APPLICATION OF QUEUING THEORY TO
OPTIMIZE WAITING-TIME IN HOSPITAL
OPERATIONS
Dr Deepak Yaduvanshi1
Dr Ashu Sharma2
Praful V More3
Abstract
Waiting time is inherent to the healthcare service sector in India and a major challenge faced
by almost every big hospital is queuing. Long waiting time can be a reflection of inefficiency
in hospital operations. The out-patient department (OPD) has the biggest queue as compared
to other departments in hospital operations. This study comprises of in-depth analysis of OPD
from different dimensions. Like in many big hospitals across India, the OPD of Fortis Escorts
Hospital in Jaipur, India is managed using experience and rule of thumb rather than strategic
research based techniques such as queuing theory. The Fortis Escorts Hospital in Jaipur
receive large number of patients each day which results in longer waiting time for patients
due to long queues. To address this challenge, a SWOT analysis was conducted for the OPD
of Fortis Escorts Hospital Jaipur (FEHJ) which resulted into dissecting the queuing problem
and coming out with solutions knowing where the hospital operations can excel and where
there is a scope of improvement to make the working and processes better. Additionally, after
examining the problem analytically and applying queuing theory, measures were suggested to
improve the delay points and make the OPD more efficient in order to gain a high patient
satisfaction rating.
Keywords:Queuing Theory, OPD, Waiting time, Hospital operations, SWOT, Patient
satisfaction
1
Chief Consultant &Head Clinical services , Pulmonology Critical Care Manipal Hospitals,
Jaipur.
2
Associate Professor, Narsee Monjee Institute of Management Studies (Deemed to be
university), Mumbai.
3
Research Scholar, Narsee Monjee Institute of Management Studies (Deemed to be
university), Mumbai.
Corresponding author:
Praful V More, Narsee Monjee Institute of management Studies, V.L. Mehta Road, Vile Parle
(W), Mumbai- 400056, Maharashtra, India.
E-mail: [email protected]
INTRODUCTION
Hospital services operations particularly, outpatient department plays a crucial role in
providing quality healthcarefor multi-speciality hospitals (Carman, 1990). The outpatient
department (OPD) often acts as profit centre in hospital operations not only for investing in
new technology but also to curb losses on inpatient services (Green, 2006). However, despite
the importance of OPD, hospitals fail to address complaints regarding long waiting time
caused majorly due to observable queues which results in patient dissatisfaction (Kim 2t.al,
2009). Thus, hospital service operations should have a smooth flowto satisfy the patient’s
expectations by redesigning their systems and adapting to the best practices and tools with
improved processes (Natrajan, 2006) which has a huge scope in developing economies such
as India (Natchair et al., 1994).
The OPD of a hospital acts as a bridge between hospital and community, hence it is very
important to plan the OPD with the idea of maximizing the utilisation and quick turnover.
(McQuarrie, 1983). It is imperative to have effective co-operation between the medical
services and the support line services catering to the OPD requirements (Kritchanchai, 2012).
The interpersonal skills of the medical personnel, availability of medicine, hospital
infrastructure and medical information plays an important role in managing OPD and create a
positive influence on patient satisfaction (Natarajan, 2006). Hence, it is necessary to focus on
optimizing waiting time in hospital operations for the benefit and wellbeing of patients.
Due to poor hospital service operations, patients tend to spend a lot of time getting the
services they need (Dellaert et al., 2015; Lohlun et al., 2015). Long queues are an indication
of lack of coordination, poor management and insufficient resources, which affects the
quality of services in hospital operations and reduces patients’ satisfaction (Basta et al., 2016;
Bringedal.B., 2016; Bachmann MO&Barron P., 1997). Given the role of waiting time in
improving service quality for higher satisfaction of patients, it is necessary to review it as one
of the most common problems in hospital service operations (Benson et al., 2001; Bleustein
et al., 2014).
Application of queuing theory for analysis and modelling of processes that involves waiting
lines is used widely in industries for optimizing supply of fixed resources at variable demand
conditions, however the healthcare industry views itself differently from other industry
(Kritchanchai, D., 2012).The hospital operations managers should be aware of the status of
business processes to improve operational performances and reduce waiting time (Hall et.al,
2006). There are several analytical tools for understanding the complexity of a system’s
performance, among which the queuing theory is a tool to analyse systems which include
queues and consist of clients, servers and queues (Kay EJ et al., 1996; Van Wyk R&Walubo
A., 2014). Queuing theory is a scientific approach to minimise system inefficiencies and
increase the patients’ satisfaction (Bahadori M. et al., 2014; Mayhew L&Smith D., 2008).
The hospital operations managers can increase patients’ satisfaction by making right
decisions through a proper understanding of the queuing theory and variables related to the
patients’ waiting time (Komashie A. et al., 2015).
There is a lot of research available on queuing analysis related to a variety of hospital
services such as cardiac care units, operating rooms and emergency services. However, due to
lack of real-world validation, many proposed queuing models have yet to be adopted by
hospital authorities. Therefore, there is a need to explore the utility and implications of
queuing theory by validating a simple queuing model in a busy hospital of India. This paper
through an actual OPD studyof a large multi-speciality hospital, shows how improvements in
out-patient flow through streamlining of OPD processes can be achieved using SWOT
analysis and queuing model. The study was conducted in a multi-speciality hospital called
Fortis Escorts Hospital, Jaipur (FEHJ) which is a NABH accredited hospital with 250 beds
and spread over an area of 3.67 acre in the capital of one of the largest states in India. Due to
a wide variety of healthcare services provided by FEHJ, it took a long time for patients
arriving at OPD to meet the concerned specialist leading to formation of queue. Naturally,
one of the major grievances among majority of the patients was the time they spend while
waiting in OPD. The key aim of the paper is to aid hospital service operationsat FEHJ in
identifying bottlenecks in service operations and potential areas for improvement in the
system, with the objective of optimizing patients waiting time, thereby allowing higher flow
of patients in OPD using queuing model.
The flow of the paper is organized in terms of objectives which are as follows. First, the
complete process flow of the OPD is studied which is our first objective. It is followed by
SWOT analysis to identify areas where time is consumed making it second objective. The
third objective is to understand how patients perceive waiting time through survey method.
Then, we conduct time study in different OPD’s as part of fourth objective and lastly, using
queuing model, we calculate the waiting time in different OPD’s. Finally, based upon results
obtained, we draw some conclusions and discuss some implications of our findings along
with limitations of the study.
LITERATURE REVIEW
There have been studies on waiting time in hospital operations focused on doctor and patient
consultations in general hospitals (Park, 2001) which found that the factors influencing
waiting time were characteristics of healthcare providers, consultation and patient’s
characteristics (Hwang, 2006). The classification of studies on applying queuing theory to
healthcare service can be based upon waiting time and utilization analysis (Yeo et al., 2014),
which can be further classified into those on reneging (Broyles & Cochran, 2007), variable
arrival rate (Worthington, 1987), priority queuing discipline (Fiems et al, 2015) and blocking
(Koizumi et al., 2005); whereas studies on system design with respect to queuing (Green et
al., 2006;Park &Kwag, 2009) are classified into cost minimization (Gorunesc et al., 2002)
and blocking (Bruin et al., 2007).Based on size of the system (Hall et al., 2013), studies have
been conducted atdepartment-level which includes Departments of Internal Medicine
(Hwang, 2006), Orthopedics (Yeo et al., 2014), Emergency Room(Kim et al.,
2009;Mandelbaum et al., 2012), Radiology (Park &Kwag, 2009) and MRI (Green &Savin,
2008); while those conducted at healthcare centre-level had the whole outpatient department
(Park, 2001;Ko, 2010;Kim et al., 2008).
The analysis of waiting time in healthcare systems can be approached mathematically using
queuing theory (Ozcan, 2006).It is been established that queuing theory can be used for
improving patient waiting time in hospital operations by extensive review of literature
(Green, L.V.2006a;McQuarrie, D.G.,1983;Siddhartan et al.,1996).There are already large
publication involving the application of queuing theory to service operations in hospital
settings (Adele and Barry, 2005;Ivalis and Millard, 2003;Vasanawala et al.,, 2005).
Unfortunately this vital tool is underutilised in most hospital operations across India. There
has also been extensive research on queuing analysis to enhance performance at various
hospital departments (Green, L.V., 2002; Kim et al., 1999) and emergency departments
(Green et al, 2006).Most hospital operations involve appointment system and the use of
queuing is done in either of the two ways i.e. first-in-first-out or different classes of patients
solely based on priority for e.g. in case of emergency which automatically gets first priority
before others (Adele et.al, 2005). It is indeed possible to optimise patient waiting time on
priority basis by addressing the issue of which patient requires shorter service time
(McQuarrie, D.G., 1983). The studies on models of queuing theory is provided by Green
(2006a) and analysis of the effect of waiting times on patients in Emergency department is
given by(Siddhartan et al., 1996).The flow of patients in queue can lead to good patient flow
if the queuing is minimized whereas queuing delays can lead to patient suffering causing poor
patient flow (Hall et. al,2006).The demand for health care services can be determined by
effective resource allocation and capacity planning (Murray,S.C.,2000). Based on specific
probability assumptions, queuing theory can be used to provide exact or approximate
estimate of performance measures (Daulatani et al., 2016). However the results are
approximated because the assumptions rarely hold (Cochran et al., 2006).
Lewis, Bernard & Booms (1983) have defined that service quality is a measure of gap
between customer expectations and perceptions, and meeting customer expectations on a
consistent basis. The outcome of evaluation process is defined as perceived service quality
and consumers tends to compare his expectations with the services received (Gronroos,
1984). Parasuraman et al., (1991) emphasized the use of SERVQUAL as a diagnostic
methodology for addressing service quality shortfalls and strengths. SERVQUAL has been
extensively used to measure service quality in a variety of service sectors such as healthcare
(Carman, 1990; Kilbourne et al., 2004).Service quality focuses on meeting customers’ needs
and requirement and how well the delivered service meets the expectations of customers
(Lewis and Booms, 1983).Customer dissatisfaction occurs when expectations are higher and
perceived quality of service is less than satisfactory (Parasuraman et al., 1988; Lewis and
Mitchell 1990).
Effective external communication creates realistic consumer expectations and enhances
consumer perceptions which offsets other service quality problems as well (Parasuraman et
al., 1985). Making patients entering OPD systems aware of the apparent services could
improve service quality perceptions and increase awareness about hospital service operations
(Kilbourne et.al, 2004). Patients are likely to perceive service delivered in a favourable way
by segmenting on the basis of their service quality expectations which will ultimately lead to
higher customer satisfaction. (Lewis et.al, 1990)
External communications affects not only consumer expectations about a service but also
consumer’s perceptions of the delivered service (Siddhartan, 1996). Consumers’ quality
perceptions of the service quality model are influenced by a series of distinct gaps occurring
on the marketers’ side (Itumalla et al., 2014). A key challenge for researchers is to devise
methods to measure these gaps accurately (Parasuraman et al., 1985). This paper intends to
address the gap between actual service delivery and external communication about the
hospital which affects service quality from a patient’s point of view.
RESEARCH DESIGN
In service operations management, it is always recommended to use a standard methodology
that enables to understand the current processes, determine the desired changes and improve
them. The present paper aims at optimizing the performance of OPD department using
queuing theory and increase patients’ satisfaction. Using in-depth analysis of OPDs from
different dimensions, the objectives involved in the study are listed as follows:
1. To study the complete process flow of the OPD at Fortis Escorts Hospital, Jaipur.
2. To identify areas where patient’s time is consumed by performing SWOT analysis of
the existing OPD.
3. To find out patient's perception of delay in OPD through satisfaction survey.
4. To do time study on different OPD stations at Fortis Escorts Hospital, Jaipur.
5. To calculate the waiting time of patients in different OPD stations using queuing
model.
RESEARCH METHODOLOGY
The management of patient flow is an important element in improving efficiency of hospital
service operations. It requires handling arrival of patients, service process and queuing
process, which directly impacts the delivery of healthcare services. Since it is a study which
emphasize the legal phenomenon of cause and effect of a condition, it is a positivist social
science research done by cautiously using the empirical observations. Research methodology
used in this paper is case study due to in-depth examination of an extensive amount of
information about very few units or cases across single time frame. To optimize waiting time
in hospital operations using queuing theory, the study design is a time study. The study was
stretched around a week of observation for the OPD working pattern and the probable delay
points, data collection of time consumed at each step involved in getting a consultation done
in the OPD. The instrument used for the analysis was questionnaire and time study analysis
were done for getting the results of the survey.
The study was conducted in two dimensions namely, Objective and the Subjective approach.
In objective assessment, it was observed that for how much time the patients waited in the
queue, the time they spent at the registration counter, the time consumed in reaching the OPD
and the waiting time in the OPDs for consultation, etc. Initial part of objective assessment
involved identifying key informant in OPD to get information about general overview of
outpatient system. After that, collection of more data and information related to this study
was analysed using queuing model to optimize waiting time and arrival pattern of outpatient
department for objective assessment.This data was then used for analysing the situation and
derive an insight to give recommendations which could reduce the waiting time for patients.
The subjective approach included the patients’ perception about the delay, the reasons behind
the delay, the psychology and opinion regarding the promptness in the registration time,
getting the consultation, type of investigation done, promptness in giving the investigation
report etc. and the number of possible reasons of the delay.The observations for subjective
assessment were collected through field visits and to see directly outpatient service an arrival
pattern of patients in OPD of FEHJ.
RESULTS AND FINDINGS
The results of the study are obtained by addressing each objective as follows:
Results: Objective 1- To study the complete process flow of the OPD at Fortis Escorts
Hospital, Jaipur
The first point of contact between the patient and the hospital staff is OPD, which acts like a
mirror reflecting the functioning of the hospital operations. Patients visit OPD for variety of
purpose like,consultation, day care treatment; investigation, referral, admission and post
discharge follow-ups which generates first impression of the hospital service operations.
The process flow at Fortis Escorts Hospital OPD
Patient entry in the OPD
Measuring the time a patient has to stand in the queue
Measuring the time patient takes at the OPD desk
(This time is studied under 2 purviews,for the patients who are registered and for the
patients who are not registered)
Measuring time taken by the patient to reach the concerned OPD
Measuring the waiting time of patient in OPD
OPD is a critical process for any hospital and analysis of OPD helps to not only identify but
also eliminate unnecessary movements for efficient and effective patient care. Assessment of
the OPD layout can lead to reduction in overcrowding and consultation delay which
drastically decreases the efforts, patients need for treatment and/or routine check-ups.
Process analysis of Fortis Escorts Hospital OPD
Results: Objective 2-Toidentify areas where patient’s time is consumed by performing
SWOT analysis of the existing OPD
An objective assessment of 50 patients was done by observing how much time the patients
waited in the queue, the time spent by patients at the registration counter, the waiting time in
the OPDs for consultation, etc. The study reveals the average waiting time spent by the
patients at different OPD and also expresses their view towards the hospital service
operations.The study also sheds light on the total time consumed by different OPDs.
Pareto’s 80:20 Principle, which is a law applicable to all fields of study, states that only 20%
of the reasons generate 80% delay in operations. Hence, it is necessary to focus on those
critical and few reasons rather than diverting attention towards 80% trivial issues. A
retrospective analysis in consultation with doctors for delays in OPD of hospital operation
helped in identifying major reasons for delay and recommendations were provided to reduce
waiting time of patients in OPD.
Following Pareto’s principal, few critical areas were identified which caused delay and
addressing these issues could possibly save more than half of patients waiting time.
Table 1- Areas where patient time is wasted
S.N Problem area identified Average wait Projection of time which can
time(minutes) be saved
1 Lack of proper system for 9.86 43.86%
informing first time visitors
about registration
2 Delay due to technical 2 11.12%
errors such as problem with
printers, etc.
3 Delay due to receptionist 0.5 3.87 %
taking appointments on
phone
The reason for applying SWOT was to give holistic view of the current strengths,
weaknesses, opportunities and threats possessed by OPD. The diagrammatic representation of
the SWOT analysis is given below:
Figure 1- Result of SWOT analysis at OPD of Fortis Escorts Hospital, Jaipur
Results: Objective 3-To find out patient’sperception of delay in OPD through
satisfaction survey
Patients arriving in the OPDs of hospitals are responsible for spreading the good image of the
hospital and therefore patient satisfaction is equally important for hospital management. Due
to continuous changes in hospital operations, it is difficult to maintain patients’ satisfaction as
a top priority for OPD which is the first interaction for hospital management. An OPD is a
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place where non-emergent ambulatory medical care is provided under the supervision of a
physician and the attitude of health care providers has its own impact on satisfaction level of
patients. More the positive attitude more the patient is satisfied, patient satisfaction also
depends on ‘nursing care’ because nurses are involved in almost every aspect of patient care
in hospital operations.
In this study, it has been observed at 80% of patients rated their level of satisfaction at OPD
as Good, 6% patients were dissatisfied with the services at OPD and remaining 14% patients
felt average level of satisfaction at OPD.While conducting this study, we found health
services make hospital operations more sensitive and alert to patient needs. Many instances in
which patients were eager about the services they had received in the hope that some action
would be taken determining their level of satisfaction.
Results: Objective 4- To do time study on different OPDstations at Fortis Escorts
Hospital, Jaipur.
OPD indicators related to services in hospital operations are as follows:
The outpatient department is open from 9.00am till 5.00pm working a total of 9 hours per
day. It must be noted that for the purpose of this study, the emergency department which
remains open even after 5.00pm is not included. The patient arrival rate each day at OPD is
calculated by dividing the average patients per day i.e. 288 by 9 hours of work resulting 32
patients per hour.The service rate of patients was calculated after interviewing with the
doctors, one doctor averagely takes 8 minutes to treat one patient which implies that a doctor
can see 7 patients per hour.
The registration time is the time consumed at the registration desk and the registration
turnaround time (TAT) is the time from when patient enters OPD till the patient was
registered. Patients at OPD have to undergo registration and the registration TAT at OPD
came out to be 12minutes out of which the average registration time was 3 minutes so we
decided to find out the results for OPD 2 without registration using the mean inter arrival
time as 9 minutes.
The waiting time hugely depends upon the flow of patients in different OPDs and thus the
average waiting time of patients before seeing a doctor was calculated OPD wise.
Table 2- Average waiting time in different OPDs
S.N OPD Percentage(%) of patient Average time taken
flow before seeing a doctor
(Minutes)
1 Cardiac OPD 66.66% 16
2 OPD2 19.62% 61
3 OPD1 7.84% 9
4 Paediatric OPD 5.88% 7.5
Source: Fortis Escorts Hospital, Jaipur
Results: Objective 5-To calculate the waiting time of patients in different OPD stations
using queuing model
There is always random arrival of patients for receiving healthcare services and that require
immediate availability of service, but they should be able to wait in line with patience when
the hospital services are operating at peak capacity. Due to the dynamic nature of hospital
service operations, it is often difficult to predictarrival of no. of patients andtimetaken for
consultation at any given moment. The ultimate goal of the queuing theory is to reach an
optimal equilibrium between arrival rate and service rateof patients in OPD for smooth
functioning of hospital operations.
The input parameters for queuing model M/M/1 are calculated using number of patients in
the system denoted by n, average arrival rate i.e. no. of arrivals per hour denoted by λ and
average service rate per server denoted by μ.
Table 3- Input parameters for Queuing Model
Parameter M/M/1 (exponential service Value
times)
Arrival rate (λ) 32 patients per hour
Service rate(μ) 8 patients per hour
No .of OPDs OPD1,OPD2,Cardiac OPD and Paediatric
OPD
The symbols and formulae to be used are given in table below:
Table 4-Symbols and Formulae to be used in calculation of M/M/1 model
Symbol Meaning Formulae in
M/M/1 model
ρ Operation rate ρ = λ /μ
Wq Average waiting time in a queue Wq = ρ /μ – λ
Ws Average entire time in a system Ws = 1 /μ – λ
Lq Average number of patients in a queue Lq = ρλ/ μ – λ
Ls Average number of patients in a system Ls = λ /μ – λ
While using queuing model, only 3 OPDs with the highest patient flow i.e. Cardiac, OPD and
OPD2 were considered, comparing the number in queue, waiting time of patients in the
queue, waiting time of patients in the system and number in the system all calculated using
queuing formulae for modelling. The mean inter- arrival time is exponentially distributed
whereas service time of different OPDs is uniformly distributed, hence avg. is considered.
Table 5- Sensitivity Analysis of different OPDs
OPD Mean inter Service Number Wait in Wait in Number
arrival time time in the the queue the in the
(minutes) (minutes) queue Wq system system
Lq (minutes) Ws L
(minutes)
Cardiac 10 8 1.608 16.08 24.08 2.408
OPD I 12 11 5.045 60.54 71.54 5.961
OPD II 8 6 1.135 9.08 15.08 1.885
OPD II 9 7 1.384 12.45 19.45 2.161
with
registration
Sensitivity Analysis
160
140
120
100
80
60
40
20
0
Cardiac OPD II OPD I OPD II with
registration
Lq Wq W L
Figure 2- Graphical Plot of results of sensitivity analysis
From the results of the sensitivity analysis, OPD II without registration produces inferior
performance compared to other OPDs. OPD I provides optimal performance along with
cardiac OPD and the change in time spent in the queue as we move from OPD II without
registration to OPD II with registration is very appreciable. In addition, authentication of the
results obtained was conducted by cross checking the time registration system of OPD II
wherein the waiting time in the system of OPD II post registration was calculated manually
according to the flow of patients. It was found with 95% accuracy that waiting time according
to our study was 19.45 minutes and manually calculated waiting time according to patient
flow came out to be 20.6 minutes.
Based on the results obtained, it is found that first, the hospital lacks in having a proper
system for letting patients know about registration especially the first-time visitors. There is
wastage of time for patient or their relatives in figuring out the exact procedures for the
registration of new patients. Secondly, there were some minor technical errors such as
improper placement of the registration form in the OPD main lobby, printer problem, etc.
which added to the queuing challenge at OPD. Lastly, the signage indicating the counters for
new registration, old registration and golden age club patients were hanged little too high
which makes it difficult for patients entering the hospital to read the signage and choose the
queue accordingly which later created confusion and delayed the process. However, given the
size and scale of the multi-specialty hospital, these were just few indicators giving scope for
improvement in future.
RECOMMENDATIONS AND CONCLUSION
First and foremost, it is necessary to prioritize hospital operations according to the need,
benefit and feasibility since the OPD coordinators find it difficult to keep track of patients
especially on Mondays, Thursdays and Saturdays when there is high foot fall. The
registration forms must be placed near the new registration counter which should be made
noticeable by bringing the signage a little down. Due to place constraints, not more than 2
attendants should be allowed per patient and guidance must be provided to the same for
procedures expected as soon as the patient enters main lobby. Queue managers can help in
separating the patients into old and new and also make sure no appointment is scheduled at
the time of clinical rounds of consultants. The perceived waiting time can be reduced by
providing facilities such as proper sitting arrangements, putting TV, air conditioners, etc.
The most crucial element in increasing patient satisfaction in hospital operations is timely
access i.e. “When” care is provided followed by “What” care is given. Waiting time plays a
very crucial role in healthcare business and this study demonstrates the analysis and
application of queuing theory in hospital operations for the improvement of process
efficiency of OPDs. Patients’ dissatisfaction associated with long waiting queues is well-
known and the perceived waiting is much more annoying for the patients than the actual
waiting time. The study has revealed that the subjective waiting time is highly co-related with
the frustration of the patient than the objective waiting time. It is highly recommended to
replicate the study in OPDs of other hospitals to verify the effectiveness of queuing theory for
addressing queuing challenges faced by hospital operations in India.
IMPLICATIONS AND LIMITATIONS OF THE STUDY
Research focusing on the relative impact of word of mouth communication, personal needs
and past experience on patients’ service expectations in hospital operations within as well as
across service categories can have useful managerial implications. Empirical research aimed
at ascertaining whether, and in what ways patients service expectations differ will be valuable
from a service marketers’ viewpoint with regards to hospital operations and healthcare
industry in general. The major insights gained through this study will hopefully spawn both
academic and practitioner’s interest in using queuing theory for service quality determination
in hospital operations.
The morbidity pattern and thus the foot fall may vary during the period of study since it was
done for a confined time period. The emergency counter which also deals with the outpatients
was not included in the study as there are patients of critical nature and they serve on first
come, first serve basis. In addition, in-depth interviews of the patients would have yielded
better understanding but due to time constraints and also considering the restless conditions
of the patients it was deliberately avoided.
Acknowledgements
Hereby, authors would like to express their sincere gratitude to the entire staff and
management of Fortis Escorts Hospital, Jaipur for their support and co-operation.
REFERENCES
Adele, M., & Barry, S. (2005), ‘Modelling patient flow in hospital using queuing theory’,
Unpublished Manuscript.
Bachmann MO&Barron P. (1997),‘Why wait so long for child care? An analysis of waits,
queues and work in a South African urban health centre’,27(1): pp.34–38.
Bahadori M, Mohammadnejhad SM, Ravaged R &Teymourzadeh E. (2014), ‘Using queuing
theory and simulation model to optimize hospital pharmacy performance’, Iran Red Crescent
Med J.;16(3):ee16807. doi: 10.5812/ircmj.16807. [PubMed: 24829791].
Basta YL, Tytgat KM, Klinkenbijl JH, Fockens P&Smets EM. (2016), ‘Waiting time at a
fast-track diagnostic clinic’, Int J Health Care Qual. Assur. ;29(5): pp. 523–535.
Benson RJ, Burnet NG, Williams MV&Tan LT. (2001), ‘An audit of clinic consultation
times in a cancer centre: implications for national manpower planning’, Clin Oncol.
2001;13(2): pp. 138–143.
Bleustein C, Rothschild DB, Valen A, Valatis E, Schweitzer L & Jones R. (2014),’Wait
times, patient satisfaction scores, and the perception of care’, Am J ManageCare ;20(5): pp.
393–400.
Bringedal B., (2016) [Not Available]. Tidsskr Nor Laegeforen., 136(1):
57.doi:10.4045/tidsskr.15.1228. [PubMed: 26757667].
Broyles JR&Cochran JK. (2007), ‘Estimating business loss to a hospital emergency
department from patient reneging by queuing-based regression’, Proceedings of the 2007
Industrial Engineering Research Conference; May 19-23; Nashville, TN. pp. 613-618.
Carman, J.M. (1990), ‘Consumer perceptions of service quality: an assessment of the
SERVQUAL dimensions’, Journal of Retailing, 66(1), pp.33-55.
Cochran, K. J., & Bharti, A. (2006),‘A Multi-stage Stochastic Methodology for Whole
Hospital Bed Planning Under Peak Loading’, International Journal of Industrial and Systems
Engineering (1 (1/2)), pp.8-35.
Daulatani Y., Kumar, S. &Vaidya O. (2016), ‘Improving Out-Patient Flow at An Indian
Opthalmic Hospital’, Operations and Supply Chain Management,9(1), pp. 15-21.
Dellaert N, Cayiroglu E&Jeunet J. (2015), ‘Assessing and controlling the impact of hospital
capacity planning on the waiting time’, Int J Prod;54(8):2203–14. doi:
10.1080/00207543.2015.1051668.
Fiems D, Koole G&Nain P. (2015), ‘Waiting times of scheduled patients in the presence of
emergency requests’, (Source- Internet).
Gorunescu F, McClean SI&Millard PH. (2002), ‘A queueing model for bed-occupancy
management and planning hospitals’, J Oper Res Soc;53(1): pp.19-24.
Green, L. V. (2002),’How many Hospital Beds?’, Inquiry, 37(4), pp. 400-412.
Green, L. V. (2006),’Queuing analysis in healthcare, in Patient Flow: Reducing Delay
inHealthcare Deliver’, (Hall, R.W.ed). New York: Springer. pp. 281-307.
Green LV &Savin S. (2008), ‘Reducing delays for medical appointments: a queueing
approach’, Oper Res;56(6):152638.
Green, L. V., Soares, J., Giulio, J., & Green, R. (2006),’Using Queuing Theory to Increase
the Effectiveness of Emergency Department Provides Staffing’, Academic Emergency
Medicine, 13(1), pp. 61-68.
Gronroos, C. (1984),’A service quality model and its marketing implications’, European
Journal of Marketing, 18(4), pp. 36-44.
Hall, R., Belson, D., Murali, P., &Dessouky, M. (2006), ‘Modeling patient flows through the
health care system, in Patient Flow: Reducing Delay in Healthcare Delivery’, In Hall, R.
Editor New York: Springer. pp. 1-44.
Hall R, Belson D, Murali P, &Dessouky M. (2013), ‘Modeling patient flows through the
health care system’, In Hall R, editor. New York: Springer; pp. 3-42.
Hwang JI. (2006),’Factors influencing consultation time and waiting time of ambulatory
patients in a tertiary teaching hospital’, Qual Improv Health Care ;12(1): pp. 6-16.
Itumalla, R., Acharyulu, G.V.R.K.&Raja Shekhar, B. (2014),’Development of HospitalQual:
A service Quality Scale for Measuring In-patient Services in Hospital’, Operations and
Supply Chain Management 7(2), pp. 54-63.
Ivalis, S., & Millard, P. (2003),’Health care modelling operating the black box’, British
Journal of Health Care Management (8(7)), pp. 251-255.
Kay EJ, Hough D&Blinkhorn AS. (1996),‘Operational research in the dental hospital setting
an application of queuing theory’, J Dent Res;75(5):1181.
Kilbourne, W.E., Duffy, J.A., Duffy, M., &Giarchi, G. (2004),’The applicability of
SERVQUAL in cross-national measurements of health-care quality’, Journal of Services
Marketing, 18(6/7), pp. 524-533.
Kim, S., Horowitz, I., Young, K., &Buckly, T. (1999), ‘Analysis of Capacity Management of
the Intensive Care Unit in a Hospital’, European Journal of Operational Research, 105,
346355.
Kim S, Seo H, Lee J, Kwon Y, Kim S&Park I, et al. (2009), ‘An application of a queueing
network for waiting time reduction at the emergency care center’, Proceedings of the Korean
Operations and Management Science Society Conference; Seoul, Korea. pp. 298-316.
Kim S, Son U, Choi J, Roh J&Yang Y. (2008),’Analysis of factors delaying on waiting time
of outpatient in a general hospital’, Health Welf;10: pp. 107-120.
Ko YK. (2010), ‘The relationships among waiting time, patient's satisfaction, and revisiting
intention of outpatients in general hospital’, J Korean AcadNurs Adm;16(3): pp.219-228.
Koizumi N, Kuno E&Smith TE. (2005),’Modeling patient flows using a queuing network
with blocking’, Health Care Manag Sci;8(1): pp. 49-60.
Komashie A, Mousavi A, Clarkson PJ & Young T. (2015), ‘An Integrated Model of Patient
and Staff Satisfaction Using Queuing Theory’, IEEE J TranslEng Health Med.;3:2200110.
doi: 10.1109/JTEHM.2015.2400436.[PubMed: 27170899]
Kritchanchai, D. (2012),’A Framework for Healthcare Supply Chain Improvement in
Thailand Improvement in Thailand’, Operations and Supply Chain Management, 5(2), pp.
103-113.
Lewis&Mitchell, (1990),’Defining and Measuring the Quality of Customer
Service’, Marketing Intelligence & Planning, Vol. 8 Issue: 6, pp.11-17,
Lewis, Robert C. &Bernard H. Booms (1983), ‘The Marketing Aspects of Service Quality, in
Emerging Perspectives on Services Marketing’, L. Berry, G. Shostack, and G. Upah, eds.,
Chicago: American Marketing, pp.99-107.
Lohlun KN, Kotzen JA&Lakier R. (2015),‘A prospective study on the impact of waiting
times for radiotherapy for cervical cancer at Charlotte Maxeke Johannesburg Academic
Hospital’, South Afr J Obstetr Gynaecol.;21(1):6. doi: 10.7196/sajog.985.
Mandelbaum A, Momcilovic P&Tseytlin Y. (2012), ‘On fair routing from emergency
departments to hospital wards: QED queues with heterogeneous servers’, Manag Sci
2012;58(7):1273-91.
Mayhew L&Smith D. (2008),’Using queuing theory to analyse the government’s 4-H
completion time target in accident and emergency departments’,Health Care Manag Sci;
11(1):11–21. [PubMed: 18390164].
Murray, S. C. (2000),’Understanding the Patient Flow’, Decision Line.
McQuarrie, D. G. (1983),’Hospital utilization levels. The application of queuing theory to a
controversial medical economic problem’, Minnesota Medicine, 66, pp.679-686.
Natarajan, R. N. (2006),’Transferring best practices to healthcare: opportunities and
challenges’, The TQM Magazine, 18(6), pp. 572-582.
Natchiar, G., Robin, A. L., Thulasiraj, R. D., & Krishnaswamy, S. (1994),’Attacking the
backlog of India's curable blind: the Aravind Eye Hospital model’, Archives of
Ophthalmology, 112(7), pp. 987-993.
Ozcan, Y. A. (2006), ‘Quantitative methods in health care management’, Techniques and
applications (First edition) Jossey-Bass Publications.
Parasuraman, A. Zeithaml, V.A., & Berry, L.L. (1985), ‘A conceptual model of service
quality and its implication’, Journal of Marketing, 49(Fall), pp.41-50.
Parasuraman, A., Zeithaml, V.A., & Berry, L.L. (1988),’SERVQUAL: a multi-item scale for
measuring consumer perceptions of the service quality’, Journal of Retailing, 64(1), pp.12-40.
Parasuraman, A., Zeithaml, V.A., & Berry, L.L. (1991),’Refinement and reassessment of the
SERVQUAL scale’, Journal of Retailing, 67(4), pp.420-450.
Park CS&Koh SH. (2011),’A case study on the improvement of general hospital outpatients
waiting time using TOC methodology’, Korean J Hosp Manag 2011;16(1): pp. 77-100.
Park CK&Kwag EJ. (2009), ‘A case study about managing waiting time for raising
customer’s satisfaction in the medical service’, Korean J Hosp Manag;14(3): pp. 132-153.
Park SH. (2001),’ Analysis of factors delaying on waiting time for medical examination of
outpatient on a hospital’, J Korean Soc Qual Assur Health Care;8(1): pp.56-72.
Roche KT&Cochran JK. (2007), ‘Improving patient safety by maximizing fast-track benefits
in the emergency department: a queuing network approach’, Proceedings of the 2007
Industrial Engineering Research Conference; Nashville, TN. pp. 619-624.
Siddhartan, K., Jones, W. J., & Johnson, J. A. (1996),’A priority queuing model to reduce
waiting times in emergency care’, International Journal of Health Care Quality Assurance, 9,
1016.
Van Wyk R&Walubo A. (2014), ‘The use of queuing theory and patient-basedcharacteristics
to Assess the Performance of the Paediatric Intensive Care Unit (picu) At Universitas
Academic Hospital in South Africa’, Basic Clin Pharm Toxicol;115:235.
Vasanawala, S. S., &Desser, T. S. (2005),‘Accommodation of requests for emergency US
and CT: Applications of queuing theory to scheduling of urgent studies’, Radiology (235),
pp. 244-249.
Worthington DJ. (1987), ‘Queueing models for hospital waiting lists’, J Oper Res Soc;38(5):
pp. 413-422.
Yeo H, Bak W, Yoo M, Park S&Lee S. (2014), ‘Evaluation of patients' queue environment
on medical service using queueing theory’, J Korean Soc Qual Manag;42(1): pp. 71-79.
