1. A Survey of Health Care Models that Encompass Multiple Departments
Peter Vanberkel, PhD Candidate
University of Twente

2. Outline Part 1: Literature Overview
Part 2: ORchestra – online bibliography

3. Introduction Background: Our Intention:
Although there is an abundance of models for health care processes, few consider multiple units or departments. – Jun et al. 1999
Our Intention:
What relationships were being accounted for? (i.e. What areas of the hospital?)
How were they being modelled?
(i.e. What techniques?)
Identify examples of multi-department models.
What factors are holding modellers back?

4. Search Method Other papers found via citations
Jun, J., Jacobson, S., and Swisher, J. (1999). Application of Discrete-Event Simulation in Health Care Clinics: A Survey. Journal of the Operational Research Society, 50(2):109–123.
Cited by over 70 papers
21.4% Tutorial or Instructional
10% Surveys
40% Applications / Case Studies of a Single Department
28.6% Applications / Case Studies of a Multiple Department
Other papers found via citations
In Total: Identified 78 papers which we considered to be of “Multiple Department”

5. What relationships were being accounted for. (i. e
What relationships were being accounted for? (i.e. What areas of the hospital?)
How were they being modelled?
(i.e. What techniques?)
Identify examples of multi-department models.
What factors are holding modellers back?

6. What relationships were being accounted for. (i. e
What relationships were being accounted for? (i.e. What areas of the hospital?)

7. Our Idealized Hospital
Diagnostics (Lab / Pharmacy / X-Ray)
Outpatient
Clinics
Operating
Room
Inpatient
Wards
Emergency
Department
Diagnostics (Lab / Pharmacy / X-Ray)

8. Emergency Department (12)
OR(1)
ICU(1)
Ward(10)
Emergency
Department
Referrals(1)
Ambulances(1)
Lab/DI(5)

9. Chart depicting the successive loss of French Army soldiers during Napoleon’s Russian Campaign ( )
Charles Joseph Minard

10. Surgical Care (36) DI(2) PACU(10) Operating Ward(22) Room
ICU(9)
Operating
Room
Waiting List(11)
Emergency(0)

11. Inpatient Wards(20) Lab/DI(0) ICU(9) Inpatient Community Wards Care(1)
OR(8)
Emergency Dept (9)

12. Outpatient Clinics (4) DI/Lab(2) Pharmacy(1) Outpatient
Operating Room(0)
Emergency Dept (0)
Primary Care(0)
(3)

13. Diagnostics (3)
DI / Lab Pharmacy
OR(1)
Ward(2)

14. OR in Health Care Campaign
Diagnostics (Lab / Pharmacy / X-Ray)
Outpatient
Clinics
Operating
Room
Inpatient
Wards
Emergency
Department
OR is the engine that drives the hospital… clearly modelling believe this
Inpatient Beds are the most expensive Resources (surgery wards are studied more, medical wards less)
Emergency Room Congestion is caused by inability to admit patients
Diagnostics is studied much less
Looking downstream is more common
Diagnostics (Lab / Pharmacy / X-Ray)

15. Simulation(36) Other(17) Mathematical Programming(16)
How were they being modelled?
(i.e. What techniques?)
Systems
Dynamics(6)
Simulation(36)
Queueing
Theory(7)
Mathematical
Programming(16)
Other(17)

16. Department by Department

17. Two Dept. (38) Three Dept. (34) Departments is Scope Four Dept. (5)
Five Dept. (1)
Six Dept. (1)

18. Identify examples of multi-department models.

19. Notable References
Brailsford, S. et al (2004). Emergency and on-demand health care: modelling a large complex system. Journal of the Operational Research Society, 55(1):34– 42.
Scope: Referral, Ambulances, ED, Lab/DI, ICU, Ward
Technique: Systems Dynamics
Dexter, F. (2009). Bibliography of Operating Room Management Articles. Retrieved October 10,2008 from
Scope: Surgical Services
System dynamics is an approach to understanding the behaviour of complex systems over time. It deals with internal feedback loops and time delays that affect the behaviour of the entire system.[1] What makes using system dynamics different from other approaches to studying complex systems is the use of feedback loops and stocks and flows. These elements help describe how even seemingly simple systems display baffling nonlinearity.

20. Belien, J., et al. (2006). Visualizing the Demand for Various Resources as a Function of the Master Surgery Schedule: A Case Study. Journal of Medical Systems, 30(5):343–350.
Scope: OR, Lab/DI
Technique: Software
Cochran, J. and Bharti, A. (2006a). A multi-stage stochastic methodology for whole hospital bed planning under peak loading. International Journal of Industrial and Systems Engineering, 1(1):8–36.
Scope: OR, ICU, Ward
Technique: Queueing Theory & Simulation
System dynamics is an approach to understanding the behaviour of complex systems over time. It deals with internal feedback loops and time delays that affect the behaviour of the entire system.[1] What makes using system dynamics different from other approaches to studying complex systems is the use of feedback loops and stocks and flows. These elements help describe how even seemingly simple systems display baffling nonlinearity.

21. Fletcher, A. and Worthington, D. (2007)
Fletcher, A. and Worthington, D. (2007). What is a ‘generic’ hospital model? Retrieved October 13, 2008:
System dynamics is an approach to understanding the behaviour of complex systems over time. It deals with internal feedback loops and time delays that affect the behaviour of the entire system.[1] What makes using system dynamics different from other approaches to studying complex systems is the use of feedback loops and stocks and flows. These elements help describe how even seemingly simple systems display baffling nonlinearity.

22. What factors are holding modellers back?

23. Factors Ambiguous Care Paths Complexity & Variability Hospital Culture
Sorry… I have no scale for these factors

24. Problem 1: Ambiguous Care Paths
“patient care plans for the individual patient are rarely formally recorded, as such, they tend to evolve with the patient stay, and exist in a piece-meal fashion in the minds of physicians, nurses, and discharge planners” (Kopach-Konrad et al., 2007).

25. Overcoming: Ambiguous Care Paths
Discussions with managers and care providers
Information system protocol HL7
Medical record audits
Billing code audits
Radio frequency identifiers
Bar codes
Patient tracking systems
Clinical Pathways*

26. Problem 2: Complexity & Variability
The complexity and variability that is inherent in health care either greatly limits the scope of models or forces modellers to take a more macro view.
Either way, researchers loose a certain amount of perspective and perhaps draw conclusions on a model that does not incorporate the entire set of circumstances

27. Coping with: Complexity & Variability
distinguish between those complicating factors that have the greatest influence and those factors which are simply attributes.
To limit the amount of variability time should initially be spent eliminating the variability caused by the system itself.
good protocols or work practices
a clear understanding of the patient care trajectories.

28. Problem 3: Hospital Culture
“management does not consider the total care chain from admission to discharge, but mainly focuses on the performance of individual units. Not surprisingly, this has often resulted in diminished patient access without any significant reduction in costs” (de Bruin et al., 2005).
People working in the health care system are very knowledgeable about their own area but have relatively little understanding of what goes on in the next department. (Carter 2002)

29. Coping with: Hospital Culture
From an Operational Research Perspective:
Better Models
Larger Scopes with a more sophisticated understanding of the requirements of the environment
Practically Relevant
Results which illustrate the benefits of coordination between departments

30. Part 2: ORchestra Bibliography

31. ORchestra Bibliography
A comprehensive overview of scientific literature in the field of “Operations Research in Health Care”
Can be accessed at:
Is maintained by the Center for Health Care Operations Improvement and Research (CHOIR)

32. ORchestra Bibliography
Categorized According to:
Medical Category (MeSH terms)
Model Category (Mathematics Subject Classification)
Publication Type (MeSH terms)
Multiple Departments?
Interacting Patient Flows?

33. ORchestra Bibliography
What’s Available Online?
Detailed descriptions of the categorization method
Sorted pdf’s of all articles in each category
Free Text Searching of all Articles (Coming soon)

36. Discussion & Questions?
(Literature Review)
(ORchestra)