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Analysis of an Open Access Scheduling System in Outpatient Clinics: A

Simulation Study

Article in SIMULATION: Transactions of The Society for Modeling and Simulation International · August 2010
DOI: 10.1177/0037549709358295 · Source: DBLP

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Analysis of an Open Access Scheduling
System in Outpatient Clinics: A Simulation
Study
Sangbok Lee
Yuehwern Yih
School of Industrial Engineering,
Purdue University,
315 North Grant Street,
West Lafayette, IN 47907,
USA
{lee309, yih}@purdue.edu

Open access (OA) is a scheduling system which leaves the majority of the slots open to same-day
appointments (SDAs). The OA is expected to reduce patient waiting time and no-show rate, and,
in turn, increase clinic performance including patient satisfaction. Although many success stories
have been reported, there is no study investigating the impact of OA configuration considering envi-
ronmental conditions. In this paper, we conducted a simulation study in an outpatient clinic setting.
The clinical environments we consider include the demand variability, no-show rate, and the ratio of
SDA patients. The OA configurations are constructed by the slots for pre-book which is a comple-
ment of SDA and the scheduling horizon for the pre-book. The experimental results demonstrate the
performance of different OA configurations under various clinical environments in terms of patient
waiting time, patient rejection rate and clinic utilization. The results are scrutinized in the method of
a multi-objective optimization.
Keywords: appointment scheduling, discrete event simulation, efficient frontier, open access,
outpatient clinic

1. Introduction
The healthcare facilities are experiencing problems with
the traditional appointment scheduling (AS) system, such
as long waiting times, high rates of no-shows and can-
cellations [1]. In the traditional system, patients wait for a
long time to see physicians because the service sessions of
the physicians in the near future have already been filled
by previous appointments. This long waiting time results
in a high likelihood of no-shows and cancellations. Since
the no-shows and cancellations are difficult to predict, the
resources are not fully utilized. Consequently, this con-
tributes to further delays for future patients. It is likely
SIMULATION, Vol. 86, Issue 8-9, August-September 2010 503–518
1
c 2010 The Society for Modeling and Simulation International
DOI: 10.1177/0037549709358295
that patients who cannot wait that long will use the service
of an emergency department (ED) rather than the primary
care facilities [2]. This is costly, in terms of the effective
use of clinical resources and the cost of care.
Open access (OA) is an advanced scheduling system
developed to alleviate the problems of the traditional sys-
tem [3, 4]. The ideal concept of the OA is “do today’s
work today” [3]. In contrast to the traditional system, the
OA opens the majority of slots, which is approximately
65–75% (see [3]) of the slots per day, for patients who
want to be seen on the same day. It is asserted that the re-
maining slots should be return appointments which were
deliberately made by a patient or a physician and the wait-
ing time is at most 2 days [3, 5]. The OA reduces no-shows
and cancellations, and, thus, is expected to be a solution
for the problems of the traditional system [6, 7].
The problems of the OA can be induced from its sim-
ilarity to just-in-time (JIT), although the OA is expected
to be a solution to the traditional system. The ideal con-

Volume 86, Numbers 8-9 SIMULATION 503

 Lee and Yih
Figure 1. Hybrid system between traditional system and ideal Open Access system
cept of the OA is similar to that of JIT, “Right time, right
production” [8]. The “production” of JIT is analogous to
the “service to patients” in the OA. Thus, as JIT pro-
duces products when an order is placed, the OA attempts
to take care of patients who want to be seen on the day
when the request for the appointment is made. JIT is oper-
ated properly under a routine production or acute demand
prediction environment [9]. In the case that the demand
stream is not stable and prediction is difficult, hybrid sys-
tems, which combine JIT and material resource planning
(MRP), is developed and adopted [9–11]. Since patient
demand is not stable and it is difficult to predict the in-
stability, a hybrid system which incorporates the ideal OA
and the traditional system is required (Figure 1). In this
paper, we refer to the hybrid system as an alternative OA
policy.
The guideline on the configuration of the alternative
OA policies has not yet been proposed. In [4] it was
claimed that the modification on the OA configuration
is necessary based on the clinic environments. The 65–
75% of the open slots per day [3] is not the absolute
configuration for a universally applicable OA policy
throughout all clinic environments. In this work, various
alternative OA policies are simulated in diverse clinic
environments and the guideline will be presented. The
guideline can reduce the time for trial and error to find
the best fit OA in each outpatient clinic.
The remainder of this paper is organized as follows.
In Section 2 we present a review of the previous research
on the AS system and the OA. The simulation model for
this study is described in Section 3, which is followed by
504 SIMULATION Volume 86, Numbers 8-9
the results and analysis in Section 4. Section 5 contains
concluding remarks.
2. Literature Review
This study is on the AS system in an outpatient clinic.
Since the AS is a major component that affects clinic
performances [12], there have been many studies on this
topic. In [12] the methodologies employed in the AS stud-
ies were classified: analytical, simulation, and case study.
In this section we provide a brief overview of patient AS
systems and simulation study as a methodology. Research
on OA will be addressed in more detail.
The AS system can be classified by clinic operation
policies. A clinic can pre-determine the AS rule before
its session begins and the employed rule is a one-time
decision unless there is an administrative need. Mean-
while, a clinic can change its scheduling policy contin-
uously over a day, monitoring current clinic states. In
[12] they were categorized as static and dynamic sys-
tems (Figure 2). That is, the static system configures the
scheduling policies based on overall clinic state informa-
tion relying on the clinic’s historical data. The schedul-
ing policy configuration of the dynamic system changes
over the day based on the real-time decision from the
current clinic’s patient waiting time, available number of
physicians, lab room, etc. The static case is more com-
mon in actual clinic environments and much research has
been concerned with the static system. The dynamic case
was studied in [13–15]. The static clinic environments
 ANALYSIS OF AN OPEN ACCESS SCHEDULING SYSTEM IN OUTPATIENT CLINICS: A SIMULATION STUDY
Figure 2. Static and dynamic scheduling scheme
can be broken down by appointment rule. In this study,
the “individual-block/fixed-interval” appointment rule (a
term adapted from [13]) is applied for clinic modeling.
The individual-block/fixed-interval appointment rule was
employed in [16–18].
Simulation is an appropriate methodology to use for
analysis on the system and the system’s effect on diverse
performance measures because outpatient clinics are very
complicated multi-stage queueing systems [12, 19, 20].
That simulation can be a good tool to make decisions in
the healthcare system addressed in [21]. In [22] the first
simulation study was conducted in the AS. They assumed
that all patients have the same service time distribution
and there is no lateness or earliness in their arrival, while
in [16] patient unpunctuality and no-show rates were con-
sidered. In [22] comprehensive AS was simulated under
various operating environments and the conclusion was
that there is no globally applicable appointment rule under
all clinic environments. Fluctuating demand-loads were
introduced in [18] and the authors suggested good deci-
sions in each demand pattern scenario. Further, in [24]
a review was presented on research studies in healthcare
clinics, which used simulation as a methodology.
Although there are numerous successful implications
of OA reported [3, 6, 7], in [25] it was declared that the
implementation of the OA is still challenging because the
OA cannot absorb daily variations on patient demand, al-
though mean patient demand and mean clinic resources
are in equilibrium. In [5], similarly, it was stated that the
problems of the OA come from fluctuating patient de-
mand. They suggested a conservative OA configuration,
which opens 20% of the slots for same-day appointments
(SDAs) and the remaining 80% slots are for pre-booking
(pre-book). The majority of the OA papers [6, 7, 26–28],
as well as [5], have little quantitative modeling of OA, but
delivered case studies and managerial remarks. In [29] a
simulation model was developed of a clinic and an OA
performance was evaluated in terms of patient through-
put and cycle time in a day. However, the authors did
not provide an OA policy guideline to improve patient
accesses in the OA. In [30] four clinic parameters were
configured: the fractions of SDA patients to AS patients,
the planning horizons for the AS patients, the groupings
of primary care physician (PCP) group, and the overbook-
ing policy. They examined the OA in various clinic envi-
ronments configured by the clinic parameters in terms of
clinic throughput and patient continuity of care.
3. Modeling
In this section we describe a clinic environment and its
system dynamics, which is followed by the simulation
model. A discrete-event simulation model is constructed
and the modeling is based on an outpatient clinic of a
medical center in Indianapolis [31]. Through the regular
meetings with clinical and technical staff from the med-
ical center, the model was modified and validated. The
fundamental clinic environment was set up on the basis
of a real data set which was obtained from the year 2003
to 2004 when the traditional scheduling system was em-
ployed in the clinic. The AutoModTM simulation package
was used for running the simulation model and obtaining
the resultant data.
3.1 Clinic Environments and System Dynamics
A typical timetable of the physicians in the outpatient
clinic was used in our simulation model. There are 14 ser-
vice sessions available per day, per physician and each ser-
vice session lasts exactly 30 minutes. In the clinic, seven
physicians were regularly working. There was an adminis-
trative meeting on Wednesday, and thus, only seven slots
were available for each physician on the day. The clinic
operates from 8:00 to 16:00 and the lunch break is from
12:00 to 13:00. It is assumed that, in our model, there is
no modification in the timetable over a simulation run.
Volume 86, Numbers 8-9 SIMULATION 505
 Lee and Yih
Figure 3. Patient age composition in an outpatient clinic of a med-
ical center in Indianapolis
The majority of the patients in the outpatient clinic re-
quired continuity of care. Figure 3 shows the age compo-
sition of patients in the clinic. More than 70% of the pa-
tients were aged 50 or older. They used to visit the clinic
regularly, although the visiting interval was flexible, and
their allegiance to the clinic was relatively high. Patients
who were unable to make an appointment did not leave the
scheduling system, but attempted to make an appointment
again. In the model, we designed the number of attempts
to be three. That is, a patient can try to make an appoint-
ment up to three times.
There are three considerations of system dynamics in
patient AS. First, the patient daily demand is not stable,
but is fluctuating. That is, although the mean demand over
a year stays the same, the daily patient demand increases
when there is an epidemic or decreases in a vacation sea-
son [32]. Second, the arrival of patient calls for making
an appointment in a day is not distributed evenly. In [33,
34] it was stated that there is a time-of-day difference in
the arrival rate in systems such as telephone call centers.
Since the arrivals in our model are patient calls for ap-
pointments, it is suitable to adopt the uneven arrival rate
over the day. Under an OA scheduling scheme, the clinical
and technical staff in the clinic believe that more calls are
received in the beginning of the day because SDA patients
want to call earlier as there is a higher chance of getting
an appointment. Third, the no-show rate is substantial in
the system dynamics. [35] investigated patient no-show
rates in various clinic environments, which ranges from
12% to 42%. In a clinic, although the mean no-show rate
is estimated, individual patient no-show rates vary and it
is highly dependent on their appointment lead time [30].
For example, if a patient’s appointment is on the next day,
the predicted no-show of the patient is likely to be less
than the estimated no-show rate of the clinic [30]. We de-
veloped an adjustment function to predict an individual’s
no-show rate as follows:
506 SIMULATION Volume 86, Numbers 8-9
f 1x2 2 1 3 035 4 e3030174x 4
where x is appointment lead time. (1)
This function gives an adjustment rate. That is, if a pa-
tient’s appointment lead time is 1 in a clinic with a no-
show rate of 0.5, the predicted no-show rate for the pa-
tient is improved at most by half, which is close to 0.25.
The value 0.017 is an exponential decay constant of the
no-show improvement determined by their model fitting.
3.2 Simulation Model
When defining clinic environments, three environmental
factors were employed: patient demand variability, mean
no-show rate, and the ratio of SDA patients to the total
demand per day (SDA-ratio). First, the demand variabil-
ity is modeled with different variance levels against the
mean patient demand. The prior condition to a success-
ful OA is that the demand and the clinic resource capacity
are in equilibrium [3]. Since this study is on the OA, the
equilibrium between the mean demand and the capacity is
assured. A normal distribution is employed with the same
mean demand and different levels of demand variabilities.
The coefficient of variation (CV), C5 2 6 78, measures
the dispersion of a probability distribution. In the model,
three levels of CV, 10%, 20%, and 30%, are selected as
low variability, moderate variability, and high variability,
respectively.
Second, the mean no-show rates are 0.1, 0.3, and 0.5
following [35], who mentioned the range is from 0.12
to 0.42. With the no-show adjustment function (Equa-
tion (1)), the predicted no-show rate for individual patients
can be obtained by the following function f ns 1x2:
f ns 1x2 2 Ns 4 11 3 035 4 e3k4x 2 (2)
where f ns 1x2 is an individual’s predicted no-show rate
against appointment lead time x, Ns is the clinic’s esti-
mated no-show rate, and k is the exponential decay con-
stant. The exponential decay constant, 0.017, which was
employed in [30], will be modified and stated as k in
Equation (2). With the value 0.017, the clinic’s estimated
no-show rate can be closely reached when a patient’s lead
time is greater than 6 months. It was reasonable that the
mean appointment lead time was as great as 6 months
when the data was collected. Following the method with
use of our data, the decay constant is set to 0.076 because
the mean lead time was 92 days. The decay constant can
be calculated using
f ns 1x2 2 Ns 11 3 035e3kh 2 5 Ns
6 035e3kh 5 0 (3)
6 035e3kh 9 03001 (4)
 ANALYSIS OF AN OPEN ACCESS SCHEDULING SYSTEM IN OUTPATIENT CLINICS: A SIMULATION STUDY
Table 1. Environmental factors
Environmental factors
SDA-ratio
no-show 0.1
CV 1876 2 level 10% 20% 30%
demand 7 N 184 6 2 8 2 97
6 2 10 19 29
where h is the mean appointment lead time. We designed
that the similarity is achieved when the exponential term
is less than 0.001.
Third, the level of the SDA-ratio is 0%, 20%, 40%,
60%, and 80%. There are two types of patient calls: pa-
tients who want to make an appointment on the same day
(SDA) and patients who want to schedule in a future day
(pre-book). Thus, for example, a SDA-ratio of 20% means
that 20% of the patient calls are SDA patients and the other
80% are pre-book patients. The preference of the SDA or
the pre-book is the patient’s decision. The clinic, however,
can estimate the SDA-ratio through patients’ calls and the
SDA-ratio is highly likely to be dependent on external en-
vironmental conditions, such as the spread of a pandemic.
For these reasons, the SDA-ratio is chosen as an environ-
mental factor.
The equilibrium between the mean patient demand and
the clinic capacity must be considered along with the pa-
tient no-show rate. If a mean patient no-show rate is 0.3,
then the equilibrium is achieved when D 2 133C, where
D is the mean patient demand and C is the clinic capacity.
In the model, thus, the mean number of patients gener-
ated every day is 133C. As explained above, the number
of available slots per week is 114 8 14 8 7 8 14 8 142 4
7 physicians 2 441 and special cases such as days off are
not considered in the model. Divided by five business days
per week, the daily mean patient demand is 88. Consider-
ing the no-show rates 0.1, 0.3, and 0.5, the adjusted patient
demands are 97, 114, and 132, respectively. Table 1 de-
scribes the environmental factors and their detailed levels.
The clinic environments will be called “(no-show, SDA-
ratio, CV)” in this paper. For example, a clinic, (0.3, 0.6,
30%) means that the clinic’s no-show rate is 0.3, the SDA-
ratio is 0.6, and the CV is 30%.
Figure 4 illustrates the scheduling logic of the model.
The overall system is first-come-first-serve (FCFS) based.
Every day, the model generates patients and the num-
ber of the patients follows the normal distribution which
was specified above. All of the patients are queued in the
scheduling process in the order of their arrival times. As
stated in the previous section, the arrival rate is not the
same over the day. The number of patient calls is large at
the beginning of the day and it declines as the day ends.
The diminishing arrival rate was modeled with an expo-
nential distribution with a parameter of 2 hours, which
means up to 60% of patient calls come in the morning.
Levels
0.0 7 0.8 incremented by 0.2
0.3 0.5
10% 20% 30% 10% 20% 30%
8 2 114 8 2 132
11 22 33 13 26 39
The exponential distribution was selected because it cap-
tures the diminishing arrival pattern and its memoryless
property explains that each patient’s arrival is independent
of the time frame. The operating hours of the clinic which
is the basis of our model are from 09:00 to 17:00. Hence,
the exponential distribution is truncated at the end of the
operating hours.
Established patients go directly to their preferred pri-
mary care physician’s queue and non-established pa-
tients are randomly assigned to any physician. The non-
established patient implies new patients or patients who
do not have primary care physicians. The established pa-
tients in the model are 90% of the demand and the non-
established patients are 10% of the demand. This is a typ-
ical mix in the clinic studied.
Once the assignments are completed, following the
SDA-ratio, the types of the patients are determined and
each patient starts to search for a slot. Pre-book patients
search for a slot in the next days within the clinic’s plan-
ning horizon. If a pre-book patient fails to book in an at-
tempt, we assume that the patient comes to the scheduling
system again in a day within a week. As Figure 4 shows,
the return interval is assumed to be determined by a uni-
form distribution, U [14 5]. The sensitivity of the return in-
terval will be examined in Section 4. When a patient fails
in the first attempt and re-enters the scheduling system af-
ter a few days, the patient is removed from the queue of
the day of the first attempt and is moved to the queue of
the day of the next attempt. SDA patients first look for
a slot available for SDAs. In the case of pre-book slots
which have not been booked by pre-book patients, they
are also available to be chosen by the SDA patients. If
no SDA sessions or pre-book slots are available, the SDA
patients wait until a pre-book patient’s no-show occurs.
When there is a no-show, one of the waiting SDA patients
will occupy the slot. The waiting list will be cleared at
the end of every day and the SDA patients on the wait-
ing list at that time will be counted as a forfeit of the
clinic. As described above, pre-book patients with more
than three attempts are rejected resulting in a penalty for
the clinic. Meanwhile, when pre-book patients re-visit the
scheduling system, the patients can choose either a SDA
or a pre-book with 50% probability. Since there is no data
on the probability, we arbitrarily select the value as 0.5
and a sensitivity analysis on the probability will be con-
ducted. In the case that the pre-book patient transforms to
Volume 86, Numbers 8-9 SIMULATION 507
 Lee and Yih
Figure 4. Appointment scheduling flowchart
the SDA type, the patient follows the SDA route and can
be rejected, not reaching the next attempt. This process
is reasonable because, when a pre-book patient changes
his/her mind and chooses a SDA, it is likely that the pa-
tient needs to see a physician as soon as possible. Thus,
if the patient fails, he/she transfers to another clinic or se-
lects an ED.
3.3 Alternative OA Policy
When defining an alternative OA policy, two factors are
considered. One is the proportion of the SDA/pre-book
slots per day. The other is the planning horizon for the
pre-book slots. The simulation model alters the number
of pre-book slots (which are the complement of the SDA
slots) per day and tries to find the most appropriate pro-
portion between the SDA and the pre-book slots. Since
the alternative OA policies allow pre-books, the planning
508 SIMULATION Volume 86, Numbers 8-9
horizons for the pre-book slots are considered. Between
2 and 14 pre-book sessions per day per physician will be
selected as the proportion of the SDA/pre-book slots. [30]
set the planning horizons as 30 and 60 days. In our model,
a 10-day horizon is added and, thus, there are three lev-
els of planning horizons, 10, 30, and 60 days. At the same
time, locating the pre-book slots and the SDA slots in a
day is another decision. We located all of the pre-book
slots at the beginning of the day and all of the SDA slots
of the end of the day. This is suitable for the following rea-
son. Suppose that the SDA slots are placed at the begin-
ning of the day. Since the SDA patients are only available
to search a slot after they call in, it is more likely that the
SDA patients miss the slots which were not occupied.
Table 2 summarizes the decision factors. In an experi-
ment with 10 pre-book slots and a 30-day planning hori-
zon, the pre-book patients can search a service session
from every 10 slots at the beginning of the day in the next
30 days. We call the alternative OA policies “(planning
 ANALYSIS OF AN OPEN ACCESS SCHEDULING SYSTEM IN OUTPATIENT CLINICS: A SIMULATION STUDY
Table 2. Decision factors
Decision factors Levels
Pre-book slots 2 7 14 incremented by 2
(out of 14/day/physician)
Planning horizon 10, 30, and 60
horizon, pre-book slots)”. That is, a 30-day planning hori-
zon and 10 pre-book slots is denoted as (30, 10).
3.4 Performance Measures and Design of
Experiments
There are two classes in the performance measure, which
are a measure from the patient’s perspective and another
measure from the clinic’s perspective. In [12] it was stated
that the appointment system is evaluated in terms of the
patient waiting time, the clinic utilization and the physi-
cian overtime work. In this study, the patient waiting time
is in the class of the patient’s perspective and the clinic
utilization is in the clinic’s perspective. Since the study
focuses on the OA scheduling system, the overtime is not
considered. The overtime is meaningful when there is ser-
vice time randomness. In fact, the clinic which is the pro-
totype of our study fixes the service time as 30 minutes
and there is little overtime for each service session.
The measure from the patient’s perspective has two
sub-categories: the mean patient waiting time and the
number of patients rejected. The mean waiting time
is1only for pre-book patients and is calculated by
1 P W p 27num1P2, where P stands for the set of indi-
vidual pre-book patients and W p implies the waiting time
of a patient p, where p 9 P. Here num1P2 denotes total
number of elements in a set P and W p is the time differ-
ence between the call arrival for an appointment and the
patient’s scheduled time. If a pre-book patient fails in an
attempt and succeeds in the next attempt, the waiting time
is only calculated with the latter call. That is, the patient
call arrival time is updated every attempt. The patient’s
return call interval should not be included in the waiting
time because the interval is determined by the patient, and
it is the intended waiting time. In [25] this type of wait-
ing time is defined as “indirect waiting time”. The num-
ber of rejected patients takes the role of a complement to
the mean indirect waiting time. Patients do not satisfy the
clinic’s service if their attempts for appointments increase,
even when the mean waiting time is still in an acceptable
range. Thus, it should be pursued that the mean waiting
time and the number of rejected patients are minimized at
the same time.
Slot utilization is the measure in the clinic’s point of
view. The utilization is obtained from the number of ser-
viced slots divided by the total number of slots in a simu-
lation run. Even when all of the patients are SDA and the
clinic’s policy is to allow only pre-book patients, a utiliza-
tion of more than 90% can be achieved because the SDA
patients can occupy a slot whenever it is available. The
SDA patients only search for slots on the same day and, if
a slot is available on the day, it means no pre-book patients
have occupied that slot yet or there is a pre-book no-show.
In terms of the clinic’s satisfaction, the clinic utilization
should be maximized.
A full factorial design is employed [36]. There are three
levels of the no-show, five levels of the SDA-ratio, and
three levels of CV. Thus, total 45 clinic environments are
constructed. For the alternative OA policies, seven lev-
els of the number of pre-book slots and three levels of
the planning horizon make 21 different policies. There-
fore, the 45 clinic environments are investigated with 21
alternative OA configurations in the simulation. The best
OA configurations for each clinic environment will be de-
termined by the performance measures. Since there are
three performance measures, a multi-objective optimiza-
tion methodology is used. In the multi-objective optimiza-
tion with three performance measures, the efficient fron-
tier [23] should be constructed in three-dimensional space.
In this paper, the three-dimensional space is broken up
into three two-dimensional spaces.
4. Analysis of Simulation Results
The analysis of the simulation results is two phased. In
Phase I, the overall behavior of the alternative OA policies
over the environmental factors is presented and, then, the
best alternative OA policies for each clinic environment
are determined in Phase II.
4.1 Overall Behavior of the Alternative OA Policies
Figure 5 illustrates the rejection rate and the utilization
variations along with SDA-ratio at each level of no-shows.
Both the rejection rate and the utilization are little af-
fected by the scheduling policies when the SDA-ratio is
0.8. Each data point in the figures indicates an individual
alternative OA policy. Throughout the no-show levels, it is
observed that the rejection rate and the utilization saturate
as the SDA-ratio goes to 0.8. That is, all of the alternative
OA policies perform similarly in the sense of the rejec-
tion rate and the utilization when the SDA-ratio is 0.8.
Since SDA patients can make an appointment on any type
of slots available, when there are many SDA patients in a
clinic, the various slot compositions in the alternative OA
policies do not have a considerable impact on the rejection
and the utilization. For example, suppose that a clinic uses
a 1304 122 policy. The clinic allows pre-book patients to
book in the first 12 slots in the next 30 days. Assume that
there is an epidemic disease and, thus, the SDA-ratio in-
creases to 0.8. The pre-book patients who constitute only
20% of the daily demand can schedule on the 12 pre-book
available slots which are over 85% of the total slots per
day. Also, remaining 80% of the demand, SDA patients
Volume 86, Numbers 8-9 SIMULATION 509
 Lee and Yih
Figure 5. Rejection-rate/utilization against the SDA-ratio with the CV fixed at 20%
can obtain slots whether those are SDA slots or pre-book
slots left over.
It is shown that the rejection rate increases as the no-
show rate decreases in Figure 5. If the SDA-ratio is fixed
at 0.8, the rejection rate is above 0.3 when the no-show
rate is 0.1. The rejection rate, however, is below 0.2 when
the no-show rate is 0.5 given the SDA-ratio at 0.8. This
is obvious because more pre-book patient no-shows mean
a higher chance of acceptance for the SDA patients. That
is, when the no-show rate is from 0.1 to 0.5, the rejection-
rate decrease comes from the increased number of SDA
patients accepted. Then, in the case of a SDA-ratio of 0.0,
the rejection rate should be the same regardless of dif-
ferent no-show rates. However, it is observed that the re-
jection rate is higher when the no-show rate is 0.1 than
when the no-show rate is 0.5. In the model, if patient fails
to find a slot in an attempt, then the patient can be ei-
ther a SDA patient or a pre-book patient in the next at-
tempt. This is the reason why the rejection rate is dif-
ferent along with the no-show rates when the SDA-ratio
is 0.0.
Figure 5 shows that the utilization is lower at higher
no-show rate given a fixed level of SDA-ratio. Although
the slots which are available because of the no-shows can
be occupied by the SDA patients, that is not the perfect
compensation for the idle slots. If a SDA patient comes
later than the idle slot and there is no waiting SDA patient,
then the slot stays unoccupied.
510 SIMULATION Volume 86, Numbers 8-9
Figure 6 illustrates the rejection rate and the utilization
along with the CV while we fixed the SDA-ratio at 0.4. In
each figure of the rejection rate, the data cluster at each
CV level is little different. The utilization, however, de-
creases as the CV level increases from 0.1 to 0.3. That is,
the utilization is affected by the patient demand variabil-
ity while the rejection rate is not. If patient demand varies
day by day, it is possible that the demand of a day can
be less than the capacity or more than the capacity. Thus,
a day with smaller demand is likely to show slot under-
utilization.
The alternative OA policies can be clustered by their
planning horizons in terms of the waiting times. The clus-
ters, however, overlap as the SDA-ratio increases. Figure 7
illustrates the waiting time of the alternative OA policies
classified with the planning horizons. The clinic environ-
ments in Figure 7 are (0.5, SDA-ratio, 20%) and the SDA-
ratios are 0.2, 0.4, 0.6, and 0.8. When the SDA-ratio is 0.2,
there are three distinctively classified clusters. When the
SDA-ratio is 0.8, the three clusters overlap. This is reason-
able because, with a SDA-ratio of 0.8, the number of SDA
patients is four times higher than the number of pre-book
patients. Thus, the SDA patients are supposed to get ap-
pointments on the same day or leave. When the SDA-ratio
is 0.6, the waiting time is highly dependent on the OA
policies. For example, the policies with the 60-day plan-
ning horizon, the waiting time spreads from close to 0 to
more than 50 days. This implies that it is highly likely that
 ANALYSIS OF AN OPEN ACCESS SCHEDULING SYSTEM IN OUTPATIENT CLINICS: A SIMULATION STUDY

Figure 6. Rejection-rate/utilization against CV with the SDA-ratio fixed at 0.4

the waiting time can be controlled by how we design the

proportion of the slots in clinics of the SDA-ratio is 0.6. Table 3. Summarized ANOVA tests: Performance measures af-
Table 3 is a summary of analysis of variance (ANOVA) fected by no-show rate, SDA-ratio and CV (W: Waiting time, R:
results. An ANOVA is conducted to explain the variability Rejection rate, U: Utilization)
of the waiting time, the rejection rate and the utilization,
respectively, in terms of the environmental factors. In each OA policy No-show rate SDA-ratio CV
alternative OA policy, the performance measures affected (Planning horizon,
Pre-book slots)
by each environmental factor are presented. For example,
the CV has impact on the utilization when policy 2 is em- (10, 2) W, R, U W, R, U R, U
ployed. Table 3 describes that the no-show and the SDA- (10, 4) W, R, U W, R, U U
ratio have a significant impact on the three performance (10, 6) R, U W, R, U U
measures while the CV affects, generally, only the utiliza- (10, 8) R, U W, R, U U
tion. Similar observations were obtained from Figures 5 (10, 10) R, U W, R, U U
and 6. (10, 12) W, R, U W, R, U U
(10, 14) W, R, U W, R, U U
(30, 2) W, R, U W, R, U R, U
4.2 The Best OA Policy for Each Clinic Environment (30, 4) W, R, U W, R, U U
(30, 6) R, U W, R, U U
In this section, we refer to each alternative OA policy as (30, 8) W, R, U W, R, U U
an alphabetical character. Table 4 is the reference table for (30, 10) R, U W, R, U U
the alternative OA policies. (30, 12) W, R, U W, R, U U
Figure 8 presents the efficient frontiers for the clinic (30, 14) W, R, U W, R, U N/A
environments (0.3, 0.0, 10%). Each data point indicates (60, 2) W, R, U W, R, U R, U
the performance of an alternative OA policy. For exam- (60, 4) W, R, U W, R, U U
ple, in Figure 8(a), each point illustrates the waiting time (60, 6) R, U W, R, U U
and the rejection rate of an OA policy. The data points (60, 8) W, R, U W, R, U U
with a letter written beside each of them are the dominant (60, 10) W, R, U W, R, U U
scheduling policies (efficient frontier) over all of the alter- (60, 12) W, R, U W, R, U U
native OA policies in this clinic environment. Figure 8(a) (60, 14) W, R, U W, R, U N/A

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 Lee and Yih

Figure 7. Waiting times of the alternative OA policies classified with the planning horizons in the clinic environments of “no-show = 0.5 and
CV = 20%”

Table 4. Alternative OA policy reference

Alternative OA policy (10, 2) (10, 4) (10, 6) (10, 8) (10, 10) (10, 12) (10, 14)
Character a b c d e f g
Alternative OA policy (30, 2) (30, 4) (30, 6) (30, 8) (30, 10) (30, 12) (30, 14)
Character h i j k l m n
Alternative OA policy (60, 2) (60, 4) (60, 6) (60, 8) (60, 10) (60, 12) (60, 14)
Character o p q r s t u

displays the performance measures from the patient point
of view. Hence, the objective for the figure is to minimize
a linear cost function, Wtime 8 Rrate , where Wtime is the
waiting time and Rrate is the rejection rate. The and are
the unit costs for the waiting time and the rejection rate,
respectively. The decision maker in a clinic determines the
weights, and . If a clinic puts more weight on the pa-
tient rejection than the waiting time, the policy “u” can
be the choice because the rejection rate for the policy “u”
is the smallest, although the waiting time is longer than
that of “g” and “n”. Figure 8(b) illustrates the alternative
policies’ performances in terms of the utilization and the
rejection rate. It is recommended to have higher utilization
and lower rejection rate. Based on the criteria, the policies
“g”, “n” and “u” are selected as efficient frontiers. Among
the optimal policies, if a clinic weights on the utilization
rather than the rejection, the policy “g” can be the choice.
Although the “g” is selected as the dominant policy in
Figure 8(c), “g” cannot be the best policy because there
are three performance measures. Figure 8(c) determines
the best policy in terms of the utilization and the waiting
time. As stated earlier, however, if the efficient frontiers
are drawn in a three-dimensional space, the “g” cannot be
dominant over “n” and “u”. It is induced from Figure 8(a)
and (b). That is, “g” does not dominate “n” and “u” when
the performance is evaluated with the rejection rate. All of
the policies “g”, “n”, and “u” have 14 pre-book slots. That
is, consequently, the policies having 14 pre-book slots are
selected as the optimal policies in the clinic environment
(0.3, 0.0, 10%).
Table 5 presents the efficient frontiers of the alterna-
tive OA policies for each clinic environments. Note that,
when the no-show increases, the alternative OA policies
with higher number of pre-book slots are selected as the

512 SIMULATION Volume 86, Numbers 8-9

 ANALYSIS OF AN OPEN ACCESS SCHEDULING SYSTEM IN OUTPATIENT CLINICS: A SIMULATION STUDY
Figure 8. Efficient frontiers (with policy named) and inferior OA policies in clinic environments (0.3, 0.0, 10%)
Table 5. Efficient frontiers for the clinic environments
No-show 0.1
CV 10%, 20%, 30%
0.0 g, n, u
0.2 f, g, m, n, t, u
SDA-ratio 0.4 e, f, l, m, s, t
0.6 c, d, j, q
0.8 N/A
efficient frontiers. For example, the efficient frontiers for
the environments of no-show 0.1 and SDA-ratio 0.6 are
the policies with six pre-book slots, “c”, “j”, and “q”, and a
policy “d” having eight pre-book slots. The efficient fron-
tiers of the clinics with the same SDA-ratio, 0.6, but the
no-show rate is 0.5, are the policies “d” and “k” which
have eight pre-book slots and “e” and “f” having more
than eight pre-book slots. It connotes that the clinics with
higher no-show rates select an OA policy with a larger
number of pre-book slots. The clinic environments with
the SDA-ratio of 0.8 do not have the efficient frontiers.
As described in the previous section, the performance of
all of the alternative OA policies are similar in all of the
clinic environments with SDA-ratio 0.8. When the clinic
is (0.1, 0.2, any CV), all of the policies with 14 and 12
pre-book slots constitute the efficient frontiers. The poli-
cies with 12 pre-book slots, however, are dominated by
the policies with 14 pre-book slots in the clinics (0.3, 0.2,
0.3 0.5
10%, 20%, 30% 10%, 20%, 30%
g, n, u g, n, u
g, n, u g, n, u
f, g, e, l, s f, g, m, t
c, d, e, j, q d, e, f, k
N/A N/A
any CV) and (0.5, 0.2, any CV). That is, when the no-show
rate is 0.3 and 0.5, the clinics of the SDA-ratio 0.2 do not
need to prepare the SDA slots for their SDA patients who
take up around 20% of the demand. It is reasonable be-
cause more no-shows create a higher acceptance rate of
the SDA patients.
Overall, the alternative OA policies which retain the
number of pre-book slots as many as the expected number
of pre-book patients can be an optimal scheduling scheme.
Figure 9 illustrates that the number of pre-book slots of the
efficient frontiers encompasses the number of pre-book
patients in the clinic. The values in the cells above the
gray cells indicate the average daily pre-book patient de-
mand per physician of a clinic. The gray cells indicate the
number of pre-book slots of the selected frontiers. For ex-
ample, for the clinic environment with the no-show 0.3
and the SDA-ratio 0.4, the mean pre-book demand is 11.
The efficient frontiers are the scheduling policies with 10,
Volume 86, Numbers 8-9 SIMULATION 513
 Lee and Yih
Figure 9. Mean number of daily pre-book patients per physician and the number of pre-book slots of the efficient frontiers for each clinic
environment
12, and 14 slots for pre-book which encompass the num-
ber of the mean pre-book demand 11.
In addition, the alternative OA policies which have pre-
book slots more than the expected number of pre-book
patients can be an optimal scheduling scheme. Figure 9
shows that the gray cells are more than one and the most
of the gray cells extend rightward, when the SDA-ratio
is greater than 0.4. The reason is that, if a clinic offers
more pre-book slots for appointments, it increases the ac-
ceptance probability of pre-book patients and the SDA pa-
tients who cannot be admitted in the SDA slots can be as-
signed to the pre-book slots available due to no-shows. For
example, when the no-show rate is 0.5 and the SDA-ratio
is 0.8, the gray cells covers 8, 10, and 12 pre-book slots,
because there are many no-shows which can be covered
by the SDA patients.
4.3 Sensitivity Analysis
When a patient cannot make an appointment in the first
attempt, it is assumed, in the model, that the probability
of the patient’s return-attempt to pre-book is 0.5. From
the previous analysis, it was shown that the SDA-ratio is
a significant factor on the performances of the alternative
policies. The SDA-ratio is a portion of SDA patients in a
day. Thus, in addition to the SDA-ratio, the return-attempt
ratio takes a role in constituting the number of SDA pa-
tients per day. Owing to this, a sensitivity analysis on the
return-attempt probability is required.
Figures 10 and 11 illustrate the three performance mea-
sures of the optimal OA policies in each clinic envi-
ronment. Table 6 describes the clinic environments and
the implemented optimal policies for Figures 10 and 11.
There are four clinic environments in Figure 10 and those
514 SIMULATION Volume 86, Numbers 8-9
are (0.1, 0.0, 20%), (0.1, 0.2, 20%), (0.1, 0.4, 20%) and
(0.1, 0.6, 20%). Figure 11 has four environments with
same SDA-ratios and CV, but different no-show rate at
0.5. The optimal policies are selected among the efficient
frontiers for each clinic environment from Table 5.
The optimal policies are robust when the return-
attempt ratio to pre-book is up to 0.5 and the 0.5 was the
modeling assumption. If the return-attempt ratio is greater
than 0.5, the rejection rate increases and the utilization
decreases significantly, in particular in clinics with a no-
show rate of 0.5. If the return-attempt ratio is greater than
0.5, this implies that more than 50% of patients who fail
to book in the first attempt want to be pre-book patients
from the second attempt. Hence, the clinic has an increas-
ing number of pre-book patients in the scheduling sys-
tem. Since the no-show rate is critical to pre-book pa-
tients, it is expected that more pre-book patients cause
lower utilization. Also, an increasing number of pre-book
patients prompts a higher rejection rate. The robustness of
the optimal policies in clinics with lower a no-show rate,
0.1, maintains a return-attempt ratio of 0.7. In case of the
return-attempt ratio of 0.9 in Figure 10, the performance
of the optimal policies in clinics with lower SDA-ratio,
such as 0.0 and 0.2, tends to be worsened. This is because
the clinic’s ability to give a service to the pre-book patients
is close to its limit and more pre-book patients are likely
to cause a higher rejection rate. The utilization is directly
affected by the no-shows and not likely to be covered by
SDA patients because the number of the SDA patients de-
creases.
When there is a return-attempt, the return interval is
assumed to follow a uniform distribution, U [14 5] days.
That is, the patient’s return-attempt occurs on a day
equally likely in the next 5 days. The maximum return-
interval is 5 days and it is shorter than the minimum plan-
 ANALYSIS OF AN OPEN ACCESS SCHEDULING SYSTEM IN OUTPATIENT CLINICS: A SIMULATION STUDY

Figure 10. Performance measures of the efficient frontiers in the clinics of CV 20%, no-show 0.1, and different levels of SDA-ratio, against
the ratio of the return-attempt to pre-book

Figure 11. Performance measures of the efficient frontiers in the clinics of CV 20%, no-show 0.5, and different levels of SDA-ratio, against
the ratio of the return-attempt to pre-book

Volume 86, Numbers 8-9 SIMULATION 515

 Lee and Yih

Table 6. Selected clinic environments and optimal OA policies for sensitivity analysis on the ratio of the return-attempt to pre-book

Figure Clinic environs. Optimal policies Number

No-show SDA CV PH Pre-book slots in the legend
Figure 10 0.1 0.0 20% 10 14 1
30 14 2
0.1 0.2 20% 10 12 3
30 12 4
0.1 0.4 20% 10 10 5
30 10 6
0.1 0.6 20% 10 6 7
10 8 8
Figure 11 0.5 0.0 20% 10 14 1
30 14 2
0.5 0.2 20% 10 14 3
60 14 4
0.5 0.4 20% 10 12 5
30 12 6
0.5 0.6 20% 10 8 7
10 10 8

Table 7. Performance of the optimal policies in clinic environments along with different return-intervals

Clinic environments Optimal policy Return-interval Waiting time Rejection rate Utilization
[1, 5] 1.360 0.111 0.930
(0.1, 0.4, 20%) (10, 12) [1,10] 1.360 0.111 0.930
[1,20] 1.360 0.111 0.930
[1, 5] 1.360 0.111 0.930
(0.5, 0.4, 20%) (10, 12) [1,10] 1.360 0.111 0.930
[1,20] 1.360 0.111 0.930
Clinic environments: (no-show, SDA-ratio, CV)
Optimal policy: (Planning horizon, pre-book slots)
Return-interval: Uniform [a, b] days

ning horizon (10 days) of the alternative OA policies. Thus 5. Conclusion

a sensitivity analysis on the return-interval is conducted.
Three time intervals are studied and those are U [14 5],
U [14 10], and U [14 20] days. Only the optimal policies
with the 10-day planning horizon are used and it implies
that the sensitivity of the time intervals which are less
than, equal to, or more than the planning horizon is an-
alyzed.
Table 7 summarizes the sensitivity analysis. As shown
in Table 7, the values of the waiting time, the rejection
rate, and the utilization are identical throughout differ-
ent return-intervals. This implies that the performances of
the optimal policies are not affected by the return-interval.
From the two sensitivity analyses, it is concluded that the
decision to be a SDA or a pre-book in the return-attempt
has a considerable impact on the functioning of the al-
ternative OA policies regardless of how long the return-
interval is.
OA has been reported as a successful advanced scheduling
system in outpatient clinics. The system configuration of
OA has to be different to fit in each different clinic envi-
ronment. To date, however, the OA configuration has been
adjusted and implemented by trial and error. In this work,
we have studied the OA system in various clinic environ-
ments with a discrete-event simulation model developed
with AutoModTM simulation package. The result analysis
gives a suggestion of how to configure the OA policies to
perform properly.
The model implemented the daily demand of patients
which is normally distributed and the different arrival rate
over the day. This work has investigated the effect of
the slot composition of the SDA/pre-book on the various
clinic environments. The investigated slot compositions
are called the alternative OA policies. The clinic environ-
ments were constructed with three variables: the patient

516 SIMULATION Volume 86, Numbers 8-9

 ANALYSIS OF AN OPEN ACCESS SCHEDULING SYSTEM IN OUTPATIENT CLINICS: A SIMULATION STUDY
no-show rate (no-show), the ratio of SDA patients (SDA-
ratio), and the demand variability (CV). Since the funda-
mental condition of the OA is the equilibrium between the
demand and the capacity, the mean demand was set to the
capacity which is adjusted with the clinic’s estimated no-
show. The alternative OA policies have been scrutinized
in terms of patient indirect waiting time, patient rejection
rate, and clinic utilization. The indirect waiting time im-
plies the waiting time from the patient’s request to the
patient’s scheduled time. The rejection rate describes the
failure rate of patients who cannot make an appointment
with up to three attempts. The utilization is a measure to
analyze the clinic service slot’s utilization.
The results were two phased. Phase I described the
relation between the environmental conditions and over-
all performance of the alternative policies. Phase II iden-
tified the best OA policy in each environment. Overall,
all of the policies function differently when the clinics
are differentiated by the no-show rate or the SDA-ratio.
When only the demand variability is different, the poli-
cies perform dissimilarly only in terms of the utilization.
In detail, higher no-show causes lower rejection rate and
higher utilization, especially in clinics with many SDA pa-
tients. Higher demand variability results in lower utiliza-
tion when the SDA-ratio is fixed. If the SDA-ratio is high,
then the alternative policies perform similarly in the sense
of utilization and the rejection rate. Meanwhile, the wait-
ing time tends to be longer and closer to the planning hori-
zon as there are smaller SDA patients. If we configure the
slot compositions for the best performance, then setting
the number of pre-book slots as many as the expected pre-
book patients can be an optimal choice. When the number
of SDA patient and the no-show rate is large, healthcare
providers can prepare SDA slots as many as or more than
the expected SDA patients in the clinic.
Sensitivity analyses on the assumptions of the patient
return-attempt have been conducted. When a pre-book pa-
tient fails to obtain a slot in an attempt, the patient is as-
sumed to choose a pre-book again in the next trial with
probability of 0.5 and the time interval between the two
attempts is assumed to be within the next 5 days. The sen-
sitivity analysis demonstrated that the optimal policies are
robust over the return-interval. The optimal policies, how-
ever, are robust only when the return-attempt ratio to pre-
book is less than or equal to 0.5. Hence, more studies are
required with the ratio of the return-attempt to pre-book
as another environmental factor.
This study can be extended to incorporate the physi-
cian’s service time randomness. A service session length
is fixed as 30 minutes and it is a limitation of this study.
In the challenge with the service time randomness, physi-
cian’s idle time and overwork will be integrated. Also, in
the analysis of the OA policies, the daily waiting time of
the SDA patients can be a measure of performance. An-
other challenge is to devise a new scheduling scheme,
such as a mixed OA scheduling system with double-
booking policy. Our simulation model will be adjusted
to pursue developing an optimal design of the mixed
system.
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Sangbok Lee is a Ph.D. student in the School of Industrial En-
gineering, Purdue University, West Lafayette, IN, USA. He re-
ceived the B.S. degree from the Department of Industrial Systems
and Information Engineering, Korea University, Seoul, Korea in
2003 and the M.S.I.E. degree from the School of Industrial En-
gineering in Purdue University, West Lafayette in 2006.
Yuehwern Yih is Professor of Industrial Engineering at Purdue
University and the Director of Smart Systems and Operations
Laboratory. She is the Regenstrief Center for Healthcare En-
gineering Faculty Scholar. Her research focuses on design and
control of complex systems, which incorporates multiple system
outcomes, and dynamic environmental conditions into a respon-
sive and effective controller. The applications of her research
results include semiconductor fabrication, e-tailing, machine di-
agnosis and prediction, water networks, advanced life-support
system, and healthcare systems. She received her Ph.D. in In-
dustrial Engineering from the University of Wisconsin–Madison
in 1988. She is an IIE fellow.