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Document de travail du LEM

2009-03


HOSPITAL BED CAPACITY AND MIX PROBLEM
FOR STATE SUPPORTED PUBLIC AND FEE PAYING
PRIVATE WARDS



Yazgi Ttnc, David Newlands

ISEG School of Management, CNRS-LEM (UMR 8179)




















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Hospital Bed Capacity and Mix Problem for State Supported
Public and Fee Paying Private Wards
Yazgi Ttnc and David Newlands
IESEG School of Management
in collaboration with Izmir University of Economics and Ege University Hospital
Oncology Department, Izmir, Turkey

1. Abstract
Hospital bed capacity planning accuracy is important to satisfy patients needs, organize
departments and improve the quality and amount of service provided. Health care management
thus should aim to optimise activities within the imposed. This study applied the branch-and-
bound method, M/M/s algorithm, genetic algorithm and Dijkstra algorithm. This article
presents techniques and solutions used to solve the bed capacity planning problem. Results
obtained via these techniques enabled the efficiencies to be compared. Comparison to actual
data suggest specific techniques generate higher accuracy predictions that we recommend by
applied by hospital managers to commit resources that more closely match demand.
In this study, Bed Capacity Planning Problems have been modeled using two time buckets:
annual bed capacity planning and monthly bed capacity planning. The annual capacity problem
is investigated using three techniques:
1) as an Integer Programming Model. The objective is to minimize total waiting cost
and total cost,
2) as an M/M/s Queue Model in which the beds are considered as servers, and
3) as a Genetic Algorithm.
Monthly time buckets were defined as Shortest Path Problems (SPP) in which the vertices
meaning have been considered as possible monthly bed capacity decisions for the department
and solved using the Dijkstra Algorithm. The variances between results and observations were
analysed to identify accurate and repeatable methods for the application.


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2. Introduction
To satisfy patients needs and organize departments, hospital managers periodically review
tactical and strategic plans for anticipated bed capacity. The objective is to define requirements
for months and years ahead. In most of the cases, patients arrival times appear to vary
randomly and their length of stay are functions of various internal and external influences and
constraints. Hence, the factors that influence bed capacity planning can be modeled
stochastically. A stochastic variable construction of the health care process increases the model
complexity. Estimating ranges, probabilities and limiting values are required. Underestimating,
planned resourcing slow response times and random events. This in turn makes the
determination of the optimum bed capacity, measured via utilisation for a time period, more
problematic. In order to overcome these difficulties some hospitals keep their bed capacity
sufficiently large to overcome this periodic fluctuations. This approach reduces inbound
registration delays, turning away walk-in patients, and transfers to other health care sites are
kept minimum. Typically, the occupancy level decreases as the bed capacity increases. Keeping
more beds and staff active on a just-in-case basis (uncontrolled bed capacity) incurs extra
hospital costs as a result of constantly available additional service provision that is may be in
emergency situations be required but for normal operations are not required. Management,
funding bodies and society then can perceive that the cost to benefit ratio is unjustified and
prevision should be trimmed to suit reliable and forecastable demand profiles. Hence, hospital
administration perceive it as vital to estimate the optimum bed capacity for any period through
the year.
Literature [1] suggests various methods including ratios, discrete event analysis, queuing
dynamics and stochastic simulation have been to solve the bed planning problem. Ratio-based
methods using average treatment durations have been applied extensively to determine required
bed capacities [2-3]. The average required bed capacity is derived from a function of the length
of stay (LOS) ratio [3]. Long and short term capacity decisions tend to be made based on target
occupancy levels. These two methods tend not to take into account day to day and hour by hour
admissions request fluctuations. This type of variation in part is due to the unpredictable nature
of hospital admission rates and patients length of stays. Stochastic simulation models also have
been used to determine the size of the required bed capacity based on the number of patients in
the hospital [4-5]. A combination of simulation, queuing theory, statistical analysis and
mathematical modeling are used to determine the bed requirements and to predict the
probability that patients needing admission will be turned away or transferred [6-7-8].
Stochastic methodologies that combine queuing network analysis with integer programming
models and discrete event simulation are used to balance bed occupancy rates against reduced
delays, reduced patient blocking and reduced poor bed assignment [9-10]. Network ow

3
models that incorporate facility performance and budget constraints also have been developed
to determine the optimum size of bed capacity [11]. The studies cited to a certain extent are
theoretical and are arduous to apply by hospital management in a real life.
This article proposes a decision analysis method that easily can be used by decision makers
without specific technical modeling knowledge. The proposed approach enables hospital
administration to choose the most appropriate method and remains simple to understand and
apply. The project objective was to enable them to include their knowledge and insight in the
solution process.
This article defines the analysed problem in section 3. Annual bed capacity planning models,
specifically an Integer Programming Model, M/M/s Queue Model and Heuristic Methods are
reviewed in section 4. Monthly time bucket bed capacity planning models based on the
Network Model and Modified Network Model are reviewed in section 5.

3. Problem Definition
This article summarises analysis of a bed capacity planning problem at Ege University Hospital
Oncology Department in zmir Turkey. At the beginning of the study, the department manager
acknowledged the Ege University Hospital Oncology Department needed to increase bed
capacity in order to satisfy their patients needs and to improve the departments service
prevision key performance metrics. The departments manager defined space and budget
limitations (53000 TL) to increase the bed capacity. At the beginning of this study, there were
22 beds in the department, of which 10 were reserved for private practice and the remaining 12
served both state assisted and private health care requirements. The limited floor place limited
the potential department capacity increase to a maximum of 30 beds. It was widely accepted by
administration and medical team representatives alike, that should the enlargement occur, there
were enough doctors to provide sufficient health care attention for the anticipated maximum
capacity. Nurses and auxillliaries would need to be recruited to fully service the increased
capacity. Initially there were 11 nurses and 9 nurse-aids.
Another issue that the department was dealing with was that since most of the patients who
come to this department must be treated urgently, the use of private beds as common beds.
This was attributed to there being insufficient common beds in the original prevision mix.
Initial meetings with the hospital manager lead to defining the problem as determining the
number and the allocation of the beds needed in total in order to decrease the occupancy level
(waiting time per patient) without exceeding the departments budget. The randomness in the
number of patients arriving and their length of stay typically presupposes a stochastic analysis.

4
Such processes make determining the optimum capacity more arduous. The key parameters that
affect the optimum size of the required bed capacity are: occupancy levels, the number of
admissions per day, service level expectations and the incurred staff cost to service the demand.
Some of these parameters are known. Most, however, have to be estimated. This study
combined deterministic, stochastic and heuristic approaches to solve the problem.

4. Annual Bed Capacity Planning Models
4.1. A Generic Mathematical Model for a Hospital Bed Capacity Planning Problem
4.1.1. Decision Variables
The decision variables are defined as
i CPB
i CB
i PB
i CBI
i PBI
i j NA
i j N
i j D
i j NAI
i j NI
i j DI
i
i
i
i
i
ij
ij
ij
ij
ij
ij
department in beds common as used beds private of Number :
department to added beds common of Number :
department to added beds private of Number :
department in beds common of number Initial :
department in beds private of number Initial :
department to added aids - nurse Type :
department to added nurses Type :
department to added doctors Type :
department in aids - nurse type of number Initial :
department in nurses type of number Initial :
department in doctors type of number Initial :


5
i
i
i j
i j
i j
i wcc
i wcp
i cc
i cp
i j cna
i j cn
i j cd
i
i
ij
ij
ij
i
i
i
i
ij
ij
ij
department to added be can beds Maximum :
department in beds common as used beds private of Percentage :
department to needed aids - nurse type of Percentage :
department to needed nurses type of Percentage :
department to needed doctors type of Percentage :
department in beds common for cost Waiting :
department in beds private for cost Waiting :
department in beds common operating of cost The :
department in beds private operating of cost The :
department in aids - nurse type of cost The :
department in nurses type of cost The :
department in doctors type of cost The :


4.1.2. Objective Function
The objective function is



=
= = =
= = = = = =
+ +
+ + + + + +
+ + + + +
n
i
i i i
n
i
n
i
i i i i i i
n
i
i i i i
n
i
m
j
n
i
k
j
n
i
L
j
ij ij ij ij ij ij ij ij ij
CB CBI wcc
PB PBI wcp CB CBI cc CPB PB PBI cp
NA NAI cna N NI cn D DI cd
1
1 1 1
1 1 1 1 1 1
) (
) ( ) ( ) (
) ( ) ( ) ( Minimize

4.1.3. Constraints
The constraints that are used to solve the problem are given as
(4.7) integers are , , , , ,
) 6 . 4 ( 1 ,
) 5 . 4 ( 1
) 4 . 4 ( 1 ) (
) 3 . 4 ( 1 , 1 ) (
) 2 . 4 ( 1 , 1 ) (
) 1 . 4 ( 1 , 1 ) (
1 1 1 1 1 1 1 1
i i i ij ij ij
n
i
m
j
n
i
k
j
n
i
l
j
n
i
i i i
n
i
i i ij ij ij ij ij ij
i i i
i i i i
ij i i ij
ij i i ij
ij i i ij
CB PB CBP NA N D
n i CB cc PB cp NA cna N cn D cd
n i CB PB
n i CBP CBI CB
l j n i NA CB PB
k j n i N CB PB
m j n i D CB PB

= = = = = = = =
= + + + +
= +
= +
= = +
= = +
= = +
K
K
K
K K
K K
K K



6
4.1.4. Explanation of the Constraints
department each for constraint Budget (4.6)
department each to added be can beds of number Maximum (4.5)
department each in bed common as used beds Private (4.4)
t enlargemen the to due department each to needed aids - nurse of number and Type (4.3)
t enlargemen the to due department each to needed nurses of number and Type (4.2)
t enlargemen the to due department each to needed doctors of number and Type (4.1)

4.2. Integer Programming Model
The objective function and constraints stated in section 3 were introduced into the problem.
This outputs required were minimized total waiting cost and total cost of the oncology
department. Since existing staff costs including doctors salaries and the cost of operating beds
already were nanced by the government, the only augmented cost anticipated is limited to the
salaries of the nurses and nursing assistants. As a consequence, reducing the non-occupancy
level became a primary objective.

4.2.1. Decision Variables
The decision variables are defined as
added aids - nurse of Number :
added nurses of Number :
level occupancy the of because bed common a as used beds private of Number :
added beds private of Number :
added beds common of Number :
NA
N
PCB
PB
CB

4.2.2. Objective Function
The objective function is
) 12 2700 ( 16200 ) 10 450 ( 16200
) 10 ( 16200 ) 9 ( 8760 ) 11 ( 10980 Minimize
CB PB
PCB PB NA N
+ + + +
+ + + +

Here, the rst two coefficients are the yearly costs of nurses and nursing assistants respectively.
The third statement is the annual contribution to prot generated by operating private beds. The
fourth is the opportunity cost occured when a potential private patient that had been waiting for
a private bed goes elsewhere due to semi-temporary full capacity situation exists. The
remaining expression is a fairness coefficient that balances the opportunity cost of loosing a
patient that waited for a common bed. This is required because the department does not incur
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treatment costs nor is there a lost profit opportunity from operating common beds. The
coefficient statements in this model were set using the data that is generated empirically at the
Ege University Hospital Oncology Department.
4.2.3. Constraints
The constraints that are used to solve the problem are given as
(4.12) integers are , , ,
) 11 . 4 ( 8
) 10 . 4 ( 8 . 220 )) 12 ( 2700 (
) 9 . 4 ( ) ( 409 . 0
) 8 . 4 ( ) ( 5 . 0
) 7 . 4 ( 53000 ) 10 ( 16200 ) 9 ( 8760 ) 11 ( 10980
NA N PB CB
PB CB
PCB CB
NA PB CB
N PB CB
PCB PB NA N
+
+
+
+
+ + + +

4.2.4. Explanation of the Constraints
added be can beds of number Maximum (4.11)
level occupancy the of because bed common as used beds Private (4.10)
occurs t enlargemen the case in needed aids - Nurse (4.9)
occurs t enlargemen the case in needed Nurses (4.8)
constraint Budget (4.7)

4.2.5. Solution and Interpretation
Most integer problems in practice are solved by searches using Branch-and-Bound techniques.
The approach determines an optimal solution to an integer problem by quantifying enumerating
points within sub-problem variables credible ranges. Applying the branch-and-bound method
requires a lower limit to the optimization problem to be identified and the feasible region must
be divided to obtain smaller graduations that are treated as separate subproblems. There also
must be a way to compute a feasible solution at the other extreme - an upper bound. It would be
a rare event to expect every variable to be the best case or worst case extreme. However, to
generate a viable model these extremes must be considered in order to identify more likely
combinations of scenarios. For practical purposes, it should be possible to compute upper
bounds for a set of non-trivial, yet feasible, variables.
Initially the problem is considered with the complete feasible region, which is called the root
problem. Lower-bounding and upper-bounding procedures are applied to the root problem. If
the bounds match, then an optimal solution has been found and the procedure terminates.
Otherwise, the feasible region is divided into two or more regions, each are equal divisions of
the original. All together they cover the whole feasible region; ideally, these subproblems
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partition the feasible region at a high enough resolution to identify the solution, and with as few
partitions as possible in order to reduce redundant mathematical complexity. The sub-problems
replace the single root of the search node. The algorithm approach is applied repeatedly to the
sub-problems in order to generate a complete set or tree of sub-problems. If an optimal
solution is found to a subproblem, this may be a feasible solution to the problem even though it
may not optimum solution for all the conditions and permutations. Since it is feasible, it can be
used to prune the rest of the tree: if the lower bound for a node exceeds the best known feasible
solution, no globally optimal solution can exist in the subspace of the feasible region
represented by the node. Therefore, the node can be removed from consideration. The search
proceeds until all nodes have been solved or pruned, or until some specified threshold is met
between the best solution found and the lower bounds on all unsolved subproblems. The solved
the problem using the LINGO 11.0 [12] on a standard Windows formatted computer using the
branch-and-bound method. In total 960 iterations were computed and a local optimum solution
has been found.
The analysis suggested Ege University Hospital Oncology Department required 3 common and
5 private extra beds and in addition to these, 4 nurses and 4 nursing assistants should be
recruited or assigned. A minimum additional budget of 51780 TL has been identified to fund
this enlarged service provision. By applying these changes, it was anticipated that the
occupancy level would likely decrease. The trade off anticipated was to be able to treate more
patients without exceeding the departments gross annual budget.

4.3. M/M/s Queue Model
Queuing theory can be used in various areas of real life, for example in parking places, banks,
supermarkets, post offices, traffic lights, toll booths and in data analysis, telecommunication,
and production systems.
In the hospital setting, the group of individuals from which arrivals come is referred to as the
call-in population. Variations occur in this population's size. Total customer demand requiring
service from time to time constitute the size of it. The cluster of customers waiting for
admission and subsequent service is known as the queue. The basic queueing process can be
considered as the following. The size of groups of customers waiting for service varies over
time. The hospital perceives such customers as a call-in population composed of unannounced
immediate requests for urgent service and those that have reserved low urgency diagnoses or
interventions. These customers enter the queuing system and join an admission or treatment
queue.
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A member of the queue is selected for service by some rule known as the queue discipline at
specific times. Queue discipline refers to the order in which customers are selected for the
service. Once selected, customer then transfers from the admissions queuing system to the
service mechanism [13] in order to receive or undergo the initiated service. Queue participants
requests can be assessed in batches or one by one. Batches are groups of requests that have
accumulated over a time interval. Convention usually dictates they are processed on a first-
come-first-served (FCFS) basis. Exceptionally, last-come-first-served (LCFS) when clearly
urgent requirements are identified. Part of the admissions process service policy criteria is to
explicitly state at the admissions stage that such cases shall be prioritized. Further prioritization
criteria can be enforced, such as premium service contracts versus basic provision cover.
Random sequencing can be identified in four respects:
Demand from individual from a given population,
Specific demand from extra-populous traveling or visiting populations,
Unscheduled and random arrival at times. A key variable is the frequency of individual
and group arrivals. Given sufficient data sets these can be modeled as an arrivals
distribution.
Demand for specific health care services that may be clustered into a limited number of
generic families. The number of families may be increased or reduced to facilitate the
modeling procedure, as well as create clear service routes through the health care
process. Increasing the number of clusters may reduce overall capacity in each process
and reduce the systems resources flexibility. The capacity of the system elements
becomes more apparent as more divisions are created. Each cluster then will be limited
to a specific capacity. Overall, the number of beds will be fixed in the short term,
although there can be specialized beds for certain conditions and client requirements,
such as day care, short and long term sequences, isolation wards, critical care and post
intervention recovery.
Most of the random criteria may be assessed retrospectively using marketing and client survey
techniques in order to better generate and validate quantitative demand forecasting models. The
health care service mechanism consists of one or more service facilities called server hubs.
Periods of saturation can be experienced. Hands may be put up to say no more for now, or
we cant take any more at the moment. At this level of activity, the admissions system shall
start diverting non-essential and even urgent cases to other health care centres.
10
The number of random drop-in events can be reduced when ambulance and other organized
patient transport services co-ordinate with central regional demand and capacity management
decision support centres. The patients in such cases can be routed directly from pick up to an
assigned health care centre in the region, such as when demand exceeds bed availability and
day-care capacity are over stretched, or in exceptional circumstances transferred outside the
region to neighbouring regions or further afield, including across national frontiers. A certain
amount of medicare tourism exists for patients that have sufficient funds or insurance to be able
to afford travel, subsistence and treatment abroad. In the United States, some 36 million
inhabitants do not have health care insurance. State aid is available for individuals with servere
medical conditions that also have had their financial resources assessed. Many others attend
day care centres. With little choice, they have to be prepared to wait many hours for dental and
other interventions.
Extreme conditions are identifiable in various locations. The hospital studied had a multi-server
queuing system represented by Figure 1.
By convention queuing models are labeled:
Z m K s B A / / / / / , where
queue in the customers order to used Discipline
stops process arrival the before arrive to allowed customers of Number
system in the allowed customers of number Maximum
services of Number
times service of on Distributi
times al interarriv of on Distributi
Z
m
K
s
B
A

A will be filled with one of M , D, where is Ek?
k
E , GI and B will be filled with M , D,
k
E , G ,
where
allowed) on distributi arbitrary (any on distributi t independen General
allowed) on distributi arbitrary (any on distributi General
times) (constant on distributi Degenerate
) (Markovian on distributi l Exponentia
GI
G
D
M

11

Figure 1. A Multi-server Queuing System Representation
Source? Replace with ppt version

4.3.1. Terminology and Notation
State of system Number of customers in the queueing system, that is, number of customers waiting in
the queue + number of customers that are being served at this time.
Queue length Number of customers waiting in the queue.
) (t N Number of customers in the queueing system at time t , ( 0 t )
) (t pn Probability of exactly n customers in the queueing system at time t , ( 0 t ), given
the number at time 0.
s Number of servers in the queueing system.

Expected number of arrivals per unit time of new customers.

Mean long term arrival rate.
1
Expected inter-arrival time.

Expected number of customers completing the service per unit time.
) ( 1 ALOS =
Expected service time = average length of stay.

The utilization factor for the service facility = s
n p
Probability of exactly n customers in the queuing system.
) (L E
Expected number of customers in the queuing system.
) ( q L E
Expected queue length.
) (W E
Expected waiting time in the queuing system for each individual customer.
) ( q W E
Expected waiting time in the queue for each individual customer.

There are some relationships between ) (L E , ) ( q L E , ) (W E and ) ( q W E such as
) ( ) ( W E L E = , ) ( ) ( q q W E L E = and 1 ) ( ) ( + = q W E W E [14].
4.3.2. Birth-and-Death Process
Births and deaths are significant variable that influence the current size of a population. Special
continuous-time Markov processes can be used to anticipate long-term macro-level population
fluctuations of regions and states. Expatriation, immigration, repatriation and illegal or
unregistered residents are other variables that can be configured. However, to simplify Markov
12
models these typically only focus on population changes of the resident majority, hence the key
variables represented are limited to births and deaths. Birth-and-death processes have many
applications such as macro and regional population demographics, queuing models for local,
regional and national facilities and genetic pool associated biological susceptibilities that can be
measured via reported cases and treatment frequencies.
When a birth occurs, the population changes state, from n to 1 + n . When a death is
registered, the process goes from current state n to state 1 n . The process is specified by
birth rates ) 0 ( , = K i i and death rates ) 1 ( , = K i i .

Figure 2. The Rate Diagram for the Birth-and-Death Process Reference
A fundamental flaw in the birth-and-death process structure is a reliance on an equilibrium
between birth and death rates. This assumes the overall population shall remain constant,
particularly in the short term. There are significant examples of exceptions to this principle: the
government of The United Kingdom of Great Britain and Northern Ireland anticipate a
population increase from just over 60 million to a desired maximum 70 million during the first
half of the 21
st
century. Countries such as Italy have negative population growth. Both Italy
and the UK now have more of retired people than under sixteen years of aging.
The balanced population model models queuing system dynamics on a Rate in = Rate out
basis. This principle imposes that for any state of the system can be expressed by an equation
which is called the balance equation for state n.
, , 2 , 1 , 0 K = n
mean entering rate = mean leaving rate.
Constructing balanced equations for all the states in terms of an unknown population n p , we
can find probabilities for given levels by solving the the equation 1
0
=

= n
n p . Balance equations
are given in Table1.
Table 1. Population Equilibrium Equations

13
State Rate In = Rate Out

0
1
2
M
1 n
n
M
0 0 1 1
p p =
1 1 1 2 2 0 0
) ( p p p + = +
2 2 2 3 3 1 1
) ( p p p + = +
M
1 1 1 2 2
) (

+ = +
n n n n n n n
p p p
n n n n n n n
p p p ) (
1 1 1 1
+ = +
+ +

M

Given
1 1
0 2 1


K
K


=
n n
n n
n K for K , 2 , 1 = n where 1
0
= K and 0 = n
Hence, probabilities to achieve a given steady-state are expressed as:
0
p K p
n n
= for K , 2 , 1 , 0 = n
This requires that
1
0
0

=
|

\
|
=

n
n K p .
Once
n
p is calculated, ) (L E , ) ( q L E , ) (W E and ) ( q W E can be obtained using the
following:

=
=
0
) (
n
n
np L E ,

=
=
s n
n
q p s n L E ) ( ) ( ,

) (
) (
L E
W E = and

) (
) (
q
q
L E
W E = , where

=
=
0 n
n n
p .
These steady-state expressions require both
n
and
n
to have realistic steady-state values.
Results are always valid when 0 =
n
for values of n greater than the initial state. Hence only
a finite number of states are possible. The results also are always valid when and are
14
defined by expression 4.3.1 and 1 < =

s
. The model is unreliable when

=
=
1 n
n
K .
For the multiple-server case ) 1 ( > s , we have
=
n
for K , 2 , 1 , 0 = n

+ =
=
=
K
K
, 1 ,
, , 2 , 1
s s n for s
s n for n
n


The rate diagram for the multiple-server case is given in Figure 3.

Figure 3. Rate Diagram for the Multiple-Server Case
The queuing model proposed as a result of this project is an M/M/s ) 1 ( > s model that is based
on the rate in = rate out principle of the birth-and-death process. The queue model assumes in
the short term a given steady-state condition in which customers are patients and the servers are
beds. Results here are derived when ) 1 ( > s . Hence, when 1 > s , the
n
K factors become
( )
( )

+ =
=
=

K
K
, 1 ,
!
, , 2 , 1
!
s s n for
s s
s n for
n
K
s n
n
n
n



Consequently, if 1 < =

s
, then
( ) ( )


s s n
p
s
n
s n

+
=

=
1
1
! !
1
1
0
0
, where 0 = n
gives the value 1 since 1 != n when 0 = n .
Using these
n
K factors, we have
( )
( )

s n if p
s s
s n if p
n
p
s n
n
n
n
0
0
!
0
!



Expanding this expression provides
15
( )
( )
2
0
1 !
) (

=
s
p
L E
s
q ,
( ) ( )
( )
2
2
0
1 !
1 !
) (

+
=
s
s p
L E
s
,
( )
( )
,
1 !
) (
2
0

=
s
p
W E
s
q
( ) ( )
( )
2
2
0
1 !
1 !
) (

+
=
s
s p
W E
s
.
The bed optimization project proposed an M/M/s algorithm shown in Algorithm 1 below, and
tested with variables from the parameters defined previously. When examinging this type of
system dynamic, analysts may develop and select existing verified algorithms embedded in
optimization software. Variable fields then are filled (see Figure 4) and the solution is posted in
a results box.
Algorithm 1. Pseudo-code of the M/M/s algorithm
Step 1 1.1 Set
current next
Step 2 2.1
while current next current=
Calculate expected queue length for #common bed next= Calculate expected queue length for
#common bed+1 #common bed= #common bed + 1
2.2 Set current next
Step 3 3.1
while current next
current= Calculate expected queue length for #private bed next= Calculate expected queue
length for #private bed+1 #private bed= #private bed + 1
Step 4 4.1
Display #common bed and #private bed

Figure 4 shows the Ege University Hospital Oncology Department needs 8 common beds and
one private bed. Historic data and trends can be analysed to determine expected short term and
long term demand for common and private health care treatment. The mix of preventative,
requested non-essential and urgent survival treatments must be assessed. The registration
process scheduled non-essential private treatment for defined weekly time buckets where
immobilization and monitoring where essential. Demand for non-urgent beds used defined
scheduled. Given annual current demand for this, intuitively only one extra bed was expected to
the solution. Since common beds that also can be used privately for urgent survival monitoring,
interventions and recoveries, the extra common beds shall be equipped on a just-in-case basis to
cope with these differing treatment phases. Demand traditionally had been higher for common
beds, though these did not contribute to margins. Space also was limited in the building. Taking
into account the equipment and patient access space required limited an increase in capacity up
to 8 beds, the best fit between physical and budgetary constraints and the theoretical optimum
16
(8 common and 1 private) the researchers recommended 7 common beds and 1 private bed.

Figure 4. A display window for an M/M/s algorithm
4.4. Genetic Algorithm Overview
Genetic algorithms are a class of non-deterministic algorithms that derive from Darwinian
evolutionary principles [15]. Genetic algorithms have two principal applications: to model
systems such as political systems that evolve overtime [16] and to model provision of goods.
The latter may not be optimal solutions for combinatorial optimization problems [17]. Jones,
Robertson and Willett asserted that for both uses, exploring all possible solutions using a
deterministic algorithm almost would be infeasible within an acceptable time frame [15].
With colleagues and students, John Holland [21] developed genetic algorithms (GAs). Goldberg
[18] categorises aims of their research in two groups: to abstract and rigorously explain the
adaptive processes of natural systems and to design artificial systems software that retains the
important mechanisms of natural systems. He summises these views guided subsequent
important innovations in natural and artificial systems science.
GAs are methaphorically similar to the evolutionary processes since both accept and model the
survival of the fittest concept. GAs have populations that are demographically diversified as a
result of randomly generated combinations of individual elements that have different attributes
17
and variables. In effect, mutations are permitted that build on and create permutations as a
result of selection criteria and inherited trait principles [19]. Box [20] first proposed to develop
solutions to problems using selection and variation. This work did not include the use a
computer. Some the studies conducted in the 1960s, most notably Holland [21] and Rechenberg
[22], were based on evolution principles were analysed using mainframes.
Rechenberg [22] highlighted that selection and mutation are important mechanisms used to
solve difficult numeric optimization problems. By contrast Holland [21] emphasized adaptive
properties of populations and the importance of recombination or crossover mechanisms.
GAs start with a population constituting randomly created solutions. Better fitting solutioning
have a higher probability of being recombined into new solutions via an information transfer to
subsequent generations of solutions. Furthermore, new solutions may occur through mutation
or crossover operators. Some of the fittest solutions of each generation are retained, while
others are replaced by the newly constituted solutions. The process is repeated until goals are
achieved.
In a given population, each individual is formed by a string of binary digits (bits). There are
numerous permutations possible though self selection via mutual compatibility and acceptance
criteria effectively limit a solutions fit within the acceptable limits tolerated by a population.
Binary cases are argued to be the most rudimentary repeating form [18]. In a given biological
lifeform population, each individual can be classified into a single genotype (string of bits) and
has specific or unique genetic material. Forrest [19] asserted the term bit string refers to both
genotype and the individuals that they define and proposed the metaphor that each bit position
represents one gene.

4.4.1. Crossover and Mutation Operators
The crossover proposes enables building blocks to contributions that combine into new strings.
Various crossover methods exist. This study used two different crossover methods: order-based
crossover and position-based crossover. In order-based crossover, three chromosomal elements
are combine: parent 1, parent 2 and temp_crom (temporary chromosomal abnormality/variant).
Parent 1 and parent 2 are selected from the population while temp_crom is created randomly
from binary integers. This method enables parent genes to be copied to direct decendents (child
1 and child 2). The individual trait exhibited from either parent are selected in accordance with
the temp_crom gene selection template. Remaining decendent elements are defined by forcing
gene elements into the mix from the parent deselected by temp_crom.
18
In position-based crossovers, parents genes are copied to children based on temp_crom genes
states 0 and 1 that indicate parent 1 and parent 2. Decendents missing genes are filled using the
order of elements in the childs own. Order-based and position-based crossovers are illustrated
for comparison in Figure 5.

Parent1 : 2 4 6 8 10
Parent2 : 1 3 5 7 9

Temp_crom: 0 1 1 0 0

Child1 : - 4 6 -
Child2 : 1 - - 7 9



Child1 : 1 4 6 3 5
Child2 : 1 2 4 7 9

Order-based crossover

Parent1 : 2 4 6 8 10
Parent2 : 1 3 5 7 9

Temp_crom: 0 1 1 0 0

Child1 : - 3 5 - -
Child2 : - 4 6 - -



Child1 : 2 3 5 8 10
Child2 : 1 4 6 7 9

Position-based crossover
Figure 5. Order-based and Position-based Crossover Procedures
There are also several mutation methods exist. This project used two: scrumble-sublist and two
point mutation methods. Scramble-sublist mutation selects one parent a from the population and
two positions are selected from this parent randomly. After that all elements before and
including the smallest one and also after and including the other elements are copied to
decendent chromosomes in the corresponding positions. Mutations are created when a
decendents missing chromosome elements are filled randomly. Two point mutation selects two
genes from the parent chromosomes. These are reproduced in these positions. Other elements
are copied to decendents chromosomes. Examples of scramble-sublist mutation and two-point
mutation methods are illustrated in Figure 6.

Parent1 : 2 4 6 8 10 12

Chosen points: 2 and 5



Child1 : 2 4 7 9 10 12


Scramble-sublist Mutation

Parent1 : 2 4 6 8 10 12

Chosen points: 2 and 5



Child1 : 2 7 6 8 10 12


Two-point Mutation
19
Figure 6. Scramble-sublist and two point mutations
To ensure the long term viability of sequential of chromosomal element transfers without
creating a form of sterility due to inbreading within a relatively small population, there is a 2%
probability that a mutation may occur. This then creates the possibility of enabling a population
to adapt organically over generations to external influences such as climate and other
environmental factors. In a business context various factors include: financial crisis and credit
crunches, regional and global recession and depressions, war efforts, currency value
fluctuations, political imperatives, customer requirements, supply shortages, demographic
changes, level of general and specialized employee education, use of common language and
other communication difficulties, culture clash, industrial and employee relations, technical
advances in materials used, product and process design, ability to learn and adapt, resistance to
change, entry investments, exist and diversification strategies, actions undertaken by
competitors, and un-anticipated or low probability high impact events.

4.4.2. Parent Selection
The parent selection method assigns a probability that genes shall be propogated to each
individual in a population. This is governed by a proportionality rule that evaluates individuals
fitness. In function of this viability, attractiveness or other comparable performance, the
algorithm assigns a number of opportunities. Several methods for the parent selection are widely
applied. This project used the roulette-wheel method to analyse the bed capacity problem. Davis
[23] proposed the roulette-wheel method works as follows:
1) Sum the fitness of all the individuals in the current population. This is the sum
total_fitness,
2) Generate a random number k between 0 and total_fitness,
3) Select the first fitness value for T such that:

T
i
k i fitness
1
) (
This procedure forces the
th
T chromosome to be a parent.
Although the selection process is random, the chance of selection of a parent is directly
proportional to that individuals fitness. Since selection is random, a population member that
has a poor fitness has a lower probability, though still in with a chance, of being selected as a
parent.
20
The starting conditions for the model used in this study had randomly created a population, with
a range of both feasible and unfeasible solutions. The procedure enabled each individual, that
had a fitness value and a individual code, to be kept in the init_pool. The init_pool already has a
maximum capacity and after this capacity is reached, one of the two operators (mutation or
crossover), is selected randomly. Operators are chosen using a roulette-wheel method. One or
both parents can be replaced by the selected operator. In most cases only one parent is replaced.
Both parents can only be replaced when the crossover operator is used. In this context, a new
generation can only be created using selection and operator methods. While the new generation
is being created, the 2% of the best solution is kept and copied to the next generation base upon
the survival of the fittest principle. This process is iterated until evolutionary process suspension
criteria are activated. Algorithm 2 enumerates a GA pseudo code based on boulean logic and
BBC BASIC language.



Algorithm 2. Pseudo-code of the genetic algorithm
Step 1
1.1. Randomly generate an initial population composed of distinct individuals and combine
them into the init_pool (initial populations pool)

Step 2
2.1. Assign a fitness value to each individual
2.2. Retain and duplicate the best 2% of population to the prod_pool (producing pool) that
subsequently shall form part of the new generation.
2.3. Select operators randomly
IF Mutation operator is selected, THEN choose the mutation type randomly
(Scramble-sublist or two-point mutation)
ELSE Choose crossover type randomly
(Order-based or position-based crossover)
2.4. Choose parent by the roulette-wheel method
IF crossover operator is selected, THEN choose another parent by the same
way
2.5. Apply chosen operator to the chosen parent or parents
IF crossover operator is selected THEN 2 children are produced
ELSE one child is produced
2.6. Take all children into prod_pool
Take also feasible solutions (children) to the feas_pool (feasible solutions pool). Keep
the best feasible solution as a best_of_generation.
Step 3
3.1 IF the prod_pool is full and there is no improvement in the best_of_generation for 30
generations or there is improvement in 3000 generations produced, THEN STOP; ELSE
go to Step 2


21
Figure 7 shows the use of genetic algorithm and results for Ege University Hospitals
Oncology Department; 3 common and 5 private extra beds are recommended plus 4 nurses and
4 nurse-aids. The minimum total extra budget is 51780 TL.

Figure 7. Client needs analysis using a Genetic Algorithm


5. Monthly Bed Capacity Planning Models
5.1. Network Model
Network model structers are defined below. In order to find the optimum solution for the mix
of the beds required, let the edges i to j denote the type of the beds that are used during the
th
k month.
kij
c is the incurred cost of using beds i to j at the
th
k month. The variable
kij
x is
denoted as follows:

=
otherwise , 0
month at the used is to from edge the if , 1
th
kij
k j i
x
22
An optimising mathematical model is formulate as follows:
) 3 . 5 ( 12 , , 2 , 1 , 1
) 2 . 5 ( 12
Subject to
) 1 . 5 ( Minimize
9
1
9
1
12
1
9
1
9
1
12
1
9
1
9
1
K = =
=

= =
= = =
= = =
k x
x
x c
i j
kij
k i j
kij
k i j
kij kij

The objective function ) 1 . 5 ( minimizes costs that occur if the edge from i to j is used at the
th
k month. Constraints ) 2 . 5 ( ensure the network model will be complemented MEANING?
by passing 12 edges. Constraints ) 3 . 5 ( ensure that for each month only 1 edge can be used.
Such mathematical models require significant computation time in order analytically to solve
the model. Figure 8 shows all possible routes from starting point to end point. Due to the fact
that it is nearly impossible to arrive at a single optimum solution, the network model is
modified as a shortest path problems (SPP). The Dijkstra algorithm is viable to solve the
proposed SPP model.

Figure 8. Network flow repsentation

23
5.2. Shortest Path Problems
Shortest path problems (SPP) focus on finding a path between two vertices in order to minimize
the sum of the weights of its constituent edges. Finding the shortest route to get from one
location to another on a road map can be given as an metaphor. In this problem, vertices show
locations and edges show segments of a route. Time needed to travel a specified distance is
used to weight these two variables. There are many types of algorithms available to solve SPPs
including: Dijkstra algorithm, Bellman-Ford algorithm, A* search algorithm, Floyd-Warshall
algorithm, Johnson's algorithm and Perturbation theory. This study used the Dijkstra algorithm
to solve the SPP.

5.2.1. The Dijkstra Algorithm
Dijkstras algorithm takes its name from the Dutch computer scientist Edsger Dijkstra. In his
1959 paper, he explained a graph search algorithm that solves the single-source shortest path
problem using only positive edge path costs. The result is a shortest path tree.
The model assumes that a weighted, connected simple graph is viable and all weights are
positive. This graph, called G, has vertices K , , ,
2 1 0
v v v where 0
0
= v for the starting
vertex and n v
n
= is the terminating vertex for the path. Weights are stored in a 2-dimensional
array where [ ] =
j i
v v w , EQUALS WHAT? an integer when there is an edge between
i
v and
j
v , else infinity . The proposed Dijkstra Algorithm's pseudo code is given in Algorithm 3.
During processing, an array [ ] n L K 1 records path lengths, called vertex labels. This array is set
to infinity for all entries except the starting vertex that initially is set to 0. Set S contains all
vertices processed so far. According to Dijkstras algorithm, when the terminating vertex
equates to S n , the main loop ends and the length of the shortest path becomes equal to value
[ ] n L . To find the shortest path from vertex 1 to vertex n requires analysis backward from
vertex n
.
The aim is to find vertex labels differing by exactly the length of the connecting
value in the weighted matrix.

24
Algorithm 3. Pseudo-code of the Dijkstra algorithm
Step 1
1.1
for i = 1 to n

L[vi] =

L[0] = 0
S =



Step 2
2.1 while n S u=vertex not
in S with L value minimal S = S {u}
2.2 for all vertices v S do if L[u]
+ w[u,v] < L[v] then L[v] = L[u] +
w[u,v]
Step 3 3.1
while n 1
for i=1 to n
if L[n]- L[n-i] = w[n,n-i] then record n-I
n = n-i

5.3. Changing Bed Classification using a Modified Network Model
Let
kij
c

and
kij
x be defined as 5.1, then the mathematical model can be given as follows:
) 3 . 6 ( 12 , , 2 , 1 , 1
) 2 . 6 ( 12
Subject to
) 1 . 6 ( Minimize
8
2
1
1
9
9
1 1
1
1
12
1
9
1
9
1
12
1
9
1
9
1
K = = + +
=

=
+
= =

= =
+
=
= = =
= = =
k x x x
x
x c
i
i
i j i
i
i j
kij kij
i
i
i j
kij
k i j
kij
k i j
kij kij

In this problem, we have derived a cost function that represents the cost of changing type of the
total 8 beds. The cost function is as follows:

= = =
+ + + + +
12
1
12
1
12
1
) 12 12 ( 1350 ) 10 10 ( 1350 10 ( 1350
m
m
m m
m
cb WC pb WP pcb pb ,
MISSING ) IN FIRST EXPRESSION where pb and cb represent an initial
number of private and common beds respectively. New variables waiting
cost for a common bed WC, waiting costs a for private bed WP and average
stay for patients APS are required to define marginal costs incurred when
beds are reallocated. Values of WC, WP and APS are given in Table 2.

25
Table 2. Waiting cost for a common bed and private bed (WP) with average
length of stay per patient (APS) data

Months WC WP APS
1 19.115 13.793 1.56
2 16.59 13.793 1.8
3 15.165 2.297 2.13
4 17.593 3.448 1.8
5 16.282 1.148 2.2
6 25.131 1.253 1.53
7 26.653 1.148 1.5
8 19.546 1.060 1.93
9 16.282 2.297 2
10 17.241 1.253 2.06
11 16.282 1.493 2.1
12 19.115 1.919 1.76

Figure 9 provides an example of a network representation for the shortest path problem. This
model has 110 nodes that including a source and a terminal node. Arcs connect the nodes.
These represent the reclassification of the type of the bed. Algorithm 3 is proposed in a user
interface shown in Figure 10. The user must enter the number of total nodes in the data box,
shown in the top of the left corner, and click the OK button. An empty matrix appears. This
matrix is filled by the user. After the matrix is filled, the user should click the OK button that
to set the Show Route box. The shortest route is shown in this window. The shortest route
result appears in the Additional Needed Beds Per Month data field.
Figure

26
9. A network flow repsentation for a shortest path problem
5.3.1 Interpretation of the result
Figure 10 shows the shortest path from the starting to end points for this Dijkstra algorithm
problem as:
109 105 97 88 79 69 59 50 42 34 26 18 8 0
This path represents reallocations of bed type required for each month.
The numbers of needed additional private and common beds are given in Table 3.
Since the demand of the private beds is larger than the common beds during the first month of
the year; Table 3 shows that Ege University Hospital Oncology Department needs an
additional 7 private beds and a common bed. Some beds must be reclassificed during the
summer, for example in June they require 4 additional private beds and 4 common beds. The
result for June shows that demand for additional common and private beds can be similar.

27
Figure 10. A display of the Dijkstra algorithm

Table 3. Additional type of beds per month
Table 3. Optimum bed types calculated in monthly time buckets

6. Conclusion and Further Work
This study identified annual demand and monthly bed classifications for Ege University
Hospital Oncology Department. An integer programming model, a M/M/s queue model and a
genetic algorithm approaches were used to solve annual bed capacity requirements. A network
model and a modified network model were used to solve monthly bed allocations.
For the annual bed capacity problem, results are found from the integer programming model
differed from results that are obtained from the M/M/s queue model. These inaccuracies
principally stem from the M/M/s queue model since the budget, costs of additional nurses and
nurse-aids were not taken into account. The M/M/s queue model does not consider constraints
and objective functions. Data used by the model are limited to expected number of patients, and
waiting times for private or common beds. When budget limits and the costs of the employees
are not known or estimated, the proposed M/M/s queue model can be used effectively. Given
the information available, the genetic algorithm approach yielded the same results as those
obtained using integer programming. These results show the robustness and effectiveness of the
proposed genetic algorithm since the results obtained from the integer programming model are
short time bucket optimums found by applying the branch-and-bound method. For more
Months The number of needed
additional private bed
The number of needed
additional common bed
1 7 1
2 8 0
3 7 1
4 6 2
5 5 3
6 4 4
7 4 4
8 5 3
9 6 2
10 6 2
11 6 2
12 5 3
28
complex problems, when branch-and-bound methods are unable to cope, can be solved within
an acceptable computation time by the proposed genetic algorithm.
For the monthly bed capacity planning problem, results obtained from the modified network
model enable the client to use the additional beds more efficiently by defining the optimum
combination of bed types for each month. Weekly time buckets may also be used in response to
demand.
All of these results demonstrate that the client can increase bed capacity and avoid exceeding
their budget. This leads to an increase in the service quality and a decrease in expected waiting
time of the patients; both are vital since patients that come to this department typically have to
be treated urgently. Comparison between analysis techniques illustrate the contribution to
understanding made by each method. This enables analysts to propose an appropriate solution.
Research into different kinds of bed capacity planning problems is still in its infancy. This
research project contributes to the debate by focusing on identifying the value and accuracy of
various analytical techniques. Further work should be undertaken with other departments and
hospitals in order to validate the proposed algorithms.

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