healthcare

Review
An Overview of Hospital Capacity Planning and Optimisation
Peter Humphreys 1, *, Belinda Spratt 1 , Mersedeh Tariverdi 2 , Robert L. Burdett 1 , David Cook 3 ,
Prasad K. D. V. Yarlagadda 1 and Paul Corry 1

1 School of Mathematical Sciences, Queensland University of Technology, Brisbane, QLD 4000, Australia;
sprattbelinda@gmail.com (B.S.); r.burdett@qut.edu.au (R.L.B.); y.prasad@qut.edu.au (P.K.D.V.Y.);
p.corry@qut.edu.au (P.C.)
2 World Bank, Washington, DC 440236, USA; mtariverdi@worldbank.org
3 Princess Alexandra Hospital, Brisbane, QLD 4000, Australia; david.cook@health.qld.gov.au
* Correspondence: peter.humphreys@hdr.qut.edu.au; Tel.: +61-07-448-963-844

Abstract: Health care is uncertain, dynamic, and fast growing. With digital technologies set to
revolutionise the industry, hospital capacity optimisation and planning have never been more
relevant. The purposes of this article are threefold. The first is to identify the current state of the
art, to summarise/analyse the key achievements, and to identify gaps in the body of research. The
second is to synthesise and evaluate that literature to create a holistic framework for understanding
hospital capacity planning and optimisation, in terms of physical elements, process, and governance.
Third, avenues for future research are sought to inform researchers and practitioners where they
should best concentrate their efforts. In conclusion, we find that prior research has typically focussed
on individual parts, but the hospital is one body that is made up of many interdependent parts. It is
also evident that past attempts considering entire hospitals fail to incorporate all the detail that is
necessary to provide solutions that can be implemented in the real world, across strategic, tactical
and operational planning horizons. A holistic approach is needed that includes ancillary services,
equipment medicines, utilities, instrument trays, supply chain and inventory considerations.
Citation: Humphreys, P.; Spratt, B.;
Tariverdi, M.; Burdett, R.L.; Cook, D.;
Keywords: hospital capacity and planning; optimisation; literature review; overview; health care;
Yarlagadda, P.K.D.V.; Corry, P. An holistic; hospital
Overview of Hospital Capacity
Planning and Optimisation.
Healthcare 2022, 10, 826. https://
doi.org/10.3390/healthcare10050826 1. Introduction
Academic Editor: Gang Kou
1.1. Context
Hospital capacity is defined in a general sense as an upper bound that describes
Received: 24 March 2022
the best possible performance of the hospital in terms of productivity, output or number
Accepted: 27 April 2022
of patients treated [1]. This paper seeks to provide an overview of the optimisation of
Published: 29 April 2022
hospital capacity and planning, and its focus will be to take a detailed view, mapping out
Publisher’s Note: MDPI stays neutral its various components.
with regard to jurisdictional claims in All hospitals are constrained by their available resources and the public, for the most
published maps and institutional affil- part, have limited funds to avail themselves of those services. For example, approximately
iations. half the world’s population do not have access to basic health care [2]. The demand for
hospital services exceeds capacity at a global level [3].
One of the major challenges in any form of research is the practical application of
findings in the real world. There is a need to link academic research and optimisation
Copyright: © 2022 by the authors.
models to the day-to-day operational needs of hospitals [4]. When managing hospitals,
Licensee MDPI, Basel, Switzerland.
planners and executives must contend with many challenging capacity-related questions.
This article is an open access article
The following is a small snapshot:
distributed under the terms and
conditions of the Creative Commons 1. What proportion of time should be allocated to different specialties in operating theatres?
Attribution (CC BY) license (https:// 2. How many ward beds should be allocated for each specialty?
creativecommons.org/licenses/by/ 3. What is the impact of changes to the master surgical schedule on capacity utilisation
4.0/). throughout the hospital?

Healthcare 2022, 10, 826. https://doi.org/10.3390/healthcare10050826 https://www.mdpi.com/journal/healthcare

Healthcare 2022, 10, 826 2 of 27

4. How well aligned is the current hospital configuration to forecasted patient case mix
and volume?
5. What improvements would result from a proposed expansion or reconfiguration?
6. What are the benefits of outsourcing or caseload sharing applied at a regional level?
This multi-faceted state of flux gives rise to the necessity for a hospital system to
constantly adapt to optimise its objectives and performance goals and to deliver the best
health care for everyone.

1.2. Significance and Scope

Many of the world’s health systems are struggling to maintain financial sustainability
in an uncertain and changing environment. Examples of contributing factors include
expanding and aging populations; increasing numbers of people with chronic, long-term
conditions; costly infrastructure and medical technology investments (compounded by
low levels of capital spending over many years); rising labour costs and staff shortages;
and growing demand for a larger ecosystem of services (general practitioner, community
and home based, mental health, long term, etc.) [5]. Global health care spending could
reach over $10 trillion by 2022 and is one of the fastest-growing industries in the world [2].
PolicyAdvice [2] goes on to say that the internet of things (training, patient monitoring,
preventative care, and workflow optimisation) and digitalisation is set to revolutionise
health care permanently.
So why is there a need for yet another review paper on hospital capacity? As we will
later show, there are many opportunities to improve the health care sector, and to apply
advanced operations research methods. It is quite evident that the health care sector is not
optimised sufficiently and may well never be. In a report by Limb [6], “Health economists
have estimated that a fifth of spending on healthcare in countries of the Organisation
for Economic Co-operation and Development is ineffective and have issued a call for
action”. Even if there were methods to fully optimise hospitals today, due to the rapid,
ever-changing environment especially with respect to digital technologies, government
policy and medical procedure advancement, there is a very strong need for an overarching
framework for hospital capacity planning and optimisation which brings together all the
parts of the hospital. Secondly, there is a need for optimisation and mathematical decision
support tools to be developed that can operate within this framework, that are novel,
implementable, and extendable.

2. Overview
2.1. Methodology of the Overview and Mapping Process
This paper was designed to be a combination of the overview and mapping review
types as defined by [7]. Overviews attempt to survey the literature, while a mapping
review attempts to map out and categorize existing literature, identifying gaps leading to
further reviews and/or research [7]. The first part of this article’s review process was to
analyse the entire hospital system and understand it. In addition to analysing the literature,
interviews with staff from South-East Queensland hospitals were conducted (South-East
Queensland is a large Australian metropolitan region). The interviews and site tours
were conducted with managers from the following departments: emergency, outpatient
clinics, surgical bookings, intensive care unit, day surgery admission, imaging, operating
theatres, equipment, storerooms, central sterile services department, allied health, pre-op
and recovery wards. Figure 1 shows the concept map that was constructed to illustrate how
the parts of the hospital system interact and relate to each other. This map was employed
as a framework to search for the literature review. A table was developed to document
the search process for all the parts of the hospital system (see Table 1). Due to the complex
nature of the subject, many articles were relevant to multiple parts of the system. A search
of the top medical journals was also conducted to ensure the literature review was targeted
to the industry. The QUT and Google Scholar search engines were used. The QUT search
engine has access to over 400 databases including over 100 specifically related to health.
Healthcare 2022, 10, 826 3 of 27

Another table was developed to document every article included in this paper to facilitate
analysis over several key parameters including mathematical methodologies employed,
date of research, authors, parts, and sub-parts of the hospital. The purpose of choosing
this style of research approach was to achieve transparency and robustness, with an aim to
establish past and future trends, and to identify the gaps in the literature.
2.2. Overview of Hospitals
A brief overview of the hospital system is given in this section. A hospital is an
institution providing medical and surgical treatment and nursing care for sick or injured
people. The first hospital in the modern sense of the word was developed in the 4th
century, by a wealthy Christian widow named St. Fabiola in Rome [8]. Since then, the
hospital system has continually evolved. A consideration of hospital optimisation starts
with government policy, human philosophy of care and stewardship of resources.
A hospital is a complex system made up of many parts. The following gives a snapshot
of some of the parts of a hospital and how they relate to each other within the context of the
whole system. At the highest level, hospitals are places where activities requiring resources
(e.g., operations and medications) are performed on patients. There are many different
patient care pathways and specialties. Within each of these pathways and specialties, many
intricate and valuable pieces of equipment are required. There are financial limitations on
resources; staff are qualified for specified tasks and have constraints as to when and where
they can work [9]. Methodologies such as staff and patient scheduling, administration,
queuing, information and filing systems contribute immensely to hospital efficiency. Aside
from the core activities, there are context-specific variations between countries. Patients
have diverse backgrounds, with various religious, ethnic, and socio-economic needs and
desires. Ancillary parts of the hospital provide essential support services to the core
activities of the hospital. Buildings and equipment require regular maintenance and must
be managed well to avoid excessive costs and operational bottlenecks [10]. Consumables
such as face masks, hand sanitiser, food, instruments, and linen are required at the right
time in the right quantities. Supply chains that deliver these consumables need to be risk
diversified as the recent COVID-19 pandemic has shown. Visitors need car parks, public
transport, coffee shops and chaplains. Even the architectural design of the hospital and
location of various wards has a significant impact on cost and efficiency [11]. Energy,
heating, and water consumption are precious resources that need to be carefully used and
optimised [12]. Waste processing and recycling can also have a significant effect on the
hospital system that can affect the financial budget and therefore total number of services
performed [13]. Overarching all these parts of the hospital is legislation and philosophy of
care. This realm of management has an enormous impact on every part of the hospital and
is ultimately responsible for how the hospital is run.
In summary, just as the human body is made up of many parts, the hospital system is
synonymous with one body made up of many parts. Each part is important to the overall
function and is intricately related to each other. Therefore, a study into optimising an entire
hospital needs to consider all parts of the system and how they relate to each other. Hospital
capacity optimisation is much more than solving a mathematical programming problem
because it involves the subjective factors in addition to the objective ones. For example,
themes such as teamwork, trust, social interdependence, and communication have a major
impact on productivity [14]. Story [9] goes further and asserts that culture, especially
in health care, is perhaps the dominant detractor to true capacity optimisation. Figure 1
graphically displays the parts of a hospital system and how they relate to each other. For
reference, ‘External uncontrollable’ includes aspects such as location, supply chains, wars,
natural disasters, and pandemics. ‘External controllable’ refers to location, supply chains,
car parking, transportation, waste, recycling, playgrounds, and green spaces.
 to facilitate analysis over several key parameters including mathematical methodologies
employed, date of research, authors, parts, and sub-parts of the hospital. The purpose of
choosing this style of research approach was to achieve transparency and robustness, with
Healthcare 2022, 10, 826 an aim to establish past and future trends, and to identify the gaps in the literature. 4 of 27

Optimisation attributes of each part of the hospital

Controllability Timeframe Probability Rate of change Financials

Resources and operational activities of the Hospital

External Controllable

External Uncontrollable

Ancillary components Operational

Demand Profile Human Resources
Systems

Pre-hospital
Considerations Post-hospital
Considerations
Design and Architecture

Philosophy / Policy / Management

Figure 1. The ‘many parts, one body’ framework for understanding hospital capacity optimisation.
Figure 1. The ‘many parts, one body’ framework for understanding hospital capacity optimisation.
Healthcare 2022, 10, 826 5 of 27

Table 1. Literature search criteria and summary (Search history for the systematic review—Time period: 2000 to 2021).

No. of Entries Returned in Search

Part Search Statement Search Criteria Date Searched QUT Library Google Scholar Notes
Total subject hospital capacity model all words in the title. Jun 2021 29 34
Total subject “hospital capacity” all words in the title. Jun 2021 230 984
Total subject Hospital capacity AND optim * all words in the title. Jun 2021 20 0
Total subject Hospital capacity AND simulation all words in the title. Jun 2021 25 42
Hospital capacity AND (mixed integer OR linear
Total subject all words in the abstract Jun 2021 53 n/a
programming OR mixed integer linear programming)
hospital AND (CAPEX OR ‘capacity planning’ OR
‘capacity analysis’ OR ‘capacity assessment’ OR Only 9 articles, all
Total subject ‘bottleneck analysis’ OR ‘work flow planning’ OR all words in the title Jun 2021 74 n/a irrelevant, the rest
‘system analysis’ OR ‘facility planning’ OR ‘patient newspaper articles.
pathways’ OR ‘capacity modelling’)
Architecture hospital capacity AND Architecture all words in the title. Jun 2021 0 0
Architecture hospital capacity AND Architecture all words in the abstract Jun 2021 1 n/a
Architecture hospital capacity AND Design all words in the title. Jun 2021 0 4
hospital capacity AND (Philosophy OR Policy
Philosophy all words in the title. Jun 2021 37 94
OR Management)
hospital capacity AND (operations OR resources OR
operating rooms OR operating theatres OR
QUT Library: 194 of
emergency department * OR bed * OR equipment OR
Core Activities all words in the title. Jun 2021 247 40 these were newspaper
scheduling OR resource consumption OR
articles
bed-planning OR theatre planning OR day surgery
planning OR resource planning)
QUT Library: Only 3 of
hospital capacity AND (food OR ‘patient food’ OR
these were articles and
cafes OR maintenance OR waste OR trash OR
Ancilliary all words in the title. Jun 2021 428 21 1 was a conference
recycling OR water OR wastewater OR sewerage OR
proceeding. The rest
electricity OR energy)
were newspaper articles.
hospital AND (“casemix planning” OR “case-mix
Demand Profile planning” OR “case mix planning” OR “demand all words in the abstract Jun 2021 7 n/a
profile” or patient case mix)
Healthcare 2022, 10, 826 6 of 27

Table 1. Cont.

No. of Entries Returned in Search

hospital capacity AND (‘natural disasters’ OR
External
earthquakes OR floods OR fires OR pandemics OR all words in the title. Jun 2021 1 15
Uncontrollable
war OR location OR ‘supply chains’)
hospital capacity AND (‘natural disasters’ OR
External
earthquakes OR floods OR fires OR pandemics OR all words in the abstract Jun 2021 31 n/a mostly not relevant
Uncontrollable
war OR location OR ‘supply chains’)
hospital capacity AND (car parks OR green spaces
OR playgrounds OR waste OR electricity or
External Controllable all words in the title. Jun 2021 0 3 Only related to location
wastewater or sewerage or location or recycling or
supply chains)
“hospital capacity” AND (training OR “professional
Human Resources development” OR communication OR safety OR all words in the abstract Jun 2021 109 5
error * OR teamwork OR staff)
Human Resources nurse rostering problem all words in any field Jun 2021 1998 17,000
Pre-hospital
hospital capacity AND (prevention) all words in the title. Jun 2021 0 0
considerations
Post-hospital “hospital capacity” AND (“outpatient care” OR
all words in the title. Jun 2021 0 0
considerations “prevention of re-admission”)
hospital capacity AND (IT systems OR payroll
Google scholar:
Operational Systems systems OR scheduling software OR scheduling tools all words in the title. Jun 2021 0 4
irrelevant articles
OR planning tools)
Totals 3290 18,246
Notes: the asterisk indicates a wildcard. It will return all the words that begin with the letters prior to the asterisk. Eg. Optim * includes optimisation, optimal, optimising etc.
Healthcare 2022, 10, 826 7 of 27

The diagram has been intentionally laid out to represent a physical hospital building.
Just as a building has foundations, a hospital organisation is founded on philosophy, policy,
and management principles, e.g., What is the purpose of the hospital? Why do we look after
the sick? Emanating from philosophy comes the architecture and design of the hospital,
both physical and operational. These two parts of the hospital are coloured dark grey to
denote that they are foundational and cornerstones of the hospital. All other parts of the
hospital are affected by these parts. The light grey parts represent the remainder of the
hospital, and the arrows describe the relationships between each of the parts. The position
denotes whether they exist inside or outside the hospital building. The roof of the building
is shaded differently as it represents the collection of optimising elements that apply to
each part of the hospital. For example, consider optimising the operating theatre resources
of the hospital. There is a controllability element to optimising that—is it easy to change its
capabilities? There is a timeliness element—how long will it take to change its capabilities?
There is a probability or distribution element to its optimisation—what is the probability
of surgery cancellation or finishing late? There is a rate of change element—when will
I need to change the operating theatre capabilities when patient case mix changes and
population size grows in the future? Finally, there is a financial element to the optimisation
of the operating theatre. All these optimisation elements need to be considered within each
part of the hospital and how they relate together within the context of entire system. They
also need to be understood from the perspective of each planning horizon—strategic (long
term), tactical (<1 year) and operational (day of operations). The framework (see Figure 1)
is proposed here as an aid to facilitate an understanding of these matters as they relate to
hospital capacity optimisation and planning.

2.3. Previous Reviews

This section summarises the review papers that have already been published regarding
hospital capacity optimisation. For succinctness, Table A1 summarises the papers by year
and part of the hospital and their key findings. This appendix can be used as a reference
point to compare with articles found in this article’s review.
Fifteen review papers were found over the last twenty-one years. Seven were classified
as core activities, three were classified as philosophy, two as external uncontrollable, and
one paper was classed as patient case mix. Only two papers were classed as holistic,
meaning that they looked at the overall hospital system. One focussed on capacity strain
(i.e., approaching capacity limits) issues and inpatient outcomes [15] while the other had a
specific focus with a review of ten papers on implementing process-oriented organisation
designs [16]. This literature review is different from these papers because it summarises all
the parts of the hospital from an operations research perspective, with a unique focus on
problem-solving methodologies related to hospital capacity and planning.

2.4. Literature Analysis of the Parts of a Hospital

The literature search identified over 3000 articles and 245 of these were included for
further comment and analysis in this article. A systematic approach was applied to decide
which articles to include or not include. Based on a qualitative assessment by the authors
of this review, any articles included relate to hospital capacity planning and optimisation
within an operations research context and judged to come from reputable sources. These
articles are grouped into the parts of the hospital identified in Figure 1. It is worth noting
that it was not the intention of this research to include every article written on the subject,
but rather to include a representative cross-section of literature, so that a high-level analysis
of the subject may be discerned, for practical reasons. If less than approximately 10 papers
were found for a part of the hospital and methodology type, then all the papers were
included, but if more than approximately 10 papers were found, then a representative
sample was included based on a subjective assessment of the contribution of the article.
Additionally, note that not all 245 articles were cited in this paper but were used for the
high-level analysis. This section firstly presents the articles in various graphs to draw out
Healthcare 2022, 10, 826 8 of 27

relationships and trends, then it goes on to analyse each part of the hospital in detail for
key papers.
Table 2 summarises the papers found by part, and sub-part of the hospital, and the
approach taken. Many articles did not have a mathematical approach, but rather used a
qualitative research approach, e.g., process oriented, experimental, or survey based. This
table highlights the fact that not all parts of the hospital have been researched extensively.
For example, only five articles were found regarding architecture and hospital capacity
optimisation and planning. It also highlights that stochastic approaches are employed more
abundantly than deterministic ones. For the purposes of this classification, stochastic refers
to approaches that consider random variables as opposed to static deterministic ones.

Table 2. Summary of articles by part, sub-part and problem-solving approach.

# Stoch. Det. # Stoch. Det.

Ancilliary 13 Holistic 21 6 2
Cooling, Heating and Power 3 Assessment Tool 1
Energy 1 Hospital Optimisation 9 1 2
Energy, Heating 1 Literature Review 2
Facility Management 3 Policy 1
IT Systems 1 Surge events 1 1
Safety 1 Capacity Management 1
Staff 1 Core Activities 1 1
Training 1 No secondary category 5 3
Wastewater 1 Human Resources 11
Architecture 5 Literature Review 1
Facility Management 3 Nursing Staff 8
Safety 1 Safety 1
No secondary category 1 No secondary category 1
Core Activities 118 61 26 Operational Systems 7 1
Beds 29 18 11 IT Systems 6 1
Capacity Planning 1 Medical Records 1
Capacity Strain 1 Patient Case Mix 9 5 5
Communication 1 Literature Review 1
Emergency 15 10 1 Operating Rooms 1 1
Inventory 2 No secondary category 7 4 5
Literature Review 7 2 Philosophy 17 2 2
Nursing Staff 1 Core Activities 1
Operating Rooms 5 1 1 Decision Making 2
Patient flow 3 3 Financials 4 2 1
Post-hospital considerations 1 IT Systems 1
Pre-hospital considerations 1 Literature Review 3
Process Flow 1 1 Patient Case Mix 1
Resources 9 5 Policy 2
Scheduling 28 14 12 No secondary category 3 1
Staff 2 1 1 Post-hospital considerations 1 1
Surge events 1 1 No secondary category 1 1
No secondary category 10 5 Pre-hospital considerations 4
External Controllable 9 4 3 Post-hospital considerations 1
Location 6 3 1 Prevention 1
Multi-Hospital Network 2 2 No secondary category 2
Supply Chain 1 1 Grand Total 245 89 43
External Uncontrollable 30 10 4
Core Activities 1 1
Literature Review 2
Pre-hospital considerations 1
Surge events 25 9 4
No secondary category 1

Figure 2 displays a summary of the articles regarding the mathematical methodology

employed by part of the hospital. It clearly demonstrates that the bulk of research has
focussed on the core operational workings of the hospital, with a noticeable lack of attention
to the ancillary parts of the hospital, namely ancillary, architecture, external controllable,
human resources, operational systems, patient case mix, philosophy, pre- and post-hospital
considerations and holistic. It also highlights a noticeable disparity between methodologies
 Figure 2 displays a summary of the articles regarding the mathematical methodolo
employed by part of the hospital. It clearly demonstrates that the bulk of research h
focussed on the core operational workings of the hospital, with a noticeable lack of atte
tion to the ancillary parts of the hospital, namely ancillary, architecture, external contr
Healthcare 2022, 10, 826 9 of 27
lable, human resources, operational systems, patient case mix, philosophy, pre- and po
hospital considerations and holistic. It also highlights a noticeable disparity betwe
methodologies
employed. Aemployed. A three-dimensional
three-dimensional chart was chosen to chart was
illustrate thechosen to of
magnitude illustrate
articles forthe mag
tude each
of articles for each category.
category.

40

35

30

25
# Articles

20

Constraint Programming
15 MIP

Methodology
Linear Programming
Stochastic Programming
Stochastic Optimisation
10 Meta Heuristics
Simulation
Queuing Theory
5 Theory of Constraints
Activity Based Costing
Process Oriented
0 Lean

Part of Hospital

Figure 2. Literature
Figure review:
2. Literature review:prevalence
prevalence ofof methodologies
methodologies used used
by partby
ofpart of hospital.
hospital.
Healthcare 2022, 10, x FOR PEER REVIEW 10 of 29
Figure 3 shows that stochastic approaches are more common than deterministic ap-
Figure 3 shows that stochastic approaches are more common than deterministic a
proaches for every part of the hospital.
proaches for every part of the hospital.
Deterministic Stochastic

70
60
# Articles

50
40
30
20
10
0

Part of Hospital

Figure
Figure 3. Literaturereview:
3. Literature review: problem
problem characteristics
characteristics byby
part of hospital.
part of hospital.
There are pros and cons to every problem-solving method. When solving a complex
There are
problem, pros and
a common cons employed
strategy to every problem-solving
by researchers is tomethod.
first solveWhen solving
a simplified a complex
version
problem, a common
or variant, strategy
and then employed
incrementally add by researchers
complexity. is to first solve
Throughout a simplified
this iterative version
journey,
or variant, and thenmay
various methods incrementally addand
be employed, complexity.
the benefitThroughout thisisiterative
of this strategy journey, var-
that a thorough,
ious methods may be employed, and the benefit of this strategy is that a thorough, robust
understanding of the system is obtained. For example, a deterministic integer program-
ming approach may be used initially, and then a stochastic simulation model might be
used to understand the uncertain components of the system. This methodology was em-
Healthcare 2022, 10, 826 10 of 27

robust understanding of the system is obtained. For example, a deterministic integer

programming approach may be used initially, and then a stochastic simulation model
might be used to understand the uncertain components of the system. This methodology
was employed by Banditori et al. [17]. This observation may account for the reason why
we see such a spread of methodologies across the various parts of the hospital.
Now that the contextual overview of the articles has been made, each part of the
hospital system will be analysed in detail to draw out further insights.

2.4.1. Architecture and Design

There has been very little research on architecture and design with respect to hospital
capacity optimisation. Optimising facility-related processes in hospitals has the potential
to achieve major savings and improve medical processes at the same time—meeting the
strategic need to reduce health care costs without having a negative impact on the quality
of the core competencies and processes of hospitals [18]. That paper presents the findings
of the Optimisation and Analysis of Processes in Hospitals research project, which analysed
the interaction between primary (medical) and secondary (facility management) business
processes in six hospitals, with a view to identifying a holistic approach and comprehensive
framework for evaluating business processes to ensure their optimisation. It follows that
any study to determine an optimal hospital capacity must include optimising facility-related
processes as an integrated hospital activity.
Diez and Lennerts [19] investigated the interdependencies between facility man-
agement performance, costs, and primary processes in hospitals. They developed an
activity-based costing model to assign facility management costs to a unit within a hos-
pital and acknowledged that the model needed to be extended to the rest of the hospital.
Pati et al. [20] states that while facility design is increasingly playing a role addressing
strategic organisational objectives, issues pertaining to facility maintenance have typically
been left out of the decision-making process. The paper discusses two sets of facility main-
tenance indicators that have the potential to bridge the traditional divide between design
and maintenance. This study demonstrates the need to incorporate maintenance issues
into the overall strategic design process of a hospital.
However, articles found in the public domain have cited that architecture and design of
hospitals are areas that need more attention. Heller [11] states that, in the past, architecture
has typically not been considered a key predictor of health outcomes, but now it is changing
as there is a growing awareness of the importance of incorporating design that promotes
operational efficiency into the health care built environment. The article went on to say
that there were many avoidable cases with surgical complications that lead to $5 billion
in wasted spending each year. This article demonstrates the importance of design, not
only to the normal operating paradigm, but to the surge operating paradigm for events
such as pandemics and earthquakes. While there has been some research into the field
of architecture design and its implications on the efficiency of hospitals, more research
is needed in this area. The impact of good architecture design should be quantified by a
model that has sufficient detail to account for the operational efficiencies that the design
of a building affords. A conclusion from this review of literature is that there is a need for
hospital developers to learn from and apply the research that is currently available.

2.4.2. Ancillary Components

Highly related to the subject of architecture is the design of ancillary components of
a hospital such as maintenance, green areas, cafés, playgrounds, energy systems, waste
recovery and recycling, and clean water systems. No articles were found that discussed
the implications of cleaning activities in hospital capacity optimisation, and yet without
appropriate cleaning staff and resources, hospital efficiency would be impacted. Busby [21]
did, however, model cleaning staff for bed change-over in her study on surge capacity,
but did not account for variation, or other cleaning processes such as instrument tray
sterilisation. In the New York Times, Cary [22] gave a case study of a Cholera Treatment
Healthcare 2022, 10, 826 11 of 27

Center in Haiti that demonstrated the impact that good design has on health care outcomes.
The wastewater-treatment system was designed to prevent recontamination of the water
table, stopping the spread of disease. Budak and Ustundag [13] developed a mixed-integer
linear programming model to determine the optimal number and locations of the facilities
for efficient waste management in health care by minimising the total cost. Through sensi-
tivity analysis, this study established the necessity of various strategies for various waste
amounts. It also demonstrates that waste management should be included in a study of
entire hospital capacity optimisation. If waste management is not adequately accounted for
when modelling entire hospital capacity, then staff utilisations may be underestimated, ren-
dering throughput results inaccurate. Recently, there has been technological advancement
in the field of energy, cooling, and heating [12,23–25]. Implementation of these solutions
has the potential to save a significant amount of money which can be used in other areas of
the hospital, while at the same time reducing supply risks of these critical resources.

2.4.3. External Controllable

External controllable aspects of hospital include carparks, supply chains, waste man-
agement and recycling, playgrounds, green spaces, and location. Six papers were found
that considered location elements of a hospital [26–31], one that focussed on supply chain
issues [32], and two concerning multi-hospital networks [33,34]. Multi-hospital networks
is a subject that has been alluded to within the context of case mix planning discussed
earlier. It must also be noted that this subject has implications on the inventory models,
supply chain models, surge demand events and resource sharing within hospitals. Mahar,
Bretthauer and Salzarulo [33] developed an optimisation model to determine the best
hospitals within a network to deliver a specialised service. The model considered finan-
cial criteria and patient service levels. Their results demonstrated the benefits of sharing
resources and highlighted the need for optimisation in this domain. Similarly, Mestre,
Oliveira and Barbosa-Póvoa [34] built two models pertaining to location and allocation
to improve geographical access while minimising costs. Clearly, any optimisation on this
topic will require context-specific information for the group of hospitals considered. There
is a need for a framework to be developed that can be used as a generic guide for any
network of hospitals to use, which incorporates all the components of a hospital that it
relates to. It is hypothesised that several different optimisation techniques may be needed
in the framework so that the best methodology can be used for any given context.

2.4.4. External Uncontrollable

External uncontrollable factors include surge events, such as earthquakes, wars, and
pandemics, supply chains, public transport and locations. Many articles found for this
part of the hospital dealt with coping mechanisms and reallocation of hospital capacity
amid surge events, primarily pandemics [35–59]. Surge events highlight the importance of
modelling the detail of every element within the hospital, from the hand sanitiser required,
to the availability of doctors and specialised equipment, and how they interact with each
other. The recent COVID-19 pandemic has brought these issues to the forefront. While
this subject has received comprehensive attention, more research is needed in the areas of
supply chains and location issues.
Supply chain issues and management policies are generally not considered in hospital
optimisation studies, but they are a critical part of the system. Bhakoo et al. [60] set out
to study the inventory management practices of participants in health care supply chains.
They found several contingent factors that influence the type of collaboration arrange-
ment. These include product characteristics, spatial complexity, degree of goal congruence
between supply chain partners, the role of the regulatory environment and the physical
characteristics of the organisation. More research is needed in this area to determine how
to optimise such a system. Niakan and Rahimi [61] developed a multi-objective mathe-
matical model to optimise medicinal drug distribution to health care facilities. The model
Healthcare 2022, 10, 826 12 of 27

minimised total inventory and transportation costs, while minimising forecast error, thus
mitigating product shortage and expired drug risks.

2.4.5. Human Resources

Four articles were found concerning human resources. Lennerts, Abel, Pfründer
and Sharma [18] surveyed registered nurses, physicians, and hospital executives about
the shortage of nursing staff. Not surprisingly, substantial proportions of respondents
perceived negative impacts on care processes, hospital capacity, and nursing practice, but
there were also many areas of divergent opinion within and among these groups. The
paper went on to say that resolving these differences was key to improving the quality
and safety of patient care. Bornemann-Shepherd et al. [62] conducted a study aimed at
improving safety and patient and staff satisfaction within the emergency department. This
quality-improvement project involved a questionnaire to gain feedback from key staff
and patients and a task force was setup to implement the measures. Articles of this type
show, via feedback from those questionnaires that a multi-disciplinary approach is needed
to comprehensively address the hospital capacity optimisation problem. Kaw et al. [63]
demonstrated a nursing staff cost reduction of 7% by analysing past nurse absences and
developing a mixed-integer program to minimise costs subject to the size and skill mix of a
nursing resource team, overtime costs and casual staff costs.
The nurse scheduling problem (NSP) has been considered extensively. Approximately
2000 articles were returned from the literature search, but only three articles were included
here to give a representative snapshot of the literature. Cheang et al. [64] gives a bibliog-
raphy and summary of the research on the NSP, discussing methods. They conclude that
while optimisation approaches may be found, the computational time can restrict the size
and complexity of the problem solved. They also acknowledged that it was difficult to in-
corporate all the hard and soft constraints into these approaches, which has lead researchers
to solve the NSP using meta-heuristics. The authors of [65] analysed the literature from
a practical implementation point of view and noted that there was a disparity between
the models and the practical requirements of the real world. Smet et al. [66] also agreed
with this assertion and went on to propose a more realistic NRP, presenting a suite of
hyper-heuristics able to provide solutions.

2.4.6. Operational Systems

Operational systems are tools that are used to administrate the hospital. These include
but are not limited to information technology (IT) systems, accounting packages, patient
booking systems, audio-visuals and communication systems. Most of the literature for
this part of the hospital related to IT systems. IT systems can have an enormous impact
on hospital capacity. For example, electronic dashboards that increase communication
across hospital departments [67]; efficient management of medical records [68]; web-
based real-time capacity management [69,70]; and data capture to track health care more
efficiently [69]. It is this level of detail which needs to be incorporated into hospital capacity
estimations since it directly affects all parts of the hospital system. For example, if a model
is being used to determine the most efficient way to increase capacity, then for a given
process improvement measure, it needs to calculate the flow-on effect to downstream
and upstream processes within the whole system. Some performance improvements for
one component may have little or no benefit to overall system performance. Similarly,
a performance improvement in one component may have a profound benefit to overall
system performance. For example, Burdett and Kozan [71] found that patient activity end
times, such as post-op, were not acted upon because the IT system did not alert staff. This
lead to extended length of stay durations for patients, which in turn reduced overall system
capacity. Similarly, Ahalt et al. [72] used discrete event simulation to determine the most
appropriate emergency department crowding score for a given hospital. This alert system
allowed managers to reallocate resources in response to impending demand, increasing
efficiency and patient care.
Healthcare 2022, 10, 826 13 of 27

2.4.7. Core Activities

Perhaps one of the most important activities with respect to hospital capacity manage-
ment is operating theatre scheduling. Building on from previous research [23,73–76], Spratt
and Kozan [77] completed significant work in this area by demonstrating an integrated
rolling horizon approach to increase efficiency. They used a constructive heuristic and
two hyper-metaheuristics to produce near optimal feasible solutions. While they factor
in many variables that affect the schedule, such as surgeon availability, their scope does
not include ancillary staff such as nurses and cleaners, shared equipment, and upstream
and downstream hospital processes that can cause major bottlenecks when modelled as
an entire hospital system. Burdett and Kozan [71] addressed the scheduling problem
using a sophisticated flexible job shop scheduling model. This was a valuable contribution
because it addressed the upstream and downstream processes that many other articles did
not consider. This study, however, did not model the emergency department and other
shared resources used by other parts of the hospital. The authors of [78,79] incorporated
equipment and all the staff types required in surgeries, but did not account for stochasticity,
the patient treat-in-time objective and only considered a short planning horizon of a week
or less. The other area for improvement could be to consider the difference between the
estimated surgery time and the actual surgery time. If the plan is more accurate, then
this would lead to reduced variability, reaction and noise within the system. Burdett and
Kozan [80] suggested the strategic placement of idle time and the dynamic selection of
multiple free resources at each time in the scheduling process, proved to be effective in
addressing uncertainty and variability.
Nguyen et al. [81] defines the number of beds to be optimal when the unoccupied
beds is not excessive, patients transferred due to a lack of beds available is not excessive,
and there are several beds available for unscheduled admissions. Kokangul [82] used
a combination of deterministic and stochastic approaches to optimise bed capacity in a
hospital unit. Cochran and Roche [83] developed a capacity planning tool in Microsoft
Excel, based upon queuing theory and financial data. Li et al. [84] developed a multi-
objective decision support model for allocation of beds in a hospital. The model was based
on queuing theory and goal programming to allocate beds to meet targets and objectives
related to customer service and profits. Ben Abdelaziz and Masmoudi [85] developed a
multi-objective stochastic model to minimise three functions: bed creation and management,
doctors and nurses. Utley and Peters [86] estimated the number of beds required for the
smooth operation of a multi-specialty paediatric intensive care unit. Their study considered
variability in timing, nature of referrals and length of stay. Devapriya et al. [87] developed
a decision support tool for planning and budgeting of current and future bed capacity, and
evaluating potential process improvement efforts. The key inputs of this discrete event
simulation model included timing, quantity and category of patient arrivals and discharges;
unit-level length of care; patient paths; and projected patient volume and length of stay.
While all these papers addressed the aspect of bed planning and allocation they were
intended for, there were not any papers that optimised bed capacity within the context
of the entire hospital system and all its constraints, for example shared equipment and
staff resources, medical inpatients and outpatients, surgical inpatients and outpatients,
emergency department, laboratories, imaging and allied health professionals.
McManus et al. [88] established that queueing theory accurately modelled the level
of need for intensive care. They concluded that the stochastic nature of patient flow may
falsely lead health planners to underestimate resource needs in busy intensive care units.
Madell et al. [89] conducted a rapid review of literature focussing on optimisation of
resource use in hospitals. They outlined several practical strategies that hospitals could
employ to optimise their overall efficiency. Chief among these was the use of specially
trained nurses for special patient cases. Khaiter et al. [90] tried to optimise the resource
allocations for the image guided therapy department of a hospital. They found that none
of the investigated optimisation algorithms was able to optimise the schedules with respect
to all the selected time-based performance criteria. Each algorithm generated schedules
Healthcare 2022, 10, 826 14 of 27

which are more efficient from the perspective of a single performance indicator. It was
suggested that for a complex non-trivial problem of this kind, a hybrid approach combining
several optimisation techniques might be successful. Bastian et al. [91] optimised resources
across the United States Military Hospital System using mixed-integer linear programming,
including some stochastic elements, but this was only for staff and funding. Another
study by Feng et al. [92] produced a multi-objective stochastic mathematical model for
medical resource allocation in emergency departments. It allocated the resources (i.e., staff,
equipment, and beds) to minimise length of stay and medical waste cost. This highlights
the need to model hospital resources with a high level of detail.
Ahmadi et al. [93] presented an up-to-date review of research in the field of inventory
management of surgical supplies and instruments. They organised the papers into two
groups: those published by scientific researchers who developed optimisation techniques
and those that were published by practitioners and reported their observations of the
current issues in the operating room. An interesting finding was that preference card
optimisation (i.e., the items and their quantities) was a topic that had been untouched thus
far in the research literature. Another question that remains unanswered in the literature
is the location and the quantity of surgical supplies that must be stocked according to
the operating room’s specific process. A further question that needs to be answered is
what methodology can help physicians to decide the appropriate quantity of material to be
opened before the procedure with the aim of minimising waste without sacrificing patients’
quality of care. Optimal surgical tray configuration is another topic that needs addressing.
They state that the future research direction is to develop stochastic models which must
consider both cost, service level, operational risk, and disruption risk. These findings
were also echoed by the staff in the case study hospitals that confirmed that management
of preference cards and surgical trays is a key issue—specifically around the timing and
resources required to sterilise them so they are available for surgeries.
Emergency department optimisation has received significant attention in the literature.
A literature review by Ahsan et al. [94] found that not all modelling approaches were
suitable for all situations and there was no critical review of optimisation models used
in hospital emergency departments. Their analysis of all the methodologies revealed
that every modelling approach and optimisation technique has some advantages and
disadvantages, and their application is also guided by the objectives.
As a general comment on the articles found, there was little or no consideration of
integration with the rest of the hospital and the support staff such as cleaning, ward and
administration. One article that did highlight the importance of ancillary tasks such as
medication delivery and lab sample collection is Batt and Terwiesch [95]. They noted that
a load dependent mechanism, where staff in an upstream stage proactively initiate tasks
normally handled by downstream staff, lead to a 20 min reduction in treatment time. The
emergency department needs to be optimised within the context of the entire hospital
system since it is integrally related, using shared resources, and in many cases dependent
on hospital beds being available for patients to leave the emergency department. A similar
conclusion was drawn by Zhu, Fan, Yang, Pei and Pardalos [4], where they recommend
a better integration of compatible resources and the need researchers to narrow the gap
between theory and practice. Even ancillary infrastructure such as carparks can affect
the number of people arriving at an emergency department if patients have a choice of
hospitals. Lack of carparking can also delay patients arriving on time for appointments
and be a leading contributor to staff turnover.

2.4.8. Patient Case Mix

Freeman et al. [96] state that case mix planning refers to allocation of time to operating
rooms and is an important tool for achieving the goals of a hospital with respect to quality
of care and financial position. Hof et al. [97] performed the first standalone literature
review of case mix planning. They state that, in general, literature on case mix planning is
scarce. Three gaps in the research were identified. Firstly, the incorporation of stochastic
Healthcare 2022, 10, 826 15 of 27

parameters into strategic case mix planning problems. Secondly, the consideration of
hospital systems as they increasingly face market and financial pressures. Thirdly, whether
it is more cost efficient to provide the majority of services in one hospital or have many
specialised hospitals that each focus on specific services.
Freeman, Zhao and Melouk [96] developed a multi-phase approach that used math-
ematical programming and simulation to generate a pool of candidate solutions to the
case mix planning problem. Each candidate solution was evaluated with respect to a
broad range of strategic and operational performance measures. In comparison to a more
traditional single-solution approach, they found that the solution pool approach identified
case mix plans with higher expected patient reimbursement, lower over-utilisation of oper-
ating theatre time, and lower variability in the number of beds required in downstream
recovery wards. McRae et al. [98] analysed the effect of economies of scale and scope on the
optimal case mix of a hospital or hospital system. The non-linear mixed-integer program
they formulated, however, did not account for staffing resources and for variation within
the system. McRae and Brunner [99] subsequently tried to address these limitations and
developed a framework for evaluating the impact of uncertainty and the use of different
aggregation levels in case mix planning.

2.4.9. Philosophy, Policy and Management

Philosophy of care, policy, and management has an enormous impact on hospital
capacity. This is illustrated in Figure 1 by positioning philosophy as the foundation upon
which all other parts of the hospital depend. Durán and Wright [100] devote a chapter in
their book to hospital governance and give an excellent historical synopsis of the various
issues around the world and how they impact health care. Positions on abortions and
euthanasia greatly affect the efficiency and throughput of a hospital. Respect for patient’s
religious beliefs and preferences such as diet also have an impact. Zaric [101], in his book
‘Operations Research and Health Care Policy’, brings together a group of papers by leading
experts, showcasing the current state of the field of operations research applied to health
care policy.
There were five articles chosen for consideration relating to financial matters within
hospitals. The authors of [102] state that time-driven activity-based costing (TDABC) has
been suggested as the cost-component of value-based health care capable of addressing cost-
ing challenges. Only one paper proposed a multi-objective stochastic programming (MSP)
model to maximise both revenue and equity for patients [103]. The rest ([102,104–106])
discuss static analysis of costs, though essential and inherently of critical importance, has
limited use informing future dynamic operating paradigms proposed by strategic and
tactical models. Clearly, there exists the need for further research to incorporate financial
analysis into a multi-objective holistic optimisation of hospital capacity, not only for the
present, but projected into the future.

2.4.10. Pre-Hospital Considerations

Only four articles were found relating pre-hospital considerations. Khorram-
Manesh et al. [107] reviewed the regional registry at the Pre-hospital and Disaster Medicine
Center in Sweden with respect to hospital-related incidents and its causes. Emergency
department overcrowding, lack of beds at ordinary wards and/or intensive care units and
technical problems at the radiology departments were the leading causes of the incidents,
thus consuming capacity within the hospital. These incidents resulted in ambulance
diversions and reduced pre-hospital capacity. Hanan et al. [108] undertook a robust
evaluation of a community oncology nursing program in Ireland, which found that defined
clinical procedures traditionally undertaken in hospitals were safely undertaken in the
patient’s home with no adverse effects. The outcome of this program was a dramatic
decrease in hospital attendances, thereby releasing hospital capacity. Patients also valued
having care delivered at home and reported that it improved their quality of life, including
reduced hospital visits and travel time. Burkett and Scott [109] focussed on the patients in
Healthcare 2022, 10, 826 16 of 27

aged care and developed a program that improved the quality of care for patients in a cost-
effective way that minimised hospital admissions. These articles highlight the importance
that pre-hospital considerations have on hospital capacity. Further research could include
other novel ways to reduce hospital admissions, ‘no-show’ patients and length of stay
at hospitals.

2.4.11. Post-Hospital Considerations

One article was found considering post-hospital factors [110]. It addresses a vehicle
scheduling problem encountered in home health care logistics. It concerns the delivery of
drugs and medical devices, and pickup of bio samples, unused drugs, and medical devices
from patients. Mixed-integer programming models are proposed and then Tabu Search
and Genetic Algorithm heuristics are used because of computational intensity. While
this problem was successfully solved for the given assumptions for a day, the authors
acknowledged that in the real world, there are uncertainties around some variables. In
addition, there is also a need for a much longer planning horizon than one day. These
characteristics make the problem much more complex. To produce an implementable
solution, perhaps other methods such as simulation optimisation may be required because
it is well suited to encapsulating the manifest complexities within the system. The findings
from this paper may be applied to other applications including the community oncology
nursing program in Ireland described by Hanan, Mullen, Laffoy, O’Toole, Richmond and
Wynne [108]. As technology increases, more services and tests may be performed outside
the hospital thereby freeing up hospital capacity.

2.5. Analysis of Entire Hospital System Optimisation

Several articles were found that consider the entire hospital system and its capacity
optimisation. Rechel et al. [111] discuss general principles and methodologies for hos-
pital capacity planning and optimisation, but do not put forth any solution, method, or
mathematical model for practical application. Hall [112] systematically goes through many
aspects of hospital operations and discusses solutions but does not pull everything together
into an integrated system. Yang et al. [113] built a multi-objective optimiser for three control
factors—(1) bed allocation among wards, (2) overflow threshold (patients assigned to wards
not ideally suited for their primary condition), and (3) discharge distribution—but these
models did not have sufficient detail or include all the elements of a hospital to provide an
accurate estimate of capacity. The authors of [2,114] developed a mixed-integer program to
determine the maximum number of patients of each type that can be treated over time, or
the time required to process a given cohort of patients. This work is significant because it
quantified a patient throughput capacity for the major activities across the entire hospital,
but its limitations were that it was a static model and did not account for stochasticity
within and interaction between processes. Jones [115] puts forward a methodology for
entire hospital optimisation, but it is static and does not quantify capacity, account for
uncertainty, or consider the interdependencies of all components working together in real
time. It acknowledged the limitations of LEAN and 6 Sigma. LEAN generally applies to
manufacturing, where we can know and predict in detail what each of the parts will do
in response to a given stimulus. In complex adaptive systems (e.g., hospitals), however,
the “parts” have the freedom and ability to respond to stimuli in many ways [115]. While
there may be application for LEAN and 6 Sigma methodologies to be employed in some
sub-processes within a hospital, they are not suitable to be used as the only solution for
entire hospital optimisation. The authors of [21] built a hospital-wide simulation model that
facilitated the assessment of the impact of hospital-wide decisions and surge policies on
each area of the hospital. The model did not include inventory, financials, maintenance, and
ancillary staff. Bittencourt et al. [116] took a slightly different methodology and focussed
on the role of queueing theory to hospital capacity management.
Healthcare 2022, 10, 826 17 of 27

3. Discussion
3.1. Research Gaps
In general, there have been many studies on various parts of the hospital, with a major
focus on core hospital activities, and a lack of studies on the ancillary parts which have a
significant effect on entire hospital capacity optimisation. The other major limitation of
the current research is that, in general, it lacks the detail required for practitioners and
hospital administrators to implement solutions—Zhu, Fan, Yang, Pei and Pardalos [4].
In this section, we will focus on the research gaps of the two main areas that we believe
require attention—architecture and operating theatre scheduling.
As alluded to earlier, architecture is immensely important to hospital capacity planning
and optimisation because it directly impacts on every part of the hospital. For example,
where should pharmaceutical outlets be located within the hospital, and how many should
there be to minimise staff time procuring medications for patients? Where should the
storerooms be located? What size and how many storerooms should there be to minimise
staff time? Where should the shared resources such as imaging and laboratory departments
be located to improve patient flow? Where should management staff be located so they can
efficiently oversee the hospital operations? How many lifts and staircases should there be
in the hospital to remove bottlenecks and improve patient and staff flow? Where should
the green spaces and cafes be located so they enhance and not impede hospital and patient
experiences? These are just a few research questions that represent a plethora of areas that
need attention.
Operating theatre scheduling, on the other hand, has received enormous attention in
the literature. Despite this, and perhaps due to the complex nature of the problem, this
body of research has made surprisingly little impact in the real world (Zhu, Fan, Yang, Pei
and Pardalos [4]). The task that we believe remains is to pull together all this research, into
one model that can be practically implemented by hospitals. For example, the work by [79]
was particularly noteworthy as it developed a unified resource model that can include
specialised staff and medical equipment resource types (e.g., instrument nurse, surgical
trays). The question remains as to how that approach can be scaled for a large hospital with
over 1000 resource types and over 10,000 individual resources. Future research could also
focus on the combination of interdependencies on various resources along with uncertainty
in procedure times, emergency admissions and length of stay, within a rolling planning
horizon, not just a static short-term horizon.
We suggest that a simulation-optimisation environment would be the best methodol-
ogy to employ to address these major areas for further research. It is well known that these
problems are computationally intractable (i.e., NP-hard), and as such, using meta-heuristics
and/or deterministic approaches embedded within a simulation model that integrates
all the parts of the hospital is ideal for addressing the architectural design questions and
scheduling problems that remain unanswered.

3.2. Past and Future Research

Figures 4 and 5 graphically portray the reviewed research over the last 20 years. A
three-dimensional chart was chosen to illustrate the magnitude of articles considered in
this review, with respect to the parts of the hospital.
When commenting on research trends, Madell, Villa, Hayward and Comte [89] ob-
served that the increased computational complexity inherent with these types of questions
explains the current trend of researchers to focus on deterministic approaches. Since the
time that article was written, however, computer processing speeds have increased sig-
nificantly. Ritchie [117] found that computing speeds by the largest supercomputer in
any given year have increased from 93,000 trillion to 442,000 trillion (floating operations
per second) from 2016 to 2020. This advance in technology, combined with the increase
in data capture and availability, through evolved IT systems such as the integrated elec-
tronic medical record (iEMR) [118], has laid the foundation for more sophisticated and
detailed modelling techniques to be employed. For example, the collection of timestamps
 Healthcare 2022, 10, 826 18 of 27

of key events within a patient’s journey through the hospital [119] has lead to the inclusion
of stochastic elements in models, giving rise to more accurate results and the ability to
answer questions not previously attempted before. It is worth noting that exponential
improvement in computing capacity only translates to linear improvement in the scale of
NP-hard scheduling and optimisation problems that can be solved, so methods also need
to be continually improved. Furthermore, Langabeer [120] states that the challenge for
quality managers will be how to incorporate these new data into performance improvement
programs and process changes for services that require attention. It is suggested that these
are the predominant reasons accounting for the increasing trend for stochastic approaches
in research papers compared to deterministic ones as seen in Figure 5. Many of the papers
Healthcare 2022, 10, x FOR PEER REVIEW
use both stochastic and deterministic approaches, generally using stochastic simulation 19 of
to 29
Healthcare 2022, 10, x FOR PEER REVIEW 19 of 29
evaluate and test the deterministic approach [17,99,103,121–128].

30
30
25
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Figure
Figure 4. Number of
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Figure4.4.Number
Number ofarticles
articles reviewed by
by part of
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Deterministic
Deterministic Stochastic
Stochastic
25
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Articles
Number of Articles

20
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15
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10
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55

00
2003
2003 2006 2009
2009 2012
2012 2015
2015 2018
2018 2021
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Figure 5. Number of articles by problem characteristics by year.

Figure 5. Numberof
of articles
articles by
by problem characteristicsby
problem characteristics byyear.
year.

When commenting
commenting on on research
research trends,
trends,Madell,
Madell,Villa,
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Haywardand andComte
Comte[89][89]ob-
ob-
served that the increased
increasedcomputational
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complexityinherent
inherentwith
withthese
thesetypes
typesofofquestions
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explains the current
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researcherstotofocus
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ondeterministic
deterministicapproaches.
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time that article
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supercomputerininany any
given year have increased from 93,000 trillion to 442,000 trillion (floating operations
given year have increased from 93,000 trillion to 442,000 trillion (floating operations per per
Healthcare 2022, 10, 826 19 of 27

4. Conclusions
This paper provides a timely and useful cross-section of operations research literature
focussed on holistic optimisation of hospital capacity. It is particularly important that
researchers continue to innovate, and that gaps between academic research and practical
implementation are bridged. It is well known that, in general, demand for hospitals is
exceeding capacity and widely accepted that there are still significant efficiency gains to be
realised. The COVID-19 pandemic has brought this to light in an evocative way. This article
provides an overview on hospital capacity optimisation and planning with 245 articles
included for consideration. This review is novel in the sense that it summarises many parts
of the hospital from an operations research perspective. A useful conceptual framework
(see Figure 1) was also constructed to map the literature and research opportunities and
to facilitate an understanding of the subject holistically, especially with respect to the
strategic, tactical, and operational planning horizons. Perhaps the main finding, and most
unexpected, was that despite the vast amount of published theoretical work on operating
room management, there has been little or no impact of this work in an operational setting—
Zhu, Fan, Yang, Pei and Pardalos [4].
A possible limitation of this study is the selection of articles to include in the review.
Hospital capacity optimisation and planning are such broad and extensive subject, making
it virtually impossible to include every article.
There are many useful techniques such as mixed-integer programming and meta-
heuristics. Some are deterministic and some are stochastic, addressing one or more aspects
of a hospital’s operation. However, it is unclear how these methods will perform in a
dynamic, stochastic environment, where competition for resources occurs with other parts
of the hospital, not included in the considered decision problem. Discrete event simulation
is an established technique which can be used to test and calibrate these optimisation algo-
rithms in such a challenging environment. It may also be used to consider how optimisation
approaches focussing on different aspects of hospital operations can simultaneously work
together. Furthermore, it is suggested that researchers focus on including more real-life
elements in their problem descriptions so that the gap between research and the practical
implementation of it is narrowed. For example, instrument trays and other essential equip-
ment should be included in operating theatre schedule optimisation, but we could only
find two articles that considered these [78,79].
As a final remark, it is hoped that this work will promote healthy, constructive dis-
cussions around hospital capacity in a holistic sense, and how it may be optimised when
all the parts work together to achieve the ultimate end—quality of care. A guide to a
holistic approach has been produced specifically for managerial staff to implement in
their hospitals. The details may be found in Appendix B. Hopefully this article will also
inspire others to develop solutions that can be implemented and have a profound impact
in the real world.

Author Contributions: P.H.: Principal author. Material preparation, data collection and analysis. B.S.:
Developed ideas and proof read manuscript. M.T.: Provided strategic oversight with an international
focus. R.L.B.: Developed ideas and methodology. Proof read manuscript. D.C.: Developed ideas.
Proof read manuscript. P.K.D.V.Y.: Chief investigator of the project. Provided supervision of the
research. P.C.: Chief investigator of the project. Developed ideas and methodology. Proof read
manuscript. All authors have read and agreed to the published version of the manuscript.
Funding: Australian Research Council (ARC). https://www.arc.gov.au/ Linkage Grant LP 180100542.
Acknowledgments: This research is part of the Australian Research Council (ARC) Linkage Grant
LP 180100542 and is supported by the Princess Alexandra Hospital and the Queensland Children’s
Hospital in Brisbane, Australia. Key personnel to acknowledge are Donna Callow (Queensland Chil-
dren’s Hospital), Brendan Hoad (Queensland Children’s Hospital) and Audrey Hamilton (Princess
Alexandra Hospital).
Conflicts of Interest: The authors declare no conflict of interest.
Healthcare 2022, 10, 826 20 of 27

Appendix A

Table A1. Summary of literature reviews and their findings.

Date Part of Hospital Sub-Part Title Findings

“The breadth and scope of units within hospitals
and clinics makes it impossible to undertake one
single comprehensive study that addresses all these
Application of issues simultaneously . . . These observations,
Discrete-Event together with the absence of literature in complex
1999 Core Activities Holistic
Simulation in Health integrated multi-facility systems, suggest the need
Care Clinics: A Survey to develop a comprehensive simulation modeling
framework for determining clinical performance
measures and interdepartmental resource
relationships.” [129]
Systematic review of “The quality of papers is variable but improving
the use and value of over time. The potential of simulation modelling to
computer simulation inform evidence based policy development for the
2003 Core Activities Holistic
modelling in provision of health care is clear, but information on
population health and the outcomes of model implementation and hence the
health care delivery value of modelling requires further research.” [130]
The review revealed that only limited research is
applied to non-elective patient scheduling . . .
Research is needed on study of stochastic activity
Operating room
durations and their impact on the operating room
Operating planning and
2010 Core Activities practice, especially with a focus on patient pooling
Rooms scheduling:
. . . Better integration of the operating room
A literature review
downstream and upstream facilities and resources
should be favoured . . . Very little is known about
the process of implementation. [131]
Optimisation of
Papers reviewed were experimental based
hospital resource use:
2016 Core Activities Resources operational strategies . . . No mathematical
A rapid review of
optimisation studies considered. [89]
the literature
“The analysis revealed that every modelling
Emergency
approach and optimisation technique has some
department resource
advantages and disadvantages, and their
optimisation
2019 Core Activities Emergency application is also guided by the objectives. The
for improved
complexity, interrelationships and variability of
performance:
ED-related variables make the application of
A review
standard modelling techniques difficult.” [94]
Areas for more research: Preference card
optimisation (i.e., the items and their quantities),
location and the quantity of surgical supplies that
must be stocked according to the OR’s specific
process . . . There is a need for a methodology to
Inventory help physicians decide the appropriate quantity to
management of be opened before the procedure with the aim of
surgical supplies and minimising waste without sacrificing patients’
2019 Core Activities Inventory
sterile instruments quality of care . . . “From a methodology and
in hospitals: modelling perspectives, one of the obvious future
A literature review research directions is to develop stochastic
models . . . The assumption of deterministic demand
or even stochastic stationary demand hinders the
models in being practical.” Optimal surgical tray
configuration is another area to address as is the
consideration of operational and disruptive risk. [93]
Healthcare 2022, 10, 826 21 of 27

Table A1. Cont.

Date Part of Hospital Sub-Part Title Findings

“Although a great deal of theoretical work has been
published, none of them seems to have a profound
Operating room planning effect on the real-word practice of OR management.
and surgical case In regard to future research, there is still a lot to do
2019 Core Activities Scheduling
scheduling: A review of to narrow the gap between theory and
literature practice.” . . . Researchers should also put effort
into the study of stochastic surgical durations and
a better integration of the compatible resources. [4]
Hospital surge capacity:
The importance of better “Our findings support the need for an
External hospital pre-planning to evidence-based approach to preparing
2019 Surge Events
Uncontrollable cope with patient surge context-specific emergency preparedness plans to
during dengue epidemics— help healthcare administrators.” [132]
A systematic review
COVID-19 Models for The results of our study provide information on
External Hospital Surge available models for preparing scenario-based
2020 Surge Events
Uncontrollable Capacity Planning: plans for responding to the COVID-19 or similar
A Systematic Review type of outbreak. [133]
“Due to the limitations of the evidence, it is not
Towards an
known which approach, implementation of
organisation-wide
coordination measures or organisational
2011 Holistic Core Activities process-oriented
restructuring (with additional coordination
organisation of care:
measures), produces the best results in which
A literature review
situation.” [16]
The Association Between 44 observational and 8 experimental studies . . .
Hospital Capacity Strain “In highly developed countries, hospital capacity
and Inpatient Outcomes strain is associated with increased mortality and
2017 Holistic Capacity Strain
in Highly worsened health outcomes. Evidence-based
Developed Countries: solutions to improve outcomes during times of
A Systematic Review capacity strain are needed.” [15]
“In summary, we conclude that linear
programming is the most common choice to
model CMPPs.” . . . “We did not find any
formulations of CMPPs dealing with uncertainty
Case mix planning in of resource supply.” . . . “In general, literature on
2017 Patient Case Mix hospitals: a review and case mix planning is scarce.” . . . Need for
future agenda incorporation of stochasticity . . . Need for the
evaluation of which kinds of uncertainty are of
strategic importance compared with operational . . .
“Methods have to be developed and adopted to
solve such problems efficiently.” [97]
“We found that the capacity management
literature is not well populated by robust
statistical models that have been tested and
validated by researchers.” “Literature offers no
Improving Capacity specific models by which to conduct research and
Management in the test findings.” “The absence of economic and
2015 Philosophy Emergency Emergency Department: financial metrics is evidence of the literature being
A Review of the underdeveloped and highlights an additional
Literature 2000–2012 opportunity for future research.” “Future studies
examining the effects of institutional coalitions on
ED capacity management are needed.” “Future
research should examine outside forces that may
affect ED capacity management.” [134]
Healthcare 2022, 10, 826 22 of 27

Table A1. Cont.

Date Part of Hospital Sub-Part Title Findings

“Hospitals have not adopted sophisticated cost
accounting systems because characteristics of the
The growing hospital industry make the costs of doing so high
importance of cost and the benefits of service-level cost information
2016 Philosophy Financials accounting for relatively low.” If patients place more emphasis on
hospitals. Journal of shopping around for low cost services, cost
Health Care Finance accounting information will become a much more
important part of hospital management than it has
been in the past. [106]
Time-driven TDABC is able to address complexity in health care.
activity-based costing “TDABC should be gradually incorporated into
2017 Philosophy Financials in health care: functional systems, while following and building
A systematic review upon the recommendations outlined in
of the literature this review.” [102]

Appendix B. A Guide to a Holistic Approach to Capacity Optimisation and Planning

The intent of this list is to suggest a guide for how to implement a holistic approach to
hospital capacity optimisation and planning. The motivation for this guide has come from
the research gaps that emerged from the literature review, together with the feedback from
operational staff at South-East Queensland hospitals.
1. The framework in Figure 1 may be used as a guide to map all the parts of the specific
hospital and how they relate to each other. This must be performed in terms of
strategic, tactical, and operational planning horizons.
2. The hospital needs a team dedicated to the master planning and design of the hospital
including ancillary services such as maintenance, electricity, water, waste, recycling,
car parking, cafés, green break-out spaces, children’s playrooms, transport and logis-
tics, inventory, and supply chains. Such a team would ordinarily include architects,
operations research specialists, technical advisors such as engineers and operational
staff. This team could also collaborate with the group responsible for developing a risk
management strategy, so that in the event of a war, natural disaster or pandemic, the
hospital can be well positioned to maintain services at the highest level. For example,
should the hospital produce its own hand sanitiser or rely on another country to
produce it?
3. The philosophy of the hospital must be clearly defined and communicated to all staff
and manifested practically throughout the hospital. Everyone must work together as
a team (many parts, one body), supporting one another to achieve the ultimate goals
of the hospital. The management team must encourage a clear and constructive com-
munication culture throughout the organisation. The philosophy and management
of the hospital are arguably the most important parts of the hospital as they directly
influence every aspect of it.
4. Is the hospital using the best information technology systems? Some examples of a few
key systems to consider are communications, data collection and storage, data analysis,
process improvement, patient scheduling, financial, administration, inventory, human
resources, and capacity analysis. If the hospital is already using best practice, are
management using it effectively? For example, what patient case mix is optimal for
the hospital? How can the hospital be designed to optimally meet the patient case
mix it is presented with?
5. Pre-hospital considerations—how many prevention initiatives can be implemented to
reduce arrivals at the hospital? A cost/benefit table may be produced to help prioritise
initiatives. How can the hospital make it easy for patients to arrive at the hospital?
Healthcare 2022, 10, 826 23 of 27

6. Post-hospital considerations—how many initiatives can be implemented to prevent re-

admission of patients? What services can be conducted outside of the hospital to free
up capacity? How does the cost of these services compare to the cost of providing them
in the hospital? A cost/benefit table may be produced to help prioritise initiatives.
In general, the management team need to find the best way to optimise each part of
the hospital within the context of the whole system, considering site-specific factors and
issues. The management staff need to determine which problems are critical, assigning
priorities to tasks within a holistic project plan.

References
1. Burdett, R.; Kozan, E. A multi-criteria approach for hospital capacity analysis. Eur. J. Oper. Res. 2016, 255, 505–521. [CrossRef]
2. Policy Advice. The State of Healthcare Industry—Statistics for 2021. Available online: https://policyadvice.net/insurance/
insights/healthcare-statistics/ (accessed on 26 April 2022).
3. World Health Organization. Global Strategy on Human Resources for Health: Workforce 2030; WHO: Geneva, Switzerland, 2016.
4. Zhu, S.; Fan, W.; Yang, S.; Pei, J.; Pardalos, P.M. Operating room planning and surgical case scheduling: A review of literature.
J. Comb. Optim. 2019, 37, 757–805. [CrossRef]
5. Deloitte. 2020 Global Health Care Outlook; Deloitte: London, UK, 2020.
6. Limb, M. A fifth of healthcare spending is wasted, says OECD report. BMJ 2017, 356, j215. [CrossRef]
7. Grant, M.J.; Booth, A. A typology of reviews: An analysis of 14 review types and associated methodologies. Health Inf. Libr. J.
2009, 26, 91–108. [CrossRef]
8. Cilliers, L.; Retief, F.P. The evolution of the hospital from antiquity to the end of the middle ages. Curationis 2002, 25, 60–66.
[CrossRef]
9. Story, P. Optimizing Your Capacity to Care: A Systems Approach to Hospital and Population Health Management; Productivity Press:
New York, NY, USA, 2016.
10. Campbell, J.L. Significantly reducing facility maintenance costs through innovative custodial safety. J. Facil. Manag. 2005, 3,
203–214. [CrossRef]
11. Heller, C. How the Architecture of Hospitals Affects Health Outcomes; Harvard Business Review: Brighton, MA, USA, 2018.
12. Teke, A.; Zor, K.; Timur, O. A simple methodology for capacity sizing of cogeneration and trigeneration plants in hospitals: A case
study for a university hospital. J. Renew. Sustain. Energy 2015, 7, 053102. [CrossRef]
13. Budak, A.; Ustundag, A. Reverse logistics optimisation for waste collection and disposal in health institutions: The case of Turkey.
Int. J. Logist. 2017, 20, 322–341. [CrossRef]
14. Tarricone, P.; Luca, J. Employees, teamwork and social interdependence—A formula for successful business? Team Perform. Manag.
2002, 8, 54–59. [CrossRef]
15. Eriksson, C.O.; Stoner, R.C.; Eden, K.B.; Newgard, C.D.; Guise, J.-M. The Association Between Hospital Capacity Strain and
Inpatient Outcomes in Highly Developed Countries: A Systematic Review. J. Gen. Intern. Med. 2017, 32, 686–696. [CrossRef]
16. Vos, L.; Chalmers, S.E.; La Dueckers, M.; Groenewegen, P.; Wagner, C.; van Merode, G. Towards an organisation-wide process-
oriented organisation of care: A literature review. Implement. Sci. 2011, 6, 8. [CrossRef]
17. Banditori, C.; Cappanera, P.; Visintin, F. A combined optimization-simulation approach to the master surgical scheduling problem.
IMA J. Manag. Math. 2013, 24, 155–187. [CrossRef]
18. Lennerts, K.; Abel, J.; Pfründer, U.; Sharma, V. Reducing health care costs through optimised facility management-related
processes. J. Facil. Manag. 2003, 2, 192–206. [CrossRef]
19. Diez, K.; Lennerts, K. A process-oriented analysis of facility management services in hospitals as a basis for strategic planning.
J. Facil. Manag. 2009, 7, 52–60. [CrossRef]
20. Pati, D.; Park, C.-S.; Augenbroe, G. Facility Maintenance Performance Perspective to Target Strategic Organizational Objectives.
J. Perform. Constr. Facil. 2010, 24, 180–187. [CrossRef]
21. Busby, C.R. Modelling Hospital Surge with Data-Driven Discrete Event Simulation; ProQuest Dissertations Publishing: Ann Abor, MI,
USA, 2018.
22. Cary, J. In Haiti, A Building Fights Cholera. The New York Times, 12 September 2017.
23. Zhu, C.; Xu, B.; Nie, Y.Z. An Integrated Design and Operation Optimal Method for CCHP System. Energy Procedia 2019, 158,
1360–1365. [CrossRef]
24. Guo, L.; Liu, W.; Cai, J.; Hong, B.; Wang, C. A two-stage optimal planning and design method for combined cooling, heat and
power microgrid system. Energy Convers. Manag. 2013, 74, 433–445. [CrossRef]
25. Wu, Q.; Ren, H.; Gao, W.; Ren, J. Multi-objective optimization of a distributed energy network integrated with heating interchange.
Energy 2016, 109, 353–364. [CrossRef]
26. Paul, J. Study of Effects of Facility Damage on Hospital Capacity Estimates and Location-Allocation Planning for Management of
Natural Disasters. 2006. ProQuest Dissertations Publishing. Available online: https://www.proquest.com/docview/304938126?
pq-origsite=primo (accessed on 26 April 2022).
Healthcare 2022, 10, 826 24 of 27

27. Paul, J.A.; Batta, R. Models for hospital location and capacity allocation for an area prone to natural disasters. Int. J. Oper. Res.
2008, 3, 473. [CrossRef]
28. Feazel, L.; Schlichting, A.B.; Bell, G.R.; Shane, D.M.; Ahmed, A.; Faine, B.; Nugent, A.; Mohr, N.M. Achieving regionalization
through rural interhospital transfer. Am. J. Emerg. Med. 2015, 33, 1288–1296. [CrossRef]
29. Tlahig, H.; Jebali, A.; Bouchriha, H.; Ladet, P. Centralized versus distributed sterilization service: A location–allocation decision
model. Oper. Res. Health Care 2013, 2, 75–85. [CrossRef]
30. Kim, D.; Kim, W.-j.; Kim, M. Effects of Innovativeness on Customer Satisfaction in Long-Term Care Hospitals: The Effect of
Internal Capacity and Location Strategy in Hospital. Korea Acad. Ind. Coop. Soc. 2019, 20, 110–124.
31. Matsumoto, M.; Ogawa, T.; Kashima, S.; Takeuchi, K. The impact of rural hospital closures on equity of commuting time for
haemodialysis patients: Simulation analysis using the capacity-distance model. Int. J. Health Geogr. 2012, 11, 28. [CrossRef]
32. Liao, H.-C.; Chang, H.-H. The optimal approach for parameter settings based on adjustable contracting capacity for the hospital
supply chain logistics system. Expert Syst. Appl. 2011, 38, 4790–4797. [CrossRef]
33. Mahar, S.; Bretthauer, K.M.; Salzarulo, P.A. Locating specialized service capacity in a multi-hospital network. Eur. J. Oper. Res.
2011, 212, 596–605. [CrossRef]
34. Mestre, A.M.; Oliveira, M.D.; Barbosa-Póvoa, A.P. Location–allocation approaches for hospital network planning under uncer-
tainty. Eur. J. Oper. Res. 2015, 240, 791–806. [CrossRef]
35. Wilson, D.T.; Hawe, G.I.; Coates, G.; Crouch, R.S. A multi-objective combinatorial model of casualty processing in major incident
response. Eur. J. Oper. Res. 2013, 230, 643–655. [CrossRef]
36. Narzisi, G.; Mysore, V.; Mishra, B. Multi-objective evolutionary optimization of agent-based models: An application to emergency
response planning. Comput. Intell. 2006, 2006, 224–230.
37. Roccaforte, J.D.; Cushman, J.G. Disaster Preparedness, Triage, and Surge Capacity for Hospital Definitive Care Areas: Optimizing
Outcomes when Demands Exceed Resources. Anesthesiol. Clin. 2007, 25, 161–177. [CrossRef]
38. Tariverdi, M.; Fotouhi, H.; Moryadee, S.; Miller-Hooks, E. Health Care System Disaster-Resilience Optimization Given Its Reliance
on Interdependent Critical Lifelines. J. Infrastruct. Syst. 2019, 25, 04018044. [CrossRef]
39. Meites, E.; Farias, D.; Raffo, L.; Albalak, R.; Carlino, O.L.; McDonald, L.C.; Widdowson, M.-A. Hospital capacity during an
influenza pandemic-Buenos Aires, Argentina, 2009. Infect. Control Hosp. Epidemiol. 2011, 32, 87–90. [CrossRef]
40. Yi, P.; George, S.K.; Paul, J.A.; Lin, L. Hospital capacity planning for disaster emergency management. Socio-Econ. Plan. Sci. 2010,
44, 151–160. [CrossRef]
41. Paul, J.A.; Hariharan, G. Hospital Capacity Planning for Efficient Disaster Mitigation During A Bioterrorist Attack. In Proceedings
of the 2007 Winter Simulation Conference, Washington, DC, USA, 9–12 December 2017; pp. 1139–1147. [CrossRef]
42. Valdmanis, V.; Bernet, P.; Moises, J. Hospital capacity, capability, and emergency preparedness. Eur. J. Oper. Res. 2010, 207,
1628–1634. [CrossRef]
43. Schultz, C.H.; Koenig, K.L. State of Research in High-consequence Hospital Surge Capacity. Acad. Emerg. Med. 2006, 13, 1153–1156.
[CrossRef] [PubMed]
44. Delia, D.; Wood, E. The dwindling supply of empty beds: Implications for hospital surge capacity. Health Aff. 2008, 27, 1688–1694.
[CrossRef]
45. American College of Physicians. Locally informed simulation model predicts hospital capacity needs during COVID-19. Ann.
Intern. Med. 2020, 173, 21–28. [CrossRef] [PubMed]
46. Lennquist Montán, K.; Riddez, L.; Lennquist, S.; Olsberg, A.; Lindberg, H.; Gryth, D.; Örtenwall, P. Assessment of hospital surge
capacity using the MACSIM simulation system: A pilot study. Eur. J. Trauma Emerg. Surg. 2017, 43, 525–539. [CrossRef]
47. Tonna, J.E.; Hanson, H.A.; Cohan, J.N.; McCrum, M.L.; Horns, J.J.; Brooke, B.S.; Das, R.; Kelly, B.C.; Campbell, A.J.; Hotaling, J.
Balancing revenue generation with capacity generation: Case distribution, financial impact and hospital capacity changes from
cancelling or resuming elective surgeries in the US during COVID-19. BMC Health Serv. Res. 2020, 20, 1119. [CrossRef]
48. Römmele, C.; Neidel, T.; Heins, J.; Heider, S.; Otten, V.; Ebigbo, A.; Weber, T.; Müller, M.; Spring, O.; Braun, G.; et al. Bed capacity
management in times of the COVID-19 pandemic: A simulation-based prognosis of normal and intensive care beds using the
descriptive data of the University Hospital Augsburg. Anaesthesist 2020, 69, 717. [CrossRef]
49. Verma, V.R.; Saini, A.; Gandhi, S.; Dash, U.; Koya, M.S.F. Projecting Demand-Supply Gap of Hospital Capacity in India in the face
of COVID-19 pandemic using Age-Structured Deterministic SEIR model. medRxiv 2020. [CrossRef]
50. Bayram, J.D.; Sauer, L.M.; Catlett, C.; Levin, S.; Cole, G.; Kirsch, T.D.; Toerper, M.; Kelen, G. Critical resources for hospital surge
capacity: An expert consensus panel. PLoS Curr. 2013, 5. [CrossRef] [PubMed]
51. Gholamreza, K.; Hojat Sheikh, B.; Mohammad Hossein Yar, M.; Mahmoud Nekuyi, M. Hospitals Capability in Response to
Disasters Considering Surge Capacity Approach. Health Emerg. Disasters Q. 2016, 1, 111–118.
52. Sher, L. The impact of the COVID-19 pandemic on suicide rates. QJM 2020, 113, 707–712. [CrossRef]
53. Paul, J.A.; Batta, R. Improving hurricane disaster preparedness: Models for optimal reallocation of hospital capacity. Int. J.
Oper. Res. 2011, 10, 194–213. [CrossRef]
54. Handan, A.; Seyit, A. Indirect Forecasting of the Number of Intensive Care Beds and Hospital Capacity for the COVID-19
Outbreak in Turkey Until the End of April. Türk Yogun Bakim Dergisi 2020, 18, 22–30. [CrossRef]
55. Repoussis, P.; Paraskevopoulos, D.; Vazacopoulos, A.; Hupert, N. Optimizing emergency preparedness and resource utilization
in mass-casualty incidents. Eur. J. Oper. Res. 2016, 255, 531. [CrossRef]
Healthcare 2022, 10, 826 25 of 27

56. FitzGerald, G.; Patrick, J.R.; Fielding, E.L.; Shaban, R.Z.; Arbon, P.; Aitken, P.; Considine, J.; Clark, M.J.; Finucane, J.;
McCarthy, S.M.; et al. Pandemic (H1N1) 2009 Influenza Outbreak in Australia: Impact on Emergency Departments; QUT: Brisbane, QLD,
Australia, 2010.
57. Chen, J. PHP38—The Use of Simulation for Estimating Hospital Treatment Capacity in Dealing with Mass Casualty Incidents.
Value Health 2018, 21, S48. [CrossRef]
58. Texas Gov. Abbott Issues Executive Order Increasing Hospital Capacity, Announces Supply Chain Strike Force for COVID-19 Response;
Targeted News Service: Washington, DC, USA, 2020.
59. Nelson, B. Too little or too much? Missing the Goldilocks zone of hospital capacity during covid-19. BMJ 2020, 369, m2332.
[CrossRef] [PubMed]
60. Bhakoo, V.; Singh, P.; Sohal, A. Collaborative management of inventory in Australian hospital supply chains: Practices and issues.
Supply Chain. Manag. 2012, 17, 217–230. [CrossRef]
61. Niakan, F.; Rahimi, M. A multi-objective healthcare inventory routing problem; a fuzzy possibilistic approach. Transp. Res. E
Logist. Transp. Rev. 2015, 80, 74–94. [CrossRef]
62. Bornemann-Shepherd, M.; Le-Lazar, J.; Makic, M.B.F.; Devine, D.; McDevitt, K.; Paul, M. Caring for Inpatient Boarders in the
Emergency Department: Improving Safety and Patient and Staff Satisfaction. J. Emerg. Nurs. 2015, 41, 23–29. [CrossRef] [PubMed]
63. Kaw, N.; Murray, J.; Lopez, A.J.; Mamdani, M.M. Nursing resource team capacity planning using forecasting and optimization
methods: A case study. J. Nurs. Manag. 2020, 28, 229–238. [CrossRef]
64. Cheang, B.; Li, H.; Lim, A.; Rodrigues, B. Nurse rostering problems—-A bibliographic survey. Eur. J. Oper. Res. 2003, 151, 447–460.
[CrossRef]
65. Drake, R.G. The nurse rostering problem: From operational research to organizational reality? J. Adv. Nurs. 2014, 70, 800–810.
[CrossRef]
66. Smet, P.; Bilgin, B.; De Causmaecker, P.; Vanden Berghe, G. Modelling and evaluation issues in nurse rostering. Ann. Oper. Res.
2014, 218, 303–326. [CrossRef]
67. Martinez, D.; Kane, E.; Jalalpour, M.; Scheulen, J.; Rupani, H.; Toteja, R.; Barbara, C.; Bush, B.; Levin, S. An Electronic Dashboard
to Monitor Patient Flow at the Johns Hopkins Hospital: Communication of Key Performance Indicators Using the Donabedian
Model. J. Med. Syst. 2018, 42, 133. [CrossRef]
68. Bhat, S.; Gijo, E.V.; Jnanesh, N.A. Productivity and performance improvement in the medical records department of a hospital.
Int. J. Product. Perform. Manag. 2016, 65, 98–125. [CrossRef]
69. Fairman, Z. Tracking more efficient healthcare. Ind. Eng. 2012, 44, 56–57.
70. Schweigkofler, U.; Reimertz, C.; Auhuber, T.C.; Jung, H.G.; Gottschalk, R.; Hoffmann, R. Web-based evidence of treatment
capacity. An instrument for optimizing the interface between prehospital and hospital management. Unfallchirurg 2011, 114, 928.
[CrossRef]
71. Burdett, R.L.; Kozan, E. An integrated approach for scheduling health care activities in a hospital. Eur. J. Oper. Res. 2018, 264,
756–773. [CrossRef]
72. Ahalt, V.; Argon, N.T.; Ziya, S.; Strickler, J.; Mehrotra, A. Comparison of emergency department crowding scores: A discrete-event
simulation approach. Health Care Manag. Sci. 2018, 21, 144–155. [CrossRef] [PubMed]
73. Samudra, M.; Van Riet, C.; Demeulemeester, E.; Cardoen, B.; Vansteenkiste, N.; Rademakers, F.E. Scheduling operating rooms:
Achievements, challenges and pitfalls. J. Sched. 2016, 19, 493–525. [CrossRef]
74. Spratt, B.; Kozan, E. Waiting list management through master surgical schedules: A case study. Oper. Res. Health Care 2016, 10,
49–64. [CrossRef]
75. Spratt, B.; Kozan, E. A real-time reactive framework for the surgical case sequencing problem. Flex. Serv. Manuf. J. 2019, 33,
183–211. [CrossRef]
76. Spratt, B.; Kozan, E.; Sinnott, M. Analysis of uncertainty in the surgical department: Durations, requests and cancellations.
Aust. Health Rev. 2019, 43, 706–711. [CrossRef]
77. Spratt, B.; Kozan, E. An integrated rolling horizon approach to increase operating theatre efficiency. J. Sched. 2020, 24, 3–25.
[CrossRef]
78. Meskens, N.; Duvivier, D.; Hanset, A. Multi-objective operating room scheduling considering desiderata of the surgical team.
Decis. Support Syst. 2013, 55, 650–659. [CrossRef]
79. Vancroonenburg, W.; Smet, P.; Vanden Berghe, G. A two-phase heuristic approach to multi-day surgical case scheduling
considering generalized resource constraints. Oper. Res. Health Care 2015, 7, 27–39. [CrossRef]
80. Burdett, R.L.; Kozan, E. Techniques to effectively buffer schedules in the face of uncertainties. Comput. Ind. Eng. 2015, 87, 16–29.
[CrossRef]
81. Nguyen, J.M.; Six, P.; Antonioli, D.; Glemain, P.; Potel, G.; Lombrail, P.; Le Beux, P. A simple method to optimize hospital beds
capacity. Int. J. Med. Inform. 2005, 74, 39–49. [CrossRef]
82. Kokangul, A. A combination of deterministic and stochastic approaches to optimize bed capacity in a hospital unit.
Comput. Methods Programs Biomed. 2008, 90, 56–65. [CrossRef] [PubMed]
83. Cochran, J.K.; Roche, K. A queuing-based decision support methodology to estimate hospital inpatient bed demand. J. Oper.
Res. Soc. 2008, 59, 1471–1482. [CrossRef]
Healthcare 2022, 10, 826 26 of 27

84. Li, X.; Beullens, P.; Jones, D.; Tamiz, M. An integrated queuing and multi-objective bed allocation model with application to a
hospital in China. J. Oper. Res. Soc. 2009, 60, 330–338. [CrossRef]
85. Ben Abdelaziz, F.; Masmoudi, M. A multiobjective stochastic program for hospital bed planning. J. Oper. Res. Soc. 2012, 63,
530–538. [CrossRef]
86. Utley, M.; Peters, M. Bring on the geeks: The case for improved modelling of capacity requirements. Arch. Dis. Child. 2012, 97,
933–934. [CrossRef]
87. Devapriya, P.; Strömblad, C.T.B.; Bailey, M.D.; Frazier, S.; Bulger, J.; Kemberling, S.T.; Wood, K.E. StratBAM: A Discrete-Event
Simulation Model to Support Strategic Hospital Bed Capacity Decisions. J. Med. Syst. 2015, 39, 130. [CrossRef]
88. McManus, M.L.; Long, M.C.; Cooper, A.; Litvak, E. Queuing theory accurately models the need for critical care resources.
Anesthesiology 2004, 100, 1271–1276. [CrossRef]
89. Madell, D.; Villa, L.; Hayward, B.; Comte, L.L. Optimisation of hospital resource use: A rapid review of the literature. J. Hosp. Adm.
2015, 5, 107. [CrossRef]
90. Khaiter, P.; Erechtchoukova, M.; Aschane, Y. Towards a systematic approach to resource optimization management in the
healthcare domain. In Proceedings of the 22nd International Congress on Modelling and Simulation, Hobart, Australia, 3–8
December 2017.
91. Bastian, N.D.; Ekin, T.; Kang, H.; Griffin, P.M.; Fulton, L.V.; Grannan, B.C. Stochastic multi-objective auto-optimization for
resource allocation decision-making in fixed-input health systems. Health Care Manag. Sci. 2017, 20, 246–264. [CrossRef]
92. Feng, Y.-Y.; Wu, I.C.; Chen, T.-L. Stochastic resource allocation in emergency departments with a multi-objective simulation
optimization algorithm. Health Care Manag. Sci. 2017, 20, 55–75. [CrossRef]
93. Ahmadi, E.; Masel, D.T.; Metcalf, A.Y.; Schuller, K. Inventory management of surgical supplies and sterile instruments in hospitals:
A literature review. Health Syst. 2019, 8, 134–151. [CrossRef] [PubMed]
94. Ahsan, K.B.; Alam, M.R.; Morel, D.G.; Karim, M.A. Emergency department resource optimisation for improved performance:
A review. J. Ind. Eng. Int. 2019, 15, 253–266. [CrossRef]
95. Batt, R.J.; Terwiesch, C. Early Task Initiation and Other Load-Adaptive Mechanisms in the Emergency Department. Manag. Sci.
2017, 63, 3531–3551. [CrossRef]
96. Freeman, N.; Zhao, M.; Melouk, S. An iterative approach for case mix planning under uncertainty. Omega 2018, 76, 160–173.
[CrossRef]
97. Hof, S.; Fügener, A.; Schoenfelder, J.; Brunner, J.O. Case mix planning in hospitals: A review and future agenda. Health Care
Manag. Sci. 2017, 20, 207–220. [CrossRef]
98. McRae, S.; Brunner, J.O.; Bard, J.F. Analyzing economies of scale and scope in hospitals by use of case mix planning. Health Care
Manag. Sci. 2020, 23, 80–101. [CrossRef]
99. McRae, S.; Brunner, J.O. Assessing the impact of uncertainty and the level of aggregation in case mix planning. Omega 2020,
97, 102086. [CrossRef]
100. Durán, A.; Wright, S. Understanding Hospitals in Changing Health Systems, 1st ed.; Springer International Publishing: Cham,
Switzerland, 2020.
101. Zaric, G.S. Operations Research and Health Care Policy, 1st ed.; Springer: New York, NY, USA, 2013.
102. Keel, G.; Savage, C.; Rafiq, M.; Mazzocato, P. Time-driven activity-based costing in health care: A systematic review of the
literature. Health Policy 2017, 121, 755–763. [CrossRef]
103. Zhou, L.; Geng, N.; Jiang, Z.; Wang, X. Multi-objective capacity allocation of hospital wards combining revenue and equity. Omega
2018, 81, 220–233. [CrossRef]
104. Öker, F.; Özyapıcı, H. A new costing model in hospital management: Time-driven activity-based costing system.
Health Care Manag. 2013, 32, 23–36. [CrossRef]
105. Son, L.H.; Ciaramella, A.; Thu Huyen, D.T.; Staiano, A.; Tuan, T.M.; Van Hai, P. Predictive reliability and validity of hospital cost
analysis with dynamic neural network and genetic algorithm. Neural Comput. Appl. 2020, 32, 15237–15248. [CrossRef]
106. Carroll, N.; Lord, J.C. The Growing Importance of Cost Accounting for Hospitals. J. Health Care Financ. 2016, 43, 172–185.
[PubMed]
107. Khorram-Manesh, A.; Hedelin, A.; Ortenwall, P. Hospital-related incidents; causes and its impact on disaster preparedness and
prehospital organisations. Scand. J. Trauma Resusc. Emerg. Med. 2009, 17, 26. [CrossRef] [PubMed]
108. Hanan, T.; Mullen, L.; Laffoy, M.; O’Toole, E.; Richmond, J.; Wynne, M. Delivering care to oncology patients in the community:
An innovative integrated approach. Br. J. Community Nurs. 2014, 19, 382–387. [CrossRef] [PubMed]
109. Burkett, E.; Scott, I. CARE-PACT: A new paradigm of care for acutely unwell residents in aged care facilities. Aust. Fam. Physician
2015, 44, 204–209. [PubMed]
110. Liu, R.; Xie, X.; Augusto, V.; Rodriguez, C. Heuristic algorithms for a vehicle routing problem with simultaneous delivery and
pickup and time windows in home health care. Eur. J. Oper. Res. 2013, 230, 475–486. [CrossRef]
111. Rechel, B.; Wright, S.; Barlow, J.; McKee, M. Hospital capacity planning: From measuring stocks to modelling flows. Bull. World
Health Organ. 2010, 88, 632–636. [CrossRef]
112. Hall, R. Patient Flow Reducing Delay in Healthcare Delivery, 2nd ed.; Springer: New York, NY, USA, 2013.
Healthcare 2022, 10, 826 27 of 27

113. Yang, W.; Loo Hay, L.; Ek Peng, C.; Sean Shao Wei, L.; Seng Kee, L.; Eng Hock Ong, M.; Haobin, L. Multi-objective optimization
for a hospital inpatient flow process via Discrete Event Simulation. In Proceedings of the 2015 Winter Simulation Conference
(WSC), Huntington Beach, CA, USA, 6–9 December 2015; pp. 3622–3631. [CrossRef]
114. Burdett, R.L.; Kozan, E.; Sinnott, M.; Cook, D.; Tian, Y.-C. A mixed integer linear programing approach to perform hospital
capacity assessments. Expert Syst. Appl. 2017, 77, 170–188. [CrossRef]
115. Jones, J.I. Managing Healthcare Optimisation. 2017. Available online: https://get-csi.com/wp-content/uploads/2017/09/
JonesJI_HealthcareWhitepaperFinal_20170802.pdf (accessed on 26 April 2022).
116. Bittencourt, O.; Verter, V.; Yalovsky, M. Hospital capacity management based on the queueing theory. Int. J. Product. Perform.
Manag. 2018, 67, 224–238. [CrossRef]
117. Ritchie, M.R.a.H. Technological Progress. 2022. Available online: https://ourworldindata.org/technological-change (accessed on
26 April 2022).
118. QueenslandHealth. Available online: https://www.health.qld.gov.au/clinical-practice/innovation/digital-health-initiatives/
queensland/integrated-electronic-medical-record-iemr (accessed on 26 April 2022).
119. Andrews, R.; Goel, K.; Corry, P.; Burdett, R.; Wynn, M.T.; Callow, D. Process data analytics for hospital case-mix planning.
J. Biomed. Inform. 2022, 129, 104056. [CrossRef]
120. Langabeer, J.R. Performance Improvement in Hospitals and Health Systems: Managing Analytics and Quality in Healthcare, 2nd ed.;
CRC Press: Boca Raton, FL, USA, 2018.
121. Zhang, B.; Murali, P.; Dessouky, M.M.; Belson, D. A Mixed Integer Programming Approach for Allocating Operating Room
Capacity. J. Oper. Res. Soc. 2009, 60, 663–673. [CrossRef]
122. Ma, G.; Demeulemeester, E. A multilevel integrative approach to hospital case mix and capacity planning. Comput. Oper. Res.
2013, 40, 2198–2207. [CrossRef]
123. Saadouli, H.; Jerbi, B.; Dammak, A.; Masmoudi, L.; Bouaziz, A. A stochastic optimization and simulation approach for scheduling
operating rooms and recovery beds in an orthopedic surgery department. Comput. Ind. Eng. 2015, 80, 72–79. [CrossRef]
124. Cappanera, P.; Visintin, F.; Banditori, C. Comparing resource balancing criteria in master surgical scheduling: A combined
optimisation-simulation approach. Int. J. Prod. Econ. 2014, 158, 179–196. [CrossRef]
125. Schmidt, R.; Geisler, S.; Spreckelsen, C. Decision support for hospital bed management using adaptable individual length of stay
estimations and shared resources. BMC Med. Inform. Decis. Mak. 2013, 13, 3. [CrossRef]
126. Bouzon Nagem Assad, D.; Spiegel, T. Improving emergency department resource planning: A multiple case study. Health Syst.
2020, 9, 2–30. [CrossRef]
127. Kokangul, A.; Akcan, S.; Narli, M. Optimizing nurse capacity in a teaching hospital neonatal intensive care unit. Health Care
Manag. Sci. 2017, 20, 276–285. [CrossRef]
128. Liping, Z.; Na, G.; Zhibin, J.; Xiuxian, W. Public hospital inpatient rooms configuration and capacity allocation optimization
considering equity. In Proceedings of the 2017 13th IEEE Conference on Automation Science and Engineering (CASE), Xi’an,
China, 20–23 August 2017; Volume 2017, pp. 9–14. [CrossRef]
129. Jun, J.B.; Jacobson, S.H.; Swisher, J.R. Application of discrete-event simulation in health care clinics: A survey. J. Oper. Res. Soc.
1999, 50, 109–123. [CrossRef]
130. Fone, D.; Hollinghurst, S.; Temple, M.; Round, A.; Lester, N.; Weightman, A.; Roberts, K.; Coyle, E.; Bevan, G.; Palmer, S.
Systematic review of the use and value of computer simulation modelling in population health and health care delivery. J. Public
Health Med. 2003, 25, 325–335. [CrossRef]
131. Cardoen, B.; Demeulemeester, E.; Beliën, J. Operating room planning and scheduling: A literature review. Eur. J. Oper. Res. 2010,
201, 921–932. [CrossRef]
132. Rathnayake, D.; Clarke, M.; Jayasooriya, L. Hospital surge capacity: The importance of better hospital pre-planning to cope with
patient surge during dengue epidemics—A systematic review. Int. J. Healthc. Manag. 2019, 14, 723–730. [CrossRef]
133. Klein, M.G.; Cheng, C.J.; Lii, E.; Mao, K.; Mesbahi, H.; Zhu, T.; Muckstadt, J.A.; Hupert, N. COVID-19 Models for Hospital Surge
Capacity Planning: A Systematic Review. Disaster Med. Public Health Prep. 2020, 2020, 1–8. [CrossRef] [PubMed]
134. McCaughey, D.; Erwin, C.O.; DelliFraine, J.L. Improving Capacity Management in the Emergency Department: A Review of the
Literature, 2000–2012. J. Healthc. Manag. 2015, 60, 63–75. [CrossRef] [PubMed]