Health Care Management addresses speciﬁc Supply Chain Management problems in the health sector. Important applications arise in scheduling and internal logistics of hospitals. Therefore, the use of methods of Operations Research plays an important role in Health Care Management. In general, there are four different fields of application: hospitals, doctor’s practices, home health care and health care provision.
During the last years reforms of the German health system have put an increasing competitive and cost pressure on hospitals. For example, the introduction of the DRG system led to the elimination of the principle of cost coverage in favor of the medical, performance-related payment with the threat of deficits. In doing so, incentives were created to evoke economic behavior of hospital managers. Therefore, their target is to improve quality, transparency, and efficiency of hospital services in a sustainable way. To achieve this, processes have to be analyzed in order to optimize them (e.g. reduced lengths of stay) if necessary. For this purpose, there are numerous methods of Operations Research leading to significant improvements not only in an industrial but also in a service-oriented environment as hospitals. However, the unique feature in this field of application is not only to put emphasis upon the economic efficiency but also to take into account the quality of care and patient satisfaction. Accordingly, the medical competence is never interfered in.
Regarding hospitals scheduling problems and internal logistics are playing a crucial role. With the help of medical and technical devices patients will be examined, treated and cured if possible. Hospital logistics are technical and organizational measures taken in a hospital in order to transfer patients, goods and corresponding information from an initial state (“ill”) into a final state (in the best case “healthy”). Hospital processes are often grown historically (“We have always done it this way.”). Consequently, processes have not been analyzed critically until reforms of the health system have put increasing pressure on hospitals. Nowadays, hospitals are looking for possibilities to improve their processes. Therefore, the success of logistic concepts in hospitals lies in resource conservation. Successful hospital logistics enable medical care of high quality, such that the resource usage of non-value activities (not directly relevant for the healing process) is minimal. Modern planning methods are used to meet the interests of various stakeholders. Some planning tasks offer approaches for optimization by using OR methods. The following figure shows such planning tasks relating to their appearance in the clinical pathway.
Based on an admission diagnosis, clinical pathways determine an optimal sequence and schedule for interventions of diagnostics, therapy and care. These interventions are organized in accordance with the shifting of the clinical staff (physicians, nursing staff, etc.). Quantitative models will be developed and used to improve the scheduling of internal logistics. In order to analyze existing structures, processes and possible improvements the necessary information and data have to be provided. This is supported by the „Hospital Information System (HIS)“, that generates, stores, combines and transmits patient-specific data. Current implementations of clinical pathways often lack aspects of optimization or logistical integration. This means that the available Information provided by the HIS is not linked to the clinical treatment paths of the patients. Hence, the following questions cannot be answered:
- Who is responsible for the process?
- How much time does the process take?
- What are the dependencies between the individual steps?
- Is the order of the process steps mandatory?
- Is there a possibility to execute steps in parallel?
- Which rooms and resources will be used?
- Which persons are involved in the process?
- Which potential interface and communication problems can arise?
Application areas in a hospital
Examples for the use of Operations Research methods in the clinical pathway are listed below:
Apart from a central warehouse for non-medical consumables and a pharmacy for drugs and other medical demand a hospital usually has additional storage places on each ward. Stocks of material und drugs need to be continually monitored if there is no concept of portfolio consolidation. Furthermore, commissioning needs to be planed, depending on the size of the central warehouse and the pharmacy. Another challenge is the storage of blood preserves. Besides the accurate storage the guarantee of sufficient supply and the observance of the expiry date are of particular importance.
In practice, layout planning in hospitals is usually done by specialized architects' offices. They develop a layout in consideration of relevant legal guidelines and further requirements, depicted in the invitation to tender. Operational costs which will be influenced later on by the layout, e.g. the distances staff and patients have to walk, are not taken into account during the planning phase. Moreover, the multi-period perspective, that includes changes in the need of single-, double- and other shared rooms, is often missing. To close these gaps, Operations Research methods are used to develop improved layout plans by using existing data, e.g. from clinical pathways.
Operating room scheduling
In hospitals operating rooms are both main cost factor and major source of revenue. Therefore the efficient use of the critical factor operating room needs to be ensured. A distinction is made between long-, medium- and short-term operating room and surgery planning. In the long term the number of operating rooms and the allocation of quotas to the departments are determined. Based on this, the weekly schedule for each department is generated in the medium term. Short-term tasks include the planning of the surgery schedule for the following day(s) and the necessary adaptation for the treatment of emergencies.
Patients pass through different diagnostic, therapeutic and treating facilities while staying at hospital. To transport patients within or between buildings, hospitals often provide own transportation teams. Transport orders will be assigned to the staff and the corresponding tours will be planned. A particular challenge is the dynamics of transport orders as well as taking quarantine, priorities, emergencies, vehicle capacity, etc. into account.
Application areas in and outside a hospital environment
Hospitals, doctor’s practices and home health care
Shift allocation is relevant to all staff members in the health care sector, for example doctors, nurses and physician assistants. An essential part of this is the consideration of legal and operational guidelines as well as patient satisfaction in order to reach a given service level.
Appointment planning is an essential problem in health care in which patients are involved and need to be scheduled optimally. If the Walk-In policy is not executed, rules for allocating appointments to individual patients need to be defined. In the next step simulations can be carried out to test the developed scenarios.
Home Health Care
Home health care services visit and nurse various patients on a daily basis. The determination of the optimal routes, which nurses have to travel, is essential. One of the most important constraints is the consideration of recurring fixed announcements and the assignment of each patient to the same nurse at each visit if possible. This way, patients will have a regular daily routine without a need to get accustomed to different nurses again and again. Additionally, “no-shows” and emergencies have to be scheduled at short notice and it has to be decided which patients on the waiting list can be fitted into the schedule.
Health care provision
Medical care has to be available for each citizen. In order to determine the demand, the country has to be divided into territories where the specific demand can be measured. In the next few years the consideration of this problem will certainly become more and more important, as the number of general practitioners will further decrease in particular in rural areas.
Ambulance planning/Emergency services
Ambulance services include emergency services and medical transportation. Normally, rescue service is ensured by ground-based ambulance services and supported by the use of rescue helicopters. An initial problem is to determine the required number of ambulances and emergency doctors and their optimal locations. In the next step, rules and algorithms to allocate ambulances to emergencies have to be defined. Based on collected data the solution can be tested and simulated.