An intelligent real-time scheduler for out-patient clinics: A multi-agent system model.

Scheduling of resources and patients are crucial in outpatient clinics, particularly when the patient demand is high and patient arrivals are random. Generally, outpatient clinic systems are push systems where scheduling is based on average demand prediction and is considered for long term (monthly or bimonthly). Often, planning and actual scenario vary due to uncertainty and variability in demand and this mismatch results in prolonged waiting times and under-utilization of resources. In this article, we model an outpatient clinics as a multi-agent system and propose an intelligent real-time scheduler that schedules patients and resources based on the actual status of departments. Two algorithms are implemented: one for resource scheduling that is based on predictive demand and the other is patient scheduling which performs path optimization depending on the actual status of departments. In order to match resources with stochastic demand, a coordination mechanism is developed that reschedules the resources in the outpatient clinics in real time through auction-bidding procedures. First, a simulation study of intelligent real-time scheduler is carried out followed by implementation of the same in an outpatient clinic of Aravind Eye Hospital, Madurai, India. This hospital has huge patient demand and the patient arrivals are random. The results show that the intelligent real-time scheduler improved the performance measures like waiting time, cycle time, and utilization significantly compared to scheduling of resources and patients in isolation. By scheduling resources and patients, based on system status and demand, the outpatient clinic system becomes a pull system. This scheduler transforms outpatient clinics from open loop system to closed-loop system.

Integral patient scheduling in outpatient clinics under demand uncertainty to minimize patient waiting times.

This study addressed the problem of scheduling walk-in patients in real time. Outpatient clinics encounter uncertainty in patient demand. In addition, the disparate departments are locally (department-centric) organized, leading to prolonged waiting times for patients. The proposed integral patient scheduling model incorporates the status and information of all departments in the outpatient clinic along with all possible pathways to direct patients, on their arrival, to the optimal path. The developed hybrid ant agent algorithm identifies the optimal path to reduce the patient waiting time and cycle time (time from registration to exit). An outpatient clinic in Aravind Eye Hospital, Madurai, has a huge volume of walk-in patients and was selected for this study. The simulation study was performed for diverse scenarios followed by implementation study. The results indicate that integral patient scheduling reduced waiting time significantly. The path optimization in real time makes scheduling effective and efficient as it captures the changes in the outpatient clinic instantly.

[Health care claims per medical specialty in the Netherlands: a 10-year overview]. / Schadeclaims per medisch specialisme.

OBJECTIVE: To analyse the quantity and size of health care claims per medical specialty in the past 10 years. DESIGN: Descriptive, evaluative and comparative study. METHOD: Anonymised damage claim data from Centramed and MediRisk were used for this study. The numbers and sizes of the claims per specialty have been analysed over a ten-year period and plotted against production numbers of the various specialties, calculated on the basis of DBC data. All damage claims were related to regular hospital care in the Netherlands and were submitted or closed in the period from 1 January 2007 to 31 December 2016. RESULTS: A total of 15,115 claims were submitted during the period under study. 16.2% of these were related to non-surgical specialties, 64.7% to surgical specialties, 10.8% to supporting specialties, 0.7% to paramedics working at the hospital and the specialty was impossible to find out for 7.6% of them. The total cost of all damage claims closed during the study period was € 229,224,433. Of the total damage burden, 19% was paid out to patients with claims against non-surgical specialties and 63% to patients with claims against surgical specialties. General surgery, orthopaedics and gynaecology together were responsible for 47% of all submitted claims for damages and for 52% of the damage burden. CONCLUSION: General surgery, orthopaedics and gynaecology invariably are, just as in previous studies, the specialties with the highest number of damage claims and the largest damage burden. Even when corrected for production volumes, these specialties comparatively have the most and most expensive damage claims.

[Implementation of innovations in healthcare: radiotherapy as an example]. / Implementatie van innovaties in de zorg.

The implementation of innovations is considered necessary in healthcare, both for improving patient outcomes and services and to reduce costs. Two problems can occur during the implementation process: innovations that have not been properly evaluated in terms of patient outcomes or cost-effectiveness can sometimes spread quickly, whereas innovations that have shown to lead to significant improvements in a research study setting may struggle to find their way into clinical practice. Problems may also arise when organizational innovations are implemented that are not evidence-based: an example would be the implementation of a new ICT system that affects the patient's environment negatively upon introduction. In this article, the problems surrounding innovation implementation in medical care are described in general and in more concrete terms, we describe how Dutch radiotherapy centres perform in this area. Based on the findings, a systematic plan is described that can help to innovate more effectively and efficiently to the benefit of clinical practice in all disciplines.

[More and higher claims for damages: analysis of claims for damages in Dutch hospital care 2007-2016]. / Meer en hogere schadeclaims.

OBJECTIVE: To investigate the number and extent of claims concerning hospital care at a national level, thereby affording insight to the profession. DESIGN: A quantitative, descriptive and comparative study. METHOD: We used anonymised data on all claims for damages from regular hospital care that were submitted to Centramed and MediRisk between 1 January 2007 and 31 December 2016. Between them, these two companies are the insurers of 95% of all Dutch hospitals. Using SPSS and Mathematica, we analysed the number of claims submitted, the average duration of the procedures, the manner in which they were settled, developments in the total cost of claims, and the settlements paid out to claimants. RESULTS: A total of 15,115 claims were made between 2007 and 2016. Up to 2013, the number of claims increased annually, thereafter this stabilised. In 2016, 4.5% more claims were submitted than in 2007. During the same period, 15,306 claims were closed. The total claim-related cost was € 229,191,033 and showed a clearly rising trend throughout this period. In 2016 the cost of claims was four-and-a-half times as high as in 2007. CONCLUSION: The number of claims being made is rising, but not as quickly as the cost of claims which increased fivefold during the period under investigation. Compared with previous investigations, both the number and the extent of the claims increased significantly between 2007 and 2016.

[Sustainable process improvement with application of 'lean philosophy']. / Duurzame procesverbetering met de 'lean'-filosofie.

Process improvement is increasingly being implemented, particularly with the aid of 'lean philosophy'. This management philosophy aims to improve quality by reducing 'wastage'. Local improvements can produce negative effects elsewhere due to interdependence of processes. An 'integrated system approach' is required to prevent this. Some hospitals claim that this has been successful. Research into process improvement with the application of lean philosophy has reported many positive effects, defined as improved safety, quality and efficiency. Due to methodological shortcomings and lack of rigorous evaluations it is, however, not yet possible to determine the impact of this approach. It is, however, obvious that the investigated applications are fragmentary, with a dominant focus on the instrumental aspect of the philosophy and a lack of integration in a total system, and with insufficient attention to human aspects. Process improvement is required to achieve better and more goal-oriented healthcare. To achieve this, hospitals must develop integrated system approaches that combine methods for process design with continuous improvement of processes and with personnel management. It is crucial that doctors take the initiative to guide and improve processes in an integral manner.

A planning tool for multidisciplinary youth care evaluated: a case study.

OBJECTIVES: This study aims to gain more insight in whether care programming in health care can be supported by IT and what is needed for successful implementation. We evaluated a case where an organization structured its care processes into care programs and used a planning tool for planning and control of the care programs. The results of this evaluation contribute to existing knowledge about the relation between care processes and IT as well as IT implementation. METHOD: We used multiple data sources to support and complete the results. The evaluation of the case took place by means of face-to-face interviews, a document study and analyses of emails. RESULTS AND DISCUSSION: The care programs and the planning tool were not compatible and did not achieve the intended goals. The professionals failed to appreciate flexibility of the care programs. The implementation of the planning tool failed because of too little user involvement in the implementation. Moreover, care programs were in general not accepted by the professionals. All this resulted in a non-fit between the care programs and the planning tool. We advise for routine processes as care programs to develop a balance between flexibility and standardization. This is a process of trial and error and requires adaptive information technology and user involvement in development and implementation.

Healthcare system design and parttime working doctors.

More doctors would like to work parttime. Since research on fitting healthcare system design with the structure of parttime jobs is lacking, we studied how parttime work for medical doctors could be enabled from a system design perspective. A theoretical analysis was performed, illustrated by two case studies. We conclude that introducing parttime work can provide the opportunity for improving system design and, therewith, performance. From the case studies it seems that work redesign can enable parttime work, and at the same time improve system performance. Better managing variability in the system contributed to this. The case studies results also showed that systems characterized by different levels of variability fit with different work contracts.

A disease management programme for patients with diabetes mellitus is associated with improved quality of care within existing budgets.

AIM: To assess the impact of a disease management programme for patients with diabetes mellitus (Type 1 and Type 2) on cost-effectiveness, quality of life and patient self-management. By organizing care in accordance with the principles of disease management, it is aimed to increase quality of care within existing budgets. METHODS: Single-group, pre-post design with 2-year follow-up in 473 patients. RESULTS: Substantial significant improvements in glycaemic control, health-related quality of life (HRQL) and patient self-management were found. No significant changes were detected in total costs of care. The probability that the disease management programme is cost-effective compared with usual care amounts to 74%, expressed in an average saving of 117 per additional life year at 5% improved HRQL. CONCLUSION: Introduction of a disease management programme for patients with diabetes is associated with improved intermediate outcomes within existing budgets. Further research should focus on long-term cost-effectiveness, including diabetic complications and mortality, in a controlled setting or by using decision-analytic modelling techniques.

The Health Technology Assessment-disease management instrument reliably measured methodologic quality of health technology assessments of disease management.

OBJECTIVE: Systematic reviews aim to summarize the evidence in a particular topic area, giving attention to the identified methodologic quality of published research. Because research in a specific area may be susceptible to specific biases, it is assumed that the methodologic quality of Health Technology Assessment (HTA) of disease management cannot properly be measured with the existing methodologic quality assessment instruments. The purpose of this study was to describe to what extent existing instruments are useful in assessing the methodologic quality of HTA of disease management. STUDY DESIGN AND SETTING: An inventory was made of the problems that arise when assessing the methodologic quality of six HTAs of disease management with three different instruments. Based on these findings, a new instrument is proposed and validated. RESULTS: Problems mainly concern the items related to the study design, criteria for selection and restriction of patients, baseline and outcome measures, blinding of patients and providers, and the description of (co)-interventions. CONCLUSION: With its more specific characteristics, the HTA-DM addresses the problems mentioned. The HTA-DM is a reliable instrument for methodologic quality assessment of HTA of disease management in comparison with the other three instruments.

Participation of general practitioners in disease management: experiences from The Netherlands.

OBJECTIVE: To investigate the extent to which GPs in The Netherlands participate in disease management and how personal opinions, impeding and promoting incentives as well as physician characteristics influence their attitude towards disease management. METHODS: The attitude-model of Fishbein and Ajzen was used to describe the attitude of GPs towards disease management and main influencing factors. After interviewing seventeen representatives of the GPs and testing a questionnaire, the final questionnaire was sent to all GPs in The Netherlands (7680 GPs) barring those involved in the testing of the questionnaire. RESULTS: At least 10.4% of all Dutch GPs are active in disease management. The main factors predicting a positive attitude towards disease management are the following: GPs' opinion that they are improving quality and efficiency of care when executing disease management, presence of a good quality network between actors involved prior to the start of disease management, working in a health centre, and performing sideline activities besides their daily activities as GPs. The main factors predicting a negative attitude are: GPs' opinion that the investment-time is too high, lack of reimbursement for disease management activities, working in a solo practice, and not performing any sideline activities beside their daily activities as GP. CONCLUSIONS: The factors predicting a negative attitude of Dutch GPs towards disease management dominate the factors predicting a positive attitude. The arguments in favour of disease management are matters of belief, for example concerning improvements in the quality of care, while arguments against are more concrete barriers e.g. high workload and financial reimbursement. Placed on the innovation timeline, the 10.4% participation might be taken to represent the start of a trend.

Simulation as decision tool for capacity planning.

In this paper we demonstrate how discrete event simulation technique can be used to optimise the use of catheterization capacity. The patient flow at the catheterization room is described. A simulation model of the current situation was built in MedModel, a discrete event simulation package, and the model was validated. A short presentation of MedModel is given. To investigate alternative ways to optimise the use of the catheterization room three experiments were formulated, modelled and simulated. Two different scheduling strategies were applied to the current situation and the three experimental situations. The number of patients that can be treated and the duration of a working day were determined as measures of performance. The results of the simulation experiments are discussed. The results of these experiments give the management of the catheterization room valuable information how to optimise the use of the catheterization room.

Retinopathy and microalbuminuria in type 2 diabetes: determinants and time-dependency of the association.

Background: The aim of this study was to identify the independent determinants of diabetic retinopathy (RET) and microalbuminuria (MA) and to assess the time-dependency of the association of RET with MA. Methods: In 668 out-patients with type 2 diabetes, RET was assessed by stereoscopic fundoscopy and by measuring the level of MA in untimed, triplicate urine collections on at least two and four separate visits, respectively, during a period of at least 24 months. RET was defined as RET of any type and MA as a urinary albumin-to-creatinine ratio (ACR) between 2 and 30 mg/mmol. Multiple logistic regression analysis was used to determine odds ratios (OR) and 95% confidence intervals (CI). The extent of the association (OR(assoc)) was estimated by the odds that a patient with RET has MA divided by the odds that a patient without RET has MA. Results: Common determinants of RET and MA were: systolic BP, HbA(1c), and triglycerides. Age, non-Caucasian ethnicity, and RET were associated with MA, whereas duration of diabetes and ACR were associated with RET. We estimated an overall OR(assoc) of 2.36 (95% CI, 1.72-3.24). The time-dependency of OR(assoc) showed a hyperbolically shaped curve, reaching a maximum value of 2.5 at 9.8 years after the diagnosis of type 2 diabetes. Conclusions: Our study, which supports what is currently known about independent determinants of diabetic RET and MA, suggests a drastic increase in clustering of RET and MA over the first 5 years before the diagnosis of type 2 diabetes.

Discrete event simulation in the health policy and management program.

Students in Health Policy and Management at the Faculty of Health Sciences of Maastricht University must learn to analyze and design workflow processes in health care. To attain this, a discrete event simulation training, using MedModel is used. This paper describes the training in two consecutive years. In both years the training was evaluated systematically. The evaluation results demonstrate that the simulation training increased the students' knowledge about analyzing and designing workflow processes in healthcare. Students considered the training as a very important part of their program.

Impact of insurance coverage type on laboratory test ordering behaviour of general practitioners.

BACKGROUND: There exists much variation between GP's in the use of laboratory tests. Although the requesting pattern of GPs has been extensively described in the literature, little is still known of the factors which influence the GP's test ordering behaviour. AIM: This study aimed to determine whether the payment scheme according to which general practitioners are reimbursed influences the laboratory test ordering behaviour. METHOD: The laboratory test ordering behaviour of the general practitioners of Tilburg, a town with 180,000 citizens in the south of The Netherlands, was studied during a four month period, in relation to the type of insurance coverage of the patients. Two types of insurance were considered: voluntary and compulsory. The data were collected from the laboratory administration and coupled with information obtained from two, interview rounds. RESULTS: Two findings support the hypothesis that the type of insurance coverage of the patient, has an impact on the test ordering behaviour of the physician: The ratio between laboratory requests for sickness fund patients and patients with a private health insurance was found to depend on the fraction of persons with a private health insurance within the family practice. This was tested with multiple linear regression analysis. General practices were divided into two subgroups, those with many > 29%) and few (< 29%), voluntarily insured patients. Where a patient was privately insured it was found that relatively more tests were ordered. In case of general practices with many voluntarily insured patients this distinction disappears. The relative proportion of voluntarily insured patients was found to be an important variable in explaining the test ordering behaviour of general practice physicians in Tilburg.

Advanced management facilities for clinical laboratories.

As part of the OpenLabs (AIM 2028) programme a decision support system (DSS) for laboratory capacity management has been developed. This DSS contains a simulation module for determining the performance of planning rules given the equipment and staffing of the clinical laboratory and the demand for laboratory services. User requirements are discussed and a method is developed to (re-)define rules concerning various planning decisions. To show the functionality of the simulation module some simulation experiments are described.

Decision support for clinical laboratory capacity planning.

The design of a decision support system for capacity planning in clinical laboratories is discussed. The DSS supports decisions concerning the following questions: how should the laboratory be divided into job shops (departments/sections), how should staff be assigned to workstations and how should samples be assigned to workstations for testing. The decision support system contains modules for supporting decisions at the overall laboratory level (concerning the division of the laboratory into job shops) and for supporting decisions at the job shop level (assignment of staff to workstations and sample scheduling). Experiments with these modules are described showing both the functionality and the validity.