Lecture 1: Introduction healthcare operations management: Setting the scene
1. Villa, S., Barbieri, M., Lega, F. (2009) Restructuring patient flow logistics around patient care needs:
implications and practicalities from three critical cases. Health Care Management Science 12: 155-165.
2. Bruzzi, S., Landa, P., Tanfani, E., Testi, A. (2018) Conceptual modelling of the flow of frail elderly
through acute-care hospitals. Management Decision 56(10): 2101-2124.
Lecture 2: Introducing operations management
No literature, see slides.
Lecture 3: Acute patients (1) – introduction; example: acute stroke pathway –
3. Soremekun, O.A., Terwiesch, C., Pines, J.M. (2011) Emergency Medicine: An Operations Management
View. Academic Emergency Medicine 18(12): 1262-1268.
4. Churilov, L., Donnan, G.A. (2012) Operations Research for stroke care systems: An opportunity for The
Science of Better to do much better. Operations Research for Health Care 1: 6-15.
5. Lahr, M. M. H., van der Zee, D. J., Vroomen, P., Luijckx, G-J., & Buskens, E. (2013). Thrombolysis in
Acute Ischemic Stroke: A Simulation Study to Improve Pre-and in-Hospital Delays in Community
Hospitals. PLoS ONE, 8(11),
Lecture 4: Acute patients (2) – Patient flow in the emergency department –
6. Ter Avest, E., Onnes, B. T., van der Vaart, T., Land, M. (2018). Hurry up, it´s quiet in the emergency
department. The Netherlands Journal of Medicine, 76(1), 32-35.
7. Bokhorst, J. A. C., van der Vaart, T. (2018). Acute medical unit design: The impact of rearranged patient
flows. Socio-economic Planning Sciences, 62, 75-83.
8. Huang, Y., Land, M.J., Van der Vaart, T., Gough, S., Van der Heide, K., (2019) Emergency Department
Crowding: The Power of an Empty Start, working paper (see Student Portal).
Lecture 5: Elective patients (1) – introduction; planning & scheduling –
9. Gupta, D., Denton, B. (2008) Appointment scheduling in health care: Challenges and opportunities. IIE
Transactions 40: 800-819.
10. Larson, A., Frederiksson, A. (2019) Tactical capacity planning in hospital departments. International
Journal of Health Care Quality Assurance 32(1): 233-245.
11. Hans, E.W., Houdenhoven van, M., Hulshof, P.J.H. (2011). A framework for healthcare planning and
control. Working Paper, University of Twente, The Netherlands. http://doc.utwente.nl/76144/
Lecture 6: Elective patients (2) – integrative approaches for improving flow
12. Drupsteen, J., Van der Vaart, T., Van Donk, D.P. (2013), Integrative practices in hospitals and their
impact on patient flow. International Journal of Operations & Production Management 33(7): 912-933.
13. Fredendall, L.D., Craig, J.B., Fowler, P.J., Damali, U. (2009). Barriers to swift, even flow in the internal
supply chain of perioperative surgical services department: A case study, Decision Sciences 40(2): 327-
349.
Lecture 7: Elective patients (3) – capacity management & variability
14. Villa, S., Prenestini, A., Giusepi, I. (2014) A framework to analyze hospital-wide patient flow logistics:
evidence from an Italian comparative study. Health Policy 115: 196-205.
15. Bakker, M., and Van der Vaart, T., (2018) The relationship between the planning of specialist-time and
patient flow: a supply chain perspective, working paper (see Student Portal).
Lecture 8: Integral capacity management
16. Rutherford, P.A., Provost, L.P., Kotagal, U.R., Luther K., Anderson A. (2017) Achieving Hospital-wide
Patient Flow. IHI White Paper. Cambridge, Massachusetts: Institute for Healthcare Improvement.
17. Alvekransa, A.L., Lantzb,B., Rosénc, P., Siljemyra, L., Snyggd, J. (2016) From knowledge to decision – a
case study of sales and operations planning in health care. Production Planning & control 27(12):
1019–1026
1
,Summary Healthcare Operations
Villa, S., Barbieri, M., Lega, F. (2009) Restructuring patient flow
logistics around patient care needs: implications and practicalities
from three critical cases.
This study proposes a framework for investigating the emerging trends in hospital redesign
driven by patient flow logistics. All modern hospitals worldwide seem to be under several
pressures, four of the main ones being:
Financial
Institutional and social
Clinical
Professional (new professions are emerging which claim similar status to doctors
while other traditional professions, as nurses, are demanding status)
To cope with these pressures, most hospitals are looking at a new organizational paradigm:
the care-focused organization. This scheme aims at reshaping hospital care delivery
processes around the needs of patients and away from the traditional physicians-centered
view. Modern hospitals have applied various methods to make hospital organizations more
patient-centered:
Units grouping
Multidisciplinary care teams
Resources pooling
Redesign of the physical environment (unit and patient grouping and resource
pooling may require a redesign of the physical environment)
Patients grouping
To this extent, changing towards care-focused and patient driven hospitals means extensive
redesign and innovation in patient flow logistics.
Patient flow logistics
To make hospitals really patients-centered, it is necessary to realize a better patient flows
management. Patient flow logistics is the complicated set of decisions related to the
physical movement of patients throughout the healthcare chain. Healthcare organizations
can act on patients flow logistics changing:
1. Location and lay-out of spaces and facilities
2. Configuration of the wards
3. Capacity planning
4. Technologies and Information System
5. Organizational structure supporting patient flow management
These five elements are often referred to as an organization’s logistical configuration. Developing a
care-focused and patient-centered hospital, as described in the previous paragraph, requires a
proactive management of patient flow logistics, aimed at reshaping the logistical configuration
according to three key drivers:
1. Spaces and resources need to be shared managed and jointly.
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, 2. Wards should be organized around the concept of intensity of care according to the patient-
centered hospital model.
3. Hospital workload needs to be smoothed through better management of capacity planning.
The three Italian case studies
Which are the possible drives to redesign patient flow logistics around intensity of care?
Four different criteria to operationalize the concept of intensity of care are:
The expected length of stay
The level of nursing assistance
The level of technology required to support patient care
The level of urgency
The hospitals reorganized patient flow logistics and created five different and separate areas
grouping wards:
1. Urgency area: a separate area close to the emergency department that accommodates non-
elective patients that can probably be discharged within three days.
2. Week surgery: surgical patients that are expected to have a surgical follow-up of less than
five days are accommodated in a multi-specialties ward that actually closes Friday night.
3. Week hospital: medical patients who do not need to stay in the hospital for more than five
days.
4. Medium care/general wards: organized around the traditional clinical specialties where each
unit has its own bed and personnel.
5. Post-acute care: patients requiring low clinical and nursing care and who for various reasons
need to stay in the hospital more than 15 days.
Redesign patient flow logistics: the impact on the organization
The hospitals also implemented important modifications to:
1. The physical lay-out
2. The planning of available capacity
3. The organizational roles supporting the patient flow management
For implementing these modifications, it is important to:
1. Establish clear criteria for eligibility to the different clinical settings in order to avoid patients
having to be pointlessly, and possibly harmfully, moved back and forth.
2. Synchronize the operating rooms scheduling with the other hospital activities and services.
3. Enhance the coordination between the different hospital settings.
4. Smooth peaks and valleys in hospital demand avoiding to put the hospital productive
machine under unnecessary stress.
5. Centralize, as much as possible, the scheduling process of the most important hospital
resources.
Results achieved
The changes were aimed at obtaining performance improvements in:
1. Quality of care: which resulted in:
Possibility to concentrate scarce resources on the most needy patients.
Patients are no longer parked in areas where they cannot receive appropriate care.
The multi-disciplinary approach is strongly encouraged, it leads to more collaboration.
The logistics of process management is further enforces and promotes the development
of care maps and clinical pathways.
2. Appropriateness and productivity: which resulted in:
A significant reduction in average length of stay
Increase in bed occupancy rate
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, Increase in hospital case-mix complexity
Reduction in turn-over ratio
Part of the productivity increase can be linked to the presence of multi-specialty wards and multi-
skilled forces that can accommodate a wider range of patients and absorb service time variation. This
was a move from a long and thin structure to a short and fat structure.
Ideas for change
Some difficult aspects need to be taken into account in the process of changing patient flow logistics:
1. Changes in patient flow logistics need to be coherent with a hospital’s production structure.
2. The scope of specialties to be included in the multi-disciplinary wards.
3. Manage and overcome some cultural barriers especially on the physician’s side.
4. The new model relies on strong commitment from nurses who are required to take
managerial responsibilities and to deal with a wider case-mix of patients.
5. The hospital’s top management need to monitor the effects of changes and check
compliance with admission and discharge criteria for the various patient care settings.
Policy implications and conclusions (not included in exam)
The three cases confirm that hospitals have large opportunities for re-engineering their processes
and provide evidence that an organizational model based on a clinical framework can be beneficial
both in terms of efficacy and efficiency. The engagement of physicians and nurses was built up along
a three-step process:
1. Sharing of minds
2. Exposure to successful hospitals adopting innovative models.
3. Involvement in group work lead by project managers.
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