Organizing timely treatment in multi-disciplinary care

Healthcare providers experience an increased pressure to organize their processes more efficiently and to provide coordinated care over multiple disciplines. Organizing multi-disciplinary care is typically highly constrained, since multiple appointments per patient have to be scheduled with possible restrictions between them. Furthermore, schedules of professionals from various facilities or with different skills must be aligned. Since it is important that patients are treated on time, access time targets are set on the time between referral to the facility and the actual start of the treatment. These targets may vary per patient type: e.g., urgent patients have shorter access time targets than regular patients. In this thesis, we use operations research methods to support multi-disciplinary care settings in providing timely treatments with an excellent quality of care, against affordable costs, while taking patient and employee satisfaction into account. We consider settings in rehabilitation care and radiotherapy, but the underlying planning problems are applicable to many other multi-disciplinary care settings, such as cancer care or specialty clinics. The developed models are applied to case studies in the Sint Maartenskliniek Nijmegen, the AMC Amsterdam and a BCCA cancer clinic in Vancouver, Canada. The results of the thesis demonstrate that adequate admission policies and capacity allocation to different activities and stages in complex treatment processes can improve compliance with access time targets for multi-disciplinary care systems considerably, while using the available resource capacities and taking patient and employee satisfaction into account

Strategic Level Proton Therapy Patient Admission Planning: A Markov Decision Process Modeling Approach

A relatively new consideration in proton therapy planning is the requirement that the mix of patients treated from different categories satisfy desired mix percentages. Deviations from these percentages and their impacts on operational capabilities are of particular interest to healthcare planners. In this study, we investigate intelligent ways of admitting patients to a proton therapy facility that maximize the total expected number of treatment sessions (fractions) delivered to patients in a planning period with stochastic patient arrivals and penalize the deviation from the patient mix restrictions. We propose a Markov Decision Process (MDP) model that provides very useful insights in determining the best patient admission policies in the case of an unexpected opening in the facility (i.e., no-shows, appointment cancellations, etc.). In order to overcome the curse of dimensionality for larger and more realistic instances, we propose an aggregate MDP model that is able to approximate optimal patient admission policies using the worded weight aggregation technique. Our models are applicable to healthcare treatment facilities throughout the United States, but are motivated by collaboration with the University of Florida Proton Therapy Institute (UFPTI)

Applying and integer Linear Programming Model to an appointment scheduling problem

Dissertação de Mestrado, Ciências Económicas e Empresariais (Economia e Políticas Públicas), 28 de fevereiro de 2022, Universidade dos Açores.A gestão de consultas ambulatórias pode ser um processo complexo, uma vez que envolve vários stakeholders com diferentes objetivos. Para os utentes poderá ser importante minimizar os tempos de espera. Simultaneamente, para os trabalhadores do setor da saúde, condições de trabalho justas devem ser garantidas. Assim, é cada vez mais necessário ter em conta o equilíbrio de cargas horárias e a otimização dos recursos disponíveis como principais preocupações no agendamento e planeamento de consultas. Nesta dissertação, uma abordagem com dois modelos para a criação de um sistema de agendamento de consultas é proposta. Esta abordagem é feita em programação linear, com dois modelos que têm como objetivo minimizar as diferenças de cargas horárias e melhorar o seu equilíbrio ao longo do planeamento. Os modelos foram estruturados e parametrizados de acordo com dados gerados aleatoriamente. Para isso, o desenvolvimento foi feito em Java, gerando assim os dados referidos. O Modelo I minimiza as diferenças de carga horária entre os quartos disponíveis. O Modelo II, por outro lado, propõe uma nova função objetivo que minimiza a diferença máxima observada, com um processo de decisão minxmax. Os modelos mostram resultados eficientes em tempos de execução razoáveis para instâncias com menos de aproximadamente 10 quartos disponíveis. Os tempos de execução mais altos são observados quando as instâncias ultrapassam este número de quartos disponíveis. Em relação ao equilíbrio da carga horária, observou-se que o número de especialidades disponíveis para atendimento e a procura por dia foram o que mais influenciou a minimização da diferença da carga horária. Os resultados do Modelo II mostram melhor tempo de execução e um maior número de soluções ótimas. Uma vez que as diferenças entre os dois modelos não são consideráveis, o Modelo I poderá representar um melhor conjunto de soluções para os decisores já que minimiza a diferença da carga horária total entre quartos em vez de apenas minimizar o valor máximo da diferença de carga horária entre quaisquer dois quartos.ABSTRACT: Outpatient appointment management can be a complex process since it involves many conflicting stakeholders. As for the patients it might be important to minimize waiting time. Simultaneously, for healthcare workers, fair working conditions must be guaranteed. Thus, it is increasingly necessary to have workload balance and resource optimization as the main concerns in the scheduling and planning of outpatient appointments. In this dissertation, a two-model approach for designing an appointment scheduling is proposed. This approach is formulated as two mathematical Integer Linear Programming models that integrate the objective of minimizing workload difference and improving workload balance. The models were structured and parameterized according to randomly generated data. For this, the work was developed in Java, generating said data. Model I minimizes the workload differences among rooms. Model II, on the other hand, proposes a new objective function that minimizes the maximum workload difference, with a minxmax decision process. The computational models behaves efficiently in reasonable run times for numerical examples with less than approximately 10 rooms available. Higher run times are observed when numerical examples surpass these number of available rooms. Regarding workload balance, it was observed that the number of specialties available for appointments and the demand for each day were the most influential in the minimization of workload difference. Model II results show a shorter model run time and more optimal solutions. As the differences between both Models are not considerable, Model I might propose a better set of solution for decision makers since it minimizes the total workload difference amongst rooms instead of only minimizing the maximum workload difference between any two rooms

Large-Scale Solution Approaches for Healthcare and Supply Chain Scheduling

This research proposes novel solution techniques for two real world problems. We first consider a patient scheduling problem in a proton therapy facility with deterministic patient arrivals. In order to assess the impacts of several operational constraints, we propose single and multi-criteria linear programming models. In addition, we ensure that the strategic patient mix restrictions predetermined by the decision makers are also enforced within the planning horizon. We study the mathematical structures of the single criteria model with strict patient mix restrictions and derive analytical equations for the optimal solutions under several operational restrictions. These efforts lead to a set of rule of thumbs that can be utilized to assess the impacts of several input parameters and patient mix levels on the capacity utilization without solving optimization problems. The necessary and sufficient conditions to analytically generate exact efficient frontiers of the bicriteria problem without any additional side constraint are also explored. In a follow up study, we investigate the solution techniques for the same patient scheduling problem with stochastic patient arrivals. We propose two Markov Decision Process (MDP) models that are capable of tackling the stochasticity. The second problem of interest is a variant of the parallel machine scheduling problem. We propose constraint programming (CP) and logic-based Benders decomposition algorithms in order to make the best decisions for scheduling nonidentical jobs with time windows and sequence dependent setup times on dissimilar parallel machines in a fixed planning horizon. This problem is formulated with (i) maximizing total profit and (ii) minimizing makespan objectives. We conduct several sensitivity analysis to test the quality and robustness of the solutions on a real life case study

Managing Operational Efficiency And Health Outcomes At Outpatient Clinics Through Effective Scheduling

A variety of studies have documented the substantial deficiencies in the quality of health care delivered across the United States. Attempts to reform the United States health care system in the 1980s and 1990s were inspired by the system\u27s inability to adequately provide access, ensure quality, and restrain costs, but these efforts had limited success. In the era of managed care, access, quality, and costs are still challenges, and medical professionals are increasingly dissatisfied. In recent years, appointment scheduling in outpatient clinics has attracted much attention in health care delivery systems. Increase in demand for health care services as well as health care costs are the most important reasons and motivations for health care decision makers to improve health care systems. The goals of health care systems include patient satisfaction as well as system utilization. Historically, less attention was given to patient satisfaction compared to system utilization and conveniences of care providers. Recently, health care systems have started setting goals regarding patient satisfaction and improving the performance of the health system by providing timely and appropriate health care delivery. In this study we discuss methods for improving patient flow through outpatient clinics considering effective appointment scheduling policies by applying two-stage Stochastic Mixed-Integer Linear Program Model (two-stage SMILP) approaches. Goal is to improve the following patient flow metrics: direct wait time (clinic wait time) and indirect wait time considering patient’s no-show behavior, stochastic server, follow-up surgery appointments, and overbooking. The research seeks to develop two models: 1) a method to optimize the (weekly) scheduling pattern for individual providers that would be updated at regular intervals (e.g., quarterly or annually) based on the type and mix of services rendered and 2) a method for dynamically scheduling patients using the weekly scheduling pattern. Scheduling templates will entertain the possibility of arranging multiple appointments at once. The aim is to increase throughput per session while providing timely care, continuity of care, and overall patient satisfaction as well as equity of resource utilization. First, we use risk-neutral two-stage stochastic programming model where the objective function considers the expected value as a performance criterion in the selection of random variables like total waiting times and next, we expand the model formulation to mean-risk two-stage stochastic programming in which we investigate the effect of considering a risk measure in the model. We apply Conditional-Value-at-Risk (CVaR) as a risk measure for the two-stage stochastic programming model. Results from testing our models using data inspired by real-world OBGYN clinics suggest that the proposed formulations can improve patient satisfaction through reduced direct and indirect waiting times without compromising provider utilization

Joint optimization of allocation and release policy decisions for surgical block time under uncertainty

The research presented in this dissertation contributes to the growing literature on applications of operations research methodology to healthcare problems through the development and analysis of mathematical models and simulation techniques to find practical solutions to fundamental problems facing nearly all hospitals. In practice, surgical block schedule allocation is usually determined regardless of the stochastic nature of case demand and duration. Once allocated, associated block time release policies, if utilized, are often simple rules that may be far from optimal. Although previous research has examined these decisions individually, our model considers them jointly. A multi-objective model that characterizes financial, temporal, and clinical measures is utilized within a simulation optimization framework. The model is also used to test “conventional wisdom” solutions and to identify improved practical approaches. Our result from scheduling multi-priority patients at the Stafford hospital highlights the importance of considering the joint optimization of block schedule and block release policy on quality of care and revenue, taking into account current resources and performance. The proposed model suggests a new approach for hospitals and OR managers to investigate the dynamic interaction of these decisions and to evaluate the impact of changes in the surgical schedule on operating room usage and patient waiting time, where patients have different sensitivities to waiting time. This study also investigated the performance of multiple scheduling policies under multi-priority patients. Experiments were conducted to assess their impacts on the waiting time of patients and hospital profit. Our results confirmed that our proposed threshold-based reserve policy has superior performance over common scheduling policies by preserving a specific amount of OR time for late-arriving, high priority demand

Dynamic Capacity Planning of Hospital Resources under COVID-19 Uncertainty using Approximate Dynamic Programming

COVID-19 pandemic has resulted in an inflow of patients into the hospitals and overcrowding of healthcare resources. Healthcare managers increased the capacities reactively by utilizing expensive but quick methods. Instead of this reactive capacity expansion approach, we propose a proactive approach considering different realizations of demand uncertainties in the future due to COVID-19. For this purpose, a stochastic and dynamic model is developed to find the right amount of capacity increase in the most critical hospital resources. Due to the problem size, the model is solved with Approximate Dynamic Programming. Based on the data collected in a large tertiary hospital in Turkey, the experiments show that ADP performs better than a benchmark myopic heuristic. Finally, sensitivity analysis is performed to explore the impact of different epidemic dynamics and cost parameters on the results.</p

Strategies for dynamic appointment making by container terminals

We consider a container terminal that has to make appointments with barges dynamically, in real-time, and partly automatic. The challenge for the terminal is to make appointments with only limited knowledge about future arriving barges, and in the view of uncertainty and disturbances, such as uncertain arrival and handling times, as well as cancellations and no-shows. We illustrate this problem using an innovative implementation project which is currently running in the Port of Rotterdam. This project aims to align barge rotations and terminal quay schedules by means of a multi-agent system. In this\ud paper, we take the perspective of a single terminal that will participate in this planning system, and focus on the decision making capabilities of its intelligent agent. We focus on the question how the terminal operator can optimize, on an operational level, the utilization of its quay resources, while making reliable appointments with barges, i.e., with a guaranteed departure time. We explore two approaches: (i) an analytical approach based on the value of having certain intervals within the schedule and (ii) an approach based on sources of exibility that are naturally available to the terminal. We use simulation to get insight in the benefits of these approaches. We conclude that a major increase in utilization degree could be achieved only by deploying the sources of exibility, without harming the waiting time of barges too much