Hospital as logistical system: too big too detail?

In 2006 I started to model the entire logistical hospital system to assess the design of a new hospital building. With this model it was possible to analyze for example walking distances, occupation of space, elevators, hallways and crossing of clean and infectious patients or goods. The typical hospital has many nodes – 111 in the example – many relations between those origins and destinations (here 1069). Let me ask you a question. If you see this, what so you think?

A: Wow, that is a lot of flows. How am I supposed to manage this?

B: Well, I don’t really think there is much too improve on logistics

C: Cool picture. What can I do with it? What does it tell me?

D: I thought logistics was about my inventory materials, not about patients and staff

Log netwerk2
This is the same hospital, but the network is structured in a different way. Nodes that have little flows from or to other nodes are on the edges of the network. The ones with many flows between them are in the middle.
Log netwerk
The nodes on the edge of the circle are the hospital departments, the lines the patient, materials and staff flows between these departments. Wider lines represent flows that occur more frequently.


I heard all sorts of reactions, depending on the context these models were used in. The bottom line is that overseeing the logistical network of a hospital is relevant, but just seeing that it is a complex system is not enough. Knowing you are in a complex world is not necessarily reassuring. Knowing that the people who created this complex world – doctors, nurses, medical technicians and many other professionals – are not easily controlled or changed, is another worrying thought. Blueprints, benchmarks or other methodes that provide a clear idea or structure are very appealing, but in my opinion do not work in hospitals because these methods leave this complexity out.

Research shows that cooperation and coherence are key issues in achieving high efficiency and quality in hospitals, not only on a departmental, but also on hospital level. Evidence was found that efficient individual departments in a hospital did not necessarily make the entire hospital efficient [1]. So from this spaghetti picture we need to derive what cooperation and cohesion is needed to make a hospital work effectively. But where to start with this? Is this hospital wide perspective on logistics useful in large infrastructure investment decision making processes? In mergers? Is this the reason that mergers do not deliver better hospitals [2], because the spaghetti bowl gets even more messy? Who are the stakeholders at the table of large hospital transformation processes? What are their information needs? What then are the requirements for logistical models, if we want to use these at the negotiation table like we did at the outpatient department? How does this relate to philosophies like lean and six sigma? Do hospitals include a logistical perspective at all when they are taking decisions? With these questions in mind I started making a PhD research proposal.

[1] Ludwig M, van Merode GG, Groot W (2010) Principal agent relationships and the efficiency of hospitals. Eur J Health Econ 11(3): 291-304.

[2] There are several studies and articles in which the effectiveness of mergers are described. From an operations management perspective positive effects of mergers are  at least doubtful. Examples of articles are:

Weil TP (2010) Hospital consolidations: do they deliver? Physician Exec 36(5), Kmietowicz Z (2013).

Hospital merger is blocked because of failure to prove patient benefits. BMJ and Ahgren B (2008).

Is it better to be big? The reconfiguration of 21st century hospitals: responses to a hospital merger in Sweden. Health Policy 87(1).

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