Sequential and Simultaneous Decision Making for Optimizing Health Care Resource Flexibilities

Abstract

Health care administrators commonly employ two types of resource flexibilities (demand upgrades and staffing flexibility) to efficiently coordinate two critical internal resources, nursing staff and beds, and an external resource (contract nurses) to satisfy stochastic patient demand. Under demand upgrades, when beds are unavailable for patients in a less acute unit, patients are upgraded to a more acute unit if space is available in that unit. Under staffing flexibility, nurses cross-trained to work in more than one unit are used in addition to dedicated and contract nurses. Resource decisions (beds and staffing) can be made at a single point in time (simultaneous decision making) or at different points in time (sequential decision making). In this article, we address the following questions: for each flexibility configuration, under sequential and simultaneous decision making, what is the optimal resource level required to meet stochastic demand at minimum cost? Is one type of flexibility (e.g., demand upgrades) better than the other type of flexibility (e.g., staffing flexibility)? We use two-stage stochastic programming to find optimal resource levels for two nonhomogeneous hospital units that face stochastic demand following a continuous, general distribution. We conduct a full-factorial numerical experiment and find that the benefit of using staffing flexibility on average is greater than the benefit of using demand upgrades. However, the two types of flexibilities have a positive interaction effect and they complement each other. The type of flexibility and decision timing has an independent effect on system performance (capacity and staffing costs). The benefits of cross-training can be largely realized even if beds and staffing levels have been determined prior to the establishment of a cross-training initiative.

Integrated decision making in healthcare : an operations research and management science perspective

“…Also, [318] indicates that to maintain the desired staff capacity, it is necessary to determine the long-term human resource planning strategies with respect to recruiting, promotion and training. To conclude, integrating the staff capacity dimensioning decision with the care unit size decision yields a significant efficiency gain [202].…”

“…Models that consider only a single unit neglect the possibility of admitting patients in a less appropriate care unit and thus the interaction between patient flows and the interrelationship between care units. Next to estimating utilization and the probability of admission rejections or delays, models that do incorporate multiple care units, also focus on the percentage of time that patients are placed in a care unit of a lower level or less appropriate care unit, or in a higher level care unit [11,108,202,217,327,439]. The first situation negatively impacts quality of care as it can lead to increased morbidity and mortality [478] and the second negatively impacts both quality of care, as it may block admission of another patient, and efficient resource use [217,439].…”

“…For inpatient care services it mainly concerns nursing staff. To deliver high-quality care, the workforce capacity needs to be such that an appropriate level of staff can be provided in the different care units in the hospital [166,202]. In addition, holiday periods, training, illness and further education need to be addressed [74].…”

“…Workforce flexibility is indicated as a powerful concept in reducing the required size of workforce [74,127,202,451]. To adequately respond to patient demand variability and seasonal influences, it pays off to have substitution possibilities of different employee types, to use overtime, and to use parttime employees and temporary agency employees [451].…”

“…Just as with pooling bed capacity, economies-of-scale can be gained when pooling nursing staff among multiple care units. Nurses cross-trained to work in more than one unit can be placed in a so called floating nurse pool [74,202,309,451]. Note that flexible staff can be significantly more expensive [222].…”