Operations Research for Health Care 2 (2013) 7585

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Operations Research for Health Care

journal homepage: www.elsevier.com/locate/orhc

Centralized versus distributed sterilization service: A locationallocation decision model

Houda Tlahig a,b, , Aida Jebali a,c , Hanen Bouchriha a , Pierre Ladet b
a b c

Laboratoire ACS, Ecole Nationale dIngnieurs de Tunis, Universit Tunis El Manar, B.P. 37-le Belvdre-1002 Tunis, Tunisie GIPSA-Lab, B.P 46, Rue de la Houille Blanche 38402 St Martin dHres, France Prince Sultan University, P.O. Box 53073 Riyadh 1158, Saudi Arabia

article

info

abstract
The concept of networking has become central to the reform of healthcare systems. The objective is to reduce costs while improving the quality of service. This paper deals with the problem of sterilization service configuration within a hospital network. Two alternatives are considered: (1) each hospital in the network maintains its sterilization service in-house; (2) a central sterilization service ensures this function for all hospitals in the network. This decision is based on a locationallocation model of the sterilization service. A Mixed Integer Linear Program (MILP) is proposed to find the optimal configuration of the sterilization service (centralized vs. distributed), the optimal location and the optimal capacity of the centralized sterilization service over a multi-period planning horizon. The objective is to minimize costs related to transportation, production and resource acquisition and transfer. A solution method based on the addition of appropriate customized cuts to the original MILP is then proposed. The proposed models are applied to 30 scenarios extracted from a real-life case study. The obtained results show that the considered problem can be solved to optimality for moderate size scenarios with the use of commercial MILP solvers and the addition of the proposed customized cuts to the original model. Further analysis was conducted and pointed out how network configuration is sensitive to the number of human and material resources available in each hospital of the network. 2013 Elsevier Ltd. All rights reserved.

Article history: Received 12 November 2012 Accepted 24 May 2013 Available online 6 June 2013 Keywords: Hospital network Sterilization service configuration Centralized vs. distributed Optimization Locationallocation model MILP Valid cuts

1. Introduction The last two decades have witnessed the emergence of networks in the healthcare sector. In fact, there has been continuous growth in the number of hospital networks in both the USA and Europe. For example, in the USA alone, between 1980 and 1997, the number of hospitals organized in networks increased from 32.1% to 73.4% [1]. Hospital networking seems to represent an organizational choice providing interesting opportunities to cope with cost and quality issues. In [1], the author states that the pooling of available resources should improve efficiency and effectiveness due to synergies and cost savings. The need for efficient resource allocation in hospitals is obvious and represents the main objective of the networked organization. Henceforth, restructuring the location of facilities and incrementally concentrating some services to fewer locations becomes one of the major focuses of managerial tasks in the hospital environment.

Correspondence to: EIGSI, 26 Rue De Vaux De Foletier, 17041 LA ROCHELLE, France. Tel.: +33 546458015; fax: +33 546458010. E-mail address: houda.tlahig@eigsi.fr (H. Tlahig).
2211-6923/$ see front matter 2013 Elsevier Ltd. All rights reserved. http://dx.doi.org/10.1016/j.orhc.2013.05.001

Healthcare providers strive to minimize patient contamination risks and nosocomial infections. In the operating room this risk is particularly important. That is why surgical items have to be free of contamination at the time of use. This is accomplished by subjecting them to a validated sterilization process and maintaining the sterility up to the time of use. In France, hospital sterilization is regulated and restricted by the guide of good practices [2]. Minimizing the costs and ensuring a high quality level of hospital sterilization services is subscribed as one of the challenges of healthcare providers. These objectives could be reached through the optimization of the configuration of sterilization services within a hospital network. In this paper, we intend to investigate the opportunities of grouping hospital sterilization services and the economical interest of resource sharing. In order to ensure patient safety, hospitals in developed countries are investing millions of euros in sterile instruments; in The Netherlands, for example, the investment in sterile equipment can be estimated to exceed 500 million euros [3]. In France, the cost incurred by the sterilization of 1 m3 is widely varying from one hospital to another. While considering 21 hospitals of the Arc Alpin Region, the cost of sterilizing 1 m3 in 2004 ranged from 187 to 1174 euros [4]. It was noticeable, however, that this cost tends to be lower in hospitals with relatively

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large demand. This sparked the interest of studying sterilization department configuration within hospital network in order to identify and seize eventual opportunities for cost reduction while maintaining a high quality and traceability of sterilization process. Within a hospital network, two major alternatives could be considered: (1) each hospital performs in-house its sterilization activities in its premises independently of the other hospitals; (2) all hospitals of the network opt for the sharing of the common resources requested by sterilization services by grouping them in one Central Sterilization Service (CSS). The first configuration is referred to as distributed sterilization service; the second one is referred to as centralized sterilization service. The centralization could lead to better resource utilization and considerable cost savings through the advantage of economy of scale. However, this alternative can be considered only if the different hospitals are located in the same region as well as the sterilization centre and incurs transportation costs. Moreover, sterilization service centralization increases the risk of sterile item unavailability. That is why it requires a high level of management to ensure the coordination and the satisfaction of all the network actors. Reaping the benefits of a centralized sterilization service is contingent to an effective and efficient management at the tactical and operational levels. The focus of this paper is placed on finding the best choice between the two alternatives concerning the configuration of the sterilization service within a hospital network: (1) a distributed sterilization service; (2) a centralized sterilization service. If the second alternative is chosen, the common sterilization service location and sizing are also determined. The objective is to minimize the total cost of sterilization service which includes the transportation cost, the sterilization process cost and the resource transfer and acquisition costs. The constraints that have been taken into account are essentially related to resource capacities and demand satisfaction. This multi-site, multi-product and multi-period planning horizon, locationallocation problem, is formulated as a Mixed Integer Linear Program (MILP). The remainder of this paper is organized as follows: Section 2 presents a brief literature review on hospital network locationallocation problems. In Section 3, the optimization problem and the considered assumptions are described. Furthermore, the proposed mathematical model is presented. Section 4 details the proposed solution approach. Computational experiments and results are reported in Section 5. The last section highlights some conclusions; future extensions of this work are also discussed. 2. Literature review Some researchers have been investigating whether mergers and networks should take the place of independent operations, focusing on hospitals quest for better location, optimal resource dimensioning and improvement of the healthcare service and reduction of total health expenditure [58], etc. Other researchers have focused on the consequences of mergers and networking in terms of benefits versus drawbacks [1,9,10], etc. Locationallocation models have been used quite extensively for quantitative analysis in health services. The common objective is to minimize travel costs. Classical mathematical locationallocation models like p-median or maximum covering location models have been proposed [11]. Rahman and Smith [12] reviewed a number of locationallocation studies for health service development planning and found that most of the locationallocation models and methods have been formulated either as p-median problems or covering problems. Some studies have dealt with the locationallocation problem in hospital network organization and have reported a particular interest in the considered configuration problem. Or and Pierskalla [6] treated the transportationlocationallocation problem

regarding the case of regional blood banking. They suggested algorithms to decide how many banks to set-up, where to locate them, how to allocate the hospitals to the banks and how to root the supply operations in such a way that the transportation and system costs are minimized. In [7], a multi-objective heuristic approach has been developed for determining the location and the size of medical departments in a hospital network. The authors aimed to minimize the patient travel cost, the total cost incurred by the locationallocation plan and the total number of unit moves necessary for the restructuring of the new allocation. They proposed a two-phased solution procedure to solve the proposed mathematical model. This approach sought efficient solutions by means of multi-objective Tabu Search in the first phase. In the second phase, they proposed clustering to allow the decision makers to explore the solution space interactively until the optimal configuration was found. Gunes and Yaman [8] studied the modelling change in healthcare networks with particular reference to the implication on patient flows and resource allocation. They also modelled hospital mergers at a facility planning level using a resource-based view of hospitals. Their objective was to find the optimal resource allocation after a merger of two networks. They focused on the gains in network design and flow related costs. Few studies have considered stochastic aspects while modelling and solving locationallocation problems in the case of healthcare systems. Chao [13] used a non-linear programming approach to study the allocation of a limited amount of service capacity to different service sites in such a way that the system-wide quality is optimized. Harper [14] proposed a simulation tool for use in planning health services when geographical considerations (both service and patient locations) are of prime importance. Some other works have investigated the sterilization service department configuration problem. In the first study, Elshafei [15] proposed a mathematical model to find the location of a set of central sterilization services within a hospital network. A survey dealing with the feasibility of the sterilization service centralization in the French context has been conducted by a group of consultants. This study aimed at understanding the organizational aspects of a common centralized sterilization service and finding the best way to group hospital sterilization departments within the region under consideration for optimal functioning of this service [4]. This survey was based on an estimation of the sterilization service cost; no optimization models have been used. A study conducted in Switzerland [16] dealt with the development of an integrated logistics solution to ensure optimal sterilization for a hospital network. This study stressed on the great need of health care decision makers to improve hospital sterilization service, as a response to the pressure on costs in the field of public health. These observations let indeed many hospitals to consider the option of building a new CSS with greater capacity to serve attached hospitals working as a network. In [17], we addressed the problem of the centralization vs. decentralization of the sterilization service within a hospital: the case of a Tunisian hospital where many surgical services were located in different wings, with each surgical service having its own sterilization department. A two-stepped iterative approach solution was proposed. The first step consisted of finding the best configuration between the centralization and decentralization of the various sterilization service departments; in the second step we aimed to find the optimal size for the configuration achieved in the first step. The developed approach did not take into account demand and cost variation over the planning horizon. In addition, sterilization service locationallocation and resource dimensioning are addressed separately. In [18], we proposed a model for finding the optimal choice between the internalization vs. externalization of the hospital sterilization process. In the externalization case, two types of thirdparty providers have been considered: (1) an industrial company

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and (2) a hospital located in the same region. The proposed model considered all the sterilization process activities and took into account the variation in demand and cost from one period to another. In both [17,18], the emphasis was placed on optimizing the costs incurred by sterilization activity of one hospital. The decision is made by the management of the hospital under consideration. However, it has been noted that many hospitals located in the same country region could have a need to optimize their sterilization activity. Optimizing sterilization activity separately for each hospital overlooks the opportunities of better employment of scarce and costly resources that could be grasped when this optimization integrates all the hospitals. Optimizing sterilization activity within a hospital network is besides encouraged by the significant cost disparities mentioned above. In France, such a decision is made by Regional Healthcare Agencies which mission includes the improvement of healthcare systems efficiency within each region of the country. To the best of our knowledge, there have been no studies dealing with the choice between the centralized vs. distributed sterilization service in a hospital network using optimization tools. There have been papers dealing with the locationallocation problem in healthcare systems but without integrating resource dimensioning. In [19], the authors addressed the optimization of the sterilization costs through the grouping choices of medical devices into packages. They developed an Integer Linear Program defining the items grouped in each package. They showed how grouping choices impact process and storage costs of the sterilization activity. In [3], the authors developed optimization models to support sterilization logistics. They defended the option of maintaining in-house sterilization against outsourcing sterilization tasks. Hospitals are opting for outsourcing as an attempt to achieve cost savings. However, placing the sterilization service at a distance entails the risks of lowering sterile item availability which could increase costs rather reducing them. That is why the authors are rather promoting the idea of reducing in-house sterilization cost by optimizing sterilization logistics and the composition of the nets of sterile items. In the present paper, we rather embrace the idea that first we need to optimize the sterilization service configuration within a hospital network; then adequate management tools will be developed and implemented to deal with operational decisions in order to minimize the risk of sterile item unavailability and reach the intended objectives in terms of cost reduction. Hence, we address the optimization of hospital sterilization cost through the configuration of the sterilization services within a hospital network. Two options are considered: (1) distributed sterilization service; (2) centralized sterilization service. A locationallocation model is proposed; in the model, resource capacity dimensioning is also integrated, in that we specify the number of resources to be transferred from the hospitals to the CSS. 3. Model formulation 3.1. Problem description In this paper, centralization can be defined as the process by which hospitals within a given geographical area move towards sharing the existing sterilization resources leading to a CSS. In our study, we consider a network composed of N hospitals for which it may be beneficial to group their sterilization services into a common CSS. Our objective is to find the optimal configuration between the centralized vs. distributed sterilization service and to determine the CSS location. Indeed the CSS may be located in a separate new entity or located in one of the hospitals under consideration.

The sterilization service must ensure Reusable Medical Devices (RMD) sterility which is obtained through a high-quality regulated closed loop process. The most important point of consumption of the sterile instruments is the operating room. When a surgery is finished, all materials will be brought to the contaminated storage of the OR, from where they are taken to the sterilization service. There, they are dismounted, disinfected, perhaps precleaned, and subsequently put into the washing machines. After washing, the RMD are grouped into sets and packaged. There are many types of packaging systems such as wrapping and rigid sterile containers. The packages are put into the autoclaves where the sterilization takes place. Once sterilized, the packages are placed in the sterile storage which completes the closed loop. Many human and material resources are required to perform the sterilization activity. The human resources fully assigned to the sterilization service department are the technicians and the sterilization nurses. The technicians are responsible for instrument cleaning and disinfection; sterilization nurses are responsible for instrument packaging and the control of the sterilization process. Other human resources intervene in the sterilization service department, such as a pharmacist and an administrator, but they are assigned concurrently to other activities and responsibilities in the hospital. Several equipments and fixtures are used in the sterilization process: autoclaves, automatic washing machines, shelves, carts, etc. The most costly and critical material resources are autoclaves and automatic washing machines. Sterilization service configuration within the hospital network seeks to find the best location and allocation of the existing critical hospital resources to the CSS. Henceforth, in network configuration, human and material resources required for the CSS are determined while taking into account sterilization process specificities. In the mathematical formulation, decision variables are related to the choice between the centralized vs. distributed configuration, the location of the common sterilization service, the quantities of Sterilized Medical Devices (SMD) to be produced for each hospital, the number of resources to be transferred from each hospital to the CSS and the number of vehicle to be purchased as well. If the centralization is the chosen configuration, supply is carried out by the CSS and deliveries are achieved using available vehicles. The departure point for each vehicle is the CSS. Each vehicle has a known capacity. The objective is to minimize sterilization costs composed of sterilization fixed and variable costs, transportation costs, transfer costs and storage costs. 3.2. Assumptions In problem formulation, the following assumptions have been considered:

The potential locations of the CSS are known (existing hospitals

as well as potential new locations).

We consider only one CSS for all the network hospitals. The delivery costs are treated as variable costs and depend on
the distance between the hospital and the CSS location.

The delivery vehicles belong to the CSS. The sterilization service requires a set of human and material
resources (nurses, autoclaves, etc.). Each resource has a given capacity to produce SMD. The transfer costs for the material resources depend on the distance between each hospital and the CSS. The transfer costs for human resources are represented by the remuneration paid to each nurse/technician whose post changes [8]. This remuneration depends on the distance between the hospital where the nurse is currently working and the CSS. We do not consider layoff costs. Each nurse/technician is supposed to be transferred either to the CSS or to another service in his/her original hospital.

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At this stage, we consider that non-transferred material

resources are sold. We consider that if the decision to move to a CSS is made over a given period, it will remain the same for the upcoming periods of the planning horizon. The decision on the location of the sterilization service involves all the hospitals in the network: all the considered hospitals have to make the same decision on choosing between a centralized and a distributed organization. The initial inventory levels are considered equal to zero. Inventory levels at the CSS are not considered. As soon as sterilization has been completed, the SMDs are transferred to the appropriate hospital. The demand is considered to be deterministic and is based on historical data on demand of the operating room activity.

CFHwj,t

3.3. Notations The following sets and indices are used in formulating the considered optimization problem. H = {H1 , H2 , . . . , HN } = {set of considered hospitals}. S = {CSS1 , CSS2 , . . . , CSSN +M } = {set of potential locations of the CSS}. We can notice here that H S as the CSS could be located in one of the hospitals within the network. P : number of products. T : number of planning horizon periods. R: number of material resources. W : number of human resources. N : number of hospitals in the network. M : number of potential new sites. M1 , M2 , M3 , M4 : large numbers. i: hospitals, i = 1 . . . N . j: potential locations of the CSS, j = 1 . . . N + M . p: products, p = 1 . . . P . t : periods, t = 1 . . . T . r : material resource types, r = 1 . . . R. w : human resource types, w = 1 . . . W . We consider the following parameters: Ctransp,i,j,t Transportation cost of one unit of product p, p = 1 . . . P , between hospital i, i = 1 . . . N , and CSS j, j = 1 . . . N + M , during period t , t = 1 . . . T (in euro/unit). CAPV Transportation capacity of one vehicle (in m3 ). QMr ,i Number of material resources of type r , r = 1 . . . R, initially available at hospital i, i = 1 . . . N . QHw,i Number of human resources of type w, w = 1 . . . W , initially working at hospital i, i = 1 . . . N . Dp,i,t Demand of hospital i, i = 1 . . . N , for product p, p = 1 . . . P , during period t , t = 1 . . . T (in units). CVp,j,t Variable processing cost of one unit of product p, p = 1 . . . P , when it is performed in the CSS j, j = 1 . . . N + M , during period t , t = 1 . . . T (in euro/unit). CVHp,i,t Variable processing cost of one unit of product p, p = 1 . . . P , when it is performed in hospital i, i = 1 . . . N , during period t , t = 1 . . . T (in euro/unit). CSp,i,t Storage cost of product p, p = 1 . . . P , at hospital i, i = 1 . . . N , during period t , t = 1 . . . T (in euro/unit). CFj,t Fixed cost associated with the use of CSS j, j = 1 . . . N + M , during period t , t = 1 . . . T . CFMrj,t Fixed cost associated with the use of one material resource of type r , r = 1 . . . R, at CSS j, j = 1 . . . N + M during period t , t = 1 . . . T .

Fixed cost associated with the utilization of human resource of type w, w = 1 . . . W , at CSS j, j = 1 . . . N + M , during period t , t = 1 . . . T . CFHi,t Fixed cost associated with the use of the sterilization department of hospital i, i = 1 . . . N , during period t , t = 1 . . . T. CFHMr ,i,t Fixed cost associated with the use of one material resource of type r , r = 1 . . . R, at the sterilization department of hospital i, i = 1 . . . N , during period t , t = 1 . . . T. CFHHw,i,t Fixed cost associated with the utilization of human resource of type w, w = 1 . . . W , at the sterilization department of hospital i, i = 1 . . . N , during period t , t = 1 . . . T. CRr ,i,j,t Transfer cost of material resource of type r , r = 1 . . . R, from hospital i, i = 1 . . . N , to CSS j, j = 1 . . . N + M , at the beginning of period t , t = 1 . . . T . CTw,i,j,t Transfer cost incurred of human resource of type w, w = 1 . . . W , from hospital i, i = 1 . . . N , to CSS j, j = 1 . . . N , at the beginning of period t , t = 1 . . . T . CAVt Purchasing cost of a vehicle at the beginning of period t, t = 1 . . . T . I0p,i Initial inventory level of product p, p = 1 . . . P , at hospital i, i = 1 . . . N (in units). ISp,i,t Safety stock level of product p, p = 1 . . . P , at hospital i, i = 1 . . . N , at the end of period t , t = 1 . . . T (in unit). CAPMr Capacity of one material resource of type r , r = 1 . . . R (in m3 ). CAPHw Capacity of one human resource of type w, w = 1 . . . W (in time units). v r ,i ,t Income of selling one material resource of type r , r = 1 . . . R, belonging to hospital i, i = 1 . . . N , at the beginning of period t , t = 1 . . . T . Vp Volume of one unit of product p, p = 1 . . . P (in m3 ). w,p Number of time units of human resource of type w, w = 1 . . . W , required to produce one unit of product p, p = 1 . . . P. The following decision variables are used: Zi,t = 1 If sterilization service is performed in-house, in hospital i, i = 1 . . . N , during period t , t = 1 . . . T ; = 0 otherwise. Yi,j,t = 1 If sterilization service of hospital i, i = 1 . . . N , is performed in CSS j, j = 1 . . . N + M , during period t , t = 1 . . . T ; = 0 otherwise. Xp,i,j,t Number of units of product p, p = 1 . . . P , of hospital i, i = 1 . . . N , processed in CSS j, j = 1 . . . N + M , during period t , t = 1 . . . T . XHp,i,t Number of units of product p, p = 1 . . . P , of hospital i, i = 1 . . . N , processed in-house during period t , t = 1 . . . T. Ip,i,t Inventory level of product p, p = 1 . . . P , at hospital i, i = 1 . . . N , at the end of period t , t = 1 . . . T . TRMr ,i,j,t Number of material resources of type r , r = 1 . . . R, relocated from hospital i, i = 1 . . . N , to CSS j, j = 1 . . . N + M , at the beginning of period t , t = 1 . . . T . In case of centralization at period k, TRMr ,i=j,j,k = 0. VRMr ,i,j,t Number of material resources of type r , r = 1 . . . R, relocated from hospital i, i = 1 . . . N , to CSS j, j = 1 . . . N + M , before or at the beginning of period t , t = 1 . . . T . In case of centralization at period k, VRMr ,i=j,j,t k = 0. TRHw,i,j,t Number of human resources of type w, w = 1 . . . W , transferred from hospital i, i = 1 . . . N , to CSS j, j = 1 . . . N + M , at the beginning of period t , t = 1 . . . T . In case of centralization at period k, TRHw,i=j,j,k = 0.

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VRHw,i,j,t Number of human resources of type w, w = 1 . . . W , transferred from hospital i, i = 1 . . . N , to CSS j, j = 1 . . . N + M , before or at the beginning of period t , t = 1 . . . T . In case of centralization at period k, VRHw,i=j,j,t k = 0. AVj,t Number of new vehicles required by CSS j, j = 1 . . . N + M , at the beginning of period t , t = 1 . . . T . CAPtransj,t Transportation capacity of CSS j, j = 1 . . . N + M , during period t , t = 1 . . . T (in m3 ). CAPMr ,j,t Capacity of material resources of type r , r = 1 . . . R, at the CSS j, j = 1 . . . N + M , during period t , t = 1 . . . T (in m3 ) CAPHw,j,t Capacity of human resources of type w, w = 1 . . . W , at the CSS j, j = 1 . . . N + M , during period t , t = 1 . . . T (in time units). NMr ,i,t Number of material resources of type r , r = 1 . . . R, of hospital i, i = 1 . . . N , sold at the beginning of period t, t = 1 . . . T .

Each hospital has to choose between the two options: (1) performing the sterilization in-house or (2) sharing the sterilization service with the hospitals of the network: Yi,j,t Yi,j,t +k

j = 1 . . . N + M , i = 1 . . . N ,
(2)

t = 1 . . . T , k = 1 . . . T t .

Constraints (2) ensure that if the centralized configuration is chosen at period t , this decision should be maintained for the upcoming periods of the planning horizon: Yi,j,t Yi ,j,t

j = 1 . . . N + M , t = 1 . . . T ,
(3)

i = 1 . . . N , i = 1 . . . N /i = i.

Constraints (3) state that only one CSS is considered. If centralization is chosen for one hospital sterilization service then this decision will be applied for the other hospitals within the network. In this case, all network hospitals will be assigned to only one shared CSS:
P N p=1 i=1,i=j

Xp,i,j,t Vp CAPtransj,t

j = 1 . . . N + M ,
(4)

3.4. Mathematical model The objective is to minimize the total cost of the sterilization service which is composed of the delivery cost, the production cost (both fixed and variable costs are considered), the storage cost, the purchase cost of new resources (vehicles) needed by the CSS, the cost incurred by relocating and transferring some existing resources (autoclaves, nurses, technicians, etc.) and to maximize cost savings made by selling unused material resources and by the redeployment of human resources to other services of the considered hospitals. The MILP can be modelled as follows: Min

t = 1 . . . T .
N P i=1 p=1

Constraints (4) ensure the respect of the transportation capacity: Xp,i,j,t Vp CAPMr ,j,t

j = 1 . . . N + M ,
(5)

t = 1 . . . T , r = 1 . . . R
N P

i=1 p=1

Xp,i,j,t w,p CAPHw,j,t

j = 1 . . . N + M ,

t = 1 . . . T , w = 1 . . . W
P p=1

T N N +M P
t =1 i=1 j=1 p=1

Ctransp,i,j,t Xp,i,j,t

XHp,i,t Vp QMr ,i CAPMr

i = 1 . . . N ,
(5 )

N P
i=1 R r =1 p=1

CVHp,i,t XHp,i,t +
W

CFHi,t

r = 1 . . . R, t = 1 . . . T
P

CFHHw,i,t QHw,i Yi,j,t N

Zi,t

XHp,i,t w,p QHw,i CAPHw

i = 1 . . . N ,

p=1

CFHMr ,i,t QMr ,i +

w =1

w = 1 . . . W , t = 1 . . . T .
Constraints (5) state that the quantity of DMS produced in the CSS should respect the available resource capacities. Constraints (5 ) express that the quantity of DMS produced in each hospital when the in-house option is chosen are limited by the available resource capacities: Xp,i,j,t M 1 Yi,j,t

N +M N P
j =1 R r =1 i=1 p=1

CVp,j,t Xp,i,j,t + CFj,t

W

CFHw,j,t VRHw,i,j,t

CFMr ,j,t VRMr ,i,j,t +

w =1
N +M

i = 1 . . . N , j = 1 . . . N + M ,
(6)

N P i=1 p=1

CSp,i,t Ip,i,t +

j=1

p = 1 . . . P , t = 1 . . . T
XHp,i,t M 1 Zi,t

CAVt AVj,t

i = 1 . . . N ,
(6 )

W N N +M

CTw,i,j,t TRHw,i,j,t

p = 1 . . . P , t = 1 . . . T .

w=1 i=1 j=1

R N N +M r =1 i=1 j=1

CRr ,i,j,t TRMr ,i,j,t vr ,i,t NMr ,i,t

Constraints (6) impose that production is allowed in the CSS only in case of centralization. Constraints (6 ) are similar to constraints (6); they deal with the case of distributed configuration. M1 can be set to the biggest demand during the considered time horizon.
N +M

Subject to
N +M

Ip,i,t = Ip,i,t 1 + XHp,i,t + (1)

j =1

Xp,i,j,t Dp,i,t (7)

Zi,t +

j =1

Yi,j,t = 1 i = 1 . . . N , t = 1 . . . T .

i = 1 . . . N , t = 2 . . . T , p = 1 . . . P
N +M

Ip,i,1 = I0p,i + XHp,i,1 +

j =1

Xp,i,j,1 Dp,i,1

These constraints are related to the choice of distributed vs. centralized sterilization service for the considered hospital network.

i = 1 . . . N , p = 1 . . . P

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Constraints (7) define the inventory level at each hospital of the network at the end of a given period t as a function of inventory level at the end of period t 1, the sterilized quantities performed during period t (whether the sterilization is performed in-house or in a CSS) and of the demand fulfilled during period t . Obviously these constraints are related to flow conservation: Ip,i,t ISp,i,t

available material resources and M4 can be set to the maximum number of available human resources VRMr ,i,j,t +1 TRMr ,i,j,t +1 + M 3 1 Yi,j,t +1 Yi,j,t

(14)

VRMr ,i,j,t +1 TRMr ,i,j,t +1 t = 1 . . . T 1, i = 1 . . . N , r = 1 . . . R, j = 1 . . . N + M VRMr ,i,j,1 TRMr ,i,j,1 + M 3 1 Yi,j,1

i = 1 . . . N , t = 1 . . . T , p = 1 . . . P .

(8)

Constraints (8) imply that the stored quantities must be greater than or equal to the corresponding safety stock level: CAPMr ,j,t =
N i=1

VRMr ,i,j,1 TRMr ,i,j,1 i = 1 . . . N , r = 1 . . . R, j = 1 . . . N + M VRHw,i,j,t +1 TRHw,i,j,t +1 + M 4 1 Yi,j,t +1 Yi,j,t

CAPMr VRMr ,i,j,t (9)

VRHw,i,j,t +1 TRHw,i,j,t +1 t = 1 . . . T 1, i = 1 . . . N , w = 1 . . . W , j = 1 . . . N + M VRHw,i,j,1 TRHw,i,j,1 + M 4 1 Yi,j,1

j = 1 . . . N + M , t = 1 . . . T , r = 1 . . . R
CAPHw,j,t =
N i =1

CAPHw VRHw,i,j,t

VRHw,i,j,1 TRHw,i,j,1 i = 1 . . . N , w = 1 . . . W , j = 1 . . . N + M . Constraints (14) define the number of material resources to be relocated and the number of human resources to be transferred from each hospital to the CSS: TRMr ,i,j,t +1 QMr ,i Yi,j,t +1 Yi,j,t t = 1 . . . T , j = 1 . . . N + M , i = 1 . . . N , r = 1 . . . R (15)

j = 1 . . . N + M , t = 1 . . . T , w = 1 . . . W .
Constraints (9) ensure that the capacity of the CSS is equal to the sum of the capacity of all transferred resources from hospitals of the considered network to the CSS: CAPtransj,t = CAPV
t k =1

AVj,k

j = 1 . . . N + M .

(10)

TRMr ,i,j,1 QMr ,i Yi,j,1 j = 1 . . . N + M , i = 1 . . . N , r = 1 . . . R

N +M

Constraints (10) determine the transportation capacity of the CSS as a function of the total number of purchased vehicles: QMr ,i
T N +M t =1 j=1

NMr ,i,t +1 QMr ,i

j =1

Yi,j,t +1 Yi,j,t

t = 1 . . . T 1,

i = 1 . . . N , r = 1 . . . R (TRMr ,i,j,t + NMr ,i,t )

(11)
N +M

i = 1 . . . N , r = 1 . . . R
QMr ,i
T N +M t =1 j=1

NMr ,i,1 QMr ,i

j =1

Yi,j,1

i = 1 . . . N ,

(TRMr ,i,j,t + NMr ,i,t + M 2 (1 Yi,j,t ))

i = 1 . . . N , r = 1 . . . R.
Constraints (11) specify that the number of material resources relocated from one hospital to the CSS added to the number of sold ones must be equal to the number of these resources initially available in the considered hospital: VRMr ,i,j,t QMr ,i Yi,j,t t = 1 . . . T , j = 1 . . . N + M , i = 1 . . . N , r = 1 . . . R VRHw,i,j,t QHw,i Yi,j,t t = 1 . . . T , j = 1 . . . N + M , i = 1 . . . N , w = 1 . . . W . Constraints (12) express that resources (material as well as human resources) are transferred from hospital i to the CSS only if the centralization option is chosen: VRMr ,i,j,t VRMr ,i,j,t +k M 3 1 Yi,j,t

TRHw,i,j,t +1 QHw,i Yi,j,t +1 Yi,j,t t = 1 . . . T 1, j = 1 . . . N + M , i = 1 . . . N , w = 1 . . . W

r = 1 . . . R

TRHw,i,j,1 QHw,i Yi,j,1 j = 1 . . . N + M , i = 1 . . . N , w = 1 . . . W . Constraints (15) ensure that if the centralization option is chosen at period t , then the number of resources needed by the CSS should be transferred once at the beginning of that period: Yi,j,t {0, 1} Zi,t {0, 1}

(12)

i = 1 . . . N , j = 1 . . . N + M , t = 1 . . . T (16) i = 1 . . . N , t = 1 . . . T
(17)

TRMr ,i,j,t 0 i = 1 . . . N , j = 1 . . . N + M , r = 1 . . . R, t = 1 . . . T TRHw,i,j,t 0 i = 1 . . . N , j = 1 . . . N + M , w = 1 . . . W , t = 1 . . . T VRMr ,i,j,t 0 i = 1 . . . N , j = 1 . . . N + M , r = 1 . . . R, t = 1 . . . T VRHw,i,j,t 0 i = 1 . . . N , j = 1 . . . N + M , w = 1 . . . W , t = 1 . . . T AVj,t 0 j = 1 . . . N + M , t = 1 . . . T CAPMr ,j,t 0 j = 1 . . . N + M , r = 1 . . . R, t = 1 . . . T

(13)

VRMr ,i,j,t VRMr ,i,j,t +k t = 1 . . . T , i = 1 . . . N , r = 1 . . . R, j = 1 . . . N + M , k = 1 . . . T t VRHw,i,j,t VRHw,i,j,t +k M 4 1 Yi,j,t

VRHw,i,j,t VRHw,i,j,t +k t = 1 . . . T , i = 1 . . . N , w = 1 . . . W , j = 1 . . . N + M , k = 1 . . . T t . Constraints (13) specify that if the centralization option is retained, the number of human and material resources required at the CSS is constant from the period of the centralization until the end of the considered horizon. M3 can be set to the maximum number of

CAPHw,j,t 0 j = 1 . . . N + M , w = 1 . . . W , t = 1 . . . T NMr ,i,t 0 i = 1 . . . N , r = 1 . . . R, t = 1 . . . T CAPtransj,t 0 j = 1 . . . N + M , t = 1 . . . T Xp,i,j,t 0 i = 1 . . . N , j = 1 . . . N + M , p = 1 . . . P , t = 1 . . . T XHp,i,t 0 i = 1 . . . N , p = 1 . . . P , t = 1 . . . T Ip,i,t 0 i = 1 . . . N , p = 1 . . . P , t = 1 . . . T . (18)

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81

Constraints (16)(18), respectively, specify binary, integer and positive decision variables. 4. Solution method In this paper, we are proposing to investigate the resolution of the proposed MILP by commercial solvers which are increasingly known for their power to solve these kinds of mathematical models. More precisely, we propose here to implement and solve our model with the solver IBM ILOG CPLEX 12.2. Obviously, the first solution method that we are proposing to examine consists in the proprietary branch and bound algorithm used by the solver. Some cuts (such as Gomory fractional cuts or flow cuts, etc. [20]) are automatically generated by the solver. In this case, the obtained solution will be referred to as default settings solution. Besides, the solver can be configured to aggressively generate the cuts that could speed up the resolution. Furthermore, specific valid cuts can be directly added to strengthen the model formulation. These cuts generally permit the speeding up of the resolution by cutting away regions that contain no feasible solutions [21,22]. In the following, we propose to consider some valid cuts related to capacity dimensioning. These cuts will be referred to as customized cuts and are defined by Eqs. (19) and (20). Cuts based on the minimum number of material resources:
N i=1

CAPMr VRMr ,i,j,t

t =1...T

Min

N P i=1 p=1

Dp,i,t Vp

Yi,j,t
(19)

r = 1 . . . R, j = 1 . . . N + M , t = 1 . . . T .
N i=1

Cuts based on the minimum number of human resources required: CAPHw VRHw,i,j,t

t =1...T

Min

N P i=1 p=1

Dp,i,t w,p

Yi,j,t
(20)

w = 1 . . . W , j = 1 . . . N + M , t = 1 . . . T .

Cuts (19) calculate the minimum number of material resources (for instance the minimum number of autoclaves) required to satisfy the total network demand. Cuts (20) are similar to cuts (19) as they define the minimum number of human resources necessary to ensure the total network demand. First, we propose to solve the MILP using CPLEX default settings while enabling automatic cut generation. We note the cuts mostly used in the first resolution. Then, we solve the MILP while using aggressive settings for the generation of these cuts. Third, in addition to aggressive settings for cut generation, we integrate in the model the proposed customized cuts. The objective is to point out the interest of using CPLEX parameter settings and customized cuts in order to speed up the resolution of the considered combinatorial optimization problem. Even if most locationallocation models are defined as NP-hard optimization problems [23], we propose first to examine optimal settings solutions. 5. Experimentation and results In order to evaluate the proposed mathematical model, probable scenarios, for a case based on real life situations within a hospital network environment are developed and tested. Each scenario is characterized by the number of hospitals in the network

and the demand. All scenarios are based on a real case study in France: a nine-hospital network located in the same region [4]. The transportation time between any couple of hospitals or any hospital and the CSS is less than 1 h. 6 hospitals are located in Grenoble (H1 , H2 , H3 , H4 , H5 and H6 ), and 3 hospitals are located in Chambry (H7 , H8 and H9 ). In addition to the nine hospitals, the CSS may be located in a new site. Five-year planning horizon is considered (the period is the year). Two types of human resources essential to the completion of sterilization activity are considered: technicians (HR1) and sterilization nurses (HR2). Two material resources are taken into account: autoclaves (MR1) and automatic washing machines (MR2). The demand of each hospital, fixed costs, the number of available resources in each hospital, material resource costs, vehicle cost were extracted from [4]. Two products are considered: full-sized and half-sized standardized reusable rigid containers. All surgical instruments are supposed to be placed in a standardized reusable rigid container for the packaging, transportation and storage. Variable production costs are estimated based on the previous studies dealing with cost analysis of the sterilization process [24]. The work time needed to process each product is extracted from [25]. Transportation capacity is estimated under the assumption that a maximum of 3 trips are performed per one vehicle over one day. The capacity of autoclave and automatic washing machine are determined on a basis of 8 cycles a day. Variable production cost is the same regardless of sterilization service configuration; it depends on the volume of the sterilized item. The fixed costs are mostly incurred by personnel salaries, building, furniture, equipments, maintenance and vehicles. The cost of building is amortized over 20 years, the cost of equipment is amortized over 10 years and the cost of a vehicle is amortized over 3 years [4]. In the considered case study, the building and equipments of each hospitals sterilization department are known and will not be completely amortized over the five next years. In case of centralization, the current in-house sterilization buildings will be used by other hospitals services; equipments will be either transferred to the CSS or sold. The cost estimation of CSS building is based on the average daily volume of sterilized items. The used rule states that 60 m2 surfaces are requested per m3 of daily sterilized items [4]. Variable transportation cost of one item depends on the distance between the hospital and the CSS and includes the pay of truck driver and fuel cost. First, 21 scenarios based on real life data are developed and tested in order to investigate problem complexity and point out the interest of using CPLEX aggressive settings for cut generation and adding customized cuts. These scenarios are obtained from 7 basic scenarios: 3 scenarios consider groups of 3 hospitals, referred to as 3-G1 (H1 , H2 and H3 ), 3-G2 (H4 , H5 and H6 ) and 3-C (H7 , H8 and H9 ); 3 scenarios consider groups of 6 hospitals referred to as 6-G12 (H1 , H2 , H3 , H4 , H5 and H6 ), 6-CG1 (H1 , H2 , H3 , H7 , H8 and H9 ) and 6-CG2 (H4 , H5 , H6 , H7 , H8 and H9 ), each one is including the hospitals of two of the previous three-hospital groups; and one scenario considers the 9 hospitals (H1 , H2 , H3 , H4 , H5 , H6 , H7 , H8 and H9 ) and is referred to as 9-CG12. For each basic scenario we examine several demand patterns: (a) constant demand; (b) increasing demand and (c) decreasing demand. The MILP generated by these scenarios are solved with IBM ILOG CPLEX 12.2 on a PC Pentium IV, 3.0 GHz. The three solution methods presented above are used. Default setting solution is denoted by DSS, the solution method using aggressive settings for cut generation is denoted by ASCG and the solution method using both aggressive settings for cut generation and customized cuts is denoted by ASCG + CC. For scenarios 19 (considering three hospitals) the associated MILPs comprise 886 variables, 3557 constraints and 80 customized cuts can be added. For scenarios 1018 (considering six-hospitals)

82 Table 1 Computational results. Scenario 1 2 3 3 hospitals 4 5 6 7 8 9 10 11 12 6 hospitals 13 14 15 16 17 18 9 hospitals

a

H. Tlahig et al. / Operations Research for Health Care 2 (2013) 7585

DP a b c a b c a b c a b c a b c a b c a b c

HG 3-G1

CPU1 136 2 76 59 93 111 2 2 2 12 500a 12 025a 14 440a 3 094a 12 017 36 749 61 6 920 1 162a 9 037a 1 501a

CPU2 33 2 5 12 54 9 2 2 2 13 340a 11 483a 17 918a 22 48 46 32 41 48 60 33 009a 113

CPU3 2 2 9 2 19 5 1 2 2 24 37 039a 495 6 51 24 20 14 28 91 13 358a 144

Proposed configuration Centralization at hospital H1 from period 1 Decentralization Centralization at hospital H1 from period 2 Centralization at hospital H4 from period 1 Centralization at hospital H4 from period 1 Centralization at hospital H4 from period 2 Centralization at hospital H8 from period 1 Centralization at hospital H8 from period 1 Centralization at hospital H8 from period 1 Centralization at hospital H1 from period 1 Centralization at hospital H1 from period 2 Centralization at hospital H1 from period 2 Centralization at hospital H1 from period 1 Centralization at hospital H1 from period 1 Centralization at hospital H1 from period 1 Centralization at hospital H4 from period 1 Centralization at hospital H4 from period 1 Centralization at hospital H4 from period 1 Centralization at hospital H1 from period 1 Centralization at hospital H1 from period 1 Centralization at hospital H1 from period 1

Z 9 649 145.59 9 919 393.54 8 909 841.469 4 742 686.09 5 165 481.66 4 434 886.04 5 500 852.59 6 235 369.40 5 477 991.40 13 300 873.14 15 512 824.77 12 639 863.66 14 817 184.53 16 970 642.68 14 753 397.14 9 857 890.64 11 531 690.44 9 818 769.83 18 816 862.06 21 692 793.42 18 735 016.18

3-G2

3-C

6-G12

6-CG1

6-CG1

19 20 21

9-CG12

The obtained solution after the indicated computational time is not necessarily optimal (the solver is aborted).

the associated MILPs comprise 2731 variables, 12 074 constraints and 140 customized cuts can be added. For scenarios 19 to 21 (considering 9 hospitals) the associated MILPs comprise 5566 variables, 26 441 constraints and 200 customized cuts can be added. Table 1 presents some computational results. For each scenario the following information is provided: the hospital group (HG), the demand pattern (DP), the proposed configuration and the value of the objective function in euros (Z). In addition, for each solution method, the computational time in seconds (CPU1 for DSS, CPU2 for ASCG and CPU3 for ASCG+CC) are reported. For scenarios 19, regardless the used solution method, an optimal solution is found very rapidly (in few seconds) for all demand patterns. Based on the obtained results, we can state that the resolution of the considered locationallocation problem is not time consuming when a group of 3 hospitals is under investigation. Problem complexity appears for networks including 6 and 9 hospitals as for the majority of these scenarios computing time has exploded. However, it is clear that the use of aggressive settings for cut generation and customized cuts could reduce resolution time significantly and permits us to point out the optimal solution. The use of cuts and particularly customized cuts permits us to solve the MILP to optimality for 90% of the aforementioned scenarios. For scenarios 10 and 12, the computational time is significantly reduced only with the addition of the customized cuts. Moreover, we note that for all scenarios, the three solution methods provide the same solution. But, when default settings solution method is used, the obtained solution is not identified as optimal, adversely to the other solution methods (see for instance scenario 13). This solution is often found after a short computing time, but its optimality is not proven. When customized cuts are used, the starting lower bound is higher which permit us to prove solution optimality. This highlights the interest of developing customized cuts and solver aggressive settings for cut generation particularly for problems considering large networks. Finally, we can note that computational time could vary widely depending on demand pattern as shown for scenarios 10, 11 and 12. For scenarios 7, 8, 9, 11, 13, 14, 15, 16, 17, 18, 19, 20 and 21, a decentralized configuration is infeasible because some hospitals of the network are under capacitated: some critical resources in at least one hospital are not sufficiently available to meet the demand. In scenario 7, for instance, the existing human

resources in hospital H8 are not able to satisfy the demand. With centralization, it is not needed to hire additional resources. In scenarios 3, 6 and 12, centralization is the optimal configuration starting at period 2. We note that these scenarios are characterized by a decreasing demand. Centralizing the sterilization services at period 2 permits better optimization in resource sharing over the upcoming periods (fewer resources are needed and transferred to the CSS). In scenario 11, even though characterized by an increasing demand, the centralization is proposed from period 2: this indeed permits a better utilization of the transferred resources with regard to a centralization starting from period 1. In scenario 2, with an increasing demand pattern, the optimal configuration is the decentralization instead of the centralization obtained in scenario 1, with a constant demand pattern. When the demand increases, the utilization of available resources in each hospital is improved; this justifies the interest for decentralization. In addition, decentralization permits us to avoid transportation and transferring costs. Table 2 presents some details concerning the optimal configuration proposed for scenario 10. The number of the existing resources available in each hospital of the network is presented. For each hospital, the following information is provided: the number of existing resources (# Exist.), the number of the resources to be transferred to the CSS when the centralization is the retained configuration (# Trans.). For scenario 10 (as it has been shown previously in Table 1), the centralization of the sterilization service represents the optimal configuration from the first period of the planning horizon. The CSS is located in hospital H1 . Indeed the demand of hospital H1 is much larger than the demand of the other hospitals. Locating the CSS in hospital H1 incurs the smallest fixed cost and minimizes transportation costs as well as transferring costs. We can remark that the resource gain is of 22% for MR1, 71% for MR2, 64% for HR1 and 53% for HR2. A cost saving of 12% is also achieved with regard to the current situation where all hospitals perform sterilization inhouse. The human resources that are not assigned to the CSS will be redeployed in other hospital services. The material resources which are not transferred to the CSS will be sold. In the following, further analysis of the considered problem is conducted. 9 scenarios are developed in order to examine the impact of some parameters on the network design. In this analysis,

H. Tlahig et al. / Operations Research for Health Care 2 (2013) 7585 Table 2 Resource gain achieved by the optimal configuration based on scenario 10. Hospital MR1 # Exist. H1 H2 H3 H4 H5 H6 10 1 1 3 1 2 # Trans. 10 0 1 3 0 0 MR2 # Exist. 2 1 1 1 1 1 # Trans. 2 0 0 0 0 0 HR1 #Exist. 23 3 3 5 4 4 #Trans. 15 0 0 0 0 0 HR2 # Exist. 20 5 3 6 5 4 #Trans. 20 0 0 0 0 0

83

Table 3 Obtained results for scenarios 2230. DP Scenario 22 Scenario 23 Scenario 24 Scenario 25 Scenario 26 Scenario 27 Scenario 28 Scenario 29 Scenario 30 a b c a b c a b c Proposed configuration Centralization at hospital H1 Centralization at hospital H1 Centralization at hospital H1 Centralization at hospital H1 Decentralization Centralization at hospital H1 Centralization at hospital H1 Centralization at hospital H1 Centralization at hospital H1 from period 2 from period 4 from period 2 from period 1 from period 2 from period 1 from period 4 from period 2 Z 18 507 142.04 20 089 742.80 17 289 528.90 18 816 862.08 20 358 111.58 17 606 328.45 18 658 862.08 20 903 142.81 17 454 328.90

the 9 hospitals are considered. The generated MILPs are solved using both aggressive settings for cut generation and customized cuts. The obtained results for the 9 scenarios are reported in Table 3. Hospitals H7 , H8 and H9 are short of human resources to meet their future internal demand. That is why the proposed configuration for all networks including these hospitals was the centralization. Subsequently, we propose first to examine the impact of hiring additional human resources on the network configuration. In scenarios 22, 23 and 24, the number of HR1 and HR2 in H7 , H8 and H9 is modified in such a way that each hospital is able to perform internally its sterilization activity for the first year (we suppose that one HR2 is hired in H7 and H9 ; and one H1 and one HR2 are hired in H8 ). In case of hiring the mentioned human resources, the centralization starting at period 2 becomes the proposed configuration for scenarios 22 and 24. In scenario 22, the produced quantity over the first period must cover both the demand and the safety stock. Postponing the centralization to period 2 allows the transfer of fewer resources to the CSS and guarantees a better utilization of these resources over periods 2, 3, 4 and 5. For scenario 23, the centralization starting at period 4 is the proposed configuration. This can be explained again by the unavailability of human resources required to cover the demand of periods 4 and 5. Furthermore, the number of human resources was progressively increased in order to point out configuration change. We noted that with an increase of 12% in the number of human resources, the centralization (at hospital 1 from period 1) becomes the optimal configuration. This number of resources is used in scenarios 25, 26 and 27. In scenario 26, the decentralization can be explained by the increase of resource utilization notably over the last periods of the planning horizon. Opting for the centralization in scenario 26 means that some resources are transferred to the CSS because they are only needed to satisfy the demand of period 5; these resources are not necessarily well utilized over the other periods of the planning horizon. We consider scenario 22 while progressively decreasing the number of human resources in H1 . With a decrease ranging between 2% and 21%, the decentralization is the optimal solution. With a decrease larger than 21% (27% decrease in the number of HR1 and 15% decrease in the number of HR2), H1 will not be able to satisfy the demand in-house and the centralization starting at period 1 becomes the optimal configuration.

The number of human resources available in each hospital has an important impact on network configuration. Obviously, a number of human resources exceeding the requirements of sterilization activity in each hospital favour centralization. Meanwhile a lack of resources in any hospital of the network can be solved by centralization. But, in this case, centralization is not necessarily better than opting for recruiting the requested resources as we can notice while comparing scenarios 19 and 22. Similarly to human resources, we propose to examine the impact of the number of material resources on network configuration. While maintaining the same number of human resources considered in scenario 22, the number of material resources was progressively increased. We noted that with an increase of 64% of the total number of MR1 and 30% of MR2, the centralization (at hospital 1 from period 1) becomes the optimal configuration. This number of resources is used in scenarios 28, 29 and 30. In scenario 22, the average utilization rate of MR1 is 75% and the average utilization rate of MR2 is 27%. The centralization becomes the optimal solution from period 1 when these rates reach respectively, 47% and 21% (scenario 28). Postponing the centralization to period 2 and 3 in scenario 29 and 30 is to ensure better utilization of the transferred/shared resources. We can conclude that network configuration is sensitive to the number of material resources available in each hospital of the network. The centralization is favoured by an increase of resources number, adversely to the decentralization. Obviously, decentralization will not be the proposed configuration if the decrease generates a lack in resources so that one hospital will not be able to satisfy its demand internally. While considering scenario 22, we conducted a sensitivity analysis study on some cost parameters. Firstly, we varied the transportation cost. The proposed configuration changed only when variable transportation costs were multiplied by 5.6: decentralization becomes the optimal configuration. However, any decrease in the transportation cost favours the centralization at hospital H1 from period 2. The network configuration is not sensitive to transportation cost. Secondly, we varied the fixed cost of the CSS. This cost is primarily composed of the cost of the building and its maintenance. With an increase of 5%, decentralization becomes the optimal configuration. Nonetheless, a decrease of CSS fixed cost does not have any effect on the network configuration: centralization at hospital H1 from period 2 remains the proposed solution. The network configuration is

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H. Tlahig et al. / Operations Research for Health Care 2 (2013) 7585

very sensitive to CSS fixed cost. The estimation of this cost must be made with accuracy. An error of 5% could mislead the decision. Besides, we varied the fixed cost of in-house sterilization. Similarly to CSS fixed cost, this cost is mainly composed of the cost incurred by the building and its maintenance. From a decrease of 8%, decentralization becomes the optimal configuration. After multiplying the in-house sterilization fixed cost by a factor of 2.6, the centralization at hospital H1 from period 1 becomes the optimal configuration. We can state that network configuration is sensitive to a decrease in in-house sterilization fixed cost. However, if the configuration decision involves hospitals which have operated the sterilization activity for some time, then the incurred in-house sterilization fixed cost should be known with some accuracy. Emphasis should be rather placed in CSS fixed cost estimation by referring to experts in the field. The number of vehicles requested to ensure transportation between hospitals and the CSS is based on the annual produced quantities and the capacity of one vehicle. The latter was determined under the assumption that a vehicle ensures 3 trips a day. Obviously, vehicle dimensioning, at this level, does not take into account short-term variation of the demand. The question here is what if the number of vehicles acquired is not enough to cover the demand on a daily basis? To answer this question, we propose to assess the impact of vehicle capacity decrease on network configuration. A decrease in one vehicle capacity could be seen as lesser trips per day but more hospitals inserted in the route. With a decrease of 18% in vehicle capacity the decentralization becomes the proposed solution for scenario 22. For a decrease ranging from 2% to 17%, centralization in hospital H1 from period 2 remains the proposed configuration but 6 vehicles are required instead of 5. It means that the need for one more vehicle will not affect the quality of the decision at this level. It is clear, however, that operating and managing the CSS will bring additional difficulties and challenges to handle the demand of the different hospitals of the network on a daily basis. Integrated production and vehicle routing scheduling approach should be developed and adequately implemented to enable conducting operating theatre activities safely and smoothly. This supposes appropriate use of Information Technology (such as RFID, [3]) to ensure timely information about operating theatre schedules, hospital demand and inventory levels. The proposed locationallocation model serves as a decision making tool for the configuration of hospital sterilization service within a hospital network. Basically, it is exploited while considering one CSS and two alternatives, centralization vs. decentralization. However, it can be used more widely (while designing a proper experimentation) in the perspective to design the network configuration while considering, for example, several CSSs and several options of centralization vs. decentralization. Besides, the proposed model can be used as a what-if analysis tool to identify under which conditions the centralization vs. decentralization is the best configuration. For example, if hospitals H7 , H8 and H9 hire the human resources indicated above and the demand has a constant pattern, centralization starting at period 2 becomes the proposed configuration by the model. 6. Conclusion In this paper, we proposed an optimization model for the configuration of hospital sterilization service within a hospital network. The model examines two alternatives: the centralization of the service in a common CSS or the decentralization, meaning that each hospital keeps in-house sterilization service. The problem is formulated as a locationallocation model and permits us to determine the location and size of the CSS.

The proposed model is solved by commercial solver IBM ILOG CPLEX 12.2. Three solution methods are investigated: (1) a resolution based on default parameters of CPLEX; (2) a resolution based on default parameters of CPLEX while enabling aggressive settings for cut generation; (3) a resolution using aggressive settings for cut generation and customized cuts. In order to evaluate the proposed mathematical model, 21 scenarios, for a case based on real life situations within a hospital network environment are tested. The experimentation of the proposed model highlights the interest of the centralization of the sterilization service within hospital network through resource sharing and optimization. Moreover, the obtained results show that the proposed MILP can be solved to optimality for moderate size scenarios (like those used in our study) with the use of commercial MILP solvers and the addition of appropriate customized cuts to the original model. Further analysis was conducted and pointed out how network configuration is sensitive to the number of human and material resources available in each hospital of the network as well as to sterilization fixed costs. The proposed model can also be used in the perspective to design the network while considering the case of a mixed configuration where some of the network hospitals move to the centralization and the others keep their own sterilization services. For that, an appropriate experimentation scheme must be designed. In further work, the case of a partial centralization where some products are performed in the hospital and the others are sent to the centralized sterilization service looks to be an interesting alternative to study. In the former case, static vs. dynamic allocation resource strategies can be evaluated and compared. Another prospect of this study is to generalize the obtained results and to establish rules for the choice centralized vs. distributed sterilization service depending on other criteria like order-to-delivery time and service quality level. References
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