Abstract
This paper examines the long-standing operational issue of patients boarding in the emergency department (ED), who have been admitted to hospital (inpatient ‘boarders’). From this analysis we design a conceptual model that provides a roadmap to create sustainable improvements in ED waiting times. The conceptual model is built using system dynamics methodology, and illustrates the use of system archetypes, a set of common causal feedback loops that illustrate how well-intended decisions have unintentional side effects. This paper outlines the journey taken by one large academic health centre to address these issues, and highlights the larger implications and recommendations that are applicable to other publicly funded hospitals.
Similar content being viewed by others
References
Caesar MCW, Chouhan A and Ko A (2008). From diagnosis to cure: A process improvement journey. Electron Healthc 7: e1–e10.
Canadian Institute for Health Information (2009). Alternate Level of Care in Canada. Canadian Institute for Health Information (CIHI): Ottawa, Digital document, http://www.cihi.ca.
Coyle G (2000). Qualitative and quantitative modelling in system dynamics: Some research questions. Syst Dynam Rev 16: 225–244.
Delafuente JC (2009). The silver tsunami is coming: Will pharmacy be swept away with the tide? Am J Pharm Educ 73: 1.
Eldabi T, Paul RJ and Young T (2007). Simulation modelling in healthcare: Reviewing legacies and investigating futures. J Opl Res Soc 58: 262–270.
Fedorowicz Z, Lawrence D and Gutierrez P (2005). Day care versus in-patient surgery for age-related cataract. Cochrane Database Syst Rev 25: CD004242.
Forrester JW (1994). System dynamics, systems thinking, and soft OR. Syst Dynam Rev 10: 245–256.
Garrett C (2008). The effect of nurse staffing patterns on medical errors and nurse burnout. Aorn J 87: 1191–1204.
Gregoroff SJ, McKelvie RS and Szabo S (2004). The impact of an outpatient heart failure clinic on hospital costs and admissions. Int J Health Care Qual Assur Inc Leadersh Health Serv 17: i–xi.
Hass H, Coyer FM and Theobald KA (2006). The experience of agency nurses working in a London teaching hospital. Intensive Crit Care Nurs 22: 144–153.
Hodgson AM (1992). Hexagons for systems thinking. Eur J Opl Res 59: 220–230.
Kane RL, Shamliyan T, Mueller C, Duval S and Wilt TJ (2007). Nurse staffing and quality of patient care. Evid Rep Technol Assess (Full Rep) 151: 1–115.
Lane DC (1993). The road not taken: Observing a process of issue selection and model conceptualization. Syst Dynam Rev 9: 239–264.
Lane DC and Husemann E (2008). System dynamics mapping of acute patient flows. J Opl Res Soc 59: 213–224.
Lane DC, Monefeldt C and Husemann E (2003). Client involvement in simulation model building: Hints and insights from a case study in a London hospital. Health Care Mngt Sci 6: 105–116.
Lane DC and Oliva R (1998). The greater whole: Towards a synthesis of system dynamics and soft systems methodology. Eur J Opl Res 107: 214–235.
Lattimer VA, Brailsford SC, Turnbull JC, Tarnaras P, Smith H, George S, Gerard K and Maslin-Prothero S (2004). Reviewing emergency care systems I: Insights from system dynamics modelling. Emerg Med J 21: 685–691.
Maliapen M and Dangerfield BC (2010). A system dynamics-based simulation study for managing clinical governance and pathways in a hospital. J Opl Res Soc 61: 255–264.
Manias E, Aitken R, Peerson A, Parker J and Wong K (2003). Agency nursing work in acute care settings: Perceptions of hospital nursing managers and agency nurse providers. J Clin Nurs 12: 457–466.
Montibeller G and Belton V (2006). Causal maps and the evaluation of decision options—A review. J Opl Res Soc 57: 779–791.
Moskop JC, Sklar DP, Geiderman JM, Schears RM and Bookman KJ (2009). Emergency department crowding, part 1—Concept, causes, and moral consequences. Ann Emerg Med 53: 605–611.
Olshaker JS and Rathlev NK (2006). Emergency Department overcrowding and ambulance diversion: The impact and potential solutions of extended boarding of admitted patients in the Emergency Department. J Emerg Med 30: 351–356.
Poole B, Robinson S and MacKinnon M (1998). Resource intensity weights and Canadian hospital costs: Some preliminary data. Healthc Mngt Forum 11: 22–26.
Robinson S (2008). Conceptual modelling for simulation Part II: A framework for conceptual modelling. J Opl Res Soc 59: 291–304.
Romanow RJ (2002). Building on values: The future of health care in Canada. Commission on the Future of Health Care in Canada.
Sterman JD (2000). Business Dynamics: Systems Thinking and Modeling for a Complex World. McGraw-Hill: Boston.
Thungjaroenkul P, Cummings GG and Embleton A (2007). The impact of nurse staffing on hospital costs and patient length of stay: A systematic review. Nurs Econ 25: 255–265.
Vanderby S and Carter MW (2010). An evaluation of the applicability of system dynamics to patient flow modelling. J Opl Res Soc 61: 1572–1581.
Wolstenholme EF (1992). The definition and application of a stepwise approach to model conceptualisation and analysis. Eur J Opl Res 59: 123–136.
Wolstenholme EF (1993). A case study in community care using systems thinking. J Opl Res Soc 44: 925–934.
Wolstenholme EF (2003). Towards the definition and use of a core set of archetypal structures in system dynamics. Syst Dynam Rev 19: 7–26.
Wolstenholme EF (2004). Using generic system archetypes to support thinking and modelling. Syst Dynam Rev 20: 341–356.
Wolstenholme EF, Monk D, McKelvie D and Arnold S (2007). Coping but not coping in health and social care: Masking the reality of running organisations beyond safe design capacity. Syst Dynam Rev 23: 371–389.
Wong HJ, Morra D, Caesar M, Carter MW and Abrams H (2010a). Understanding hospital and emergency department congestion: An examination of inpatient admission trends and bed resources. Canadian J Emerg Med 12: 18–26.
Wong HJ, Wu RC, Caesar M, Abrams H and Morra D (2010b). Smoothing inpatient discharges decreases emergency department congestion: A system dynamics simulation model. Emerg Med J 27: 593–598.
Wong H, Wu RC, Tomlinson G, Caesar M, Abrams H, Carter MW and Morra D (2009). How much do operational processes affect hospital inpatient discharge rates? J Public Health (Oxf) 31: 546–553.
Author information
Authors and Affiliations
Corresponding author
Rights and permissions
About this article
Cite this article
Wong, H., Morra, D., Wu, R. et al. Using system dynamics principles for conceptual modelling of publicly funded hospitals. J Oper Res Soc 63, 79–88 (2012). https://doi.org/10.1057/jors.2010.164
Received:
Accepted:
Published:
Issue Date:
DOI: https://doi.org/10.1057/jors.2010.164