Multi Criteria and Decision Making

1st Semester 2k22

Scheduling of elective surgery patients in a private sector
hospital using an integrated AHP-LP approach

Submitted To:

Dr. Mirza Jahanzaib

Submitted By:

Muhammad Shehbaz 22-MSc-IE-04

Umair Shahid 22-phD-EM-21

Industrial Engineering Department

University of Engineering and Technology Taxila
Task Distribution

Team Member

Muhammad Shehbaz 22-MSc-IE-04

Umair Shahid 22-phD-EM-21

Work Distribution
Team Member contributions

Umair Shahid Muhammad Shehbaz

Tasks
Problem selection Yes Yes
Introduction Yes Yes
Literature Review Yes
Methodology/Modelling Yes Yes
Results and Analysis Yes
Table of Content

CONTENTS

I Introduction...............................................................................................................................................................6

II research Motivation..................................................................................................................................................7

iiI Literature Review:....................................................................................................................................................8

A. Elective Surgery Scheduling and Planning..........................................................................................................8

B. Elective Surgery Prioritization:............................................................................................................................8

C. Multi-criteria Decision Making (MCDM):............................................................................................................8

D. Analytical Hierarchy Process (AHP):...................................................................................................................9

IV Research Methodology:.........................................................................................................................................10

V RESULTS AND DISCUSSION....................................................................................................................................13

VI. CONCLUSIONS.......................................................................................................................................................17

VII.FUTURE WORK......................................................................................................................................................17

References................................................................................................................................................................. 18
List of Table

Table 1 : Criteria and sub-criteria weights.................................................................................................................14

Table 2: The AHP score of patients............................................................................................................................15

Table 3: Solution of LP model to schedule the surgeries............................................................................................16

Table 4:Comparison between old and new patients ranking.....................................................................................16

Abstract

This case study aims toward the scheduling of elective surgery patients in a private sector
hospital. Fatima Memorial Hospital (FMHP) is a renowned medical health institution in Lahore.
There are a number of specializations available in the FMHP hospital, including the general
surgery, pediatric surgery, ENT, orthopedic, urology, neurosurgery, vascular, trauma, chest, and
cardiac surgery departments. The operating theatre often represents a bottleneck and causes
unexpected inpatient treatment and stay. It generates the highest costs as it involves expensive
surgical equipment and labor resources. hospital managers are highly interested in finding
efficient and effective ways of planning and running the operating theater to improve the
quality and productivity of its services. To solve these scheduling problems the techniques of
multiple-criteria decision-making(MCDM) and multiple-criteria decision analysis(MCDN) use is
an an integrated AHP-LP approach considering their criteria and sub criteria weights. The
overall inconsistency ratio is found to be 0.1, which is acceptable. The most significant criteria,
which account for 66.45% of the total weight, are clearly disease severity and difficulty
performing daily activities. In contrast, hospital readmission accounts for 12.5% of the total
weight, and patient age and other diseases rank last among these criteria, each accounting for
9.8%. it is recommended to see if there is a department with specific criteria for prioritization of
patients. These and other possible criteria can be taken into consideration in future studies.

Keywords: Planning and scheduling ,service setor,MCDM, AHP,LP

I INTRODUCTION

Fatima Memorial Hospital (FMHP) is a renowned medical health institution in Lahore . A

prominent medical facility in Lahore, it was founded in 1977 and occupies a 24000 square
meter space. The Fatima Memorial Hospital, FMH College of Medicine, and Saida Waheed
College of Nursing are the three hospitals that make up FMH. The hospital has roughly 510 beds
available in total. There are a number of specializations available in the surgery hospital,
including the general surgery, pediatric surgery, ENT, orthopedic, urology, neurosurgery,
vascular, trauma, chest, and cardiac surgery departments. The Surgical Hospital contains 16
operating rooms, including 5 for obstetrics and gynecology, 2 for daily care, 1 for cosmetic and
burn procedures, 2 for emergencies, and 6 for elective procedures. four types of surgeries are
available in FMH Hospital, which include:

1. Emergency (Top Emergent) Surgery: In this type, cases arrive randomly and must be served
immediately to avoid permanent disability or death.

2. Urgent Surgery: It is a type of operation surgery, where procedures must be done for one day
(24 hours), like an appendectomy. Some researchers consider urgent surgery as emergency
surgery.

3. Elective Surgery: In this type, cases can be delayed and planned for future dates. This
category is for pre-schedule and non-immediate surgeries that are not urgent and can be
planned for future dates.

4. Planned (Semi Urgent) Surgery: It is a type of elective surgery which was delayed or which
should be performed within one week at most. The focus of this study will be on elective
surgery (which includes Planned Surgery).

When a patient is seen by a doctor in an outpatient clinic, elective surgery scheduling begins.
The procedure is then scheduled utilizing the First Come First Served concept in the event that
the doctor determines the patient needs surgery (FCFS). A daily average of 35 procedures are
scheduled, while a daily average of 27 elective surgeries are carried out. Due to the high patient
volume and limited operating room capacity, patients might expect to wait anywhere between
6 and 18 months for their surgery.

II RESEARCH MOTIVATION
Data for the planned and actual surgery appointments were gathered and examined for three
months, from September to December of 2017. It should be noted that just 8% of all elective
procedures were conducted as planned, whereas 32% of elective surgeries were performed
behind schedule, 21% of elective surgeries were performed in advance of schedule, and 39% of
elective surgeries were performed without a schedule. Additional investigation and analysis of
the causes of these percentages revealed that 32% of the patients had procedures that were
completed later than expected. This percentage can be explained by a variety of factors. The
first is when a patient makes an appointment, but after some time, their condition worsens. In
this situation, they go back to the doctor, who then suggests they schedule an appointment for
the closest procedure. Because another patient's appointment was taken in this instance, the
entire system of scheduling surgeries was disrupted, and ahead-of-schedule and unscheduled
patients began taking scheduled patients' appointments. The second cause is that there aren't
enough resources or time; occasionally a procedure is scheduled to take a certain amount of
time, but it actually takes longer. This has an impact on scheduling. The third reason is that
there aren't enough rooms; if an emergency case shows up at the hospital and the emergency
rooms are full, the surgery is done in one of the rooms designated for elective surgery. The
fourth cause is the cancellation rate, which happens when a patient is not healthy enough for
surgery, such as when their blood pressure is too high, or their heartbeat is irregular. This study
attempts to create a scheduling model that can address the issues with the current surgery
scheduling system that have been highlighted.

 Give priority to patients who need surgeries at the earliest appointment from patients
who can wait longer.
 Maximize the percentage of on-scheduled surgeries.

III LITERATURE REVIEW:

Generally, the operating theatre often represents a bottleneck and causes unexpected inpatient
treatment and stay. It generates the highest costs as it involves expensive surgical equipment
and labor resources[1]. Furthermore, hospital managers are highly interested in finding efficient
and effective ways of planning and running the operating theater to improve quality and
productivity of its services [2].

A. ELECTIVE SURGERY SCHEDULING AND PLANNING

Most academics believe that the "surgical scheduling problem"—the lengthy wait times for
elective surgery patients—needs to be solved. Research on the timing and planning of surgeries
uses a variety of methodologies and objectives. Regarding the goals, it is seen that several
research have attempted to maximize just one performance parameter, like increasing
operating room usage while reducing associated costs. [2] and [3], while many others have
included several performance criteria in their studies [4], and [5]. Operations research,
mathematic models programming, and discrete-event simulation are widely used techniques to
construct the master surgery plan i.e. allocation of operation rooms time blocks for each
surgeon or specialty [6] and [7]. Moreover, they can be used to specify a surgery date for each
patient, i.e. assigning surgical cases into operating rooms [8] and [9] in addition to improving
the surgery scheduling [10] and [11]. The meta-heuristics that used to workshop scheduling
problems are adapted to the healthcare systems by some researchers [11].

B. ELECTIVE SURGERY PRIORITIZATION:

The use of multi-criteria decision making (MCDM) techniques to separate patients who can wait
longer from those who need surgery at the earliest opportunity is the subject of numerous
research. The New Zealand Priority Criteria Project modified the Delphi method to generate
clinical and social criteria after reaching consensus [12]. The repertory grid method [13]elicit
criteria used by surgeons for prioritization of patients for elective general surgery. In a patient
who has a high score has the a prioritized surgery appointment in the priority scoring system, in
this system the criteria and weights to assign patients on waiting lists for elective surgery scores
are determined[14].

C. MULTI-CRITERIA DECISION MAKING (MCDM):

MCDM or MCDA are well-known techniques for multiple-criteria decision-making and multiple-
criteria decision analysis. When an analyst must address an issue involving numerous criteria,
they can apply the MCDM approach. By structuring, resolving, and planning these issues, the
MCDA outcomes can be justified. For such issues, there cannot be a single best answer; instead,
it is required to leverage the decision maker's preferences to distinguish between and choose
the appropriate alternatives. The Analytical Hierarchy Process is one of the most often used
MCDM types (AHP).

D. ANALYTICAL HIERARCHY PROCESS (AHP):

AHP was developed by Saaty [15, 16], it is a decision-making method for prioritizing alternatives
when multiple criteria must be considered. The aim, the criteria, and the options are some of
the hierarchical components of the problem's structure. Pairwise comparisons are used by AHP
to create a ratio scale of measurement. Ratio scales enable the evaluation of both measurable
and intangible elements and are a natural way to compare options. Pairwise comparison is used
to determine how objects on one level affect ones on the higher level. For instance, the
alternatives are evaluated pairwise based on their capacity to meet each of the criteria, and the
criteria are compared pairwise based on their capacity to meet the goal, which is the upper
level of the criteria. The greatest eigenvalue of the matrix for each level of the hierarchy is
computed to determine the weights of the items being compared at that level. In order to
compute a final weight for each alternative, the results from levels of the hierarchy are
combined using a weighted average approach. Saaty suggests that if the consistency ratio < 0.1,
then with respect to the pairwise comparisons are said to be consistent, otherwise, reasons
contributing to lack of inconsistency are investigated, and logic is used to revise the
comparisons until CR is acceptable. Several authors have discussed the use of the AHP across a
broad range of applications in health and medical decision making. Hatcher described how the
AHP can be included within a Group Decision Support Process (GDSS) and how the resulting
system can be applied in a variety of health care decision making settings [17]. Sloane,
Liberatore, and Nydick, discussed the applicability of the AHP for medical and hospital decision
support [17]

IV RESEARCH METHODOLOGY:
 A. Criteria Identification and Selection

The main criteria and sub-criteria that are needed to prioritize surgeries were determined from
previous research works [13-15, 19]. These criteria were discussed with FMH hospital
department heads and physicians from different surgical specializations until reaching to the
final list of criteria and sub-criteria as shown in Fig 1.

B. Criteria and Sub-Criteria Weights

A questionnaire was created to enable pairwise comparisons of the criteria for the goal of
"elective surgical priority," as well as the sub-criteria for each of the criteria. The questionnaire
was then given to the heads of four departments (General Surgery, Orthopedic, Urology, and
Neurosurgery), which account for 70% of all elective procedures performed at FMH Medical
Complex, in order to establish the importance of the various criteria and sub-criteria. The
questionnaire was given to each department head to complete on their own. Following a
thorough discussion, a joint session with the four heads was organized to determine the final
criteria weights. The results were analyzed using EXPERT CHOICE Program [20] to determine the
weights of criteria and sub criteria.

C. Linear Programming Model

Since it is well recognized that operating rooms contain a certain number of resources,
including surgeons, nurses, medical equipment, surgical teams, and rooms, this model
incorporates the operating room's capacity as a constraint. A group of surgeons are given a set
of time blocks to schedule their surgical cases in operating rooms in accordance with the block
scheduling technique. The number of doctors and capacity vary between departments, and
each department has a distinct capacity. Each department was advised to use a different model
for a week.

This model focuses on the four departments (General Surgery, Orthopedic, Urology, and
Neurosurgery). The model parameter Xij is the number of patients who need surgery of type i =
[6] (minor, moderate and major) in department j (General surgery, Orthopedic, Urology and
Neurosurgery). The objective function is to maximize the number of surgeries per week for
each department, based on (1),
3 4

∑ ❑ ∑ Dij∗Xij (1)
i=1 j=1

Where, Dij is the score from AHP of the patient who needs a surgery with type (i) in department
(j). For example, if a patient has index i=2, and j=3 (X23) it means that this patient from urology
department and he/she needs a moderate surgery.
 Figure 1: List of criteria and sub criteria

Model Constraints
1. General surgery department has allocated 3 days for surgeries in the week, for
each day, ten elective surgeries can be performed, two of them are major
surgeries, the same number is for moderate surgeries, while one is for minor
surgeries. "Therefore, the model parameters Xij(s) for this department covering the
one-week surgeries become (2), (3) and (4)". X11<= 6 (2), X21<= 12 (3), X31<=12 (4)
2. The orthopedic department has allocated 3 days in the week, for each day eight
elective surgeries can be performed, two of them are major surgery and three
surgeries for each of the two other types. "Therefore, the model parameters Xij(s)
for this department covering the one-week surgeries become (5), (6) and (7)".
X12<= 9 (5), X22<= 9 (6), X32<=6 (7)
3. Urology department has allocated two days in the week, for each day five elective
surgeries can be done, one of them is for minor and the other moderate and major
have two for each. "Therefore, the model parameters Xij(s) for this department
covering the one-week surgeries become (8), (9) and (10)". X13<= 2 (8), X23<= 4
(9), X33<=4 (10)
4. Neurosurgery department has allocated two days in the weak, for each day five
elective surgeries can be done, three of them are major and the other two types
has one operation for each one. "Therefore, the model parameters Xij(s) for this
department covering the one-week surgeries become (11), (12) and (13)".
X14<= 2 (11), X24<= 2 (12), X34<=6 (13)
 5. Equation (14) is for a constraint guarantees that allocated surgeries on Sunday are
(Urology, Orthopedic and General Surgeries) and they should not exceed 18

3 3 3

∑ Xi 1+ ∑ Xi 2 +∑ Xi 3≤18 (14)
i=1 i=1 i=1

6. Allocated surgeries on Monday are (Neurosurgery and General Surgeries) and they
should not exceed 15 as shown in constraint’s equation
3 3

∑ Xi 1 +∑ Xi 4 ≤15 (15)
i=1 i=1

7. Allocated surgeries on Tuesday are (General Surgeries) and they should not exceed
10 as shown in constraint’s equation (16).
3

∑ Xi 1 ≤10 (16)
i=1

8. Allocated surgeries on Wednesday are from all departments and they should not
exceed 23 as shown in constraint’s equation (17)
3 3 3 3

∑ Xi 1+ ∑ Xi 2 +∑ Xi 3+∑ Xi 4 ≤ (17)
i=1 i=1 i=1 i=1

9. Allocated surgeries on Thursday are (Orthopedic) and they should not exceed 8 as
shown in constraint’s equation (18).
3

∑ Xi 2 ≤8 (18)
i=1

The LP model is solved by LINDO (Linear, INteractive, and Discrete Optimizer) which is a
convenient, but powerful tool for solving linear, integer, and quadratic programming problems.
Specific application areas where LINDO has proven to be of great use would include product
distribution, ingredient blending, production and personnel scheduling, inventory management
[22]
V RESULTS AND DISCUSSION

criteria outcomes, The overall inconsistency ratio is found to be 0.1, which is acceptable.
Table I displays the average relative weights vector for each criterion in relation to the
objective. The most significant criteria, which account for 66.45% of the total weight, are
clearly disease severity and difficulty performing daily activities. In contrast, hospital
readmission accounts for 12.5% of the total weight, and patient age and other diseases rank
last among these criteria, each accounting for 9.8%. B. Outcomes of Sub-Criteria: Pairwise
comparisons at the third level of the hierarchy were used to determine the relative weight
of each subcriterion with respect to its corresponding criterion. For age’s sub criteria
results, table I shows that the highest priority is for new born patients whose ages are less
than one year, then for children aged (1-12 years) and followed by old age (more than 60
years).

Because it is well recognised that these age groups of society are frequently frail and free
of disease, this priority order makes sense. Following that, patients between the ages of 13
and 60 who are middle-aged, adult, and adolescent have approximately equal priority. As
can be seen from Table I, the results for the sub-criteria "Patient having other disease"
indicate that a patient with a haematological disease receives the highest priority for
procedures. It is also obvious that people with diabetes mellitus and people with high blood
pressure are ranked the lowest. As expected, severe pain has the highest weight, followed
by the moderate pain, and the lowest weight was for mild pain. For disease severity, the
same percentages and rankings applied. Patient Ranking, C To assign each patient a final
score based on the weights and scores of the criterion and sub criteria, a sample of 50
patients (from the four departments that are the subject of the study) were chosen. Each
criterion score is added together to produce the patient's final score. As the patients were
ranked, the one with the highest final score gets assigned to the first open spot.Table II
shows an example or 15 patients with the old and the new scheduling. The old surgeries
scheduling follows the First Come First Served (FCFS) rule, which means the patient who
first comes is assigned the first available surgery appointment. The results show that a huge
change is made in the ranking (scheduling); for example the old first, third and fifth patients
became the fifteenth (last), the thirteenth and the twelfth, respectively. While the old
fourth became the new first. This ranking provides evidence that the scheduling process
should be examined and improved and schedules should be made according to the AHP
methodology to be more rational.

LP Model Results
The model gives the optimum scheduling for each type of surgeries according to constraints
that determine the capacity and the maximum allowable number of surgeries in each
department. Table III shows the results obtained from the model after solving it by LINDO
6.1 software

Table 1 : Criteria and sub-criteria weights

From the table III, it is noticeable that the model results in a schedule of performing the
surgeries of major and moderate types in Neurosurgery department at the nearest times. It is
also obvious that the major surgeries in Orthopedic and Urology departments should take a
prioritized schedule. The major general surgeries take some appointments that are in the
middle but most of them are the last. E. Comparison Between Old and New Patients Ranking
Table IV explains a small comparison between the new ranking resulted from the research and
the old ranking collected from the surgery hospital. The comparison includes three patients
whom old ranking were the first, tenth and fourteenth. The first old ranked patient was 40
years old man who needed a minor orthopedic surgery, his degree of pain was moderate,
moreover, his disease severity was moderate, no readmission, and no other diseases. His score
was increased because of the difficulty of doing the surgery which weight was 0.266, then his
score is 35.7%. This old first became the last fifteenth. Table IV also shows that the old tenth
and fourteenth became the third and the second new ranked patients respectively. The score of
the two patients was very close because they nearly had the same score of all criteria and sub-
criteria except for the age the second was a child of 5 years old and the third was an adult of 52
years old. The other criteria and sub criteria are the same the two patients needed a major
Neurology surgery, readmission, difficulty in doing activity and a severe degree of pain.
Table 2: The AHP score of patients
 Table 3: Solution of LP model to schedule the surgeries

Table 4:Comparison between old and new patients ranking

VI. CONCLUSIONS

This study showed that the main criteria to prioritize elective surgeries are disease severity,
difficulty in performing daily activities, hospital readmission, degree and frequency of pain,
patient having other diseases and patient age. The two most important criteria were found to
be disease severity and difficulty in performing daily activities. When ranking patients, it was
found that the neurosurgery patients had the highest final score, this is due to the fact that
neurosurgery patients take a high score in severity of diseases and high degree of pain which
made their final score high. It is observed that if these criteria/cub criteria and their scores are
used, the number of surgeries which will be performed on schedule will maximized, and thus
the number of ahead of/ behind schedule surgeries will be minimized. VII.

VII.FUTURE WORK

It is recommended, in the future to take into consideration the opinions of the remaining
specialists in other departments to determine criteria. Furthermore, it is recommended to see if
there is a department with specific criteria for prioritization of patients. These and other
possible criteria can be taken into consideration in future studies.
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