Computer Simulation of Hospital Patient

Scheduling Systems

by Gordon H. Robinson, Paul Wing, and Louis E. Davis

A method of analyzing alternative systems of scheduling hospital
adxmissions by means of a computer simulation is described. The
simuzlation is divided into three programs, dealing sequentially
with requests for admission, scheduling, and evaluation of costs
of three basic scheduling systems and using the output of each
phase of the simulation as input to the following phase. The
feasibility of using the scheduling program in a real-time automated patient-scheduling system is discussed, with indications of
adaptations required and additional functions that could be
handled by the system.
By far the largest financial investment in a hospital, both in personnel and
in physical plant, is directly related to the number of patients being serviced.
Of critical importance to the possible economic value of a sophisticated
hospital scheduling system is the fact (common among "emergency" organizations) that this plant and staff size are more a function of peak than of
average utilization, thus a reduction in the variation of the census would allow
either an increase in the average census or a decrease in the plant and staff.
This report discusses a computer simulation currently being used to analyze
scheduling systems for elective patients. The intent is to provide. insight into
the general framework and usefulness of this simulation technique, as well as
information useful in attacking a specific scheduling problem.

Hospital Scheduling
Hospital patients are usually classified as elective or emergency; emergency
patients, however, simply represent a limiting case of electives with no scheduling flexibility. Elective patients usually enter the scheduling system as the
result of a telephone call from the diagnosing physician to the hospital
admissions office. At this point the potential patient has four attributes of
importance to scheduling: (1) desired admission day; (2) flexibility in possible admission days; (3) potential length of stay in the hospital; and (4)
hospital service demands (medical or surgical patient, room type, operating
room needs, special care or service needs). Information on items (1), (2),
and (3) must be available if a scheduling system is to function; and schedSupported by U.S. Public Health Service Grant No. HM-00224, Division of Hospital
and Medical Facilities. This research was performed while the authors were with the Industrial Engineering Department, University of California, Berkeley.

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uling cannot be effected if item (2) does not exist, as is essentially the case
for the emergency patient. Demands under item (4) appear to add little to
the conceptual complexity of scheduling models, although they could detract
seriously from their effectiveness.
No information is available to the hospital on a potential patient prior to
the physician's request for admission. Before this point the hospital scheduling
system can obtain and use general predictive information describing such
phenomena as growth trends, seasonal fluctuations, and weekend differences.
These data can be used to perform appropriate parameter adjustments on the
various scheduling models. Our concern here is with the scheduling of individual patients.
OnIe important reason why quantitative scheduling methods are not employed in hospitals is a lack of data on the patient attributes defined above.
This lack applies both to the potential patient requesting admission and,
perhaps surprisingly, to the patient who is actually in the hospital. Prior to his
actual admission the patient must be described by all four attributes identified
above. The description of items under (4), service demands, is relatively
straightforward. Information on desired admission day is generated by the
physician in accordance with his and his patient's needs. Information on
possible flexibility of this day, however, is generated only implicitly by
negotiations between the admissions office and the physician. No normative
medical information is available indicating the explicit costs of deferring
hospital admission for specific patient disease states. A number of other factors
such as pain, discomfort, and inconvenience enter this determination, and a
quantitative consideration of these would appear to be beyond any presently
envisaged system. The quantification of this variable will therefore probably
remain a dual effort of the physician and the admissions office. It is perhaps
not unreasonable to assume, however, that this "game" will be played fairly
and well by both parties if it is clear to both that effective scheduling will
benefit the total hospital-medical system; that is, the game is not zero sum.
The simulation models discussed here use a highly simplified scheme for
representing the desired admission day and its flexibility. It is believed that
this scheme represents the quantitative nature of the results of the physicianadmissions office negotiation and, furthermore, may present a framework within
which the physician and the admissions office can carry out this negotiation.
Substantial progress has been made in uncovering ways to produce data on
item (3), the patient's estimated length of hospital stay. It is immediately
evident that whatever the status of all other information or whatever the
scheduling policy devised, information must be available on patient length of
stay, and it must be available at the time of scheduling. Recent studies [1-3]
have shown the feasibility of using the admitting physician as an estimator,
either directly or indirectly; his estimate is apparently at least as good as that
available from statistical techniques using diagnostic data, and the data
production cost is substantially less.
Descriptive data on the statistical nature of admission requests, time

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et

al.

between request and actual admission, and length of stay were gathered at
two general hospitals in California: Alta Bates Community Hospital, Berkeley
(152 beds), and Mount Zion Hospital and Medical Center, San Francisco

(372 beds) [4].

Basic Assumptions

Several simplifying assumptions were made in order to develop an operational simulation. These arose primarily as the result of incomplete data on
certain aspects of the hospitals or as programming expedients that were
judged not to have a large effect on the simulation results. They were:
1. Patients: Only elective patients are processed by the scheduler. Emergency
patients (including maternity) are admitted according to hospital policy
outside the present scheduling considerations. One reasonable policy is
simply to reserve a fixed block of beds for emergency admissions, the size
of the block being a function of the emergency history and the hospital's
policies toward emergencies.
2. Beds: The hospital has a fixed number of identical beds, available to any
patient regardless of his description. Problems of adjusting capacity to
meet varying demand and shifting patients from one bed to another are
therefore ignored. This assumption can be relaxed by classifying the beds
according to accommodation type (private, semiprivate, ward) and tagging
patients with desired accommodations and personal characteristics (sex,
medical isolation needs, and the like).
3. Hospital operations:
a. The number of available, or potentially available, beds is the only
scheduling criterion. This assumption can be interpreted as implying
either that all other facilities are adequate or that consideration of them
is incorporated in the patient demand description. (For example,
restrictions on the availability of the operating room could be handled
by modifying the patient's desired admission day and its flexibility).
b. Patients actually enter the hospital once they have been scheduled. No
data were available on the number of "no shows" in the hospital system.
If this number is significant, an additional routine can be added to
withdraw scheduled patients.
c. Discharge of any specific patient is certain on the morning of his actual
discharge. This is close to observed practice, in which the discharge
decision is usually made at the attending physician's morning visit, and
the patient actually leaves the hospital before a new patient arrives.
d. Requests for admission are processed after the day's discharges have
taken place and the state of the hospital has been subsequently updated.
e. Priorities arising from social or professional status are not considered.
This kind of priority can be considered as embedded in the dimensions
of desired admission day and scheduling flexibility.

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f. Admission requests arise from a stationary source; that is, no periodic

or aperiodic changes are made in the characteristics of the admissionrequest generator. Consideration of this class of variation is a relatively
straightforward addition to any scheduling policy and does not warrant
study until basic scheduling models are investigated.
g. No changes in admission-request descriptions or scheduling policies are
permitted during a single run.
Assumptions 3a and 3g are basic to the simulation model and could be relaxed
only by fairly extensive modification. All the others could be relaxed relatively simply, depending, of course, on the precise policy desired.
The Simulation
The simulation is run in three phases [5]. The first phase, Request Generator, produces a set of patients and their attributes for use as input to the
second phase, the Scheduler program. The third phase, the Evaluator, uses
the output from several runs of the Scheduler plus cost data to determine the
optimal operating point of the hospital for a particular scheduling rule. The
first two phases have been coded in Simscript language [6] and the third in
Fortran 4. Simscript was chosen for the first two phases primarily because of
its timing and its Random Table Look-up feature, which, at least in the initial
stages of development of the model, made up for slower compilation and
execution times. The faster Fortran 4 was selected for the relatively straight-

forward third phase.

The Request Generator Program
All input parameters relating to requests for admission are produced by
this program and stored on magnetic tape. This tape is then used for a series
of runs of the Scheduler program, saving computation time and, more important, eliminating one source of variation in the data.
Each day of the simulation has an Exogenous Event that contains data on
all patients requesting admission on that day. The number of patients requesting admission is a random variable drawn from a Poisson distribution (a
reasonable fit to the descriptive data).
Each patient has a set of four parameters, plus a numerical name for
reference. These parameters are based on the descriptive data [4] and the
physician's estimation abilities [1,2] and are drawn randomly from their corresponding distributions. They are:
1. Actual length of stay (ALOS), to determine the discharge day for the
patient. The distribution of ALOS was based on the descriptive data from
Alta Bates Hospital [2].
2. Expected length of stay (ELOS), a parameter in two scheduling rules
presented in this study. These estimates were drawn from a binomial distribu-

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tion with mean equal to ALOS and variance proportional to ALOS. Unbiasedness is not critical, since the proper operating point of the hospital can be
determined regardless of bias.
3. Earliest possible arrival date (EPA) and latest possible arrival date
(LPA), to establish bounds on admission dates for patients. No data exist on
these values, since they are generally only implicit in the scheduling process.
The present program selects one EPA-LPA pair for each patient as follows:
EPA is drawn from a geometric distribution approximating that portion of the
Alta Bates Hospital distribution of admission intervals (time between request
and actual admission) in excess of five days [4]. LPA is then selected with
mean and variance increasing with EPA. For an EPA of 1 or 2, LPA is approximately 1 or 2, with a probability of about 0.1 of being as high as 4 or 5. For
an EPA of 11-14, LPA is approximately 6, with a 0.1 probability of being as
high as 9-12. Although this is a fairly arbitrary procedure, the resulting
distribution of admission intervals gathered from the simulation compares
favorably with the descriptive data.

The Scheduler Program

This phase of the simulation is essentially a bookkeeping routine that
maintains complete records of the status of the hospital and of future admissions lists. It has been designed primarily as a vehicle for testing various
scheduling rules that appear in a replaceable subroutine.
As requests for admission are read from the Exogenous Events tape, the
system attempts to schedule each patient by using the scheduling rules
residing in the system at the time. Totals for various patient parameters (e.g.,
ELOS) are accumulated separately for patients who are accepted and patients
who are rejected. At the end of each run these totals and measures of performance such as census mean and census standard deviation, are printed out.
Provision has been made for faster transition to steady state operations by
starting the system at a point near the normal operating level. The initial
conditions are derived from the state-of-hospital and admission lists at the
end of any previous run. Because the same Exogenous Events tape, and thus
the same initial conditions, are used for a complete series of runs, it is necessary to run the system for several "days" to allow transients peculiar to the
scheduling rule that is used to generate the initial conditions to die out.
A simulation day is organized as follows: (1) Each patient in the hospital
is checked and discharged if necessary. In scheduling systems that are based
on ELOS, each patient has his estimate updated if this is appropriate. (2)
Requests for admission are accepted after all discharges and estimate revisions
have taken place. Requests can be handled on a first-in first-out basis or can
be batched according to some external priority code. Each request is handled
in turn by the scheduling subroutine, which schedules the patient for admission on the first encountered acceptable day. (3) Patients who have.been
scheduled for admission on this day are admitted. (4) A'daily report is
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generated, presenting the supplementary data: daily census, daily overflow,

and daily turnaways.
Three basic scheduling systems of increasing sophistication were investigated. The simplest of the three was termed the "filled page" method and is
analogous to the system that appears to be used in the hospitals observed.
This method derives its name from the book used to record scheduled admissions, with one page per day and a fixed maximum number of entries per page.
A patient is scheduled for admission on the first requested day that has an
open entry on the corresponding page in the book.
Next in sophistication is the method termed "ELOS" scheduling, based on
the estimated length of stay of the patient. This method assumes the ELOS
to be correct and uses it without any direct consideration of its possible
error. The system requires carrying the expected census in the hospital out
to some fixed horizon. A patient is scheduled for admission on the earliest
requested day on which his presence in the hospital will not cause the
expected census to exceed some previously defined limit. Once a patient is
scheduled, the expected census is increased by 1 for each day that the patient's
ELOS indicates his presence in the hospital.
The third method is an extension of the ELOS method called the 'PT"
(probability table) version and includes information about the conditional
probability distribution of actual length of stay, given the ELOS. Instead of
increasing the expected census by 1 each day of the ELOS, the expected
census is increased by the probability that the patient will still be in the hospital on that specific day. For example, on the scheduled day of admission the
expected census would be increased by 1; however, for the second day after
the expected discharge, the expected census might be increased by only 0.3,
reflecting a 0.3 probability of the patient's being in the hospital two days
longer than the ELOS. This system is somewhat complicated, in that after
each day's stay the probabilities must be normalized to reflect the patient's
having completed part of his stay.
The "filled page" scheduling system is, of course, the easiest to implement,
as it makes no use of information on the current or projected state of the
hospital. It also requires a minimum of bookkeeping and no computations.
Both the ELOS and the ELOS-PT systems depend on the accuracy of the
physician's estimates of length of stay; hence they cannot be designed at an
optimal operating level unless the accuracy of these estimates is well specified
and time-invariant. Since neither of these conditions is likely, it would probably be necessary with these systems to adjust their operating level during
operation, measure the resulting costs, and thereby experimentally determine
the optimal level.
The Evaluator Program
The outputs from a series of runs of the Scheduler program are used as
inputs to the third phase of the simulation, which evaluates the performance

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of the different scheduling rules. A separate program was used for this function for economic reasons. The procedure consists in completing a series of
four or five runs at internal operating levels varying by five beds; interpolating
between these points to obtain a complete set of data; and then applying
relative costs to empty beds, to hospital overflow, and to the turning away of
prospective patients, in order to determine the "best" scheduling rule and its
associated "optimal" operating level. This procedure offers substantial savings
in computer time over the alternative of incorporating costs into the Scheduler
program, which would require a set of runs for each set of costs under consideration. Since the rules under investigation do not functionally depend on the
relative costs, there is no loss of accuracy with this approach.
As an approximation of the cost structure relevant to hospital scheduling,
the average daily cost of operation is computed as follows:
Mean daily cost of operation = cost of empty bed X mean number of empty beds
+ cost of overflow X mean number of overflows
+ cost of tumaway X mean number turned away

where the mean numbers of empty beds, overflows, and turnaways are outputs
of the Scheduler program. Turnaway costs have been included as indicative
of various costs and relationships that can, at this time, be discussed only in
subjective terms. Administrators who adopt quantitative methods in their
operations are continually called upon to define equally vague quantities as
their systems become more sophisticated. Attempts to grapple with these
problems often lead to a better understanding of the operation of the firm:
one of the hidden returns of quantitative methods. Extensions of the above
cost model rapidly lead to other subjective areas.

Fidelity and Errors

The extent to which the simulation matches any particular hospital, with
its specific patient-population, physician, and administrative characteristics,
will depend mainly on the quality of data available on these attributes. The
simulation was designed to match the general characteristics of the descriptive data available from the two cooperating hospitals. Where no data were
available, educated estimates were produced if necessary, or the variable was
eliminated if it seemed reasonably unrelated to the main scheduling issues.
All the principal variables-patient arrival rate, ALOS, the probability distribution of ELOS/ALOS, EPA, and LPA, and of course, the scheduling rule
itself-are easily adjusted to suit any particular measured or postulated situation. The scheduling rule itself can be used to effectively extend the simple
EPA-LPA assumption to a more sophisticated scheme. The cost figures are
completely flexible, although limited to the three types: empty beds, overflows,
and turnaways. These three are sufficient to define stable operation of the
hospital, and given their uncertain values at present, it would seem unreasonable to include more.

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Three provisions have been made to increase the validity of output data
and the statistical significance of comparisons between runs. Most important
of these is the large sample size. Each run of the simulation is 200 "days,"
processing approximately 3200 patients in a 100-bed hospital. A major source
of variation between runs is eliminated by using the same patient input data
for all runs, thus assuring that the scheduling rule is the only source of
variation. The hospital also is started at an initial condition with patients
in bed and on a scheduled admissions list and is run for 25 days before data
collection is started. Measurements indicate that any transients due to the
initial conditions have died out in 25 days. If the hospital is started empty,
as many as 50 days may be needed for stable operation.
Results

Six scheduling systems were investigated for one set of cost ratios: 1:10:1,
empty beds/overflows/turnaways. These scheduling systems were the three
discussed earlier (filled page, ELOS, and ELOS-PT), with four degrees of
estimate precision within the ELOS system ("poor," "normal," normal with
revision after hospitalization, and perfect).
With perfect estimation, ELOS = ALOS for all estimates. The results of
this system indicate the range of improvement possible with improvements in
estimating techniques. The costs measured in the system reflect those resulting
from patient-request variability.
The "poor" estimation system assigned ELOS values to patients according
to the following scheme:
ELOS, in days
ALOS, in days
2
1-3
6
4-8
10
>8
Length of stay is thus classified in three categories, corresponding roughly to
short, medium, and long stay in general hospitals. This represents possibly the
least accuracy that would be expected by any reasonable estimation technique.
The "normal" estimation system was designed to represent the results of
studies on the physician as an estimator of length of stay at the time an admission is requested [1,2]. The ELOS is drawn from a Poisson distribution with
mean equal to the ALOS and variance equal to 0.55 ALOS.
The normal estimation with revision selects a new value of ELOS after
three days of actual hospitalization. The variance of the new estimate is 0.55
times the remaining portion of stay (ALOS-3). Data on the third day of
hospitalization indicate this to be a conservative assumption. There is good
reason to believe that a carefully constructed revision system can substantially
reduce the ELOS variance [2,3].
The ELOS-PT scheduling system uses the normal estimate variance for
ELOS/ALOS and produces expected census values based on the probabilities

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of stay for each day, rather than simply assuming the precise termination of
stay at ELOS, as the ELOS systems do.
The results of this study are shown in the accompanying table. The optimal
operating level is simply the parameter value in the model yielding the lowest
cost figure. It is the size of the "page" for the filled-page technique, and it
represents the size of the hospital for the ELOS and ELOS-PT systems. The
actual size of the hospital is 100 beds.
Operating Characteristics for Several Scheduling Rules for a 100-bed "Hospital"
Basic
scheduling
rule
Filled page
ELOS "poor"
ELOS "nornal"
ELOS normal
with revisions

Variance
ELOS for
EachSALOr
-

0.55 x ALOS

0.55 X ALOS
and 0.55 X
(ALOS-3)
0.0

Census
Mean daily
Optimal
no. operating
operating mean standard Mean
level
mendeviation overflows
cost
16
82
95

95.0*
94.1
95.3

95
95.5
ELOS perfect
100
98.9
ELOS-PT
normal
0.55 x ALOS
105
93.4
*The probable error of these measures is somewhat less
All differences shown are, with relatively high probability,

4.8*
5.5
4.0

0.3*
0.3
0.3

12.5*
12.8
11.5

3.4

0.2
0.0

10.3
4.3

2.3

4.2
0.1
11.5
than the least significant figure.
indicative of true values.

The performance of the scheduling systems is indicated by the census

mean, census standard deviation, number of overflows, and mean daily operating cost. Several interesting properties of the system are immediately evident.
Looking only at the cost figures, it can be seen that (1) an ELOS system with
poor estimates can be worse than a simple filled-page system; (2) the complex
ELOS-PT system appears to offer no particular advantage over the ELOS
system; and (3) better estimates, and the estimate-revision process, seem to
offer a substantial gain over the filled-page system (about 17 percent cost
reduction for the revision system, 8 percent for the normal ELOS system).
One problem brought clearly to light by the simulation is the scheduling
discrimination against late requests (those having early EPA dates). The ratio
of the average EPA dates for those turned away to EPA dates for those
scheduled is approximately 1:10 for all three scheduling systems. To alleviate
this situation, a procedure has been incorporated into the Scheduler program
to reserve beds for late requests. No information is available, however, as to
precisely what pattern of priorities ought to be established, presumably as a
function of medical need but, at least for metropolitan hospitals, also a function of adopted service policy.
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A relatively simple solution to this problem is the establishment of a

monotonically decreasing (with time) "priority" function as a multiplying
factor on future scheduling capacity [17]. Such a function would start with
value 1 for the current day (fill all available beds, if possible) and decrease
at a rate depending on the hospitars service desires. If the function remains
at 1 for all days, the system is the usual first-come first-served system. If it
drops immediately to 0 for the second and all succeeding days, it is a rather
trivial example of a last-come first-served system. It may be argued that for
hospital scheduling the latter system is closer to the reality, as can be seen by
noting the emergency nature of low EPA requests often indicated by their
correspondingly low LPA values. If the hospital is unable to determine a
normative priority scheme, it is possible to construct a priority function that
allows an approximation to the hospital's current operating data. This function
could then easily be modified to reflect thoughts on "better" operation.
Analysis has shown, as one might expect, that the average cost of using
a particular scheduling rule is smallest for rules yielding the smallest census
standard deviation. If it were true that the scheduling rule yielding the lowest
census standard deviation at a particular operating level remained the lowest
at all operating levels, then the evaluation of scheduling rules could proceed
without cost considerations. Such a situation is unlikely, particularly with
increasingly sophisticated rules. In any event, it is, of course, necessary to take
costs into account in determining the optimal operating level for any particular rule.
An Automated Scheduling System

The Scheduler program used in the simulation could form the core of a
real-time automated patient-scheduling system. The economic feasibility of
such a design would depend, of course, on a number of factors specific to the
particular hospital, including the availability and cost of computer time. The
gain suggested by sophisticated scheduling techniques (see table) seems to
indicate feasibility, particularly if the data necessary to operate the system
are produced at essentially zero cost and if the present manual recordkeeping and scheduling function can be eliminated.
The data input to the system (EPA, LPA, ELOS, and special room and
service needs) would probably be generated by the admissions office and the
physician in a manner similar to present practice. With computer scheduling,
however, specific values for these quantities would have to be produced, as
contrasted with their implicit state in most current systems. Special EPA-LPA
needs could be handled by successive scheduling attempts; for example, such
a request as "Monday or Tuesday or the following Monday or Tuesday" could
be handled by two successive EPA-LPA inputs, if necessary. If the hospital
noted any patterns of requests not easily handled by the Scheduler program,
they could be incorporated in new subroutines.
It would probably be necessary to allow both the physician and the admis-

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sions office to interrogate the Scheduler program as to why a request was

not met or was filled in a particular way. This would be particularly useful
during the early periods of operation, when ability to generate the data and
confidence in the system were being produced. Both parties would learn the
mutual advantages of the system quickly.
Given the input data, the computer could then (1) schedule or turn away
prospective patients, depending on the expected load on the facilities during
the expected period of hospitalization; (2) maintain complete records of
expected demands on the hospital's facilities; (3) determine optimal assignment patterns for facilities to suit current and future demand;' (4) assign
patients to accommodations that would minimize movement and inconvenience; (5) handle changes in estimates of length of stay, diagnoses, or projected
treatments as they might affect scheduling; and (6) perform time-series
analyses of data gathered by the system for use in predicting such phenomena
as future trends and cyclical variations. A possible system is described by
Wing [8].
Functions (1), (2) and (5) are included in the Scheduler program
described in this report; function (4) would be a simple extension; and functions (3) and (6) are presented as relatively sophisticated extensions that
would enable the system to handle unusual situations and trends and optimize
itself according to more sophisticated criteria than simply the costs used in the
present simulation. A computer system to handle these tasks could be a small
or medium-size machine equipped with a disk file for data storage, one (or
several) remote stations at information-gathering points, and an "interrupt"
feature to facilitate fast handling of requests.
Acknowledgments. The authors wish to thank Mr. John Peterson and his staff at Alta
Bates Community Hospital, Berkeley, Calif., and Messrs. Mark Berke and Irving Stoller and
their staff at Mount Zion Hospital and Medical Center, San Francisco, for providing
encouragement, facilities, and assistance for these studies.

REFERENCES
1. Robinson, G. H., L. E. Davis, and G. C. Johnson. The physician as an estimator of
hospital stay. Human Factors 8:201, 1966.
2. Robinson, G. H., L. E. Davis, and R. P. Leifer. Prediction of hospital length of stay.
Health Serv. Res. 1:287 Winter 1966.
3. Gustafson, D. H. Length of stay: Prediction and explanation. Health Serv. Res. 3:12
Spring 1968.

1For example, the system could be programmed to determine which wards should be
reserved for a particular sex or disease and to change these assignments if better utilization would result.

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4. Robinson, G. H. Statistics on Hospital Census, Admission and Discharge Rates, and Admission Intervals. Report No. HFT-64-4, Human Factors in Technology Research
Group, University of California, Berkeley, 1964.
5. Wing, P. and G. H. Robinson. Computer Programs for Simulating Hospital Scheduling
Systems. Report No. HFT-66-1, Human Factors in Technology Research Group, University of Califomia, Berkeley, 1966.
6. Markowitz, H. M., B. Hansner, and H. W. Carr. SIMSCRIPT, A Simulation Programming Language, Prentice-Hall, 1963.
7. Robinson, G. H. Hospital Admission Scheduling Control. Report No. HFT-65-4,
Human Factors in Technology Research Group, University of California, Berkeley, 1965.
8. Wing, P. Automated system for scheduling admissions, Hosp. Mgt., 104:53 October
1967.

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