Proceedings of the 2016 Winter Simulation Conference

T. M. K. Roeder, P. I. Frazier, R. Szechtman, E. Zhou, T. Huschka, and S. E. Chick, eds.

HOSPITAL PROCESSES WITHIN AN INTEGRATED SYSTEM

VIEW: A HYBRID SIMULATION APPROACH

Anatoli Djanatliev Florian Meier

Computer Networks and Management and

Communication Systems Information in Healthcare
University of Erlangen-Nuremberg Wilhelm Löhe University of Applied Sciences
D-91058 Erlangen, GERMANY D-90763 Fürth, GERMANY

ABSTRACT
Processes in hospitals or in other healthcare institutions are usually analyzed and optimized isolated for
enclosed organizations like single hospital wards or certain clinical pathways. However, many workflows
should be considered in a broader scope in order to better represent the reality, i.e., in combination with other
processes and in contexts of macro structures. Therefore, an integrated view is necessary which enables to
combine different coherences. This can be achieved by hybrid simulation. In this case, processes can be
modeled and simulated by discrete simulation techniques (i.e., DES or ABS) at the meso-level. However,
holistic structures can be comfortably implemented using continuous methods (i.e., SD). This paper presents
a theoretical approach that enables to consider reciprocal influences between processes and higher level
entities, but also to combine hospital workflows with other subjects (e.g., ambulance vehicles).

1 INTRODUCTION
Improvements in healthcare delivery are important to master global challenges in future, which are particularly
triggered by demographic changes and increasing costs. Hospital managers and those of other healthcare
providers must solve many trade-off problems, i.e., a better service quality versus higher resource usage
and operational costs. Process improvements performed by simulation and modeling (SaM) allow to better
handle budgets and to increase the organizational performance prior to their cost-intensive real-world
implementation. However, the success of such improvement processes crucially depends on the applied
SaM method.
Process analysis by Business Process Modeling (BPM) plays a significant role in the management
of companies or divisions (Giaglis 2001). This modeling technique enables to structure the process
knowledge of single domain experts in common models that can be used as a basis for further discussions
and studies. Together with simulation, BPM offers an efficient and comprehensive toolset for managers
and other decision-makers (Harrison et al. 2007, Laguna and Marklund 2013, Weske 2012). This
combination helps to detect bottlenecks and problems at an early stage, and to evaluate different scenarios
and solutions prospectively. The main focus of process modeling is the (graphical) representation of different
paths and process steps, but resources and organizational structures can also be considered. The process
analysis aims to achieve an understanding of a certain process and to identify weaknesses and potential
improvements (Rebuge and Ferreira 2012). Therewith, simulation is capable to calculate the expected
outcome for both the currently existing process and for a prospectively adjusted process that does not
exist yet. In this case, management decisions, especially at the strategic level, could be more objective by
limiting biases of individual perceptions.

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BPM and DES are primarily used for studies in the inpatient sector (Vera and Kuntz 2007), but they
also can be applied in cases when abstract clinical pathways for certain diseases are evaluated. In recent
time these methods receive a growing attention in situations where hospital services are reimbursed through
flat-rate or fee-per-case charges, such as the Diagnosis Related Groups (DRGs). In this case, a hospital will
receive a predefined and agreed reimbursement value for each patient. This value is dependent on diagnosis
and not on the real costs of provided services. Consequently, hospitals are extremely interested to keep the
costs per case below this value, but also to provide an adequate service quality in a competitive market.
That means, process improvements have significant impacts on the operating result and organizational
performance.
Process modeling is widely used and already established in hospitals across different application areas.
On the one hand, the medical treatment process of a certain disease (i.e., clinical pathways) and thus the
quality of care are in focus (Ronellenfitsch et al. 2012), on the other hand, the profitability is a major
business target figure. In this case, e.g., the process structure can be modeled and underlaid with cost
data. This approach serves as a basis for an activity based costing and enables to generate important
information for an effective management (Öker and Özyapici 2013, Hada et al. 2014, Kaplan et al. 2014,
Cannavacciuolo et al. 2015). However, the prospective analysis of processes and their realization in
practice vary considerably. Furthermore, such techniques are often not used holistically, but rather for
specific diseases or for a particular hospital ward. One reason is, that experts investigate their research
scope focusing on one particular disease (Akhavadan 2016), henceforth, the willingness to model foreign
processes does not exist. Another reason is, that in economic evaluations cost centers are mostly considered
in separate studies (Ibrahim et al. 2014).
An overall view containing bordering influences typically does not exist. In particular, different related
processes in the same institution and even the broader environment of the hospital should be considered
when analyzing a system. For example, if a patient requires an imaging examination, the radiology
department usually interacts with other medical wards during a treatment process. The same also occurs
in other supporting processes like laboratory tests or occupancy management. Ideally, the whole hospital
organization should be considered, but without over-complicating a model. Going one step further, even
external influences can affect a considered process, i.e., the surrounding population structure, economical
factors, political influences, or technological developments. Using BPM and DES, a modeler has to represent
the whole environmental complexity by very detailed process models. However, in most cases it is sufficient
to represent less important influences by more abstract or aggregated models. In this paper we present a
hybrid simulation approach that allows to develop detailed process models by discrete simulation techniques
using Discrete-Event Simulation (DES) and Agent-Based Simulation (ABS), as well as to represent the
process environment and bordering processes by more abstract high level System Dynamics (SD) models.

2 RELATED WORK
The scope of this paper is particularly related to the following three topics: modeling of hospital processes,
healthcare simulations in general, and the hybrid simulation technique. There are numerous academic
publications that are focusing on these topics.
As previously described, BPM is used to develop process models for hospitals and other healthcare
institutions. Fitzgerald and Dadich (2009) discussed how process simulation can be applied in order to
identify potential improvements and perform optimizations in hospital workflows. Another paper which has
been introduced by Mathew and Mansharamani (2012) presents a review of tools and techniques focusing
on BPM. In particular, the use of the Business Process Model Notation (BPMN) and its shortcomings are
discussed as well as the applicability of DES in this context is mentioned.
In general, applying SaM techniques in healthcare is not new. There are already many example success
stories where established simulation methods have been used to represent healthcare structures. Gunal
(2012) introduced a guide for building simulation models for hospitals. In this article the author describes
important conceptual modeling steps within the context of healthcare, but also a comparison between different

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simulation paradigms (i.e., DES, ABS, and SD). Brailsford (2007) presented an interesting tutorial about
advances and challenges in healthcare simulation modeling. This paper describes a possible categorization
of healthcare models and classifies available examples in three different levels of abstraction. Finally, Gaba
(2007) introduced two possible visions for simulation in healthcare. The first one describes a successfully
achieved integration of simulation in healthcare studies until the year 2025, while the second scenario refers
to a more pessimistic view, where only few aspects have been realized until the same year.
Probably the most related topic for this paper is hybrid simulation. This technique received a considerable
attention over the last years, due to its flexibility and an increasingly improved tool support. In particular, this
observation can be supported by the growing number of publications at the Winter Simulation Conference
(WSC) focusing on hybrid simulation technique and its application in different domains. While in 2011
only few papers have been presented in different tracks, there is already a separate full track bringing
together different presentations around the area of hybrid simulation. Heath et al. (2011) presented an
interesting discussion focusing on cross-paradigm modeling. The authors considered different configurations
of DES, ABS, and SD in order to describe their advantages and problems during the model building
process. Additionally, Brailsford et al. (2013) reviewed the use of hybrid simulation for healthcare and
social care. A first generic framework for hybrid simulations in healthcare has been introduced by Chahal
(2009). This work particularly describes how to use SD and DES conjointly from a conceptual perspective. A
further paper which has been accompanied by a panel discussion at the WSC 2015 has been presented
by Mustafee et al. (2015). It generally presents definitions, challenges, and benefits of hybrid simulation,
but also its applicability in healthcare. Djanatliev and German (2013) focused on hybrid simulation for
prospective health technology assessments combining DES, ABS, and SD in common models. Moreover,
an approach has been presented to generate agents dynamically from SD models, and other inter-paradigm
connections within the scope of healthcare decision-support (Djanatliev 2015). Finally, we investigated
some work to step forward towards a guide for hybrid simulation modeling and proposed four levels to
develop modular hybrid models in healthcare (Djanatliev and German 2015).

3 HOSPITAL PROCESSES WITHIN AN INTEGRATED SYSTEM VIEW

Hospital processes are often analyzed isolated for single hospital wards, or for certain clinical pathways. In
most cases, different stakeholders are working together in order to find the most suitable process structure
representing specified processes. A main challenge during this procedure is to find a common language
between all participants within an interdisciplinary context. BPM is appropriate to collect the process
knowledge of domain experts and to present it in a standardized manner.
Depending on the question to be answered there are many situations where it is not sufficient to develop
models of specialized processes only. Often there are direct or indirect connections to other wards within
the same hospital or even to other hospitals and institutions. For example, a treatment process can start
within an ambulance vehicle and continues in the hospital. For a moment it does not seem to be challenging,
but the complexity gets clearer, if one considers different possible combinations of treatment processes for
single vehicles and different hospitals. In general, several internal and external influences can crucially
affect the considered processes. This is why an isolated analysis of hospital processes is insufficient, rather
they have to be evaluated within an integrated system view.

3.1 Structuring Hospital Processes

Before focusing on a broader scope, we particularly set the focus on hospital processes and describe how
they can be structured. First, business processes will be outlined generally, thereafter, a mapping to hospital
processes will be given.

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3.1.1 The Nature of Business Processes

A business process can be described as a sequence of single activities that run consecutively to achieve
overall objectives. Such objectives are usually oriented to customer needs and to the current market
situation. The value chain can only run unobstructed, if all involved persons and equipment items have
been previously coordinated. The better this coordination works, the more efficient procedures can be
expected. The implemented processes, seen as one entity, can be characterized as a function, transforming
a given input into a measurable output. In this case activities lead to an added value; a key aspect of
business processes (Greiling et al. 2004).
A business process can be subdivided into different hierarchical levels: the top level represents the
primary process including business objectives and the most important process groups. It can be divided into
smaller sub-processes hierarchically. The number of levels that a primary process is divided into differs
from company to company, or from project to project. Furthermore, it depends on the complexity of the
main process, and on the question, how useful is an additional level for organization and controlling of
the work routine. The benefit of different levels is to get an overview as well as a higher transparency
of detailed work. In particular, the top level enables a comprehensive global control. Value creation is
often the main aim at this management level. In contrast, sub-processes at the lowest level represent the
most detailed view on a process. Additionally, there are various supporting processes that run parallel to
the considered business process and are not directly involved in the value chain. They are not generating
directly measurable benefits for the customer, however, they are nevertheless indispensable for a realistic
evaluation. For example, the human resources department is not involved in the production process, but it
is relevant for recruiting qualified staff. Within an end-to-end business process all activities and resources
are included which are required to achieve value creation, from the first steps to the final realization, and
it comprise both the value added and the supporting processes (Bergsmann 2012).
The success of an institution crucially depends on its operational performance and management. Thus,
a constant monitoring and performance evaluation of its procedures is required. In this context, the process
management plays an essential role and represents a link between the strategic and the operative management.
The aim of process management is to combine knowledge, skills, tools, and techniques in order to achieve
the targeted outcome. Furthermore, it includes continuous redesigns, strategic planning, monitoring and
managing of business processes. In particular, continuous adaptations and improvements are necessary to
ensure a persistent and high organizational performance. Finally, the aim of process management is to
make processes more effective, efficient and flexible.

3.1.2 Business Process Management in Hospitals

In order to apply the idea of process management in the inpatient sector, the following factors have to be
considered. In contrast to an industrial production process where products are located in the center, humans
are the most important instances of service delivery in healthcare. Thus, various needs of individuals and
other sensitivities of patients have to be respected.
The primary process of healthcare provision in hospitals usually includes various medical disciplines. For
example, the emergency department is often initially involved in the treatment process of hospitals. Moreover,
established medical disciplines like the internal medicine or the cardiac medicine can come along. Ad-
ditionally, the nursing staff and other professionals have to be considered in the overall process. Thus,
the functional organization of a hospital and a high medical specialization makes process structuring very
complex and more challenging. In particular, the process manager must put increased efforts in coordination
to achieve a more efficient and appropriate structure. As presented in Figure 1, a possible structure of
primary processes in hospitals contains the following steps: admission, diagnose, therapy, post-treatment,
and finally the discharge process (Hessel 2003).

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Patient Treatment Process

Primary Processes

post-
admission diagnose therapy discharge
treatment

Sub-process
Level 2 conservative therapy

operative therapy
Sub-process
Level 3

preoperative operation
operation
preparation follow-up

Figure 1: Structuring hospital processes. Based on Hessel (2003).

In this context specific success factors have to be mentioned. They are basically measured by three
outcomes: time, costs and quality of care. These parameters constitute a triangle of independent items. The
general goal of process management is henceforth an improvement of all three items. Hence, an optimized
process ideally runs faster, at lower costs and produces an increasing quality of care. However, a simultaneous
improvement is often pretty difficult, because each dimension can affect another one. Consequently,
improvements of one parameter can lead to a deterioration of another one (negative correlation). For
example, a faster process can save costs, but may lead to a decreased service quality. Therefore, it has
to be checked how such dimensions interact within an individual setting. Generally speaking, an overall
optimum of all parameters should be achieved.

3.2 Integrating Hospital Processes by Hybrid Simulation

As long as only discrete process steps have to be represented in optimization studies, BPM in combination
with DES can be used. This modeling approach offers enough features to model processes with their special
characteristics. Even more complex processes containing substructures can be built hierarchically in DES
models. However, in this case all parts of the model are usually represented at a very low and detailed
abstraction level, even for those sections that are less important in contrast to the considered process. In this
case, high data requirements must be met and simulation can result in bad runtime performance. There are
also many examples representing hospital processes at high abstraction levels. Using rates and continuous
flows allow to represent a system of differential equations. In this case SD is appropriate to be applied.
This approach requires less input data and usually results in excellent execution times, however, detailed
coherences cannot be modeled.

3.2.1 Hybrid Simulation in Healthcare

In order to take advantages from all simulation techniques, a hybrid simulation approach can be applied.
Furthermore, guidelines or best practices from existing case-studies shall be considered. In particular, a
modular structure can help to achieve a sustainable model development and to reuse already validated

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components in different studies. As already mentioned, we distinct between the following four abstraction
levels in healthcare models (Djanatliev and German 2015):

• Holistic Level: Also called macro-level or top-down view. For example, health system models,
abstract disease models, global health economic models, as well as representations of demographic,
or epidemiological changes. SD is most appropriate to be applied, but DES can be used to change
SD parameters at discrete points.
• Process Level: Also called meso-level, or workflow perspective. In particular, representation of
hospital processes and clinical pathways. Cohorts, or entities without an individual behavior are
traversing predefined paths triggered by global instructions. Mostly modeled by the process-oriented
Discrete-Event Simulation.
• Individual Level: Represents a micro-level perspective. More detailed entities can be represented
at this level. In particular, agents which are following their own active behavior. An active behavior
include primarily actions that have been initiated explicitly (e.g., taking medication, calling the
doctor, ignoring symptoms). At this level the ABS is highly appropriate to be applied.
• Internal Level: In contrast to the micro-level, passive or background processes of agents can
be represented at the internal-level. For example, person’s internal body processes (i.e., gradual
deterioration of organs). Due to a continuous matter and lacking detail data, SD is particularly used
to model such processes.

Between all these levels different interactions from a logical and technical perspective can be consid-
ered. For example, demographic changes at the macro-level can affect the number of traversing entities
in processes, but single steps in paths can reduce financial budgets at the macro-level. Another example
is policy making in the healthcare sector. Global decisions can lead to process changes (e.g., regulatory
changes lead to a necessity of additional steps for documentation) or different study results due to changed
costs. From the technical point of view SD can be coupled with DES in this scenario. Five types of
interaction can be applied in both directions, e.g., firing events in DES after exceeding threshold values
in continuous modules (Djanatliev and German 2015). Further important connections exist between the
micro-level and the internal-level. For example, taking medication at the micro-level can lead to a slower
deterioration of organs at the internal-level, however, accruing disabilities at the internal-level can affect
the agent’s activity at the micro-level. In this case interactions between ABS and SD are required.

3.2.2 The Environment of Hospital Processes

As already stated, a considered process can be influenced by numerous factors. Some of them are depicted
in Figure 2. In particular, various holistic and micro structures are affecting the considered processes.
Typically, other intra-institutional workflows can, e.g., reduce the number of human and material resources,
otherwise, investments in new resources can improve the process quality. Moreover, processes of other
entities are also important to be considered. For example, external treatment procedures that have been
started in ambulance vehicles and are continued within the hospital.
Similarly, a nearby located hospital can have increased numbers of arriving patients. In particular,
demographic influences include population specific factors. Aging or an increasing population size are
most representative examples therefore. Epidemiological influences particularly refer to disease-specific
coherences, e.g., growing incidence rates leading to a higher bed occupancy. Political influences include
decisions of governments and regulatory agencies. Appropriate examples are changes in the reimbursement
catalog, and different legal requirements. Money flows at the holistic level, subventions and considerations
of various budgets can be represented by economic influences. Technical factors particularly refer to new
technical opportunities, or improved profits due to innovative cost-effective technologies. Going more in
detail, individual influences can play a significant role. In this case agents representing patients can refuse
to perform certain process steps, or forget to take important medications. Furthermore, wrong diagnostics

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disease-
demographic
specific
political influences influences
influences technical
influences

regional
influences
considered risks and
unknown

economic
processes influences

influences

Processes of Not considered

other entities individual hospital processes
(e.g., ambulance (e.g., other wards, other
vehicles) influences institutions)

Figure 2: Hospital processes within an integrated system view.

and treatment decisions by the staff can affect the quality of considered processes. Finally, in many strategic
studies risks and unknown influences have to be represented as well.

3.3 Building Hybrid Models

Building hybrid models in this context is not a trivial task. There are many decisions that have to be
made before. In particular, the main questions are usually, what kind of influences are important for a
case-study, and what is the most appropriate level of detail. Another problem refers to implementation
specific aspects. For example, how a running simulation can be realized and which software packages are
sufficiently featured.

3.3.1 Conceptual Modeling

According to Robinson (2011), the conceptual modeling process is the most essential success factor of any
simulation study. This kind of modeling usually does not depend on a simulation software and considers
the problem from a domain perspective. An important aim is to collect important knowledge from domain
experts in common non-formal specifications. We call them Conceptual Domain Models (CDM) (Djanatliev
2015). This structure must be understandable by all stakeholders (i.e., domain and simulation experts) and
it helps to find a consensus about the level of detail and simulation objectives.
There are different options for building CDMs. On the one hand, it is possible to start by very detailed
models and to aggregate fuzzy structures in holistic and high level models. Another possibility is to start
by top-level models combining important influences at high levels and to zoom-in those parts that have to
be considered in more detail. This approach is usually more preferable, as only necessary parts will be
modeled in detail. An appropriate and slightly formal technique is the Casual-Loop-Diagrams (CLD). They
allow to connect different entities by positive and negative influences and enable to transform a resulting
diagram to executable SD models. Figure 3 shows an example of a CLD. Positive influences mean that
changes of the source result in same directed changes of the target. For example, lower resources per person
lead to a decreased service quality. However, the amount of changes is not necessarily the same. Negative
influences mean that changes of the source contrarily affect the target.

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+
funding + hospital +
acquisition R reputation admission
- rate
service
+ quality R
service +
+ duration
+ investment + patients
- -
budget B -
- + B
+
investments
B + discharge
governmental - resources proportion
subventions per person -

Figure 3: An example scenario modeled by a Casual-Loop-Diagram. Based on Djanatliev (2015).

3.3.2 Implementation of Case Studies by Hybrid Simulation

In context of this paper we suggest to follow neither the top-down approach, nor the bottom-up. In particular,
following the previously presented four-level architecture, the focus has to be set on hospital processes at
the meso-level. That means, DES can be used to build process models in detail. Thereafter, all required
environmental influences have to be modeled around the considered process. SD can be used to represent
abstract and holistic structures, such as population dynamics, or disease dynamics, but also for bordering
hospital workflows that have not to be modeled in detail. ABS can be applied to represent the behavior
of people, i.e., patients and the hospital staff at the micro-level. Figure 4 depicts a schematic scenario
containing DES, SD, and ABS elements.

affected budgets investments

SD
hospital
service reputation
quality

diagnose 1 post
treatment

arrival admission treatment 1

discharge
process
treatment 2
diagnose 2
DES
staff quality

diagnose 2 patient
behavior

DES combined processes

ABS
Figure 4: Combining processes, holistic structures and detailed agent behavior.

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Building executable models in this context requires a powerful tool support. In particular, a suitable software
package must enable to develop models using SD, DES, or ABS in a common environment. There are a lot
of tools that can be applied to develop models referring to one of the relevant simulation techniques. Some
packages have extension features to establish connections to other tools (Heath et al. 2011). This may
be sufficient to develop simple integrated hospital models, as particularly DES is set in focus. However,
in more complex scenarios and studies representing a more integrated system view, a powerful software
package is required that enables to use all three simulation paradigms equally. AnyLogic (AnyLogic
2016) is a multi-method simulation software that flexibly allows to use different simulation techniques in
one common simulation environment. Moreover, this tool contains libraries and other pre-implemented
components for model developments in certain domains (e.g., manufacturing, road simulations). The
possibility to add own Java code makes this package more powerful particularly when modeling complex
structures. Another feature is the possibility to develop own modules hierarchically and to define interfaces
for a sustainable usage. In our previous work, we presented how dynamic process libraries can be built in
order to comfortably change internal processes of institutions or vehicles without reimplementing similar
modules in each component (Djanatliev 2015).
Due to the just presented reasons, we decided to use this tool, though the license costs are pretty high,
even for an academic usage. It should be mentioned that we did not performed a structured tool evaluation
within the scope of this work, so there are probably also other tools that can fulfill the requirements as
well. Figure 5 shows a very small illustrative extract of our first stroke hybrid model. At the left hand
side a statechart is depicted describing the behavior of an affected person. After recognizing the disease a
person can ignore symptoms or calls the emergency department.

Figure 5: A small illustrative extract of our first stroke hybrid model.

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In the latter case the pre-treatment process from the right hand side will be started. Both processes affect
the presented SD models and can be affected by them. For example the population and disease dynamics
influence the number of emergency calls. The more cases are identified, the more costs will be produced.
In this case, global budgets will be changed which can result in less financial resources for staff education
and other important investments. Finally, the better outcome hospital processes produce, the more healthy
contributors are available.

4 CONCLUSIONS
Hospital processes are usually analyzed independently for single wards or for certain clinical pathways. How-
ever, there is a need to put such workflows in a broader view in order to perform long-term evaluations from a
strategic perspective. Various internal or external influences have to be regarded. In particular, the following
high level influences can affect hospital processes: demographic, epidemiological, economic, technical,
political, regional, and further unknown processes as well as risks. Moreover, bordering workflows can
also affect a considered process. For example, a treatment begins in an ambulance vehicle and will be
continued in the hospital. Finally, individual influences including the behavior of patients and the hospital
staff must be considered. In this case a patient can, e.g., refuse certain process steps, or forget to take
medications. Wrong treatment decisions and a slow work progress is an example of how the behavior of
single physicians can affect the quality of hospital workflows.
In this paper we discussed from a theoretical perspective how hospital processes can be structured and
how they can be generally considered within an integrated system view. Furthermore, we proposed a hybrid
simulation approach that can be applied at four different abstraction levels. In this context DES is used to
represent processes, ABS and state charts are applied to consider individual behavior at the micro-level,
and SD allows to model abstract and continuous structures. We particularly suggested to begin by process
models at the meso-level and thereafter to enrich them by the surrounding process environment. As this
paper particularly focuses on theoretical aspects, the focus of future papers in this context should be set
to example case studies referring to the applicability of the presented theoretical basis.

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AUTHOR BIOGRAPHIES
ANATOLI DJANATLIEV is an Assistant Professor (AkadR) at the Chair for Computer Networks and
Communication Systems at the University of Erlangen-Nuremberg. He received his PhD degree (Dr.-Ing.)
and his diploma in computer science (Dipl.-Inf. Univ.) from the University of Erlangen-Nuremberg. His
research interests include various topics on simulation and modeling using system dynamics, discrete-event
simulation, agent-based simulation, hybrid simulation, and methods for healthcare decision-support. More
recently he focuses also on simulation of vehicular networks, and other topics from the area of connected
mobility. His e-mail address is [email protected].

FLORIAN MEIER is an Associate Professor of Health Care Management at the Wilhelm Löhe University
for Applied Sciences. He holds a PhD degree from the Friedrich-Alexander-University Erlangen-Nuremberg.
Before he started the scientific research, he worked as a business consultant for several years. Now, he
intends to use his practical experience for application-oriented developments. His research interests include
business process management and business intelligence for an objective decision making in the inpatient
sector. His e-mail address is [email protected].

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