Computers & Industrial Engineering 51 (2006) 375388 www.elsevier.

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A multi-objective programming model for scheduling emergency medicine residents

Seyda Topaloglu
*
Dokuz Eylul University, Department of Industrial Engineering, 35100 Izmir, Turkey Available online 12 September 2006

Abstract Scheduling emergency medicine residents (EMRs) is a complex task, which considers a large number of rules (often conicting) related to various aspects such as limits on the number of consecutive work hours, number of day and night shifts that should be worked by each resident, resident stang requirements according to seniority levels for the day and night shifts, restrictions on the number of consecutive day and night shifts assigned, vacation periods, weekend o requests, and fair distribution of responsibilities among the residents. Emergency rooms (ERs) are stressful workplaces, and in addition shift work is well-known to be more demanding than regular daytime work. For this reason, preparing schedules that suit the working rules for EMRs is especially important for reducing the negative impact on shift workers physiologically, psychologically, and socially. In this paper, we present a goal programming (GP) model that accommodates both hard and soft constraints for a monthly planning horizon. The hard constraints should be adhered to strictly, whereas the soft constraints can be violated when necessary. The relative importance values of the soft constraints have been computed by the analytical hierarchy process (AHP), which are used as coecients of the deviations from the soft constraints in the objective function. The model has been tested in the ER of a major local university hospital. The main conclusions of the study are that problems of realistic size can be solved quickly and the generated schedules have very high qualities compared to the manually prepared schedules, which require a lot of eort and time from the chief resident who is responsible for this duty. 2006 Elsevier Ltd. All rights reserved.
Keywords: Resident scheduling; Emergency medicine resident; Personnel scheduling; Goal programming; Emergency room; Analytical hierarchy process

1. Introduction Graduate medical education (GME) is required of all medical school graduates seeking full license in one of the specialties of medicine. GME comprises the second phase of the formal educational process that prepares doctors for medical practice. This phase of medical education is conducted primarily in clinical settings and

Tel.: +90 232 388 7869; fax: +90 232 388 7864. E-mail address: seyda.topaloglu@deu.edu.tr

0360-8352/$ - see front matter 2006 Elsevier Ltd. All rights reserved. doi:10.1016/j.cie.2006.08.003

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requires direct participation of residents in the delivery of patient care services. The residents have a unique position as both a learner and provider of services. Among the various groups of health care personnel, scheduling emergency medicine residents (EMRs) is one of the most challenging scheduling problems. The emergency room (ER) is open 24 h a day and 7 days a week, which requires EMRs to work dierent shifts and to work on nights and on weekends as during the day, and in addition they have to attend educational debriengs. For this reason, EMRs duty schedules should be prepared keeping in mind the potentially adverse impact that resident fatigue may have on the quality of patient care provided and the resident physical and emotional well-being. The scientic literature has consistently demonstrated that the sleep deprivation of the magnitude seen in residency training programs lead to cognitive impairment, which results in higher rates of medical error, motor vehicle accidents, and pregnancy complications (Grantcharov, Bardram, Funch-Jensen, & Rosenberg, 2001; Kowalenko, Kowalenko, Rabinovich, & Gryzbowski, 2000; Marcus & Loughlin, 1996; Wu, Folkman, McPhee, & Lo, 1991). Much data supports that for many residents, fatigue cultivates anger, resentment, bitterness, and depression rather than kindness, compassion, or empathy (Schneider & Phillips, 1998; Tanz & Charrow, 1993). To deal with these issues, hospitals apply certain rules for regulating the duty hours of EMRs as to meet their obligations about the quality of resident education, the well-being of EMRs, and the quality of patient care services. The EMR scheduling problem takes into account a large number of rules that often conict with each other while satisfying resident stang requirements for the day and night shifts. Today in many hospitals, the chief residents spend very long hours to manually prepare schedules by trial and error, and in spite of the eort the quality of the resulting schedule is not good. In this paper, we present a goal programming (GP) model for the EMR scheduling problem in a major local hospital, which constructs high-quality monthly schedules in signicantly reduced time and eort compared to the chief resident who devotes almost a week to perform this task. The proposed model is an abstract representation of the rules in the ER. Although the situation encountered in this hospital might not be exactly the same as of other hospitals, the proposed model is a very exible tool and can be implemented in other ERs with small adaptations required. The organization of the paper is as follows: Section 2 gives some literature review. Section 3 presents the proposed GP model along with the description of notation and variables, constraints and objective function. Section 4 makes a computational analysis of the model with real data obtained from the hospital. Finally, Section 5 gives the concluding remarks and future research. 2. Literature review Much of the research on scheduling health care personnel has been devoted to the case of hospital nurses. The nurse scheduling problem (NSP) involves allocating nurses to work shifts and work days subject to a variety of hard/soft constraints such as legal regulations, personnel policies, nurses preferences and many requirements that may be hospital-specic. The three commonly used methods for solving NSPs are mathematical programming (MP), heuristics and articial intelligence (AI) approaches. As indicated in Cheang, Li, Lim, and Rodrigues (2003), MP models employ traditional methods from linear programming, integer programming, goal programming and networks to solve NSPs. In the case where there are multiple goals with priorities, GP has received the most attention. Arthur and Ravindran (1981) presented a model for the NSP, which works in two phases. The rst phase assigns the day-on/day-o patterns to nurses using a GP model for the 2week planning horizon. In the second phase, a heuristic procedure is used to make specic shift assignments. Musa and Saxena (1984) presented a single-phase GP algorithm considering the scheduling policies of the hospital and nurses preferences for weekends on and o. Ozkarahan and Bailey (1988) proposed a GP version of the integrated personnel scheduling model of the time of day (TOD) and day of week (DOW) problems in order to schedule nurses over a weekly period. Ozkarahan (1989) proposed a exible decision support system to satisfy interests of both hospitals and nurses through alternative models that accommodate exible work patterns as it integrates TOD and DOW scheduling problems. Berrada, Ferland, and Michelon (1996) in their GP model formulated administrative and union contracts as hard constraints, while work patterns and nurses preferences have been formulated as soft constraints. Azaiez and Al Sharif (2005) developed a GP model that

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includes hospital objectives such as ensuring a continuous service with appropriate nursing skills and stang size and nurses preferences such as distributing night shifts and weekends o fairly and avoiding isolated days on and o. In addition to optimization-based approaches, heuristic approaches for the NSP have produced satisfactory results in reasonably short times. For example, Dowsland (1998) used tabu search with strategic oscillation to generate rosters for nurses. The proposed tabu search algorithm repeatedly oscillates between nding a feasible cover for demand and improving it in terms of the preferences of the nurses. Dowsland and Thompson (2000) developed a software tool to generate rosters for nurses and used a variant of tabu search as the core method, but applied knapsack and network ow models in pre- and post-processing phases. Aickelin and Dowsland (2004) developed a genetic algorithm approach that also handles the conict between objectives and constraints. Their results indicate that the proposed algorithm is able to nd high quality solutions. AI techniques have also been used to solve NSPs. Weil, Heus, Francois, and Poujade (1995) demonstrated the eciency of constraint programming using ILOG-Solver for the NSP. Abdennadher and Schlenker (1999) tackled the NSP in constraint logic programming framework. They developed an interactive constrained based scheduler, which assigns a working shift to each nurse on each day of a 1-month planning period. The proposed system incorporates several requirements, such as minimum sta requirement of a ward, legal regulations, and wishes of the personnel. Meyer aufm Hofe (1997) has used hierarchical constraint programming (HCP) for nurse scheduling, where legal regulations are hard constraints and wishes of nurses are soft constraints, which are encoded in a hierarchical constraint satisfaction problem. The resident scheduling problem exhibits dierences from the NSP. While the resident is a provider of medical services, he or she is also a student in training. This situation implies a variety of working rules to ensure an optimal learning environment and to provide a good balance between education and patient care activities. Usually in nurse scheduling models, skill-specic nursing demand varies widely on hourly and daily basis and the emphasis is on providing adequate coverage of demand. On the other hand, residents are grouped according to their seniority level and the critical issue is to allocate the minimum required number from each seniority level to each shift type. Working rules may change for dierent resident groups, and also each resident should work a certain designated number of day and night shifts. Since resident fatigue deteriorates the quality of patient care provided, it is also required to regulate consecutive shift assignments. Numerous objective functions used for the NSP include minimize stang cost, minimize number of nurses scheduled, minimize sta dissatisfaction, maximize number of days-o pairs, and minimize deviations between scheduled and desired stang levels. GP attempts to optimize various combinations of these and other objectives. Maximizing nurse satisfaction and minimizing stang cost are often considered as two objectives to achieve simultaneously. In resident scheduling, stang cost is not relevant but minimizing deviations from the working rules is especially important. There is little work in the literature about the resident scheduling problem. The rst attempt for scheduling medicine residents can be seen in Ozkarahan (1994) that proposes a GP model based on the requirements of the residency program as well as the desires of residents as to days o, weekends and on call-night for a 1-week planning horizon. Sherali, Ramahi, and Saifee (2002) addressed the night allocation problem of residents while considering departmental stang and skill requirements as well as residents preferences. Franz and Miller (1993) dealt with the allocation of residents to training rotations and associated clinics. Once this problem is solved, monthly shift schedules should be prepared for the residents in each clinic, which is of our concern in this study. Carter and Lapierre (2001) examined the problem of ER physicians in six dierent hospitals and showed how to modify a hospitals existing scheduling rules to develop techniques which produce better schedules in reduced time. Beaulieu, Ferland, Gendron, and Michelon (2000) proposed a GP model for scheduling ER physicians over a 6-month horizon considering a large number of rules such as limits on the number of work hours, special rules for night shifts and weekends, seniority rules, vacations periods, etc. While the aforementioned literature review provides many related problems and models, none of them fully consider the EMR scheduling problem at hand which acquires notable dierences and variances that need to be dealt with specically. We now proceed to describe our model for this problem.

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3. The development of the proposed GP model In the ER of our hospital, the 10-h day shift is between 8 a.m. and 6 p.m., and the 14-h nigh shift is between 6 p.m. and 8 a.m. the next day. The problem consists o assigning EMRs to day and night shifts for a monthly period, while satisfying stang requirements and adhering to the working rules. The stang requirements and working rules have been formulated as model constraints. Because of the large number of constraints that the schedule attempts to satisfy simultaneously, it is likely that no feasible solution exists for the EMR scheduling problem. For this reason, the constraints have been divided into two classes: hard constraints that should be satised and soft constraints that can occasionally be violated. The objective function of the proposed GP model minimizes these violations by reducing the relevant deviations in the soft constraints from their respective targets. The model utilizes the analytical hierarchy process (AHP) for assigning weights to the deviations in the objective function (Saaty, 1980). In the past work for the personnel scheduling problem, the incorporation of the AHP process into the GP model has not been addressed, however, there are various applications of the AHP-GP combination in other dierent areas. For example, Badri (2001) used the combined AHPGP model for quality control systems, in which the quality indicators are weighted by the AHP and the priority weights are, in turn, incorporated in a GP to help select the best set of quality control instruments for customer data collection purposes. Akgunduz, Zetu, Banerjee, and Liang (2002) incorporated the AHP and GP into the process of evaluating alternatives for sub-components and parts in the design of products by satisfying customer, technical, and nancial requirements. Sarkis and Talluri (2004) presented an integrative set of models based on the AHP and GP that will aid the members of the supply chain in deciding which electronic commerce technology media and software is most suitable for the whole supply chain. Yurdakul (2004) proposed a combined model of the AHP and GP to consider multiple objectives and constraints simultaneously in the selection of computer-integrated manufacturing technologies. 3.1. Notation and variables The following notation is required to formulate the model: Parameters i j k s l index for the residents, i = 1, . . . , I index for the days of the monthly planning period, j = 1, . . . ,J index for the shift type, k = 1 and 2 for the day (8 a.m.6 p.m.) and night (6 p.m.8 a.m.) shifts, respectively index for the seniority levels of residents, s = 1, 2 and 3 for the highest, average and lowest seniority levels, respectively index for the position of senior residents in taking responsibility of the shift they are assigned, l = 1 corresponds to the supervising resident position for the shift and l = 2 corresponds to the second position near the supervising resident as his/her helper set of residents with seniority level s set of residents who take a vacation during the planning period set of o-days for resident i, i 2 VCR set of all Mondays within the planning period set of all Tuesdays within the planning period set of all Saturdays within the planning period upper limit on the number of residents with seniority level s to assign to the day and night shift lower limit on the number of residents with seniority level s to assign to the day and night shift upper limit on the total number of residents to assign to the day and night shift lower limit on the total number of residents to assign to the day and night shift number of night shifts that resident i should be assigned during the planning period

Rs VCR VCDi M T S URs LRs UD LD NSi

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DSi mc mn tn

number of day shifts that resident i should be assigned during the planning period maximum number of supervising resident positions that can be assigned to a senior resident during the planning period maximum number of Monday night shifts that can be assigned to a resident maximum number of Tuesday night shifts that can be assigned to a resident

Binary variables Xijk Yij pstijkl 1 if resident i is assigned to shift type k on day j, and 0 otherwise 1 if resident i is assigned to work at least one shift during the weekend that starts on Saturday j, and 0 if no shift is assigned for the weekend, j 2 S 1 if senior resident i is assigned to position l for shift type k on day j, and 0 otherwise, i 2 R1

Deviation variables night1ij positive deviation from the restriction that two consecutive night shifts should not be assigned to a resident, night1ij = 1 if resident i is assigned to the night shift on days j and (j + 1) consecutively, and 0 otherwise positive deviation from the restriction that three consecutive night shifts should not be assigned to a resident, night2ij = 1 if resident i is assigned to the night shift on days j, (j + 1), and (j + 2) consecutively, and 0 otherwise positive deviation from the restriction that three consecutive day shifts should not be assigned to a resident, day1ij = 1 if resident i is assigned to the day shift on days j, (j + 1), and (j + 2) consecutively, and 0 otherwise positive deviation from the restriction that four consecutive day shifts should not be assigned to a resident, day2ij = 1 if resident i is assigned to the day shift on days j, (j + 1), and (j + 2), and (j + 3) consecutively, and 0 otherwise negative deviation from assigning at least one complete weekend o within the planning horizon for resident i, wkdi = 1 if resident i cannot take any of the weekends o, and 0 if at least takes one weekend o positive and negative deviations, respectively, from the permissible number (mc) of supervising resident positions that can be assigned to senior resident i within the scheduling period, i 2 R1 positive and negative deviations, respectively, from the permissible number (mn) of Monday night shifts that can be assigned to resident i within the scheduling period positive and negative deviations, respectively, from the permissible number (tn) of Tuesday night shifts that can be assigned to resident i within the scheduling period

night2ij

day1ij

day2ij

wkdi

pstpi, pstmi

mnpi, mnmi tnpi, tnmi

3.2. Constraints 3.2.1. Hard constraints The hard constraints satisfy the working hour restrictions of residents and stang requirements of the day and night shifts and also insure the desired allocation of residents to each shift with respect to their seniority. (1) A resident cannot work both the day and night shifts in a work day.
2 X k1

X ijk 6 1

i 1; . . . ; I; j 1; . . . ; J

(2) A resident assigned to a night shift cannot be assigned to a day shift on the next day. X ij2 X ij11 6 1 i 1; . . . ; I; j 1; . . . ; J 1 2

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(3) Each resident should be assigned to his/her required number of day and night shifts during the scheduling period.
J X j1 J X j1

X ij1 DS i

i 1; . . . ; I

X ij2 NS i

i 1; . . . ; I

(4) A resident completing a night shift on Monday should not work the night shift on Tuesday because he/ she attends an education session on that day. It should be noted that if a resident is assigned to a day shift on Tuesday, he/she does not attend the education session. X ij2 X ij11 X ij12 6 1 i 1; . . . ; I; j 2 M 5

(5) The total number of seniority s residents assigned to a day or night shift should be in the specied range. X LRs 6 Xijk 6 URs s 1; 2; 3; j 1; . . . ; J ; k 1; 2 6
i2Rs

In the ER of our hospital, minimum one senior, one less senior, and one junior EMR should be assigned to each shift. Note also that at most two senior and three less senior and junior EMRs can be assigned to each shift. (6) The overall number of residents assigned to a day or night shift should be in the specied range. LD 6
I X i1

X ijk 6 UD

j 1; . . . ; J ; k 1; 2

The head emergency medicine physician in our case has dened this range as minimum ve and maximum six residents. (7) A highest seniority (HS) level resident should be assigned to work as the supervising resident of each shift. X pstijk1 1 j 1; . . . ; J ; k 1; 2 8
i2R1

(8) At most one HS level resident can be assigned to work as the helper of the supervising resident during the shift. This restriction complies with the constraint set (6) above, which species the minimum required number of HS level residents assigned to a shift as one. In case the minimum required number is bigger than one, constraint set (9) below should be made equal to one to guarantee that this position is fullled for each shift by exactly one HS level resident. X pstijk2 6 1 j 1; . . . ; J ; k 1; 2 9
i2R1

(9) A HS level resident i will be given one of the positions (l = 1 or 2) for shift type k on day j if only he/she has been assigned to work the same shift.
2 X l1

pstijkl X ijk 6 0

i 2 R1 ; j 1; . . . ; J ; k 1; 2

10

(10) A resident should not be assigned to any shift during his/her vacation.
2 X X j2VCDi k1

X ijk 0

i 2 VCR

11

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3.2.2. Soft constraints The soft constraints relate to exible working rules and residents preferences for the scheduling of shifts. (1) A resident should not work two consecutive night shifts. X ij2 X ij12 night1ij 6 1 i 1; . . . ; I; j 1; . . . ; J 1 12

In the case of positive deviation from constraint (12), the resident will have to work two consecutive night shifts. When this constraint has a positive deviation for consecutive j values for resident i, the resident will have to work more than two consecutive night shifts. For example, when night1i1 and night1i2 deviations take value 1, resident i will be working the night shift on days 1, 2 and 3 consecutively. To prevent this situation, the following constraint (13) is required whose positive deviation should be given priority for minimization over the positive deviation of constraint (12). X ij2 X ij12 X ij22 night2ij 6 2 X ij1 X ij11 X ij21 day1ij 6 2 i 1; . . . ; I; j 1; . . . ; J 2 i 1; . . . ; I; j 1; . . . ; J 2 13 14

(2) A resident should not work three consecutive day shifts.

In the case of positive deviation from constraint (14), the resident will have to work three consecutive day shifts. When this constraint deviates in a positive manner for consecutive j values iterations for resident i, it can be noticed that more than three consecutive day shifts are assigned to a resident. For example, when day1i1 and day1i2 positive deviations take value 1, resident i will be assigned to the day shift on days 1, 2, 3 and 4 consecutively. To prevent this situation, the following constraint (15) is required whose positive deviation should be given priority for minimization over the positive deviation of constraint (14). X ij1 X ij11 X ij21 X ij31 day2ij 6 3 i 1; . . . ; I; j 1; . . . ; J 3 15

(3) Each resident should take at least one weekend o during the scheduling period. To write this constraint, the following two constraints are needed: X ij1 X ij11 X ij2 X ij12 2Y ij 6 0 i 1; . . . ; I; j 2 S X ij1 X ij11 X ij2 X ij12 Y ij P 0 i 1; . . . ; I; j 2 S 16 17

Constraint (16) requires the indicator Yij variable to take value 1 if any shift has been assigned to resident i for the weekend that starts on Saturday j. Constraint (17) enforces the same variable to take value 0 if no shifts have been assigned for the weekend. X 4 Y ij wkd i P 1 i 1; . . . ; I 18
j2S

Considering there are 4 weekends during the scheduling horizon, the deviation from constraint (18) corresponds to all Yij variables for resident i take value 1 for all the weekends, in which case the resident cannot take any one of the weekends completely o and the associated deviation variable wkdi takes value 1. To schedule at least one weekend o for the residents, this deviation variable should be tried to be minimized. (4) The supervising resident positions should be distributed fairly among the senior residents. The value of mc has been specied as 10 in our case.
J 2 XX j1 k1

pstijk1 pstpi pstmi mc

i 2 R1

19

(5) Monday and Tuesday night shifts should be distributed fairly among the residents since all residents should attend the education session on Tuesday morning except for those working a day shift. The values of mn and tn have been dened as two in our situation. X ij2 mnpi mnmi mn i 1; ::; I 20 X
j2T j2M

X ij2 tnpi tnmi tn

i 1; ::; I

21

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Table 1 Pairwise comparison of soft constraints and their relative importance values Soft constraints no. (1) (2) (3) (4) (5) (6) (7) (8) No consecutive two night shifts No more than two consecutive night shifts No consecutive three day shifts No more than three consecutive day shifts At least one weekend o Fair distribution of supervising resident positions Fair distribution of Monday night shifts Fair distribution of Tuesday night shifts (1) 1 9 3 1 8 8 8 8 (2) 1/9 1 1/9 1/9 1 1/9 1/9 1/9 (3) 1/3 9 1 9 8 8 8 8 (4) 1 9 1/9 1 7 7 7 7 (5) 1/8 1 1/8 1/7 1 1/8 1/6 1/6 (6) 1/8 9 1/8 1/7 8 1 2 2 (7) 1/8 9 1/8 1/7 6 1/2 1 1 (8) 1/8 9 1/8 1/7 6 1/2 1 1 Relative importance 0.017 0.369 0.018 0.034 0.294 0.077 0.095 0.095

3.3. Objective function The deviations in the soft constraints have dierent importance weights and these weights reect the relative importance of one constraint compared to the others while trying to be satised. The AHP is utilized to establish a relative importance among the soft constraints of the proposed GP model. The major step in this process is to elicit the preferences about the satisfaction of the soft constraints through pairwise comparisons. Saaty (1980) suggests that the comparisons be made in the range 1/99. Accordingly, in pairwise comparison of the soft constraints, a rating of 9 indicates that one constraint is extremely more important than the other, whereas a rating of 1/9 indicates that one constraint is extremely less important than the other. If one constraint is very strongly important than the other, a rating of 7 is given, while strongly more important judgment receives a rating of 5. Intermediate judgments receive values 8, 6, 4 and 2, respectively. Finally, a rating of 1 indicates equal importance between the constraints. Also, if the importance of one constraint with respect to a second is given, then the importance of the second constraint with respect to the rst is its reciprocal. In our application, the emergency physician in charge of the ER services has been asked to make pairwise comparisons, which are summarized in a pairwise comparison matrix in Table 1 with the calculated relative importance values of the soft constraints. It takes 28 pairwise comparison questions to complete this 8 8 matrix. The rst step in developing these values is to sum the values in each column of the pairwise comparison matrix and then divide each value in the matrix by its column total. This results in a normalized matrix. The next step is to compute the average of the elements in each row of the normalized pairwise comparison matrix, which provides us with the values in the last column of Table 1. From the table, it can be seen that assigning no more than two consecutive nights to a resident receives the highest priority with relative importance score 0.369. Subsequently, comes the satisfaction of at least one weekend o constraint for each resident with score 0.294. The reported relative importance values in Table 1 constitute the coecients of the concerning deviational variables in the minimization objective function as follows: Minimize 0:017
J 3 X j1 I J 1 XX i1 j1 I X i1

night1ij 0:369 wkd i 0:077

I J 2 XX i1 j1

night2ij 0:018
I X i1

I J 2 XX i1 j1

day1ij 0:034
I X i1

I X i1

day2ij 0:294

X
i2R1

pstpi 0:095

mnpi 0:095

tnpi

22

4. Computational results The GP model was coded in ILOG OPL Studio 3.7 (2003) and solved with CPLEX 9.0 (2003) on a Pentium IV microcomputer with 128 MB RAM. The model has been tested using 15 months of real data obtained from the hospital. Table 2 illustrates the input statistics. The largest model contains 5633 constraints and 5068 integer variables for scheduling 23 residents over a 31-day planning period for month 9. The table also shows the distribution of residents according to their seniority level.

S. Topaloglu / Computers & Industrial Engineering 51 (2006) 375388 Table 2 Problem input and model size analysis Month number 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15
a b c

383

Number of residents 19 20 19 18 18 19 19 19 23 19 18 21 22 18 17

No. of HSa level residents 7 4 5 5 5 6 5 7 6 7 5 7 5 6 6

No. of ASb level residents 7 4 3 4 4 3 4 7 8 5 7 9 8 6 8

No. of LSc level residents 5 12 11 9 9 10 10 5 9 7 6 5 9 6 3

No. of days to schedule 31 31 28 31 30 31 30 31 31 30 30 31 31 31 30

No. of constraints 4830 4833 4898 4555 4364 4743 4558 4831 5633 4701 4420 5248 5297 4566 4235

No. of variables 4511 4324 4456 4104 3940 4385 3950 4512 5068 4369 3977 4894 4689 4195 3878

HS: highest seniority. AS: average seniority. LS: lowest seniority.

During the execution of CPLEX, the best integer solution after a certain time period for most of the problems could not be improved. Much of the computational eort went into proving that one of the incumbents found in the rst minutes of the branch and bound process was indeed the best solution that was to be found. For this reason, CPLEX was set to run to the 4000 node limit. The minimum and maximum solution times were 477 and 3407 CPU seconds, respectively, as illustrated in Table 3. Within the iteration limit, the objective function value conrmed for optimality is for month 13, which has been found in 477 CPU seconds. Although the branch and bound process has not nished its optimum search process within the specied limit, the obtained objective function values are quite satisfactory in view of the manually prepared schedules with a lot of deviations from the specied constraints. When these objective function values are compared with the lower bound values obtained from the rst LP relaxations, the biggest gap observed is 0.239 for month 7 as shown in Table 3. The scheduler can extend this node limit and therefore let the program run longer

Table 3 Computational results Month number 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 Solution time (CPU seconds) 2906 1691 1906 2554 1543 2676 2241 2038 2317 2578 2335 3407 477 2884 2266 No. of simplex iterations 867,722 521,948 663,831 777,899 471,534 796,359 637,111 656,506 700,457 807,993 721,677 1,060,252 113,477 847,068 802,418 Objective function value 0.085 0.034 0.017 0.051 0.324 0.085 1.24 0.102 0.341 0.136 1.75 0.017 0.924 0.564 0.034 LP relaxation value (lower bound) 0 0 0 0 0.154 0 1.001 0 0.154 0 0.77 0 0.924 0.462 0.017

384 Table 4 Scheduling input for month 12 Resident number 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21

S. Topaloglu / Computers & Industrial Engineering 51 (2006) 375388

Seniority level 1 1 1 1 1 1 1 2 2 2 2 2 2 2 2 2 3 3 3 3 3

Number of day shifts to be assigned 8 5 6 9 9 6 3 10 10 10 10 6 10 10 10 10 10 10 10 10 9

Number of night shifts to be assigned 7 4 6 9 9 6 3 9 9 9 9 6 9 9 9 9 10 10 10 10 9

Planned o-days 13 1731 110

110 17, 1831

1928

in order to nd an improved solution value if there is one. However, in the current position the chief resident is very pleased about the resultant schedules of the model. To give an example about the solution quality of the GP model, the generated schedule by the proposed model for month 12 can be analyzed. The scheduling input for this month such as the total number of day and night shifts each resident should work, the o-days of residents, and the seniority level of each resident are illustrated in Table 4. The generated schedule is presented in Table 5 with HS level residents shown in bold who are assigned supervisory positions in each shift. The objective function value obtained is 0.017 as shown in Table 3. When the model execution stops at the node limit, the gap between the nal integer solution value and the bound value of the LP relaxation at node 0 is 1.7%. All the constraints have been satised for all the residents except for EMR 8 who has to work consecutive night shifts on the 13th and 14th days, respectively. When the generated schedule is compared with the manually prepared actual schedule of the hospital that is given in Table 6, it can be observed that our schedule is much better in satisfying the soft constraints because in the actual schedule there are many deviations from the soft constraints (12), (14), (18), (20), and (21) for over half of the residents. For example, residents 17, 18, 19 and 20 cannot take any one of the weekends completely o. Table 7 shows residents with two consecutive night shifts assigned. Also, residents with three consecutive day shift assignments are illustrated in Table 8. Residents 12, 18, and 19 have to work one more Monday night shift, whereas residents 8 and 9 have to work one more Tuesday night shift compared to the maximum two. 5. Conclusion and future research The primary goal of this research was to introduce the EMR scheduling problem in which a good schedule is sought that meets the compulsory working rules and conforms to the exible constraints as much as possible. The EMR scheduling problem involves assigning both day and night shifts to residents over a monthly planning horizon. Because of this it requires dealing with various constraints concerning consecutive shift assignments. It is also interesting to notice that residency programs require the residents to have a unique position as both a learner and provider of services. For this reason, it is challenging to determine residents working hours keeping a proper balance between education and patient care activities especially for those in the

Table 5 Generated schedule by the GP model for month 12 Monday Week 1 Day shift Night shift Week 2 Day shift Night shift Week 3 Day shift Night shift Week 4 Day shift Night shift Week 5 Day shift Night shift 1 4, 8, 13, 15, 17, 18 2, 11, 14, 16, 19, 20 8 2, 7, 10, 14, 16, 17 4, 13, 15, 18, 20, 21 15 2, 5, 9, 15, 17, 21 6, 11, 12, 16, 18, 19 22 3, 11, 13, 18, 19, 20 4, 10, 14, 15, 17 29 6, 11, 13, 15, 18, 20 1, 9, 10, 12, 17, 21 Tuesday 2 4, 8, 10, 12, 18, 21 5, 9, 13, 15, 17 9 7, 5, 8, 10, 14, 17 2, 1, 9, 12, 16, 19 16 5, 3, 9, 13, 14, 20 1, 4, 8, 10, 17, 21 23 3, 8, 9, 13, 20, 21 6, 5, 11, 16, 18, 19 30 3, 8, 14, 16, 18, 19 6, 11, 13, 15, 20 Wednesday 3 2, 11, 14, 19, 20, 21 4, 8, 10, 16, 18 10 5, 4, 8, 11, 20, 21 7, 10, 13, 15, 17, 18 17 3, 12, 15, 16, 19, 20 7, 5, 9, 11, 13, 18 24 1, 4, 10, 14, 15, 17 3, 8, 9, 13, 20, 21 31 5, 4, 10, 12, 16, 21 1, 9, 14, 17, 18, 19 Thursday 4 2, 1, 11, 12, 17, 19 5, 13, 15, 20, 21 11 1, 9, 12, 16, 19, 20 6, 2, 8, 11, 14, 21 18 4, 1, 8, 14, 16, 19 3, 10, 15, 17, 20, 21 25 6, 11, 15, 16, 18 5, 4, 10, 14, 17, 19 Friday 5 4, 8, 9, 10, 17 1, 12, 14, 16, 19 12 1, 4, 9, 12, 15, 17 7, 5, 10, 16, 18, 20 19 5, 6, 9, 13, 14, 18 4, 1, 8, 11, 16, 19 26 6, 1, 8, 9, 11, 18 3, 13, 15, 16, 20 Saturday 6 5, 9, 11, 13, 20, 21 2, 4, 10, 15, 18 13 4, 3, 11, 13, 14, 19 1, 6, 8, 12, 17 20 6, 5, 9, 10, 15, 21 3, 13, 14, 17, 20 27 5, 8, 10, 14, 17, 19 4, 9, 11, 18, 21 Sunday 7 1, 13, 16, 20, 21 5, 9, 11, 12, 19 14 7, 2, 11, 13, 19 3, 4, 8, 14, 20 21 1, 10, 15, 16, 18 6, 5, 8, 9, 21 28 6, 10, 15, 16, 17 3, 5, 8, 14, 19

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Table 6 Actual schedule of the ER for month 12 Monday Week 1 Day shift Night shift Week 2 Day shift Night shift Week 3 Day shift Night shift Week 4 Day shift Night shift Week 5 Day shift Night shift 1 1, 5, 9, 10, 14, 20 2, 12, 13, 17, 19, 21 8 4, 8, 10, 12, 14 5, 7, 13, 15, 17, 20 15 1, 7, 8, 11, 17, 21 2, 10, 12, 16, 18, 20 22 3, 10, 8, 16, 17, 20 6, 4, 11, 18, 19, 21 29 5, 8, 9, 16, 17, 21 6, 10, 12, 14, 18, 19 Tuesday 2 4, 5, 9, 10, 14, 20 1, 8, 11, 15, 18, 21 9 1, 10, 11, 14, 18, 19 4, 8, 9, 12, 16 16 3, 5, 4, 8, 15, 21 6, 7, 9, 13, 17, 19 23 1, 10, 8, 9, 15, 16 3, 5, 13, 17, 20, 21 30 4, 11, 13, 15, 17, 21 3, 8, 9, 16, 20 Wednesday 3 2, 12, 13, 16, 17, 20 4, 5, 9, 15, 19 10 5, 7, 2, 13, 18, 19 1, 11, 15, 17, 50 17 4, 10, 11, 16, 18, 20 1, 5, 8, 14, 15, 21 24 4, 6, 11, 14, 15, 19 5, 8, 9, 10, 16 31 5, 10, 12, 13, 14, 21 6, 11, 15, 18, 19 Thursday 4 1, 8, 12, 14, 18 2, 10, 13, 16, 17, 20 11 3, 4, 9, 13, 16, 19 2, 7, 10, 11, 14, 17 18 3, 4, 9, 11, 16 5, 10, 12, 14, 17, 21 25 6, 11, 13, 19, 20, 21 1, 4, 14, 15, 18 Friday 5 4, 1, 5, 8, 12 1, 6, 4, 5, 19 1, 8, 3, 6, 26 5, 8, 4, 1, 9, 11, 15, 19 12, 13, 14, 18 8, 15, 16, 20, 21 9, 13, 18 13, 15, 18 9, 11, 16, 20 9, 16, 19 10, 14, 17, 21 Saturday 6 2, 9, 11, 17, 19, 20 4, 8, 10, 16, 18 13 3, 2, 10, 14, 17, 19 4, 8, 11, 15, 18, 21 20 5, 9, 14, 18, 19 1, 10, 13, 17, 20 27 6, 11, 13, 15, 18 3, 8, 9, 16, 20, 21 Sunday 7 2, 12, 14, 17, 20 1, 9, 11, 16, 19 14 5, 10, 12, 13, 17, 20 6, 3, 14, 15, 19 21 6, 3, 15, 16, 18, 21 5, 9, 13, 14, 19 28 6, 13, 15, 17, 18 4, 3, 11, 19, 20

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Table 7 Residents with consecutive two night shift assignments according to the actual schedule (deviations from constraint 12) Residents Days 1 1 3 4 5 8 11 13 14 15 16 17 18 19 20 21 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 X X X X X X X X X X X X X X X X X X X X X X X X X X X X X X X X X X X X X X X X X X X X X X X X 26 X X X X S. Topaloglu / Computers & Industrial Engineering 51 (2006) 375388 27 28 29 30 31

Table 8 Residents with consecutive 3 day shift assignments according to the actual schedule (deviations from constraint 14) Residents Days 1 4 14 16 17 19 20 21 2 3 4 5 6 7 X 8 X 9 X X X X X X X X X X X X X X X X X X X 10 11 12 13 14 15 16 X 17 X 18 X 19 20 21 22 23 24 25 26 27 28 29 30 31

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ERs. There is also an apprenticeship relation between senior and less senior residents. This situation brings about the need for providing a minimum required resident allocation from each seniority level for each shift and fair distribution of duties between the residents such as the supervisory resident positions. In this paper, an AHP based goal programming approach has been proposed to computerize the scheduling process. In the current situation in our hospital, the chief EMR spends almost a week to manually prepare schedules by trial and error. In spite of the eort, the quality of the resultant schedule is not good due to the limitations in dealing with the combinatorial aspects of the problem. The proposed GP model is capable of generating high-quality monthly schedules in reasonable time considering all the hard and soft constraints in the scheduling environment. When the models solution is compared with the actual hospital schedule, it has been seen that the soft constraints are much better satised. Since the particular case studied here is representative of the situation in other major hospitals, the GP model can be adapted to their EMR scheduling problems with small modications. The new GP model presented herein oers several opportunities for future research. As an alternative solution approach, a constraint programming model can be developed and instead of using deviation variables, the problem can be solved by hierarchical constraint programming, in which a numerical value is assigned to each type of soft constraint in view of their relative importance values and an objective function is formulated with these values as coecients attached to the truth states of the constraints. The aim is to nd an optimal solution that maximizes the value of the objective function. One possible future work is to build a user-friendly computer package, since the chief resident who will use the GP model does not have the expertise of an operations research analyst to formulate the necessary constraints with proper objective function. The package will query the data required for the model at the user interface such as the number of residents, residents o-days, seniority level and number of day and night shift duties of each resident and required resident number for each shift and then formulate the model correctly according to the given data. It will also facilitate computing a new importance weight for each soft constraint if the user is not satised with the obtained solution. The model does not consider the physicians supervising the residents. Constraints related with physicians scheduling can be included in the model as a possible extension. References
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