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Optimization model to minimize the makespan in a hospitals gastroenterology service

C. Serrano, A.M. Jimenez, C.A. Amaya, N.Velasco. Universidad de los Andes PYLO H 2008 9 Diciembre 2008

Los textos publicados en la serie de los informes de investigacin de la Universidad de los Andes slo comprometen la responsabilidad de sus autores

Optimization model to minimize the makespan in a hospitals gastroenterology service

C. Serrano, A.M. Jimenez, C. A. Amaya, PhD. y N. Velasco, PhD.

Departamento de Ingeniera Industrial, Universidad de los Andes, Bogot, Colombia.

Abstract: This work presents an application case in the gastroenterology service (GS) of a hospital. Its purpose is to minimize the delays in the transportation of inpatients from their hospital room to the GS, by scheduling patient appointments. The service is represented as a flexible job shop of three stations. The first one assigns beds to outpatients. In the second one, patients are examined by the specialists and, the last one is the recovery room. The second station, identified as the bottleneck of the system, is made up of three identical rooms. Each one is equipped with three dedicated machines. Inside each room, three processes must be carried out. Each process consumes different kinds of resources and these are shared between rooms. Although several processes can operate simultaneously, their execution is limited by resource capacity constraints. Furthermore, one resource cannot be used for two procedures at the same time. The objective is to minimize the makespan. A computer tool for solving scheduling problems with heterogeneous parallel machines was developed based on several heuristics. At the end, 94% of the results obtained using the tool were better solutions compared with historical data. Keywords: Hospital logistics, Gastroenterology service, Flexible job shop, Heuristics, Parallel machines.

1. INTRODUCTION The problem arises in the gastroenterology service (GS) of a private hospital in Bogota, Colombia. Most of service delays are associated with the transportation of inpatients from the different hospital rooms to the GS, and the other way round. In the actual situation, a scheduling of the services rooms is not established, even if the demand of inpatients is known at least one day before and outpatients appointments are booked through a GS call-centre. In consequence, there is no schedule for the inpatients transportation. Such transportation requires a setup time and an adequate coordination between the medical personnel and support service involved in this activity. An improper coordination between the previous actors consumes more time and occupies more resources than the ones needed The GS offers three (3) different types of exams: colonoscopy, endoscopy and gastric ball removal. There also exists a combined procedure which

consists of a colonoscopy and an endoscopy, both in the same appointment. On the other hand, the service attends two types of demand. An unknown demand corresponding to patients who come from the emergency room (ER), and a known but variable demand which is divided between two groups; inpatients and outpatients. Within this circumstance, as soon as the gastroenterologist becomes idle he makes the requirement for an inpatient. As this event is not planned, the transportation of inpatients can last long depending on the availability of the nurse who prepares the patient and supports in charge of the transportation of inpatients in the hospital. During this time, other patients can arrive to the service and the gastroenterologist will need to examine them. When the required inpatient arrives reaches the service, there might be no rooms or resources available with which he could be examined. As a result, he must wait. 2

The objective of this study is to decrease the delays presented in the service in order to examine patients in a more efficient way. It is important to keep in mind resource constraints related to personnel and equipment, and also the demands coming from inpatients, outpatients, and the ER. The aggregated value of this project is the development of an easy-to-use computer tool designed for the medical personnel. The purpose of this tool is to support the GS scheduling and the transportation of inpatients. With its use, the expectation is to increase the service level given to patients represented in lower (or none) waiting times and to increase resources availability as a consequence of a more efficient use of them. The remainder of this article is organized as follows: First, the characterization of the GS is exposed. Then, the methodology used to model the system is presented and a brief review of the literature relating to parallel machine problems with allocation and resource constraints is provided. Afterwards, a proposed mathematical representation is shown, followed by a description of several heuristics for computing GS schedules. The computer tool and the analysis of numerical experiments based on historical data are presented. Finally, the findings are summarized and some recommendations are given for the practical implementation of the tool. 2. CHARACTERIZATION OF THE GS 2.1.The Service The service is composed by three (3) identical rooms, each one equipped with three different machines dedicated to each type of basic exam. In the actual system configuration, there is only one gastroenterologist and one anaesthesiologist available to examine patients. This means that, although there are 3 rooms, only one patient can be seen at a time. In the same way, the cleaning personnel dedicated to wash and clean the machines after every exam performed can process just one machine at a time. In addition of the described rooms, there is a recovery room which has capacity for six (6) patients or six hospital beds at the same

time. Inpatients occupy neither a hospital bed nor recovery room space as they come in their own hospital bed and must be carried to their rooms immediately after the exam is performed. Only outpatients occupy hospital beds in the GS. 2.2.Patients Flow In the transportation of a patient to the service, five (5) actors take part: the GSs secretary (ES) who calls the floors assistant (FA) to make the requirement for the inpatient to the service; the patients nurse who prepares the patient, and the support service (SS) who is in charge of the patients transportation to the GS. The same applies to return the inpatient to its hospital room. The hospital has four (4) floors, an intensive care unit (ICU) and an ER from which the transportation of inpatients is also performed. Each floor is provided with a FA who is in charge of receiving all the information concerning inpatients that belong to the same floor. In the same way, each floor is provided with one SS who is in charge of three activities: transportation of patients, transportation of laboratory samples, and transportation of supplies. The SS carries a radio communicator in order to keep in touch with the FA. When an outpatient arrives to the GS, the next steps are followed. First, the payment of the examination procedure is done. Then, the patient must change clothes and occupy an available hospital bed. Afterwards, the patient is sedated or injected with anaesthesia, as required, by the anaesthesiologist inside the room. This process is followed by the exam done by the gastroenterologist. Finally, the patient goes to the recovery room. Figure 1 illustrates this flow. Each time a machine is used it must be washed by the cleaning personnel. After the cleaning is done, the machine will be available for another procedure in the corresponding room. More over when an inpatient arrives to the GS, the same activities are performed without the processes of assigning a hospital bed, changing clothes and the recovery.

Figure 1. Patients flow in the service.


Demand stay time in the service is independent from the anaesthesiologist, the cleaning personnel, the day of the week and the time at which the exam is performed. Average times were found for the processing times to quantitatively characterize the system. These times include: patients change of clothes, setup of patients inside the room (sedation, anaesthesia), setup of machines (special cleaning), setup of the gastroenterologist (wearing medical gloves, medical mask, goggles and medical suit), setup of the room (cleaning at the end of the day), the processing time of the exam and the patients recuperation time. Table 1 report these times. Deterministic times were assumed.
Processing Times in the Gastroenterology Service Average Times Comments Minimum - Maximum (mins) Setup time of the patient 3-7 outside the room Gastric Ball 60 Removal Setup time of the patient inside the room Another 10 - 15 exam Setup time of hospital 3-7 beds Setup time of machines 10 - 15 Setup time of 3-5 gastroenterologist Setup time of the room Per room 20 Cleaning time of the GS 30 - 60 Endoscopy 3-5 Colonoscopy 7 10 EndoscopyExamination Time 10 15 Colonoscopy Gastric Ball 10 Removal Recuperation Time 60

Several observations must be done with respect to the demand of gastroenterology exams inside the hospital. When concerning inpatients, 29.73% comes from the ER; 28.38% comes from the second floor; 21.62% comes from the fourth floor and the remaining comes from the first and the third floors. It is important to highlight the fact that an important number of inpatients come from the ER. This shows that, as this demand is random, the service must be prepared in order to examine the unscheduled attendance of patients from the ER (free capacity). In addition, the exam with the greatest inpatients demand is the endoscopy (55.41%). The remaining percentage of patients demands either a colonoscopy or an endoscopy-colonoscopy procedure in the same proportion. Concerning outpatients, the most frequently demanded exam is the endoscopy (53.36%), followed by colonoscopy (21.08%), endoscopycolonoscopy (24.44%), and gastric ball removal (1.12%). Generally speaking, the demand of outpatients is higher on Tuesdays, Wednesdays and Thursdays and minimum on Mondays. 2.4.Process and Delay Times A preliminary analysis was done to determine the factors which can affect the stay time of patients inside the GS such as the patients age and the type of exam required. The first conclusion was that there is no relation between the patients age and outpatients stay time in the service; as well as no correlation exists between the gastroenterologist who performs the exam and the patients stay time, concluding that the stay time is not gastroenterologist dependant. In addition, patients

Table 1. Processing times in the GS.

3.1.Stations 1 and 3 Due to the lack of exam scheduling in the service, there exist delay times. Inpatients and the medical personnel in the service have to tolerate these delays, caused by the uncoordinated flow of information, to transport inpatients into the GS and out from it. Graphs 1 and 2 show the average waiting times for inpatients to arrive and to release the GS, represented as delays in the system. In Station 1 the hospital beds assignment is done as well as the change of bed sheets. This process lasts in average 5 minutes. In Station 3 takes place the outpatient recuperation which lasts for about 60 minutes. These times are independent from the patient and the resources used. These two stations share resources such as the hospital beds and the nurse. This happens because a hospital bed is assigned to a patient in Station 1 and is freed only until the patient finishes with his recuperation in Station 3. In this way, both stations are composed by six (6) hospital beds which can be occupied in parallel by outpatients.

Graph 1. Average waiting time until SS picks up the patient

Figure 2. GS divided into stations.

Graph 2. Average waiting time for the patient to arrive to the service.

If the system is seen in steady state, Station 3 dominates Station 1 because these stations share resources and the processing time in Station 3 is greater. A patient/hospital bed is released theoretically every 11 minutes (cycle time) under this scenario. 3.2.Station 2 This is the bottleneck station. The processes performed in this station are: sedation or anaesthesia injection; the corresponding exam and machine cleaning. Sedation or anaesthesia injection process is performed exclusively by the anaesthesiologist, inside the room. Similarly, the gastroenterologist performs the exam and the cleaning personnel wash the used machines. Calculating cycle time in this station is not as simple as in Stations 1 and 3 because it depends on the sequence of the performed exams. However, considering various scenarios, the cycle time, would result in 28.32 minutes in average with the actual resources configuration. This cycle time is greater than the cycle time found for stations 1 and 3 which confirms that Station 2 as the bottleneck station.

It is important to highlight the fact that, when the waiting times are greater than 15 minutes, it is more likely to have an outpatient arriving, and so the requirement of medical personnel in the GS to examine it. In consequence, the service will be blocked when the inpatient arrives as no resources will be available. In the same way, delays in picking up inpatients block the service area reducing the capacity of the recovery room as inpatients must wait inside the rooms until SS arrives. 3. MODELLING THE PROBLEM

The actual situation can be modelled as a flexible job shop with three (3) stations. Station 1 being the hospital bed assignment for outpatients, Station 2 is composed by the three (3) examination rooms and Station 3 corresponds to the recovery room. This configuration is shown in Figure 2.

The analysis for this station reveals some characteristics of the system: the machine cleaning process can be done simultaneously with other processes (sedation or anaesthesia injection, exam, doctor setup) only when the machine being cleaned up is not the same one required in the exam performed. Considering Station 2 as the bottleneck station, it is necessary to find the way of scheduling the exams in each room keeping in mind the availability of the required resources. The schedule needed must be one that minimizes the time in which the last patient leaves the service (makespan). In this way, a minimal waiting time for the patients and greater resource utilization can be obtained. By scheduling the GSs processes, it is expected that the actual delays in the transportation of inpatients will be eliminated as the time for each patient to arrive to the GS will be known. So, it will be possible to program the SS for patient transportation to be done on time. 4. LITERATURE REVIEW

optimality, it must be ensured that the machine sets M j in which each job j might be processed, are nested. This is, that each set of jobs M j must meet at least one of the following conditions for jobs j and k : 1) M j M k 2) M j 3) M k


4) M j M k The imposed constraints in this heuristic, in order to obtain an optimal schedule, are not valid in the GS problem because the pi are not equal to 1 and also, because the subsets of jobs Mj are not nested. Nonetheless, this heuristic is adapted for the GS because the availability of the resources required will be taken into consideration as the subset of rooms which can be used by a specific patient. Although the GS problem is similar to a R || C max problem, there is an important constraint not yet presented: machines cannot be used at the same time because there is only one gastroenterologist in the actual configuration of the GS. Various patients cannot be sedated or injected with anaesthesia because there is only one anaesthesiologist. These are resource constraints. Not much research has been done to approach this type of problems. The problem cannot be analyzed as a single machine problem because the time to perform an exam, depending on the exam performed, can be short in relation with other processes in the system. Nonetheless, an important research was done by Kellerer et al. [6] where resources were supposed to be consumed in a simultaneous way during the process. In the GS problem, resources such as the gastroenterologist, the anaesthesiologist and the cleaning personnel are used but not in a simultaneous way but in a sequential way. According to Kellerer et al. [6] this problem can | Cmax problem in be described as a PDm | res which PDm means there are m parallel dedicated 1 is the total amount of resources in machines, 1 represents the units available of the system, (1 ) and resource 1 the units of j 6

To solve the non-identical parallel machines problem or the unrelated parallel machines problem, a lot of research has been done. Using the standard notation, this problem can be written as R || C max with processing times pij in machine i , for job j (See Lawler et al [5]). According to Garey and Johnson [11] this is an NP-hard problem in the strong sense. So, a lot of effort has been dedicated in order to design approximating algorithms. The most important contributions are the ones done by Horowitz and Sahni [4], Ibarra and Kim [12], De and Morton [13], Davis and Jaffe [3], Potts [2], Lenstra et al. [7] and by Hariri and Potts [1]. If GS rooms are regarded as parallel and identical machines, the Longest Processing Time first (LPT) heuristic gives a schedule near the optimal to minimize the makespan [10]. In the case of the GS, the problem has an additional resource constraint and so, the given solution using this heuristic might not be necessarily the optimal, but at least can produce feasible solutions. The Least Flexible Job first rule (LFJ) [8] gives an optimal schedule for the problem Pm | p j 1, M j | Cmax . This is a problem with
m parallel machines with processing times all equal to 1 and dedicated machines for each job. To obtain

resource that job j consumes at any moment during the process. If different jobs require the same resource at the same time, they can be processed simultaneously only if their total consumption of the resource does not exceed the quantity . It is assumed that there is only one machine that can process job type i. The objective to be evaluated is also the makespan minimization and no pre-emption of any job is allowed. In the case of the GS problem, there are three machines available to process job type i even if these machines are available in different rooms. It might not be easy to obtain an optimal schedule for the GS problem but a solution near to the optimal can be found by generating an approximating algorithm which can be used to develop an easy-to-use computer tool for the medical personnel, in order to obtain a better appointment schedule. For this application case, the mentioned heuristics (LPT and LFJ) and Kellerer et al. procedures were adapted to generate an approximating algorithm to find asserted schedules. Four heuristics were proposed with the aim of comparing their results and determining which one gives the minimum makespan. 5. MATHEMATICAL DESCRIPTION OF THE PROBLEM In this section, the model formulation for a restricted version of the problem is introduced. For this model two assumptions were made. The first one state that a room cannot be used until the last machine used at this room finishes its cleaning process. Relaxing this assumption would result in machines being cleaned (i.e. colonoscopy machine) and used (i.e. endoscopy machine) in the same room at the same time. Note that under this scenario an available colonoscopy machine from one particular GS room cannot be used to perform a colonoscopyendoscopy exam if the endoscopy machine is being cleaned. The same applies the other way round. Generally speaking, relaxing the above constraint makes the problem more complex allowing a machine to be cleaned (outside the room) at the same time a patient is being sedated, injected with anaesthesia or examined inside the room. This could happen only if the required machine for the exam is not the same one that is being cleaned. Summarizing, both scenarios (restricted and relaxed

versions of the model) execute the three processes in its natural sequential way: (1) sedation, (2) exam and (3) machine cleaning, with the difference that the restricted version does not admit simultaneous processes intra-room. However, the two versions allow simultaneous activities inter-room (machine cleaning at the same time an exam is taking place, if each machine belongs to a different room). In the second assumption for the restricted version, it is supposed that the recovery room has infinite capacity, so the availability of hospital beds is not considered in the mathematical formulation. As mentioned above, in the actual system configuration there is only one anaesthesiologist, one gastroenterologist and one cleaning person. In addition, Station 2 is recognized as the bottleneck station of the system. Thus it is reasonable to work with the restricted version of the problem with the aim of computing optimal solutions and compare them with the results given by heuristics. Although the mathematical model for the restricted version is developed in subsection 5.2, the complete constraints of the problem are enunciated for future research. 5.1.Whole System Constraints
(1) (2) (3)




Only one patient can be examined in each room at a time. Patients are examined only once, exactly at one room. Patients cannot be examined if the required resource is not available, keeping in mind that: a. The gastroenterologist examines one patient at a time b. The anaesthesiologist examines one patient at a time c. A machine will only be used if it is available (clean). d. The cleaning personnel processes one machine at a time. Processes precedence must be respected (sedation, exam, machine cleaning, and recovery). Only one machine is needed to examine a patient, except in the endoscopycolonoscopy appointment. Sedation or anaesthesia injection and exam processes must be performed inside a room. 7

The cleaning process is performed outside the room. (7) Machine cleaning and patient sedation or examination can be done at the same time, only if the required machine for the exam is not the same one being cleaned and does not belong to the same room as the one being used to examine the patient. 5.2. Restricted Version of the System Let A denote the set of patients, indexed by i, and B denote the set of rooms, indexed by j. C denotes the set of processes done in the GS. {1=anaesthesia, 2=examination, 3=machine cleaning, 4=recuperation}, indexed by k. tProci,k is the duration of process k for patient i; Preci,j is a parameter that equals 1 if process i precedes process j and 0, if not. Consider the following decision variables: xi,j,k : Process k starting time in room j for patient i yi,j : 1 if patient i is examined in room j. 0, if not zi,j : 1, if patient i precedes in time patient j. 0, if not The makespan objective is similar to min( max (xi,j,k ) ) i A, j B, k C . Constraints for the restricted version of the problem are enunciated as follows:
xb, j ,1 ( xa, j ,3

xi, j ,l

( xi, j ,k
A, j

t Pr oci,k )
B, k , l

M * ( yi, j 1)

C | Pr eck ,l

Respect patients precedence

z i, j z j ,i 1
{i j | i, j A}

The nature of variables

xi , j ,k 0

A, j

B, k

yi, j {0,1} zi, j {0,1}

A, j B i, j A

5.3.Model Results Results for the optimization model were obtained with Xpress-MP Professional release 2007. Although the systems complexity was reduced due to mentioned assumptions, the software is able to compute optimal results in a short time for eight (8) patients or less. For nine (9) or more patients, the software takes more than half an hour to process the model without giving optimal results. Because in daily operation the GS does not examine less than nine (9) patients a day, the results obtained by the software cannot be used as optimal. Nevertheless, various historical scenarios were processed for half an hour in the software obtaining results near to the optimal schedule. From these not optimal results, it can be observed that they are consistent and generate schedules that are coherent with resource constraints and with the type of exams. Furthermore, 76.5% of the results presented a shorter makespan than the observed in historical data. Thus, the model is a good approximation to the problem. However, this model is a representation of a different system from the real situation and a better mathematical approach has to be found in order to determine a way of scheduling the examination appointments with the real constraints. 6. HEURISTICS 6.1.Heuristic 1: LPT (Longest Processing Time first) This heuristic consists in ordering the jobs by their total processing times from longer to shorter. The processing times in this case, corresponds to the total expected time of the patient inside the GS: the sedation or injection of anaesthesia time, plus the exam duration and the time spent at the recovery 8

Examine only one patient per room

t Pr oca,3 ) M *[( z a,b 1) ( ya, j 1) ( yb, j 1)]


b | a, b

A}, j

B, k

3,1 C All patients are examined only once, in only one room
yi , j
j B Patient cannot be examined if the required resource is not available, respecting precedence and room occupancy.
xb, d ,1 ( xa,c,1 t Pr oca,1 )
xb,d , 2 ( x a ,c , 2 t Pr oca, 2 )

M * [( za,b 1) ( ya ,c 1) ( yb, d 1)]

M * [( z a,b 1) ( y a,c 1) ( yb,d 1)]

xb, d ,3 ( xa,c,3 t Pr oca,3 )

M * [( za,b 1) ( ya,c 1) ( yb, d 1)]


b | a, b

A}, {c

d | c, d

B}, k

1,2,3 C

Note that patient a is sequenced before patient b in different rooms c and d. Respect the precedence of processes

room. In this way, the patients (outpatients and inpatients) will be ordered from first to last in the following way: gastric ball removal, endoscopycolonoscopy, colonoscopy, endoscopy with sedation, endoscopy without sedation. The steps to be taken in order to generate schedules are: Step 1: Choose a patient with the longest total average processing time in the GS as specified before and who has not yet been scheduled. Step 2: Assign this patient to an available room if the required machine(s) are also available. Begin the process in this room when anaesthesiologist and gastroenterologist are freed from the last patient and ready to examine the patient. Update clock and availability time for used machine(s). Step 3: Return to Step 1 until all patients are examined. 6.2.Heuristic 2: RDM (Resource Dependent Machines) Based on Kellerer et al.s [6] work, the GSs problem is similar to the PD3 | res311 | Cmax problem. For this problem, the authors do not present an approximating algorithm noting its complexity. Nevertheless, it was possible to adapt the scheme developed for the problem PDm | res 11 | Cmax . The steps needed to generate this heuristic are: Step 1: Create an artificial machine representing the joint process endoscopy-colonoscopy. Set time equal to zero. Step 2: Find an available machine in the current time. Step 3: Determine if the room corresponding to the machine in Step 2 is available. (Yes: go to Step 4; No: return to Step 2). Step 4: Find an unscheduled patient who requires the selected machine. Step 5: Assign the patient to a room and wait for the gastroenterologist and anaesthesiologist to execute procedures. Update clock and availability time for used machine(s). Step 6: Return to Step 2, until all patients are scheduled. 6.3.Heuristic 3: LFJ (Least Flexible Job First) Assuming that all patients are ready at time zero (initial time), as well as resources are available; job flexibility is calculated each time counting the

amount of available rooms to examine a patient. Room availability implies that the required machines are also available at time t. The sequence rule gives priority to patients with the least number of rooms available (least job flexibility) to enter the service. Flexibility is computed each time a machine is freed as resource availability varies in time. The steps to implement this heuristic are the following: Step 1: For each unscheduled patient, find its flexibility. Step 2: Choose the patient with the minimum flexibility. Step 3: Let this patient occupy any of its available rooms. Wait for the gastroenterologist and the anaesthesiologist. Examine the patient. Update clock and availability time for used machine(s). Step 4: Return to Step 1, until all patients are examined. 6.4.Heuristic 4: LPT + LFJ Heuristic 4 is just a hybrid between heuristic 1 (LPT) and heuristic 3 (LFJ). In this way, patients will be ordered by the LPT rule and then heuristic 3 (LFJ) will be imposed. The steps to generate this heuristic are: Step 1: Create a list of patients ordered by their total processing time in the GS (as specified in heuristic 1). Step 2: In this order, compute the amount of required machines that are available in idle rooms, at that time, for each unscheduled patient. Step 3: If no machines are available for any patient, advance the clock to the first resource release. Else, continue with Step 4. Step 4: Choose a patient who has the least amount of rooms available to perform an exam. Step 5: Let this patient occupy any of its available rooms. Wait for the gastroenterologist and the anaesthesiologist. Examine the patient. Update clock and availability time for used machine(s). Step 6: Return to Step 2, until all patients are scheduled. 7. COMPUTER TOOL DESCRIPTION The computer tool was designed in Microsoft Excels Visual Basic as it is the only software 9

resource that the personnel use in the GS. Patients information was saved in a data table. Input data included the type of appointment (Ambulatory, First Floor, ER, etc.), patient full name, type of exam, sedation or injection of anaesthesia requirements and patient age. Figure 3 illustrates the corresponding user interface. On the other hand, system parameters such as process times and resource quantities can be modified, as well as old data can be erased, using the respective yellow buttons shown in Figure 3. The blue button is used to run heuristics and obtain schedules. 7.1.Changing Systems Parameters When the Parameter Configuration button is clicked, the tool will show three (3) windows which allow the user to modify the following parameters: processing times for each type of exam, the patients setup time (sedation or anaesthesia), the gastroenterologist setup time and cleaning time for the machines. This button also allows the user to change the number of hospital beds available and the number of rooms in the GS, as well as medical personnel in charge. Figure 4 shows an example of one of these interface windows.

The button Generate Schedule allows the user to choose one of the four proposed heuristics. Then it displays a second data table with the resulting examination schedule. This data table contains, in addition, some patient information: (1) time difference between scheduled appointments, (2) scheduled appointments starting time (first one at 7:00 am), (4) the assigned room (5) the estimated time for a patient to leave the GS, and (6) the total time the patient stays in the service. Other three (3) columns are available for the user in order to generate future statistics to improve system modelling. These three columns correspond to: the real patient arrival time, the real time in which patient entered the service and the time the patient leaves the service. 8. NUMERICAL RESULTS The computer tool takes less than half a second to compute and print results. This fact supports its practical use, in addition with the following results. 8.1.Heuristics Ranking After 34 evaluated instances using historical data from May and June 2008, comparative results from heuristics are shown in Graph 3.

Figure 3. Data table of the patients information

Graph 3. Heuristics Ranking

For the considered instances the best heuristic to solve the GS problem and to minimize the makespan was LPT, followed by the hybrid heuristic LPT + LFJ. The worst heuristic was found to be the LFJ one. Following the obtained schedules with LPT heuristics, inpatients and patients coming from the ER will always be examined after outpatients in a particular day because they (inpatients) occupy the least number of resources and so, their total processing time in the service is the lowest. SS of each hospital floor must be available and prepared to transport patients from their hospital room to the 10

Figure 4. Example of an interface window of the tool

7.2.Running the Heuristics

GS and the other way round at these scheduled times. It will not interfere with ER patients as they must have a setup time to prepare themselves for the exam which can be done earlier. Comparing LPT results with the relaxed version of the mathematical model, 76.5% of the results obtained by the heuristic were better in terms of makespan. The difference between the makespan given by the relaxed system and the one given by the heuristic LPT is in average 14,26 minutes. This result reveals the fact that the schedule given by the heuristic is better than the one obtained with the mathematical model. Nevertheless, both are quite close and coherent. 8.2.Systems Improvements An average finishing time for the last patient to release the system cannot be determined because the amount of patients examined varies from day to day. However it is possible to compare theoretical finishing times given by the LPT heuristic with day to day historical data. Graph 4 illustrates these results. The conclusion is that in 94% of the cases, the LPT heuristic found a better solution. In average, the improvement in the makespan was one hour, an important improvement to consider in cases of emergency arrivals and extraordinary non programmed patients. In the same way, nurses and the cleaning personnel will have enough time to clean up the service in order to have it ready for the next day without having to leave later at night, avoiding overtime costs for the GS administration.

or colonoscopy exams have low waiting times. Nevertheless, decreasing the stay time by 18 to 22 minutes for the other procedures is a very important time reduction. It is important to underline the fact that the difference between these two times can also be interpreted as more efficient resource utilization deriving in a better service level.
DIFFERENCE BETWEEN HISTORICAL AND THEORETICAL STAY TIME G. Ball Endo Colo Endo-colo removal Historical Theoretical Difference 01:34 01:25 00:09 01:48 01:30 00:18 02:37 02:15 00:22 01:40 01:35 00:05

Table 2.Stay time improvement

However, the most important result is that medical personnel will be able to examine the patient immediately after the patient arrives to the GS (assuming that the patient arrives at the exact appointment time). So, the patient will no longer have to sit down waiting for his turn (if it is an outpatient). To accomplish this result, we recommend to advice the patient to arrive at least 15 minutes before the examination appointment for payment and paper processes before the exam. Historical data reveals that waiting times in the waiting room can be up to one and a half hours. If the theoretical schedule is performed in the real situation, the waiting time will get near cero for all patients and no more delays will be presented in the transportation of inpatients. 9. CONCLUSION

Graph 4. Difference between Historical and Theoretical finishing times of the last patient.

The stay time of patients in the GS also improves due to GS programming. A comparison was done between the average historical and heuristic results, as Table 2 shows. Differences vary from 5 to 22 minutes. A difference of 5 minutes might not be very important; that means that in the actual situation, patients who require the endoscopy

This work shows that, by scheduling the service, it is possible to improve the service level (measured in waiting times and stay time in the system), and the utilization of resources. Nevertheless, the use of the computer tool will introduce changes in the GSs organizational culture, specifically in activities related with the appointments assignation. The main difference is that once a patient requests an appointment, a confirmation process will be required for implementing the computer tool. This means that the time of an appointment will not be known in the same moment the patient asks for one. Only until the complete list of patients who will be scheduled to a specific day is known, the computer 11

tool will be used and so the time of the appointments will be revealed. Considering this fact, we propose the following steps to schedule examination appointments (for outpatients). Step 1: Indicate patients to have the whole day available or at least the whole morning (as it is required due to anaesthesia procedure). Up to 20 outpatients can be scheduled for a day. Step 2: Explain patients what are the medical conditions and requirements to perform each exam (depending on the type of exam and anaesthesia). Step 3: Advice patients that the exact time of the appointment will be confirmed at most one day before the appointment. As a general rule, we suggest that appointments for a specific day must not be scheduled until two days before that day. Step 4: Ask patients to arrive 15 minutes before the real appointment time for payment and paper work. Patients must also be warned about the fact that arriving earlier would not alter the sequence in which patients are attended. But arriving late will make them lose their appointment. If the last steps are too hard to implement, time intervals can be used in order to give the patient an approximate time for the appointment, depending on the required exam. The time intervals to be used are shown in Table 3. The only difference is that the patient will have an idea of the possible time his appointment will be scheduled. Either way, it will not be until two days before the appointment that the exact time will be revealed. The length of the time intervals shown in Table 3 considers the difference in the demand for each exam type. Note that for this scenario only LPT can be used and that for inpatients it will not be necessary to use Table 3 as inpatient cases are submitted directly by the gastroenterologist. Inpatient schedule must be used to schedule SSs activities for programming transportation at right times.
TIME INTERVALS BETWEEN EXAMINATION APPOINTMENTS Exam Time interval Gastric ball removal 07:00 09:00 07:00 10:00 Endoscopy-colonoscopy Colonoscopy 09:00 11:00 Endoscopy 10:00 13:00

If none of these alternatives is accepted to schedule examination appointment dates in the GS, either by the medical personnel or because the perception that patients will reject them, some policies may be used to schedule the appointments and obtain a schedule similar to the one generated by the LPT heuristic. The policies are: Schedule gastric ball removals as earlier as possible. No other appointments should be scheduled for the next 60 minutes (considering actual system configuration). Schedule exams in the LPT suggested order and keep Table 3 in mind. Time between appointments for endoscopies and colonoscopies (not to the same patient) must be 15 minutes. When two different types of procedures are scheduled one after the other, the time between these appointments must oscillate between 20 and 30 minutes (except for gastric ball removals). If various endoscopy-colonoscopies are scheduled one after the other, time between these appointments must be at least 18 minutes. If the patient needs an appointment for an endoscopy without sedation, it must be scheduled 30 minutes after the previous scheduled patient. It is preferable if the previous patient required an endoscopy with sedation. Although the schedule that could be obtained using these recommendations will not be as efficient as the obtained by the computer tool, these policies will improve the service level and resources utilization. 10. ACKNOWLEDGEMENTS

The author would like to thank Fair Isaac Corporation for providing the Xpress-MP software licenses under the Academic Partner Program subscribed with the Universidad de los Andes; also Dr. Fernando Sierra and his team for their support and help during the development of this project. The author also thanks ngela Jimnez, Nubia Velasco and Ciro Amaya for their support and help during the development of this project.

Table 3. Time intervals for the appointments schedule



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