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manuscript MS-
Nurse-To-Patient Ratios in Hospital Stang:
a Queuing Perspective
Francis de Vericourt
Fuqua School of Business, Duke University, Durham, NC 27708 fdv1@duke.edu
Otis B. Jennings
Fuqua School of Business, Duke University, Durham, NC 27708, otisj@duke.edu
The immediate motivation of this paper is California Bill AB 394, a piece of legislation which mandates
xed nurse-to-patient stang ratios as a means to address the current crisis in the quality of health care
delivery. With a predictive queuing analytic approach we seek to determine whether or not ratio policies are
eective and, if not, to provide an alternative stang paradigm.
We assume a signicant correlation between delays in addressing patient needs and averse medical out-
comes and we promote using the frequency of excessive delay as a measure of stang policy performance.
By applying new many-server asymptotic results, we develop two heuristic stang policies that perform
very well and are easy to implement. This is the rst many-server asymptotic analysis of health care issues.
Among the insights gained from the heuristics is the realization that no ratio policy can provide consistently
good quality of service across medical units of dierent sizes. Moreover, the optimal stang levels for larger
systems display a type of super pooling eect in which the requisite workforce is signicantly smaller than
the nominal patient load.
Key words : Queuing System, Health Care, Public Policy, Nursing, Stang, Many-Server Limit Theorems
1. Introduction
In 1999, California introduced the nations rst law mandating nurse-to-patient ratios in hospitals,
Bill AB 394. The legislation, implemented in 2004, species the minimum number of nurses that
should be staed for each hospital unit, given the current number of patients therein. The min-
imum number of nurses is a xed, unit-specic fraction of the number of patients. For instance,
according to AB 394 at least one registered nurse for every four patients should now be present at
any time in any pediatrics unit within California. This legislation has inspired other states to con-
sider establishing similar requirements. Further, two House bills in a recent Congressional session
proposed regulating nurse stang among Medicare-participating hospitals (see for instance Spetz
2005).
The rationale for implementing these ratios stems from the association between nurse stang
level and patient safety. Research studies suggest a signicant connection between nurse workload
and clinical outcomes. For instance, Aiken et al. (2002) conclude that the addition of one surgical
1
Author: Article Short Title
2 Article submitted to Management Science; manuscript no. MS-
patient to nurse assignments results in a 7% increase in mortality rates. The purpose of the man-
dated nurse-to-patient ratios is to provide a consistently high level of patient safety throughout
the state. Ostensibly, safety is partially attained through manageable workloads among those who
actually provide health care services.
In this paper, we argue that the xed nurse-to-patient ratios mandated by AB 394 can result
in inconsistent quality of care in medical units of dierent sizes. Specically, if the same nurse-to-
patient ratio is applied across the board (controlling for the patient acuity levels and the nurse
skills), delays in addressing patient needs will be longer in relatively small units. We propose stang
rules that remedy this problem. In particular, we recommend deviating from the nurse-to-patient
ratios by a factor which considers the total number of patients present in a unit. This adjustment
takes into account congestion due to variability in patient needs.
More generally, this paper intends to broaden the debate on nurse-to-patient ratios by appealing
to a normative queuing perspective. We adopt mathematical models of medical units and provide
insights without assuming any specic value for the parameters describing the system. Hence our
methodology is in sharp contrast (but complementary) to existing studies in the medical eld which
explore evidence-based results to determine adequate nurse stang strategies. Using scarce but
reasonable data, we then explore the magnitude of the inconsistency in care service levels across
hospitals in California and the potential benets of our stang rule.
So far, the large body of clinical research has not succeeded in formulating evidence-based guide-
lines for stang rules.
1
Current research data are actually not rich enough to help determine proper
nurse stang levels (Clark 2005). One of the main issues, as noted by Needleman and Buerhaus
(2003), concerns the lack of adequate documentation of the failures in the nursing process and
the impact of such failures on patient outcomes. In light of these diculties, we believe that the
normative methodology advanced in this paper not only constitutes a compelling approach for
deriving structural results without relying on actual data but also suggests new lines of future
empirical research related to the nurse stang problem.
The queuing model we consider represents a medical unit in which the number of patients is
roughly constant over a given time period. The medical activities taking place in the unit are
determined by the patients who require dierent services and the nurses who deliver these services
over time. The dynamics of the system are modelled with a nite population M/M/s//n queue,
1
In fact, the ratios recommended by the dierent stakeholders in California (such as the Californian Department
of Health Services or the nurse unions) dier signicantly. Hence, the mandated ratios have sparked active debated
throughout both academic and public sectors.
Author: Article Short Title
Article submitted to Management Science; manuscript no. MS- 3
where n is the xed number patients, who alternate between stable and needy states, and where
s is the number of nurses. Each needy patient is served by a nurse, if available. Otherwise, the
patient must wait in a (virtual) queue until service can be provided.
In our framework, the principal metric of concern is the probability of excessive delay, i.e., the
probability that the delay between the onset of neediness and the provision of care from a nurse
exceeds a given time constraint. To our knowledge, no empirical studies have explored the impact
of this metric on patient care and safety. Nonetheless, we argue that excessive delays are akin to
possible adverse events from the supply side (pressure experienced by the nurses) and from the
demand side (waiting patients), both of which factor into the overall quality of care. Accordingly,
we pose the nurse stang problem in terms of nding stang levels that guarantee a bound
on a specied probability of excessive delay. We prove new many-server asymptotic results to
approximate this probability of excessive delay. To our knowledge, this constitutes the rst many-
server asymptotic analysis of health care related issues. Based on these ndings we derive two
heuristics corresponding to the so-called eciency-driven (ED) and quality- and eciency-driven
(QED) stang regimes. In addition to performing well, the heuristics provide managerial insights.
In particular, we observe a super pooling eect in large medical units where the optimal number
of required nurses is dramatically less than the nominal patient workload.
It is worth noting that we do not try to nd what an acceptable probability of excessive delay
should be. Neither do we determine the precise values of the parameters describing our model (i.e.,
average nurse service times and frequency of patient needs). Nevertheless, we argue that, whatever
constitutes an excessive delay and our tolerance thereof, mandating nurse-to-patient ratios cannot
ensure uniform quality of care across all hospitals.
We present our basic model in Section 3. The impact of Bill AB 394 on probabilities of excessive
delay is explored in Section 4. We formulate the optimal nurse stang problem in Section 5, and
derive and test two heuristics in Section 6. Section 7 presents our main managerial insights, which
make use of the heuristics provided earlier. We conclude by discussing our results and suggesting
future analytical and empirical research. The following section contains a short survey of the
relevant literature.
2. Literature Review
Recent years have witnessed considerable debate in health-care practice, both within government
and throughout academia, over the issue of administrating nurse stang practices in health-care
facilities. Spetz (2004) provides a comprehensive overview of the history and surveys some prelim-
inary eects of nurse-to-patient ratios in California. Spetz (2005) also describes several alternative
Author: Article Short Title
4 Article submitted to Management Science; manuscript no. MS-
policies, including the development of pay-for-performance systems in hospitals. The concept of
mandatory nurse-to-patient ratios, which should help improve nurse working conditions, is moti-
vated in part by the persistent shortage of registered nurses in the United States (Sochalski 2004,
Kaestner 2005). But the primary justication for these ratios lies in the assumption that nurse
stang levels have a signicant impact on patient safety and outcomes. The bulk of research in this
eld focuses on trying to establish (or negate) this basic premise. Data that are usually collected
to explore this link include such outcome measures as mortality rates, adverse incidents, length of
stay, and patient and nurse dissatisfaction (Neisner and Raymond 2002). Lang et al. (2004) provide
a fairly exhaustive and systematic review of articles investigating this link.
2
The link between workload and quality of care is often thought of in terms of adverse events.
For instance, in evaluating how hospitals improve quality of care, Tucker and Edmondson (2003)
identify failures that occur in care delivery processes, such as tasks that are unnecessarily or
incompletely performed. In our setting, stang levels are set to prevent the assistance of patients in
need from being delayed longer than a specied time constraint. We assume that the frequency at
which delays exceed this constraint is signicantly correlated with the frequency of adverse events.
This is a reasonable assumption, since delaying certain procedures can endanger patient health.
For instance, the medical guidelines for certain myocardial infarctions recommend the immediate
administration of aspirin (American College of Cardiology 2002). Delays also give rise to unnished
tasks, either because nurses fail to remember them later or because they abandon them in order
to take care of more urgent procedures. Unnished care has been identied as a strong factor
impacting the quality of nursing care (Sochalski 2004).
Note also that in business settings, timely service has long been recognized as a main driver of
customer satisfaction and is widely used as a service quality indicator (see for instance Gans et al.
2003) for applications in call centers). For businesses, excessive delays can lead to lost business
opportunities.
This paper deals exclusively with the nurse stang regulatory issue. However, there are several
other factors that go into nursing workforce management. For example, Kao and Tung (1980) use
statistics to forecast patient loads a year into the future. Such forecasts are necessary for under-
standing nursing requirements and for eectively setting budgets to cover nurse salaries. Another
aspect of workforce management is the setting of nurse schedules, which typically is completed in
the days or weeks preceding the actual work shifts. Approaches to solving the scheduling problem
2
The study was commissioned by the CDHS and was included as part of the nal statement of evidence justifying
the implementation of California Bill AB 394 in 2003.
Author: Article Short Title
Article submitted to Management Science; manuscript no. MS- 5
include linear programming (Jaumard et al. 1998), math programming (Warner and Prawda 1972,
Miller et al. 1976), and genetic algorithms (Aickelin and Downsland 2003, Bailey et al. 1997). In
some hospital settings, patients are matched with nurses; see Punnakitikashem et al. (2006) for a
stochastic programming approach to the nurse assignment problem.
Operations management studies also extend to more general hospital capacity issues beyond
the nurse stang problem. Green (2004) presents a recent overview of queuing models used in
capacity planning and management of hospitals (see also Smith-Daniels et al. 1988). Typically,
medical units are modelled as multi-server, open-loop, M/M/s queues, where the arrival process
represents the stream of incoming patients and the service time captures the average length of stay.
Studies of these models provide, for instance, the number of required beds to achieve availability
targets in a given unit. On the other hand, our model seeks to capture the workload variability
experienced by the nurses. During a time period when the number of patients is relatively constant,
the dynamics of the system are better captured by a closed queue with a nite population of
patients (an M/M/s//n queue), where each patient can independently require processing by a
nurse. In a previous paper (de Vericourt and Jennings 2006a) we provide preliminary asymptotic
results for this system via many-server limit theorems. Those results, combined with extensions
herein, allow us to derive ecient stang rules with general targets for the probability of excessive
delay, as well as to evaluate the performance of nurse-to-patient ratio policies relative to this metric.
Many-server asymptotic analysis has proven exceptionally useful for other service-oriented capac-
ity management problems, specically those focusing on call centers. Many recent call center papers
can be directly linked to the conceptual breakthrough of Haln and Whitt (1981), who recognized
that, at least for large open queueing systems, one can sta service operations that achieve not only
a high level of utilization but also very fast customer response times. In other words, the stang
policies studied by Haln and Whitt are eciency-driven (ED) from the standpoint of the service
provider and quality-driven (QD) from the perspective of the customer, yielding a hybrid quality-
and eciency-driven (QED) stang regime. Garnett et al. (2002) later studied the distribution of
the virtual waiting time of call centers staed in the QED regime in more detail. They also observed
that by including abandonment in many-server queueing models, one can consider the ED case, for
which the nominal load exceeds the processing capacity. Whitt (2004), Mandelbaum and Zeltyn
(2006) and Baron and Milner (2006) have all extended the study of open many-server systems with
abandonment and staed in the ED regime. The latter two, both contemporaneous papers, also
consider minimizing service capacity, subject to constraints on the frequency of excessive delay, as
the primary objective of system design.
Author: Article Short Title
6 Article submitted to Management Science; manuscript no. MS-
3. The Queuing Model
Consider a medical unit of s nurses serving n patients. Over time, each patient repeatedly requires
the assistance of a nurse for various care procedures. When a patient requires the assistance of a
nurse, we refer to the patients state as needy. Otherwise the patient is said to be stable. We assume
that the time for a stable patient to become needy, referred to as the activation time, is random
and independent of all other system dynamics. Upon becoming needy, a patient is immediately
treated by a nurse, if an idle nurse is available. Otherwise, a needy patient waits for an available
nurse; queued patients are assisted in a rst-come-rst-served fashion. The nurses service time is
also random and independent of other system features. Once treated, a patient becomes stable
again, until she needs other care procedures. We assume that nurses work as a team so that any
one of them can serve any patient. In some medical units however, a nurse is assigned to a specic
set of patients. Our model remains relevant in such settings, provided that nurses whose patients
temporarily require less care will help their busier colleagues, as is often the case in practice.
In general, activation times and nurse service times depend on patient acuity levels and nurses
skill levels. Unfortunately, when setting public policy, the possible combinations of these levels
are too vast to accommodate fully using specic guidelines. Instead, policy makers may want to
set nurse-to-patient ratios assuming either the lowest or the highest possible acuity level for all
patients in the unit.
3
For practical modeling purposes, the possible discrepancy in acuity levels
and dierent skill levels of nurses can be captured by adjusting the probability distribution of the
activation time and the nurse service time accordingly.
To our knowledge, no empirical studies have tried to estimate the probability distributions of
activation and service times. We suspect that these distributions can be quite general in practice.
For analytical tractability, however, we assume that activation and service times are exponentially
distributed with rates and , respectively. In some respects, the exponential assumption is a
reasonable one. The wide range of possible patient needs and nursing tasks suggests a high degree
of variability in the health care process, which is consistent with the high coecient of variation
of the exponential distribution.
In a system in which each patient has a dedicated nurse, the long run fraction of nursing time
required by a typical patient is equal to r :=/(+) while the long run fraction of time a patient
is stable is given by r := 1 r . The quantity rn then is the nominal patient load (also referred
3
In fact, California Bill AB 394 specically advises that, in order to account for case mix and patient acuity levels,
hospitals use the mandated minimum stang ratio recommendations in conjunction with stang policies and proce-
dures developed locally at the hospitals. We consider the case of homogeneous patients for which such adjustments
are not required.
Author: Article Short Title
Article submitted to Management Science; manuscript no. MS- 7
to as the total oered workload), i.e., the long run average number of needy patients among a
population of size n.
Variability in the system leads to congestion and, hence, treatments will occasionally be delayed.
The frequency and magnitude of delay are functions of the total number of nurses that are staed.
The principal metric of concern is the probability of excessive delay, the likelihood that a needy
patients waiting period before getting access to a nurse is longer than a time threshold T 0.
For the special case threshold for which any delay is excessive (T =0), this performance metric is
simply referred to as the probability of delay.
The medical unit is modelled as an M/M/s//n queue. Letting :=/ =r/ r, the steady state
probability distribution of N, the number of needy patients in the system, is given as (see for
instance Kleinrock 1975):

k
=

0
_
n
k
_

k
if k <s;

0
_
n
k
_
k!
s!
s
sk

k
if k s,
(1)
where
0
is a normalizing constant. A patient who becomes needy when there are already k other
needy patients will experience an in-queue random waiting time that follows an Erlang distribution
with (k s +1)
+
stages, each with rate s. The probability that this Erlang-distributed random
variable is greater than t is e
st

ks
j=0
(st)
j
/(j!). Clearly, the patient only waits if k s. Let W
denote the steady state, in-queue waiting time for a hypothetical newly needy patient. A similar
random variable is V , referred to as the virtual hitting time. The latter quantity is equal to zero
if the number of needy patients is strictly less than s; otherwise, the quantity is equivalent to the
time required for the number of busy servers to fall below s, provided no new jobs arrive in the
interim. (If the number of busy servers is s 1 or less then an additional needy patient can be
assisted immediately.) By conditioning on the queue length, we obtain the tail of the steady state
distribution of the virtual hitting time:
P(V >t) =e
st
n

k=s

k
ks

j=0
(st)
j
j!
.
The steady state distribution of the virtual hitting time V does not capture, however, the steady
state distribution of the needy patient waiting time W, whose tail is denoted p
n
(s, t). This is
because the total activation rate, i.e. the rate at which the collective stable patient population
produces needy patients, is modulated by the number of needy patients. As a result, the PASTA
property does not hold.
4
Hence, we must change the measure above to account for the activation
4
A similar complication was encountered in de Vericourt and Jennings (2006a), where the probability of having all
servers occupied P(N s) was used as a surrogate for the probability of delay P(W >0). In that paper it was shown
that, asymptotically, PASTA holds, and thus these quantities are equivalent in the limit as the number of patients
goes to innity.
Author: Article Short Title
8 Article submitted to Management Science; manuscript no. MS-
rate intensity. Letting
k
:= (n k) denote the activation rate when k patients are needy (and
suppressing the parameter n except when necessary), we obtain
p
n
(s, t) =
n

k=s

n
i=0

i
P(V >t[N =k) =e
st
n

k=s
(nk)
k

n
i=0
(ni)
i
ks

j=0
(st)
j
j!
. (2)
Recall that the parameter T 0 delineates between acceptable and excessive delays. The probabil-
ity of excessive delay for a system with n patients and s nurses is denoted p
n
(s, T), or simply p
n
(T)
when no confusion is possible, and is a point along the function p
n
(s, ). An interesting property of
the expression (2) when evaluated for a specic T is that, given the number of nurses and patients
in the unit, the probability of excessive delay is entirely described by the parameters r and the
target T since
k
in (1) only depends on = r/(1 r). For ease of exposition, we will always
specify the time target T as an integer multiple of the service time (T =i/).
In the next section we study the impact of nurse-to-patient ratios on the probability of excessive
delay.
4. A Queueing Model Perspective on California Bill AB 394
Let us consider California Bill AB 394, which has governed nurse stang over the past few years,
and pediatric units in the state. The law requires that at all times, regardless of the size of a
hospital, at least one nurse must be staed for every four patients under care (see Table 2 in the
appendix for the full list of these mandated ratios). In the following, we investigate the theoretical
eect of the mandated ratios, as predicted by our queueing model. We focus our investigation on
pediatric units exclusively, with the understanding that our analysis extends to all units for which
pooling of nurses is a reasonable operating assumption.
The main idea when deriving the collection of stang ratios was to evaluate, for each hospital
unit, the proportion of nursing time a patient requires during a typical shift (controlling for patients
acuity level and nurses skills). One should note that this proportion of time is precisely the same
as the load factor r in our queuing framework. Because quantitative data are lacking, the interest
groups and research teams who framed Bill AB 394 and ultimately set the ratio values, relied
heavily on expert panels comprised primarily of highly qualied and experienced registered nurses
and nurse administrators (see California Department of Health Services 2003, Institute for Health
& Socio-Economic Policy 2001). The suggested ratio values from these panels diered greatly (see
Table 2), perhaps as a result of the various constituents involved in the process. Nevertheless,
compromises among the various suggestions were made and the results are our best estimates for
the nominal patient load for each hospital unit.
Author: Article Short Title
Article submitted to Management Science; manuscript no. MS- 9
In this paper we consider only pediatric units, primarily because of the relative consensus among
the expert panels suggested pediatric unit ratio values. The mandated ratio policy sets the number
of nurses s
n
equal to the nominal patient load rn, when there are n patients in the unit:
s
R
n
=rn|, (3)
with r =1/4 (for pediatric units) and where x| is equal to the smallest integer larger or equal to
x. We also refer to this stang rule as the nominal ratio policy.
Given the size n of the pediatric unit, we can compute the required number of nurses s
n
based
on (3) and deduce the resulting probability of excessive delay using (2) for dierent time thresholds
T. Figures 13 show the impact of the size of the pediatric unit on the probability of excessive
delay experienced by the needy patients for T =0 (any delay), 1/ (delay longer than an average
nurse service time), and 2/ (delay longer than two average nurse service times), respectively. The
sharp oscillations in performance can be explained by the step-wise increase in the stang level
that occurs at four-patient intervals when rn is rounded up to the nearest integer. The magnitude
of these oscillations decreases with n. For T = 0, Figure 1 suggests that when disregarding these
oscillation eects, the excessive delay probability remains roughly stable around 65% for most n.
On the other hand, for T >0, Figures 2 and 3 indicate that as the size of the unit grows, patients
can expect to see progressively lower probabilities of excessive delay. In other words, patients in
larger pediatric units appear to be better o than patients in smaller units, although all units are
consistent in the implementation of the 1:4 stang ratio dictated by law.
In order to explore the magnitude of this inconsistency in California we need information on the
distribution of the number of patients in Californian pediatric units, which can signicantly vary
over time. Unfortunately such detailed information is not publicly available. As an alternative,
we use the data provided by the California Oce of Statewide Health Planning and Development
(OSHPD) as part of the state-wide hospital utilization data it collects annually.
5
In this study
we use the data from 2003 which contains the patient numbers reported by all pediatric units of
Californian hospitals, averaged over the year. These census averages are used as if they represent
the typical sizes of corresponding units at any given time. For our sample, a total of 134 pediatric
units in California with average occupancies between 2 and 154 were identied (see Table 3 in the
appendix).
5
The database was and continues to be used by many of the interest groups and research teams that framed Bill AB
394 and its implementation.
Author: Article Short Title
10 Article submitted to Management Science; manuscript no. MS-
Figure 1 Delay Probability under Nominal Ratio Stang, T =0
0 10 20 30 40 50 60
0.25
0.3
0.35
0.4
0.45
0.5
0.55
0.6
0.65
0.7
n

p
n
(
T
)
Figure 2 Excessive Delay Probability under Nominal Ratio Stang, T =
1

,
0 10 20 30 40 50 60
0
0.05
0.1
0.15
0.2
0.25
0.3
0.35
0.4
n

p
n
(
T
)
The rst two rows of Table 1 contain our chosen partition of the pediatric unit sizes in California.
Interestingly, the average pediatric unit occupancies are considerably skewed, with a majority of
hospitals reporting average occupancies below 20 patients; only 11% of the 134 pediatric units
reported average occupancies greater than 20. The remaining rows of the table provide excessive
delay probabilities, as predicted by our model, for the specied choice of time constraint parameter
T. The data is presented in a fashion that controls for the rounding-up eect. Namely, for each unit
Author: Article Short Title
Article submitted to Management Science; manuscript no. MS- 11
Figure 3 Excessive Delay Probability under Nominal Ratio Stang, T =
2

,
0 10 20 30 40 50 60
0
0.02
0.04
0.06
0.08
0.1
0.12
0.14
0.16
0.18
0.2
n

p
n
(
T
)
Table 1 Excessive Delay Probabilities in Californian
Pediatric Units
n n 5 5 <n 10 10 <n 20 20 <n
%Units 36% 38% 15% 11%
T =0 66% 67% 67% 67%
T =1/ 38% 28% 24% 15%
T =2/ 20% 10% 6% 2%
size partition / delay threshold pair, the table reports the largest predicted probability of excessive
delay among all unit sizes in the partition. The table summarizes the theoretical performance
of the current law under alternative denitions of acceptable delay. For instance, when T = 0,
the probability of delay hovers around 66% for all n. Although the performance is consistent,
it is consistently poor. For acceptable delays that are strictly positive (T > 0), Table 1 suggests
signicant discrepancies in service quality across the dierent hospitals in California. For instance,
in 36% of pediatric units (for which n 5) the probability that delays exceed a time equivalent
to a nurses average service time (T = 1/) can be as high as 38%, whereas in another 26% of
the units (for which n >10) this probability is less than 24%. When T = 2/, the probability of
excessive delay appears to be reasonable (less than 6%) for 26% of the units, but can still reach
20% in small units.
The nominal ratio policy is but one of many within the spectrum of possible ratio policies, each
having the form s
n
=n| for some real number > 0. Studies have argued that decreasing the
Author: Article Short Title
12 Article submitted to Management Science; manuscript no. MS-
number of patients per nurse leads to a reduction in adverse events. In Figure 4, we provide the
predicted probability of delay (T = 0) when r = 1/4 and a ratio policy with = 1/3 is employed
(see Figure 10 in the appendix for the case where T =1/). As expected, performance is improved,
but exhibits a signicant inconsistency across unit sizes. On the other hand, when = 1/5, the
ratio policy provides consistent but poor performance for the delay threshold T =1/, disregarding
again the oscillation eect; see Figure 5 (see also Figure 11 in the appendix for T =0).
Figure 4 Delay Probability under Ratio Stang, r =
1
4
, =
1
3
, T =0
0 10 20 30 40 50 60
0.05
0.1
0.15
0.2
0.25
0.3
0.35
0.4
0.45
0.5
n

p
n
(
T
)
In summary, the nurse-to-patient stang ratios
appear to have dierent performance implications for smaller units than for units with larger
patient populations, with the trend showing that patients in smaller units will see higher proba-
bilities of excessive delay in relation to units of larger size,
can, in many cases, result in very high probabilities of excessive delays which in turn might
lead to poor levels of quality of care.
In the remainder of this paper, we use a more analytic approach to formalize and generalize
the ndings of this section. In particular, we will show that these insights depend neither on the
precise values of the dierent parameters which describe our system, nor on the choice of the ratios
mandated by law.
Author: Article Short Title
Article submitted to Management Science; manuscript no. MS- 13
Figure 5 Delay Probability as a Function of n, r =
1
4
, =
1
5
, T =1/
0 10 20 30 40 50 60
0.05
0.1
0.15
0.2
0.25
0.3
0.35
0.4
0.45
0.5
0.55
n

p
n
(
T
)
5. The Optimal Nurse Stang Rule
The purpose of the AB 394 legislation is to guarantee a certain level of quality of care in all
Californian hospitals. Agreeing upon what exactly constitutes quality of care, much less quantifying
a reasonable minimum level, has yet to be accomplished in practice. In our framework, however,
quality of care corresponds with dening an upper limit on the probability that patient needs are
delayed more than a specied target time T. The threshold T eectively denes which delays are
excessive and the parameter is a reection of our tolerance for excessive delays. The stang rule
should guarantee that, whatever the number n of patients in the unit, the probability of excessive
delay is less than . More formally, for each n 1,
Minimize s
n
, for s
n
[1, . . . , n] (4)
such that:
p
n
(s
n
, T) <.
Given the optimal policy s

n
solving (4), the corresponding probability of delay is denoted p

n
(T) :=
p
n
(s

n
, T).
The ratio policy mandated by law ignores variability in the care delivery processes and stas
at the nominal patient load (s
R
n
=rn|). A literal interpretation of the law suggests that it aims
to eliminate delays in treatment altogether, which corresponds in our framework to specifying the
time and frequency constraints in the strictest possible fashion: = 0 and T = 0. However, if the
Author: Article Short Title
14 Article submitted to Management Science; manuscript no. MS-
Figure 6 Optimal versus nominal ratio stang, r =
1
4
, =1%, T =0
0 10 20 30 40 50 60
0
5
10
15
20
25
n

s
n
s
n
*
s
n
R
system exhibits any level of variability, such a target can only be achieved with a dedicated nurse
for each patient, an unreasonable expense in most units. Determining acceptable values of and
T is a subject for future research. On the other hand, our analytic approach, and in particular
our test for a range of values for and T, allows one to develop insights into the form of the best
possible stang policy, as well as pointing out the shortcomings of the current legislation, without
assuming the exact levels of the probability and/or dening what constitutes excessive delays.
For each n 1, the optimal stang level s

n
satisfying (4) can be obtained using a simple
enumerative search algorithm over all possible values of s
n
. For each step of the procedure, the
probability of excessive delay p
n
(s
n
, T) is calculated using equation (2) and compared to the bound
. Of course, the optimum stang level is an increasing function of n. So s

n
provides a natural
starting point in the search for s

n+1
.
Figures 68 compare the stang of pediatric units (r =1/4) under the mandated nominal ratio
policy (s
R
n
= rn|) with the optimal stang policy s

n
, for = 1% and for T = 0, 1/ and 2/,
respectively. When T =0, Figure 6 shows that the nominal ratio policy underestimates the stang
requirements that ensure that the excessive delay probability is less than 1%. Furthermore, the gap
between the ratio stang rule and the optimum one seems to be increasing with n. For T =1/,
the number of nurses scheduled in the nominal ratio policy is still not large enough to guarantee
that at most 1% of needy patients will wait more than a time equivalent to a nurses average service
time, 1/. The deviation from the optimal stang rule quantity seems however to decrease with
n, at least within the range of unit sizes considered. Figure 8 provides a more intriguing situation
Author: Article Short Title
Article submitted to Management Science; manuscript no. MS- 15
Figure 7 Optimal versus nominal ratio stang, r =
1
4
, =1%, T =
1

0 10 20 30 40 50 60
0
2
4
6
8
10
12
14
16
n

s
n
s
n
*
s
n
R
Figure 8 Optimal versus nominal ratio stang, r =
1
4
, =1%, T =
2

0 10 20 30 40 50 60
0
5
10
15
n

s
n
s
n
*
s
n
R
in which the nominal ratio policy underestimates the number of required nurses needed by small
units (n 25), but is conservative relative to the optimal number needed by larger units. In eect,
only larger units achieve the target probability of excessive delay of at most 1%, but the stang
for these situations is needlessly excessive.
The poor performance of the nominal ratio policy is also conrmed by the signicant gap in the
probability of excessive delay for the nominal ratio policy versus the optimum policy. For instance
Author: Article Short Title
16 Article submitted to Management Science; manuscript no. MS-
Figure 9 Excessive Delay Probability as a Function of n, r =0.25, =0.05, T =1/
0 10 20 30 40 50 60
0
0.05
0.1
0.15
0.2
0.25
0.3
0.35
0.4
n

p
n
(
T
)
p
*
n
(T)
p
R
n
(T)
Figure 9 illustrates the signicant gap in the probability of excessive delay for the nominal ratio
policy versus the optimum policy for r = 1/4, = 5% and T = 1/. As shown by the gure, the
nominal ratio policy meets the service level requirement consistently only for large unit size (n 45)
(see de Vericourt and Jennings 2006b, for more details).
These results suggest that nominal ratio policies do not possess the structure of the optimal
stang rule. In particular, the unit size n seems to aect the slop of s

n
as a function of n, while
the slop of a ratio policy is independent of n. This will be conrmed in the following section.
6. Heuristics
In the following, we introduce and test alternative stang rules that perform well and are easy
to implement. The heuristics provide important insights into the structure of appropriate nurse
stang rules that cannot be directly obtained from the optimization problem in (4).
We derive the heuristics via many-server asymptotics, an approach that investigates properties
of families of stang rules (i.e., mappings n s
n
) as the number of patients becomes very large. It
turns out that depending on the limit s =lim
n
s
n
/n, the system exhibits two distinct behaviors.
When s < r, for large values of n, all nurses are practically always busy. Hence we refer to such
policies as eciency-driven (ED), or belonging to the ED stang regime. Another phenomenon in
this setting is that all needy patients must wait a non-trivial amount of time before being assisted.
This suggests that, when stang in the ED regime, the time delay threshold T must be strictly
positive. On the other hand, when s > r, needy patients experience little or no wait and, hence,
Author: Article Short Title
Article submitted to Management Science; manuscript no. MS- 17
such policies are referred to as quality-driven. Moreover, the corresponding value of T is small or
zero. In this case there will often be some idle nurses. The so-called QED regime, arising when
s =r, exhibits the dening characteristics of both the ED and QD regimes. (See de Vericourt and
Jennings (2006b) for more details on the many-server framework.)
6.1. QED-Based Heuristics
Our rst heuristic is based on the assumption that optimal stang levels are slight deviations from
those provided by the nominal ratio policy. Under this assumption, the resulting stang policy
can initially be thought of as being in the QED regime.
Suppose we have a QED stang policy s
n
. To capture the microscopic dynamics of the system,
we consider the following process
N
n
(t) :=
N
n
(t) rn

n
, t 0, (5)
where the process N
n
tracks the number of needy patients and its initial value N
n
(0) is assumed
to be approximately equal to the centering constant rn. We refer to the transformation in (5) as
diusive scaling. In de Vericourt and Jennings (2006a), functional central limit theorems (FCLTs)
are taken for this sequence of processes. The result, summarized below, is a diusion process which
serves to approximate the stochastic dynamics of N
n
.
It was shown in de Vericourt and Jennings (2006a) that the sequence of virtual hitting time
processes V
n
, n 1 converges to zero at the same rate as 1/

n converges. It follows that, in order

to approximate needy patient waiting times, we must zoom in on this process. Dene the inated
virtual hitting time processes

V
n
, n 1, where

V
n
:=

nV
n
, for each n 1. As Proposition 1
states below, under the QED stang regime, the diusion-scaled needy patient process and the
inated hitting time process converge together to scalar multiples of the same diusion process.
Consider rst the following series
n
, n 1 associated with the stang rule n s
n
,

n
:=
_
s
n
n
r
_

n. (6)
Modulo round-o error, the quantity
n

n is the deviation of s
n
from the nominal ratio policy.
The following proposition states that if
n
converges to a nite value , which also requires that
s =r (conrming that indeed the policy operates in the QED limiting regime), then the inated
virtual hitting time converges in distribution to a diusion process.
Proposition 1. Consider a stang rule n s
n
such that
n
where (, ) as n
. If N
n
(0) converges in distribution to a proper random variable N(0) as n , then

V
n
and
Author: Article Short Title
18 Article submitted to Management Science; manuscript no. MS-
(N
n
)
+
/(s
n
/n) converge jointly in distribution to (N)
+
/(r). Moreover, the steady state
distribution of N has probability density
f
QED
(x) =

1()

r r

_
x

r r
__

r r
_
x <,
()

r

_
rx+ r
r

r
__

r
_
x .
(7)
with
() =

1 +e

2
2r
2

rr
_

r
_

1
, (8)
and where the function () is the standard normal cumulative distribution function.
Proof. The result is a direct consequence of Theorem 2 and Corollary 2 of de Vericourt and
Jennings (2006a).
To derive our rst heuristic, consider a stang rule of the form s
n
= rn +
n

n and assume
that
n
converges to some constant . The excessive delay probability can be approximated by the
tail of the virtual hitting time distribution: p
n
(s
n
, T) P(

V
n
>

nT).
6
Using Proposition 1, we
approximate the distribution of

V
n
with that of (N)
+
/(s
n
/n):
P(

V
n
>

nT) P
_
(N
n
)
+
s
n
/n
>T

n
_
.
We then consider the distribution of N in steady state given by (7) so that
p
n
(s
n
, T)
(
n
)

r
1

_
n
r

r
_
_

n+
snT

_
rx+ r
n
r

r
_
dx
= (
n
)
_

n
r

s
n
T

n
__

n
r

r
_
. (9)
where () is the standard normal distribution function. Our rst heuristic consists of nding
n
such that the approximation in (9) is equal to the target :
Heuristic 1. (H1)
For a given >0 and T 0,
s
H1
n
=rn+
n

n| (10)
where
n
satises
=(
n
)
_

n
(1 +rT)
r

r
rT
_
n
r
__

n
r

r
_
, (11)
and where (
n
) is given by (8).
6
Notice the implicit asymptotic PASTA assumption.
Author: Article Short Title
Article submitted to Management Science; manuscript no. MS- 19
Note that when T = 0, (11) simplies considerably: = (). It follows that, when T = 0, we
have
n
=
1
() for each n. When T =0, our rst heuristic is equivalent to the one developed in
Section 5 of de Vericourt and Jennings (2006a) and performs exceptionally well. In particular, the
heuristic policy never deviates from the optimal one by more than one nurse; i.e., for each n 1,
[s

n
s
H1
n
[ 1.
When T >0, nding s
H1
n
involves solving equation (11) in its general form. The next proposition
guarantees the existence and uniqueness of the solution. It also leads to ecient numerical methods
to determine
n
.
Proposition 2. The function : ''
+
such that
(x) =(x)

_
x
r

r
(1 +rT) rT
_
n
r
_

_
x
r

r
_
is strictly decreasing in x.
Proof. Note rst that () can be written as
(x) =(x)
(axb)
(cx)
,
where a, b and c are positive constants. Denote by h() the hazard rate of the standard normal
distribution, i.e., h(x) =(x)/(x) for every real x. We can restate (8) as
(x) =

1 +

r
h
_
x
r

r
_
h
_
x

rr
_

1
.
Because the hazard rate of the normal distribution is increasing, the function () is decreasing. It
remains to show that x (axb)/(cx) is also decreasing. Taking the rst order condition,
this is equivalent to showing that,
a(axb)(cx) >c(axb)(cx),
or equivalently, because (x) =(x) for the standardized normal distribution, that
h(ax+b) >
c
a
h(cx).
This nal relation follows because h() is increasing, c/a =1/(1+rT) <1, and ax+b >cx for any
real x.
The monotonicity of allows us to use a simple bisection search algorithm in order to solve
equation (11). This procedure is more ecient than solving the optimal problem in (4) but still
requires some computation eort.
Author: Article Short Title
20 Article submitted to Management Science; manuscript no. MS-
6.2. ED-Based Heuristics
In designing Heuristic 1 we assumed that the optimal stang policy was a slight deviation from the
nominal ratio policy. This approach is valid for small values of T, a feature that suggests stang in
the QED regime. However, when T is large we should sta in the ED regime because the nominal
ratio policy is no longer close to the optimal one. Our second heuristic is based on the assumption
that, for every value of T >0, there exists a unique quantity r
T
<r such that the optimal policy is
an order

n deviation from r
T
n.
Heuristic 2. (H2) For a given >0 and T >0,
s
H2
n
= r
T
n+
T

n| (12)
where
r
T
=
r
1 +rT
(13)
and

T
=r
1
()

r +rT
(1 +rT)
3
. (14)
The following argues that Heuristic 2 is asymptotically optimal as n , thereby justifying its
use for large values of n. As discussed later, it works well for all values of n.
Proposition 3. For any given T >0, the probability of excessive delay p
n
(s
n
, T) has a nonde-
generate limit (0, 1) if and only if
_
s
n
n
r
T
_

n , as n ,
for some (, ), with
=

(1 +rT)
3
r +rT

. (15)
Proof. The probability of excessive delay can be written as
p
n
(s
n
, T) =
_
n

k=0

k
(nk)
_
1
_
n

k=sn

k
(nk)e
sT
ksn

j=0
(sT)
j
j!
_
=
D
n
B
n
_
1 +
A
n
B
n
_
1
,
where
A
n

sn1

k=0
_
n
k
_
(nk)
k
,
B
n

k=sn
n!
s
n
!
(nk)s
sn
n
_

s
n
_
k
Author: Article Short Title
Article submitted to Management Science; manuscript no. MS- 21
and
D
n

k=sn
n!
(nk)!
s
sn
n
s
n
!
_

s
n
_
k
e
sT
ksn

j=0
(s
n
T)
j
j!
.
The quantity A
n
can be expressed as
A
n
= n(1 +)
n1
sn1

k=0
_
n1
k
_
r
k
r
nk
= n(1 +)
n1
P(X
n
s
n
1),
where for each n, X
n
is a binomial random variable with parameters n 1 and r. Similarly, one
can express B
n
as
B
n
=
n!
s
n
!
s
sn
n
_

s
n
_
n1
e
sn/
nsn1

k=0
_
s
n

_
k
1
k!
e
sn/
=
n!
s
n
!
s
sn
n
_

s
n
_
n1
e
sn/
P(Y
n
ns
n
1)
and D
n
as
D
n
=
n!
s
n
!
s
sn
n
_

s
n
_
n1
e
sn/
_
nsn1

k=0
_
nsnk1

j=0
_
s
n

_
k
1
k!
(s
n
T)
j
j!
e
(sn/+snT)
__
=
n!
s
n
!
s
sn
n
_

s
n
_
n1
e
sn/
P(Z
n
ns
n
1),
where Y
n
and Z
n
are independent Poisson random variables with parameters s
n
/ and s
n
/+s
n
T,
respectively. For each sequence of the random variables X
n
, Y
n
and Z
n
, we generate a central
limit theorem. Starting with X
n
, we center and rescale to obtain
P(X
n
s
n
1) =P
_
X
n
(n1)r
_
(n1)r r

s
n
1 (n1)r
_
(n1)r r
_
, (16)
P(Y
n
ns
n
1) =P
_
Y
n
s
n
/
_
s
n
/

n1 s
n
/r
_
s
n
/
_
(17)
and
P(Z
n
ns
n
1) =P

Z
n
s
n
(
1

+T)
_
s
n
(
1

+T)

n1 s
n
(
1
r
+T)
_
s
n
(
1

+T)

. (18)
The sequences (X
n
(n 1)r)/
_
(n1)r r, (Y
n
s
n
/)/
_
s
n
/ and (Z
n
s
n
(
1

+
T))/
_
s
n
(
1

+T) each converge in distribution to standard normal random variables (i.e., with
mean zero and variance one). It is given that the stang level as a function of n is s
n
=rn/(1 +
rT) + o(n). It follows that [s
n
1 (n 1)r]/
_
(n1)r r as n . By (16) one can
conclude that
lim
n
P(X
n
s
n
1) =0. (19)
Author: Article Short Title
22 Article submitted to Management Science; manuscript no. MS-
Likewise, (n1 s
n
/r)/
_
s
n
/ as n , so that by (17),
lim
n
P(Y
n
ns
n
1) =1. (20)
Finally, by the conditions provided for s
n
,
n1 s
n
(
1
r
+T)
_
s
n
(
1

+T)

(1 +rT)
3
r +rT
as n , and by (18) we have
lim
n
P(Z
n
ns
n
1) =

(1 +rT)
3
r +rT

. (21)
The ratio A
n
/B
n
can be written as
A
n
B
n
=C
n
P(X s
n
t)
P(Y ns
n
1)
,
where
C
n
=
s
n
!
n!
_
s
n

_
n1
(1 +)
n1
s
sn
n
e
sn/
.
Following the analysis in the proof of Proposition 1 of de Vericourt and Jennings (2006a), we have
C
n
r
_
1
r
+T
_
e

2
/2r
2
as n . The relevant feature is that the limit of C
n
is nite. It follows
then by (19) and (20) that A
n
/B
n
0. Finally, notice that D
n
/B
n
=P(Z
n
n s
n
1)/P(Y
n

ns
n
1) so that by (20) and (21),
lim
n
p
n
(s
n
, T) =

(1 +rT)
3
r +rT

6.3. Numerical Study

We explore the performance of the previously introduced heuristics through numerical examples.
Tables 4-6 report the dierences s

n
s
H1
n
and s

n
s
H2
n
for dierent values of T, n and for r =
0.1, 0.25, 0.9 and = 1%. (de Vericourt and Jennings (2006b) provides supplementary numerical
results.)
For T =0, H1 performs extremely well with [s

n
s
H1
n
[ 1 for all tested cases. This is consistent
with the results in de Vericourt and Jennings (2006a). (Note that since H2 is only dened for
positive T, the tables do not report its performance for T =0.) For T >0, H1 also performs well
with [s

n
s
H1
n
[ 1 for r =0.1 and 0.25. However the performance of H1 deteriorates as n increases
for r =0.9, as shown by Table 6.
Author: Article Short Title
Article submitted to Management Science; manuscript no. MS- 23
This is not the case for H2, which exhibits stable performance. In all tested cases, we nd that
[s

n
s
H2
n
[ 1 except in Table 4, where r = 0.1 and = 1%, for which [s

n
s
H2
n
[ 2. Further, for
small r (r =0.1 and r =0.25), H1 seems to dominate H2 when T =1/.
Overall both heuristics perform well for reasonable values of r and n. When T and r are small
(T 1/ and r 0.25) H1 outperforms H2 and guarantees that [s

n
s
H1
n
[ 1; H2 outperforms
H1 otherwise, with [s

n
s
H2
n
[ 1.
7. Managerial Insights
In the previous section we developed heuristics for nurse stang and, using numerical examples,
demonstrated that the heuristics do well in approximating actual optimal stang levels. In this
section we use the heuristics to evaluate the performance of ratio policies. In particular, we nd
that only in limited, and arguably impractical, circumstances does the ratio policy mandated by
California law i.e., the nominal ratio policy provide consistent quality of service. We also use the
heuristics to investigate the structure of the optimal policy. Of particular interest is the unusually
strong (super) pooling eects for large units that the optimal stang policy exhibits.
Recall that when the delay constraint is T = 0, we are forced to use Heuristic 1; Heuristic 2 is
undened. For strictly positive excessive delay thresholds (T > 0), the previous section suggests
that we use Heuristic 1 for small values of T and Heuristic 2 for large values.
Consider now the probability of delay (T = 0). If we assume that stang levels and unit sizes
take real values (i.e. we ignore round-up eects), the optimal stang rule can be approximated
by s
n
=rn +
n

n where
n
is the solution of (11). One interpretation is that the nominal ratio
policy is close to optimal whenever
n
=0; that is, when plugging
n
=0 and T =0 into (11) and
solving for the probability of delay, we obtain
=
2
1 +

r
(0) =
1
1 +

r
. (22)
In this case, the probability of delay is at least as large as 50%. In fact, for pediatric units in
California, this probability of delay under the ratio policy is predicted by our heuristic to be 2/3,
a quantity consistent with Figure 1: when controlling for the oscillation eects (due to the stang
level round-up), the ratio policy seems to guarantee a consistent delay probability of roughly 65%.
Now consider another ratio policy s
n
= r
T
n| with r
T
,=r. If r
T
<r then for any reasonable target
probability of delay , this policy will lead to understang. Supposing instead that r
T
> r, then
for only one value of n (using real values for n), will the ratio policy deliver the target probability
of delay:
n =
_

r
T
r
_
2
,
Author: Article Short Title
24 Article submitted to Management Science; manuscript no. MS-
where is chosen so that () as expressed in (8) yields the target delay probability. Of course,
this yields only one unit size for which this particular ratio policy is optimal. This leads to our rst
observation.
Observation 1. For any given unit type, only one ratio policy can yield a consistent probability
of delay across all hospitals, the nominal one mandated by California legislation. However, the
nominal ratio policy cannot guarantee a probability of delay smaller than 50%.
Consider the probability of excessive delays with T >0. Suppose that the nominal patient need
is r, the threshold for delay is T >0, and a ratio stang policy is implemented for which (ignoring
round-up eects) s
n
= r
T
n, where r
T
satises (13). For a given target probability of excessive delay
, the approximately optimal stang policy is, by Heuristic 2, r
T
n +
T

n, where
T
is given by
(14). This implies that for s
n
to be optimal,
T
=0, and hence, by (15), the probability of excessive
delay must be 50%.
Suppose a dierent ratio policy is chosen perhaps even the nominal policy and can be
expressed as n, for some ,= r
T
. Then, given any target excessive delay probability , this ratio
policy is optimal for at most one value of n. This leads to our second observation.
Observation 2. For any given unit type and specied delay threshold T > 0, only one ratio
policy can yield a consistent probability of excessive delay across all hospitals, and it is not the
nominal ratio policy mandated by California legislation. Moreover, the consistent ratio policy cannot
guarantee a probability of delay smaller than 50%.
Suppose stang conforms to the nominal ratios dictated by California Bill AB 394. When the
delay threshold is strictly positive and the target probability of excessive delay is less than 50%,
solving
rn = r
T
n+
T

n
for n leads to a unique solution
n =
_

1
()
T
_
2
_
r +rT
1 +rt
_
.
If >50%, then the nominal ratio policy exceeds the optimal policy for all values of n. Otherwise,
the nominal ratio policy understas for n < n and stas more than the optimal stang policy does
for n > n. This leads to the following observation.
Observation 3. For a strictly positive delay threshold (T >0) and a reasonable target proba-
bility ( <<50%), the nominal ratio policy stas too few nurses and therefore fails to achieve the
target for small units (n < n) while it stas too many nurses and outperforms this target for large
units (n > n).
Author: Article Short Title
Article submitted to Management Science; manuscript no. MS- 25
This observation is consistent with Figure 3 where n is roughly equal to 28. In Figure 2 the crossing
point n is larger than 60.
The next observation summarizes the trends in quality of service and identies the limitation of
the ratio policy mandated by California law.
Observation 4. For any medical unit, any delay threshold, and a ratio policy s
n
= n, the
probability of excessive delay increases (resp. decreases) monotonically with the size of the unit and
asymptotically approaches 1 (resp. 0) if is less than (resp. greater than) the nominal patient load
of that unit.
Observation 4 is consistent with Figure 11 (in the appendix) which shows an increasing trend of
the probability of excessive delay for =1/5 < r =1/4.
In short, according to Observations 1-4 the Californian legislation appears to provide consistent
performances only for poor service levels when the target times are restricted to zero. The previous
discussion also sheds light on pooling eects under the optimal stang rule. Pooling eects appear
when the number of additional nurses required per new patient is decreasing in the unit size n,
that is when s
n
n is concave in n. When unit size and the stang levels are assumed to take real
values, Heuristic 2 can easily be shown to be concave, which suggests that the optimal stang level
exhibits this pooling eect
7
. However, the eects are more dramatic than just concavity. Recall
that rn represents the nominal patient load, that is, the long run cumulative fraction of nursing
time required in the unit provided nurses are always available when patients become needy. For
large system (n > n), Heuristics 1 and 2 actually specify a number of nurses less than the baseline
rn (since
n
<0 under Heuristic). In fact the deviation from the baseline is order n.
Observation 5. When the time target is positive (T >0), the optimal stang rule shows super
pooling eects for large units (n > n): the stang level is less than the nominal patient load (s

n
<
rn).
In traditional stang problems, a common point of departure is covering at minimum the total
demand of the system. Observation 5, however, indicates that for large systems, stang levels can
be set signicantly below nominal total demand. This observation is particularly relevant when
viewed in the context of nurse shortages.
7
The concavity of Heuristic 1 is much harder to prove.
Author: Article Short Title
26 Article submitted to Management Science; manuscript no. MS-
8. Conclusion
This paper addresses the health care quality crisis in the US (as depicted by Institute of Medicine
(2001)) and more specically its relationship to the management of nursing resources. Our primary
assumption is that adverse events in the care delivery process are inversely related to the timely
provision of services to needy patients. Accordingly, in tackling nurse stang problems, we promote
design criteria that limit the frequency of excessive delays in addressing patient needs. Moreover,
we believe that good public policy should aim to provide this quality of service on a consistent
basis, i.e. regardless of the unit size.
However, using an analytical approach we have shown that ratio policies (nominal or not), as
mandated by California Bill AB 394, cannot provide consistently low probability of excessive delay.
This inconsistency can only be observed when recognizing the randomness inherent to care deliv-
ery processes. To the best of our knowledge, variability and congestion have been systematically
ignored in both the debate surrounding nurse-to-patient ratios and the supporting empirical stud-
ies. Nonetheless, as our ndings demonstrate, the randomness in the system has a profound impact
on stang rule performance. We hope that our results will stimulate the medical community to
consider waiting time related metrics as part of future empirical studies addressing nursing issues.
As an alternative to ratio policies, we develop two heuristics (based on many-server asymptotic
results) which provide stang rules that 1) are easy to implement, 2) are consistent across unit
size, and 3) can achieve pre-specied limits on the probability of excessive delay. Furthermore,
our results do not make any assumptions about what this target or the system parameters should
be. We believe our approach provides not only a rich family of objective measures for quality of
service, but also the right framework for public policy discourse. This paper also constitutes the
rst many-server asymptotic analysis of health care related issues.
There are several ways our model can be extended. For instance, accounting for a heterogeneous
workforce (such as the combination of licensed and registered nurses) can be achieved by consid-
ering mean service times which are skill level specic. Likewise, acuity levels can be captured by
dierent activation rates as well as dierent service level targets. This raises the question of how
to dynamically dispatch nurses when patients in dierent conditions are in need. Finally, we have
assumed that the number of patients in the unit remain constant over a nurses shift. It would
be interesting to extend our results in order to account for changes in the patient population. A
starting point, for instance, would be to allow patient admission and dismissal processes to be
Markovian. Our model would then become a hybrid closed/open loop queuing system.
Author: Article Short Title
Article submitted to Management Science; manuscript no. MS- 27
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Author: Article Short Title
Article submitted to Management Science; manuscript no. MS- 29
Appendix
Table 2 AB 394 Nurse Stang Ratio (from http://www.governor.ca.gov/)
Hospital Unit CDHS Proposal
Intensive/Critical Care Unit 1:2
Operating Room 1:1
Neonatal ICU 1:2
Intermediate Care Nursery 1:4
Well-Baby Nursery 1:8
Postpartum
a
1:6 (mothers only)
Labor & Delivery 1:2
Post Anesthesia Care Unit 1:2
Emergency Departments
b
1:4, Critical Care: 1:2, Trauma: 1:1
Burn Unit (considered a CCU) 1:2
Pediatrics 1:4
Step-down/Telemetry 1:4
Specialty Care (Oncology) 1:5
Telemetry Unit 1:5
General Medical-Surgical 1:6 (initial)
1:5 (phased in 12 to 18 mos. after eective date of regs.)
Behavioral Health Psychiatric Units 1:6
Mixed Units 1:6 (initial)
1:5 (phased in 12 to 18 mos. after eective date of regs.)
a
When multiple births, the # of newborns and # of mothers shall never exceed 8 per nurse
b
Triage, radio, or other specialty nurse are to be added as additional workforce & not included in the ratio.
Author: Article Short Title
30 Article submitted to Management Science; manuscript no. MS-
Figure 10 Excessive Delay Probability under Ratio Stang, r =
1
4
, =
1
3
, T =
1

0 10 20 30 40 50 60
0
0.05
0.1
0.15
0.2
0.25
n

p
n
(
T
)
Note. For an acceptable delay of one average service time, Figure 10 illustrates that for unit sizes of 25 or higher,
the probability of excessive delay is very small. For small units the performance is arguably poor (probabilities of
greater than 10%) and for large units the performance is better than necessary (probabilities arbitrarily small). One
can infer from the Figures 4 and 10 that there is no time threshold T for which the ratio policy with =1/3 yields
a consistent probability of excessive delay.
Figure 11 Delay Probability as a Function of n, r =
1
4
, =
1
5
, T =0
0 10 20 30 40 50 60
0.2
0.3
0.4
0.5
0.6
0.7
0.8
0.9
1
n

p
n
(
T
)
Note. Figure 11 illustrates that the discrepancy in performance can lead to a disadvantage for larger medical units,
when a non-nominal ratio such that <r is implemented.
Author: Article Short Title
Article submitted to Management Science; manuscript no. MS- 31
Table 3 Annual average census in pediatric units in California (after rounding to the closest integer)
Annual average census (n) #(Pediatric Units) Annual average census (n) #(Pediatric Units)
2 8 17 1
3 21 20 1
4 8 21 2
5 11 26 2
6 15 31 1
7 13 32 1
8 8 38 1
9 6 50 2
10 9 57 1
11 2 67 1
12 3 74 1
13 3 83 1
14 6 103 1
15 3 154 1
16 1
A total of 134 pediatric units in California with average occupancies between 2 and 154 were identied in
the OSHPD database. We considered only hospitals with n >1. When n =1, most reasonable stang policies
will dictate that one nurse is present.
Table 4 Performance of Heuristics H1 and H2; r =0.1; =0.01
T =0 T =1/ T =2/
n s

n
s

n
s
H1
n
s

n
s

n
s
H1
n
s

n
s
H2
n
s

n
s

n
s
H1
n
s

n
s
H2
n
2 2 0 2 1 1 2 1 1
3 3 1 2 1 1 2 1 1
4 3 1 2 0 1 2 1 1
5 3 0 2 0 1 2 0 1
6 3 0 3 1 1 2 0 1
7 4 1 3 1 1 2 0 0
8 4 1 3 1 1 2 0 0
9 4 0 3 1 1 3 1 1
10 4 0 3 0 1 3 1 1
15 5 0 4 1 1 3 0 1
20 6 0 5 1 2 4 1 1
25 7 0 5 1 1 4 0 0
50 11 0 8 1 2 7 1 1
100 18 0 13 1 1 11 0 0
200 31 0 23 1 1 20 0 0
500 67 1 51 0 1 46 0 0
Author: Article Short Title
32 Article submitted to Management Science; manuscript no. MS-
Table 5 Performance of Heuristics H1 and H2; r =0.25; =0.01
T =0 T =1/ T =2/
n s

n
s

n
s
H1
n
s

n
s

n
s
H1
n
s

n
s
H2
n
s

n
s

n
s
H1
n
s

n
s
H2
n
2 2 0 2 0 1 2 1 1
3 3 0 2 0 0 2 0 0
4 4 0 3 1 1 2 0 0
5 4 0 3 0 1 3 1 1
6 5 0 3 0 0 3 1 1
7 5 0 4 1 1 3 0 0
8 6 1 4 0 1 3 0 0
9 6 0 4 0 0 3 0 0
10 7 1 5 1 1 4 1 1
15 9 1 6 1 1 5 1 1
20 10 0 7 0 1 6 1 1
25 12 0 8 0 0 7 1 1
50 21 1 14 0 1 12 1 1
100 36 0 25 0 0 21 0 0
200 65 0 47 1 1 39 0 0
500 149 1 110 0 0 92 1 0
Table 6 Performance of Heuristics H1 and H2; r =0.9; =0.01
T =0 T =1/ T =2/
n s

n
s

n
s
H1
n
s

n
s

n
s
H1
n
s

n
s
H2
n
s

n
s

n
s
H1
n
s

n
s
H2
n
2 2 0 2 0 0 2 1 0
3 3 0 3 0 0 3 1 0
4 4 0 4 1 0 3 1 0
5 5 0 5 1 0 4 1 1
6 6 0 5 1 0 4 1 0
7 7 0 6 1 0 4 1 0
8 8 0 6 1 -1 5 1 0
9 9 0 7 1 0 5 1 0
10 10 0 8 2 0 6 2 0
15 15 0 11 2 0 8 2 0
20 20 0 14 2 0 10 2 0
25 25 0 16 2 0 12 2 0
50 49 -1 30 3 0 21 3 0
100 96 -1 56 5 0 39 4 0
200 189 -1 107 7 0 74 6 1
500 465 -1 255 10 0 175 8 0