total number of function nents. The rst was a homogeneous continuoustime Markov chain
1162 A.R. Andersen et al. / European Journal of Operational Research 260 (2017) 11521163
Table 6
Results from the ve parameter adjustment tests. Both initial and optimal solutions are presented. Information on the heuristic progression is presented in the last four
columns.
# Initial Optimal
(CTMC) used to evaluate the patient ow behavior. The second 5.1. Future work
incorporated the Markov chain model in a heuristic to optimize
the distribution of bed resources. For a specic hospital case, our For future work, a larger number of wards should be consid
approach was used to nd a 11.8% reduction in number of primary ered. We notice that such an expansion would require a substantial
rejections that is, the number of patients rejected on rst arrival increase in state space, possibly reducing the practical use of our
to the hospital. In addition, we found that a relatively small modeling approach. It should be considered how other methods
( 8%) increase in bed resources to the medical area has a po could help to support the CTMC model approach with a view to
tential to reduce this rejection rate from the current conguration decrease runtime spend on function evaluations. Moreover, as the
with 38.9% fewer patients per day. Regarding this, hospital man problem complexity grows, other local search techniques, such as
agement should consider how the increase in resources relates to Tabu Search, might be more suitable approaches.
the overall cost, and if a potential increase in cost is compensated Lastly, to further support our modeling approach, simulation
by the increased service level. experiments should be conducted to assess the nature of the
We collected data for the casehospital by conducting inter system under different parameter settings, as well as the CTMC
views with hospital staff, and using patient data already registered robustness to different interarrival and service time distributions.
in the hospital system. During this process we found dependencies
in the ow system that stretches toward far more wards than Acknowledgments
were resources to include in this study. On the other hand, we
found it reasonable to assume the medical area as an isolated This research was supported by the Danish governmental
system with patients going out, rather than in from other wards. organization Region Sjlland. The managing organization of seven
Hourly arrival rate was found to be timedependent, but with public hospitals located on Zealand and Falster. We particularly
discharges mainly occuring during the day, the timedependent thank the department of Production, Research and Innovation for
behavior could be neglected, as was conrmed from observations providing us with the necessary data to conduct this research.
of ward occupancy. Additionally, we found it reasonable to assume In addition, we would like to thank Senior Project Manager,
that patient length of stay was independent of the system load. Pernille Kirkvg for providing us with essential information on
However, for other applications where loaddependency cannot be patient ow, as well as Associate Prof. Anders Stockmarr for
neglected, such behavior can be implemented by dening service statistical advice.
rates of the CTMC as function of the ward occupancy.
We statistically tested the CTMC model by replicating sim Appendices
ulations of the CTMC itself. These were compared to hospital
observations, and a simulated pvalue of p = 0.32 was derived. We Derivative of the ErlangB formula,
i Mi+1 i Mi i
i Mi M +1 M
dB (Mi + 1 ) i G32,,03 1,1

0,0,Mi +1 i
i + (Mi + 1 ) (Mi + 1 ) ln ii i ii i ii i i i
i
= i +1 M 2 (10)
i
(Mi + 1 ) + i ii i Mi + 1, ii (Mi + 1 )
dMi M
ei /i Mi !
i
i i
Bartolomeo, N., Trerotoli, P., Moretti, A., & Serio, G. (2008). A markov model to eval Li, X., Beullens, P., Jones, D., & Tamiz, M. (2009). Optimal bedallocation in hospi
uate hospital readmission. BMC Medical Research Methodology, 8(1), 23. doi:10. tals, Lecture Notes in Economics and Mathematical Systems: 618 (pp. 253265).
1186/1471 2288 8 23. Springer, Berlin. doi:10.1007/978 3 540 85646 7_24.
Boucherie, R. J., & van Dijk, N. M. (2011). Queueing networks: A fundamental ap Newsholme, H. (1932). Hospital bed accommodation. Public Health The Journal of
proach. Springer. doi:10.1007/978 1 4419 6472 4. the Society of Medical Ocers of Health, 46, 7377. doi:10.1016/s00333506(32)
Broyles, J. R., Cochran, J. K., & Montgomery, D. C. (2010). A statistical markov chain 800417.
approximation of transient hospital inpatient inventory. European Journal of Op Pendergast, J. F., & Vogel, W. B. (1988). A multistage model of hospital bed require
erational Research, 207(3), 16451657. doi:10.1016/j.ejor.2010.06.021. ments. Health Services Research, 23(3), 381399.
Cochran, J. K., & Bharti, A. (2006). Stochastic bed balancing of an obstetrics hospital. Pinto, L. R., Cardoso de Campos, F. C., Oliva Perpetuo, I. H., & Neves Marques Barbosa
Health Care Management Science, 9(1), 3145. doi:10.1007/s10729 006 6278 6. Ribeiro, Y. C. (2014). Analysis of hospital bed capacity via queuing theory and
Cochran, J. K., & Roche, K. (2008). A queuingbased decision support methodology simulation. (pp. 12811292). doi:10.1109/WSC.2014.7019984.
to estimate hospital inpatient bed demand. Journal of the Operational Research Sinreich, D., Jabali, O., & Dellaert, N. P. (2012). Reducing emergency department
Society, 59(11), 14711482. doi:10.1057/palgrave.jors.2602499. waiting times by adjusting work shifts considering patient visits to multiple
Deng, X., Deng, Y., Deng, X., Liu, Q., & Liu, Q. (2015). Newborns prediction based on care providers. IIE Transactions Industrial Engineering Research and Development,
a belief Markov chain model. Applied Intelligence, 43(3), 473486. doi:10.1007/ 44(3), 163180. doi:10.1080/0740817X.2011.609875.
s1048901506679. Stewart, W. J. (2009). Probability, Markov chains, queues, and simulation The math
Goldman, J., Knappenberger, H. A., & Eller, J. C. (1968). Evaluating bed allocation pol ematical basis of performance modeling (1st). Princeton University Press.
icy with computer simulation. Health Services Research, 3(2), 11929, 119129. Wilcoxon, F. (1945). Individual comparisons by ranking methods. Biometrics Bulletin,
Gorunescu, F., McClean, S. I., & Millard, P. H. (2002a). A queueing model for bedoc 1(6), 8083.
cupancy management and planning of hospitals. Journal of the Operational Re Xie, X., Li, J., Swartz, C. H., & Dong, Y. (2013). Modeling and analysis of hospi
search Society, 53(1), 1924. tal inpatient rescue process: A Markov chain approach. In Proceedings of IEEE
Gorunescu, F., McClean, S. I., & Millard, P. H. (2002b). Using a queueing model to international conference on automation science and engineering (pp. 978983).
help plan bed allocation in a department of geriatric medicine. Health Care doi:10.1109/coase.2013.6653987. 6653987.
Management Science, 5(4), 307312. doi:10.1023/a:1020342509099. Zeraati, H., Zayeri, F., Babaee, G., Khanafshar, N., & Ramezanzadeh, F. (2005). Re
Green, L. (2002). How many hospital beds? Inquiry The Journal of Health Care Or quired hospital beds estimation: A simulation study. Asian Network for Scientic
ganization Provision and Financing, 39(4), 400412. doi:10.5034/inquiryjrnl_39.4. Information. Journal of Applied Sciences.
400. Zhang, X. L., Zhu, T., Luo, L., He, C. Z., Cao, Y., & Shi, Y. K. (2013). Forecasting
Harris, R. A. (1984). Hospital bed requirements planning.. European Journal of Oper emergency department patient ow using markov chain. In Proceedings of 2013
ational Research, 25(1), 121126. 10th international conference on service systems and service management, ICSSSM
(pp. 278282). doi:10.1109/icsssm.2013.6602537. 6602537.
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