Budget Allocation for Permanent and Contingent Capacity under Stochastic Demand.

We develop a model of budget allocation for permanent and contingent workforce under stochastic demand. The level of permanent capacity is determined at the beginning of the horizon and is kept constant throughout, whereas the number of temporary workers to be hired must be decided in each period. Compared to existing budgeting models, this paper explicitly considers a budget constraint. Under the assumption of a restricted budget, the objective is to minimize capacity shortages. When over-expenditures are allowed, both budget deviations and shortage costs are to be minimized. The capacity shortage cost function is assumed to be either linear or quadratic with the amount of shortage, which corresponds to different market structures or different types of services. We thus examine four variants of the problem that we model and solve either approximately or to optimality when possible. A comprehensive experimental design is designed to analyze the behavior of our models when several levels of demand variability and parameter values are considered. The parameters consist of the initial budget level, the unit cost of temporary workers and the budget deviation penalty/reward rates. Varying these parameters produce several trade-offs between permanent and temporary workforce levels, and between capacity shortages and budget deviations. Numerical results also show that the quadratic cost function leads to smooth and moderate capacity shortages over the time periods, whereas all shortages are either avoided or accepted when the cost function is linear.Stochastic; Capacity planning; Contingent workers; Budget allocation; Non-linear stochastic dynamic programming; Optimization;

Strategic Nurse Allocation Policies Under Dynamic Patient Demand

ABSTRACT STRATEGIC NURSE ALLOCATION POLICIES UNDER DYNAMIC PATIENT DEMAND by Osman T. Aydas The University of Wisconsin-Milwaukee, 2017 Under the Supervision of Professor Anthony D. Ross Several studies have shown a strong association between nurse staffing and patient outcomes. When a nursing unit is chronically short-staffed, nurses must maintain an intense pace to ensure that patients receive timely care. Over time this can result in nurse burnout, as well as dissatisfied patients and even medical errors. Improved accuracy in the allocation of nursing staff can mitigate these operational risks and improve patient outcomes. Nursing care is identified as the single biggest factor in both the cost of hospital care and patient satisfaction. Yet, there is widespread dissatisfaction with the current methods of determining nurse staffing levels, including the most common one of using minimum nurse-to-patient ratios. Nurse shortage implications go beyond healthcare quality, extending to health economics as well. In addition, implementation of mandatory nurse-to-patient ratios in some states creates a risk of under- or over-estimating required nurse resources. With this motivation, this dissertation aims to develop methodologies that generate feasible six-week nurse schedules and efficiently assign nurses from various profiles to these schedules while controlling staffing costs and understaffing ratios in the medical unit. First, we develop and test various medium-term staff allocation approaches using mixed-integer optimization and compare their performance with respect to a hypothetical full information scenario. Second, using stochastic integer programming approach, we develop a short-term staffing level adjustment model under a sizable list of patient admission scenarios. We begin by providing an overview of the organization of the dissertation. Chapter 1 presents the problem context and we provide research questions for this dissertation. Chapter 2 provides a review of the literature on nurse staffing and scheduling specifically from the Operations Management journals. We introduce the challenges of nursing care and nurse scheduling practices. We identify major research areas and solution approaches. This is followed by a discussion of the complexities associated with computing nursing requirements and creating rosters. Staffing requirements are the result of a complex interaction between care-unit sizes, nurse-to-patient ratios, bed census distributions, and quality-of-care requirements. Therefore, we review the literature on nursing workload measurement approaches because workloads depend highly on patient arrivals and lengths of stay, both of which can vary greatly. Thus, predicting these workloads and staffing nurses accordingly are essential to guaranteeing quality of care in a cost-effective manner. For completeness, a brief review of the literature on workforce planning and scheduling that is linked to the nurse staffing and scheduling problem is also provided. Chapter 3 develops a framework for estimating the daily number of nurses required in Intensive Care Units (ICUs). Many patient care units, including ICUs, find it difficult to accurately estimate the number of nurses needed. One factor contributing to this difficulty is not having a decision support tool to understand the distribution of admissions to healthcare facilities. We statistically evaluate the existing staff allocation system of an ICU using clinical operational data, then develop a predictive model for estimating the number of admissions to the unit. We analyze clinical operational data covering 44 months for three wards of a pediatric ICU. The existing staff allocation model does not accurately estimate the required number of nurses required. This is due in part to not understanding the pattern and frequency of admissions, particularly those which are not known 12 hours in advance. We show that these “unknown” admissions actually follow a Poisson distribution. Thus, we can more accurately estimate the number of admissions overall. Analytical predictive methods that complement intuition and experience can help to decrease unplanned requirements for nurses and recommend more efficient nurse allocations. The model developed here can be inferred to estimate admissions for other intensive care units, such as pediatric facilities. Chapter 4 examines an integrated nurse staffing and scheduling model for a Pediatric Intensive Care Unit (PICU). This model is targeted to recommend initial staffing plans and schedules for a six-week horizon given a variety of nurse groups and nursing shift assignment types in the PICU. Nurse rostering is an NP-hard combinatorial problem, which makes it extremely difficult to efficiently solve life-sized problems due to their complexity. Usually, real problem instances have complicated work rules related to safety and quality of service issues, as well as preferences of the personnel. To avoid the size and complexity limitations, we generate feasible nurse schedules for the full-time equivalent (FTE) nurses, using algorithms that will be employed in the mixed-integer programming models we develop. Pre-generated schedules eliminate the increased number of constraints, and reduce the number of decision variables of the integrated nurse staffing and scheduling model. We also include a novel methodology for estimating nurse workloads by considering the patient, and individual patient’s acuity, and activity in the unit. When the nursing administration prepares the medium-term nurse schedules for the next staffing cycle (six weeks in our study), one to two months before the actual patient demand realizations, it typically uses a general average staffing level for the nursing care needs in the medical units. Using our mixed-integer optimization model, we examine fixed vs. dynamic medium-term nurse staffing and scheduling policy options for the medical units. In the fixed staffing option, the medical unit is staffed by a fixed number of nurses throughout the staffing horizon. In the dynamic staffing policy, we propose, historical patient demand data enables us to suggest a non-stationary staffing scheme. We compare the performance of both nurse allocation policy options, in terms of cost savings and understaffing ratios, with the optimal staffing scheme reached by the actual patient data. As a part of our experimental design, we evaluate our optimization model for the three medical units of the PICU in the “as-is” state. In Chapter 5, we conduct two-stage short-term staffing adjustments for the upcoming nursing shift. Our proposed adjustments are first used at the beginning of each nursing shift for the upcoming 4-hour shift. Then, after observing actual patient demand for nursing at the start of the next shift, we make our final staffing adjustments to meet the patient demand for nursing. We model six different adjustment options for the two-stage stochastic programming model (five options available as first-stage decisions and one option available as the second-stage decision). Because the adjustment horizon is less than 12 hours, the current patient census, patient acuity, and the number of scheduled admissions/discharges in the current and upcoming shift are known to the unit nurse manager. We develop a two-stage stochastic integer programming model which will minimize total nurse staffing costs (and the cost of adjustments to the original schedules developed in the medium-term planning phase) while ensuring adequate coverage of nursing demand. Chapter 6 provides conclusions from the study and identify both limitations and future research directions

Budget allocation for permanent and contingent capacity under stochastic demand

We develop a model of budget allocation for permanent and contingent workforce under stochastic demand. The level of permanent capacity is determined at the beginning of the horizon and is kept constant throughout whereas the number of temporary workers to be hired must be decided in each period. Compared to existing budgeting models, this paper explicitly considers a budget constraint. Under the assumption of a restricted budget, the objective is to minimize capacity shortages. When over-expenditures are allowed, both budget deviations and shortage costs are to be minimized. The capacity shortage cost function is assumed to be either linear or quadratic with the amount of shortage, which corresponds to different market structures or different types of services. We thus examine four variants of the problem that we model and solve either approximately or to optimality when possible. A comprehensive simulation study is designed to analyze the behavior of our models when several levels of demand variability and parameter values are considered. The parameters consist of the initial budget level, the unit cost of temporary workers and the budget deviation penalty/reward rates. Varying these parameters produce several trade-off between permanent and temporary workforce levels, and between capacity shortages and budget deviations. Simulation results also show that the quadratic cost function leads to smooth and moderate capacity shortages over the time periods, whereas all shortages are either avoided or accepted when the cost function is linear

An Integrated Framework for Staffing and Shift Scheduling in Hospitals

Over the years, one of the main concerns confronting hospital management is optimising the staffing and scheduling decisions. Consequences of inappropriate staffing can adversely impact on hospital performance, patient experience and staff satisfaction alike. A comprehensive review of literature (more than 1300 journal articles) is presented in a new taxonomy of three dimensions; problem contextualisation, solution approach, evaluation perspective and uncertainty. Utilising Operations Research methods, solutions can provide a positive contribution in underpinning staffing and scheduling decisions. However, there are still opportunities to integrate decision levels; incorporate practitioners view in solution architectures; consider staff behaviour impact, and offer comprehensive applied frameworks. Practitioners’ perspectives have been collated using an extensive exploratory study in Irish hospitals. A preliminary questionnaire has indicated the need of effective staffing and scheduling decisions before semi-structured interviews have taken place with twenty-five managers (fourteen Directors and eleven head nurses) across eleven major acute Irish hospitals (about 50% of healthcare service deliverers). Thematic analysis has produced five key themes; demand for care, staffing and scheduling issues, organisational aspects, management concern, and technology-enabled. In addition to other factors that can contribute to the problem such as coordination, environment complexity, understaffing, variability and lack of decision support. A multi-method approach including data analytics, modelling and simulation, machine learning, and optimisation has been employed in order to deliver adequate staffing and shift scheduling framework. A comprehensive portfolio of critical factors regarding patients, staff and hospitals are included in the decision. The framework was piloted in the Emergency Department of one of the leading and busiest university hospitals in Dublin (Tallaght Hospital). Solutions resulted from the framework (i.e. new shifts, staff workload balance, increased demands) have showed significant improvement in all key performance measures (e.g. patient waiting time, staff utilisation). Management team of the hospital endorsed the solution framework and are currently discussing enablers to implement the recommendation

Designing the Liver Allocation Hierarchy: Incorporating Equity and Uncertainty

Liver transplantation is the only available therapy for any acute or chronic condition resulting in irreversible liver dysfunction. The liver allocation system in the U.S. is administered by the United Network for Organ Sharing (UNOS), a scientific and educational nonprofit organization. The main components of the organ procurement and transplant network are Organ Procurement Organizations (OPOs), which are collections of transplant centers responsible for maintaining local waiting lists, harvesting donated organs and carrying out transplants. Currently in the U.S., OPOs are grouped into 11 regions to facilitate organ allocation, and a three-tier mechanism is utilized that aims to reduce organ preservation time and transport distance to maintain organ quality, while giving sicker patients higher priority. Livers are scarce and perishable resources that rapidly lose viability, which makes their transport distance a crucial factor in transplant outcomes. When a liver becomes available, it is matched with patients on the waiting list according to a complex mechanism that gives priority to patients within the harvesting OPO and region. Transplants at the regional level accounted for more than 50% of all transplants since 2000.This dissertation focuses on the design of regions for liver allocation hierarchy, and includes optimization models that incorporate geographic equity as well as uncertainty throughout the analysis. We employ multi-objective optimization algorithms that involve solving parametric integer programs to balance two possibly conflicting objectives in the system: maximizing efficiency, as measured by the number of viability adjusted transplants, and maximizing geographic equity, as measured by the minimum rate of organ flow into individual OPOs from outside of their own local area. Our results show that efficiency improvements of up to 6% or equity gains of about 70% can be achieved when compared to the current performance of the system by redesigning the regional configuration for the national liver allocation hierarchy.We also introduce a stochastic programming framework to capture the uncertainty of the system by considering scenarios that correspond to different snapshots of the national waiting list and maximize the expected benefit from liver transplants under this stochastic view of the system. We explore many algorithmic and computational strategies including sampling methods, column generation strategies, branching and integer-solution generation procedures, to aid the solution process of the resulting large-scale integer programs. We also explore an OPO-based extension to our two-stage stochastic programming framework that lends itself to more extensive computational testing. The regional configurations obtained using these models are estimated to increase expected life-time gained per transplant operation by up to 7% when compared to the current system.This dissertation also focuses on the general question of designing efficient algorithms that combine column and cut generation to solve large-scale two-stage stochastic linear programs. We introduce a flexible method to combine column generation and the L-shaped method for two-stage stochastic linear programming. We explore the performance of various algorithm designs that employ stabilization subroutines for strengthening both column and cut generation to effectively avoid degeneracy. We study two-stage stochastic versions of the cutting stock and multi-commodity network flow problems to analyze the performances of algorithms in this context

A novel healthcare resource allocation decision support tool: A forecasting-simulation-optimization approach

© 2020 Informa UK Limited, trading as Taylor & Francis Group. This is an accepted manuscript of an article published by Taylor & Francis in Journal of the Operational Research Society on 03 Feb 2020, available online: https://doi.org/10.1080/01605682.2019.1700186.The increasing pressures on the healthcare system in the UK are well documented. The solution lies in making best use of existing resources (e.g. beds), as additional funding is not available. Increasing demand and capacity shortages are experienced across all specialties and services in hospitals. Modelling at this level of detail is a necessity, as all the services are interconnected, and cannot be assumed to be independent of each other. Our review of the literature revealed two facts; First an entire hospital model is rare, and second, use of multiple OR techniques are applied more frequently in recent years. Hybrid models which combine forecasting, simulation and optimization are becoming more popular. We developed a model that linked each and every service and specialty including A&E, and outpatient and inpatient services, with the aim of, (1) forecasting demand for all the specialties, (2) capturing all the uncertainties of patient pathway within a hospital setting using discrete event simulation, and (3) developing a linear optimization model to estimate the required bed capacity and staff needs of a mid-size hospital in England (using essential outputs from simulation). These results will bring a different perspective to key decision makers with a decision support tool for short and long term strategic planning to make rational and realistic plans, and highlight the benefits of hybrid models.Peer reviewe