Proceedings of the 2003 Winter Simulation Conference

S. Chick,P. J. Srinchez, D. Ferrin, and D.J. Morrice, eds.

A SIMULATION-ILP BASED TOOL FOR SCHEDULINGER STAFF

Martha A. Centeno Abdullah M. Ismail

Ronald Giachelti
Richard Linn Information Technology
Baptist Health South Florida
Industrial and Systems Engineering Coral Gables, FL 33143, U.S.A.
Florida Intemational University
Miami, FL 33199, U.S.A.

ABSTRACT entific management tools, and better scheduling systems,

to reduce their staffing levels without affecting quality of
Healthcare facilities, especially hospitals, are under fman- services. Patients become dissatisfied with the service lev-
cia1 pressure to control cost. One element that affects cost els, especially in the Emergency Room, when they have to
significantly is staff. We have developed a tool that inte- wait for a long period of time to receive much needed care.
grates a simulation model and an integer linear program The latter situation occurs when staff is reduced arbitrarily.
(ILP). The simulation model establishes the staffing re- For the last few years, administrators and managers in
quirements for each period, and the E P produces an opti- healthcare have turned to scientific methods to reduce cost
mal calendar schedule for the sW, i.e. how many staff and improve their practices. However, managers in health-
members to start at each shift. The two models were fully care, especially in ER, are clinicians not analysts; thus,
integated, under a Visual Basic interface that allowed a they need tools that are easy to use and flexible for their
non expert user of the heuristic to interact with it on a re- environment. We have developed a tool that is simple to
petitive planning basis. use, and which embeds a simulation and mathematical pro-
gramming under a VBA application. With it, the ER ad-
1 INTRODUCTION ministration obtains the optimal number of nurses required
per shift to satisfy a predefmed patients’ length of stay
Personnel or staff scheduling problems have been studied (LOS) in the ER, based on demand and service times.
for many years due to its importance on the overall per- Section 2 of this paper reviews literature pertinent to
formance of a system in terms of quality of service to the the staff scheduling problem. Section 3 provides a descrip-
customer and cost to the organization. Different ap- tion of the framework under which the tool was developed.
proaches have been taken, including mathematical models Section 4, 5 , and 6 provide a description of the simulation
as well as computational ones. Some of these models have model, the ILP model, and the integration respectively.
been embedded in scheduling systems. A scheduling sys- Section 7 summarizes the findings and lessons learned out
tem has two goals: 1) determine the minium number of of this effort, and it suggests some extensions to this work.
personnel to satisfy a set of service level requirement, and
2) build a schedule that specifies when a person should 2 PREvIouswoRK
start hisher shift so that all periods in a day are covered,
the staffing level requirement of each period are met, and This section provides a review of the literature organized
labor laws mandates are preserved. in two parts: 1) focuses on mathematical models and 2) fo-
With shrinking reimbursement rates from the federal cuses on discrete event simulation for staff scheduling.
government (Medicare and Medicaid) and Managed Care
Companies, hospitals must provide a higher level of care at 2.1 Operations Research
a lower cost in order to survive (Ismail and Miville, 1999). Based Scheduling Tools
Due to the Balanced Budget Act of 1997, the federal gov-
ernment has cut Medicare and Medicaid spending by $70.1 For decades, researchers have used several approaches to
billion; thus, producing negative margins (Lewin Report, the staff scheduling problem including the use of statistics,
1999, AHA statistics). work measurement, queuing models, and integer pro-
Over 60% of the cost of operating a hospital is in staff- gramming. Isken and Hancoek (1998) discussed Tour
ing (Hancock and Chan 1988). Hospitals need to use sci- Scheduling models as they apply to scheduliig in hospital

1930
 Cenfeno,Giachetti, Linn, and Ismail

ancillary units where demand is variable by day of the and day-off scheduling in general, as well as the methods
week and time of the day; specifically, the authors intro- to solve such problems using mathematical programming.
duced Tactical Staffing Analysis. This model was written He presented a model for allocating overlapping shifts with
in AMPL language and solved using the CPLEX Optimiza- demand fluctuations (the Klein City Problem). He also
tion package. The output of the solution is a text file that presented the service level policy for staff requirement in
lists all the scheduling tours. However, as they point out shifts scheduling. For the day-off scheduling, he discussed
mathematical models seldom provide complete answers to the problem where an employee workweek does not match
real problems, but they provide partial solutions, and a the service facility operating week. For this situation, he
greater understanding of the problem. presented a model that provides equal assignments by ro-
Khan (1991) presented a solution that was a network tating individuals among day-off patterns.
model to minimize the flow of resources through the net-
work The resonrce is the nursing staff that needs to be as- 2.2 Scheduling Using Simulation
signed to different departments in the hospital. Khan used
the minimal flow algorithm to solve the problem. He Computer simulation can be.used to model and analyze
proved that using the minimal flow algorithm would yield real-world problems that cannot be successfully ap-
the same results as the simplex method. This study can proached by other types of analytical techniques (Fitz-
provide some insights into the staff scheduling problem of patrick et. al, 1993). In the last two decades, the use of
ER systems, but it does not provide a complete methodol- simulation as a planning and decision making tool has been
ogy for staffing a complex system such as an ER system. spreading rapidly in the healthcare arena. Many simulation
Haocock and Chan (1988) addressed the problem of projects have been done for hospitals around the world,
staff schedulingwhere the workload varies from day to day primarily in Emergency Departments.
and the administrators need to schedule staff weeks in ad- Pitt (1997) reports on a project that uses simulation as a
vance. The variability in demand is addressed by one of resource planning tool. The project is the PRISM project
the following strategies: (planning Resources using Interactive Simulation Model-
0 Staffing at average demand levels w i d no consid- ing). PRISM is a general hnework that supports the
eration to work force capability. analysis of a range of models and variables to test different
0 Staffig at constant level, overtime permitted, and scenarios in the resource and strategicplanning in hospitals.
considerationsto work force capability. A simulation model of a new one-stop pre-procedural
Staffing at constant level, no overtime permitted, work-up and assessment area of the University of North

- and Considerations to work force capability.

Staffing at different level each day, no overtime,
and considerationsto work force capability.
Carolina Hospitals was developed by Glick (1996) to
evaluate different scenarios (staftkg levels versus patient
volume). For each scenario, the simulation predicted the
Staffing at different level each day, limit on over- utilition for nurses, anesthesiologists, and other pertinent
time and demand, work force capability consid- staff throughout the day. The simulation also produced pa-
ered tient waiting time, patient time in the system and the total
Staffing at different level each day, limit on over- n u b e r Of Patients Processed throughout the day. using
time, capability and work these results, a schedule for the different required staff was
task may span over two days. formulatedbased on the simulation results.
For each of these strategies, the authors calculated the Evans, Gor, and Unger (1996) used simulation as well
labor and &e productivity for the deparhnentbeing to investigate various schedules of nurses, ER technicians,
staffed. and doctors to reduce the average patient time in the sys-
~i~~ and mayma (1982) provided a review of the tem. The authors created a simulation model of a particu-
manpower scheduling algorithms from a common frame- lar Emergency R” us@ ARENA Skdation Package
work, n i s scheduling approach is based on the idea software to evaluate different personnel schedules. Five
the scheduling problem is composed of five or sub- different schedules were evaluated, and a decision was
problems. These five stages are the determination of tem- made based On the average time in the
poral manpower requirements, total manpower require- Other researchers have used simulation in this same
ment, recreation blocks, recreatiodwork schedules, and manner; For instance, McGuire (1994) used SimdatiOn to
shift schedules. For each of these stages, they suggested Len@h Of stay (Los)in an emergency department.
different algorithms. They also compared and discussed One Of the a~temativesthat was evaluated is the introduc-
the algorithms and solutions for each stage. The authors tion Of additional staff the emergency room.
presented a review of the available algorithms to analyze Hammond and Mahesh (1995) used simulation to test
each of the five stages of the scheduling problem. manning heuristics for hank tellers to meet the desired
Baker (1976) surveyed the basic mathematical models level Of Services in banks. In this study, the researchers
for workforce scheduling. He discussed shift scheduling used a model based 00 queuing theoly to CalCu-

1931
 Centeno, Giochetti, Linn, and Ismail

late the required number of employees U, meet the level of

service requirements. The second part of this study is the
utilization of simulation to test new management policies.
The manning model provided a methodology to calculate W A Shlatimr M&I Fioal
the required number of employees while the simulation
model tested for the corresponding service level.
Garcia et al. (1995) studied the flow of patients at
Mercy Hospital in an effort to reduce the waiting times of
D
CW LM"
patients. As a result of this study, a Fast Track lane was U&
conditions
added to the Emergency Room; thus, reducing the total
time in the system by 25% for patients with low priority
without affecting the times of patients with higher priority.
This study was performed using simulation where the au-
thors conducted the simulation of this system with and
without the Fast Track to test the effect of implementing
this Fast Track on the system.
Fitzpatrick. Baker, and Dave (1993) used simulation
modeling to improve scheduling of the operating mom of
an 800 bed medical center in the southeastern United
States. In this study, three different block schedules were
compared based on throughput, average waiting time, the
distribution of waiting time, queue characteristics, facility
utilizatjon, and cost effectiveness. The simulation model
was built using GPSS.

3 TBEFRAMEWORK

Simulation models can provide a statistically accurate and

insightiid means to analyze and predict the performance of
a system such as a hospital's emergency deparbnent, which
is a complex system formed by a large number of units
with strong interrelationships. O n the other hand, Integer
Linear Programming is an optimization technique that is
concerned with fmdhg the best possible answer to a prob-
lem. In the case of an emergency department, the schedule
must meet certain conditions, such as those imposed by
regulations andor to protect staff and patients, including
maximum shift length, or maximum overtime bows.
In order to make the simulation and the linear pro-
gramming model useful to ED management, these two
techniques have been integrated under a VBA for ARENA
application (Figure 1). The simulation model determines
the staff requirements during each of the predetermined pe-
riods in a day, given current conditions of demand and ser-
vice times. The results, namely the number of the RN's in
each of those periods, are then fed automatically to the ILP
model to generate a shift-based 24-hour schedule.
Through User-Defied Conditions, the analyst provides
the current system's conditions such as the patients arrival
pattern, the service patterns of different servers in the ER
system, and the target performance level of the LOS. There
are two different alternatives to get the data into the simula-
tion model. The first option is to have the user input the data
manually into the simulation model. The second option is to
have the user create text files that contain the data for each
category. For this effort, the second option was chosen for

1932
 Centeno, Giachetti, Linn, andlsmail

Once the patient is stable and treatments are complete, the Table 3: MD Sewice Times
physician decides on the patient’s disposition. The RN IMLl Phase I Service TimeIMD Phase I1 Service Time
prepares and mange for patient’s disposition documenting Acuity 1 Distribution 1 % 1 Distribution I %
all actions on patient’s chart.
The arrival pattern presented seven different distribu-
tions (Table I). The service times of the RN and the MD
were divided into two main stages since they do not service
a patient from start to finish and then move on to the next
patient. For the RN, Phase 1 is from the time patient occu-
pies a bed in the treatment area until the physician sees the
patient, and phase 2 is made of the rest of the time until all
treatments are completed. For the MD, Phase 1 is the time
of the patient initial evaluation by the MD, when tests and
treatments are ordered and documented, and Phase 2 is the
time from the completion of tests until the patient is stabi- Table 4 Patient Behavior Percentages
lized and a decision on disposition of patient is to be made. 1 Action I Percentage
In this manner, the server (RN and MD) is seized to per- I Anival by hre rescue or 1 24
form the task and then released once this task is completed.
Each service time for the RN’s and the MD’s consisted of
multiple distributions as given in Tables 2 and 3.
To build a model for the system being studied, it is
necessary to h o w the properties of the patients being
treated. All patients that came in to the emergency depart-
ment were logged in with all their properties including
their method of anival, disposition, and the auxiliary pro-
cedure received (Table 4).
Times for other ancillary activities are in given in Ta-
ble 5. Procedures procedures
Patients that have EKG I 42
Table 1: Distributions for Inter Arrival Times

Table 2: RN Service Times Once the model was verified and validated, the condi-
1RN Phase I Service TimelRN Phase II Service Time tions for the experiments were established. &tially, the
Acuitv IDistribution 1% IDishibution I% simulation model was run for 10 replications, and the LOS
for each replication was recorded. These values were used
to calculate the sample size required to achieve a reliability
level of +- 3.61 when building a 95% confidence interval.
From these, it was established that the number of replica-
tions required is 38.

5 ILPMODEL

An optimization ILP model is used to fmd the optimal

number of staff (RN’s) needed to work each shift. To
build the ILP model, the fmt step was to identify the shifts
that are used by the hospital. In this case, the shifts used
are 12 hours in length, with start and end times as in Table
6 . Based on these shifts, a period could have nurses from

1933
is given in Table 6. A minimum of one RN is required at 5 1 3:OOAM I 3:OOPM I $400.00 I
Time Period

Subject to

gxi5 aj Vj = 1,2, ..., m

i l

X i 5 1 andinteger V i = 1,2, ..., n

Where
X i = Number of nurses working shift i
ci = Salary cost for a nurse during shift i
aj = Number of R”s required per period as de-
termined in the simulation model
i = Indexforshifts In the above ILP model, there are three equations that
j = Index forperiods are similar, (Period 3,4, and 5) differing only in the right
n = Maximumnumberofshifts hand side (RHS) constant ( U ,’
~
.
). The constraint with the
I

m = Maxi“ number of periods

~

nea p model w i h actual data (Table and ~ ~ b 1 ~ 7 ) fnax{u3.u4.a5) will render the other two constraints re-
is as follows: dundant. These equations are left in the ILP model be-
cause the values of a3, U , , and a5may change due to
changes in the input parameters of the simulation model.
Any change to the input parameters of the simulation
Subject to: model will result in changes to the results of the simulation
model, which in tum will affect the values aj . Since this
X3 + X4 2 al (Period 1) model is meant to be reusable, these similar constraints
X, + X5 5 a2 (Period2) have been left in to allow the model to choose its own re-
X, + X s 2 a3 (Period3) dundant constraints, depending on current conditions. It is
also worth noting that labor costs change over time.
XI + XI 2 u4 (Period4)
Therefore, the values of c j (salary cost for a nurse during
+ x5 5 4 (Period5) a shift) are read fiom a text file, allowing flexibility in the
+ x2 + x5 2 ‘ 6 (Period6) constraint equations as well as in the objective function of
the ILP model. Every time the ILP model is nm, the labor
+ x2 + x3 > (Period 7) cost text file is read by the ILP model assigning values to
each c j. The LINGO Model is given in Figure 2.
xl + x 2 + x3 + x4 2 as (Period8)
X2 + X 3 +. x4 2 9‘ (Period 9) 6 VEAINTEGRATION

The tool is the integration of several commercial of the self

(COTS)sofrware. As shown in Figure 1, the two main

1934
 Centeno. Giachetii.Linn. and Ismail

;ETS: Nurses-Periods/ RN1 RN2 RN3 RN4 RN5 RN6 Figure 3 shows the steps in the VBA integration. It re-
"7 RN8 RN9/ : Demand; quired the programming of several ARENA model events:
Nurses-Shifts/ SH1 SH2 SH3 SH4 SH5/ : Re-
pirement ; RunBegin
i
Cost-ehi€ts/Cl C2 C3 C4 C5/ : Cost; RnnEndReplication
$nd Set8 RnnEnd
>ATA:
lemand = @File( 'Finalschedules.txt') ; The code for gathering data and implementing Reyes'
30st = @File( 'ShiftCost.txt' 1 : (1998) goal driven simulation heuristic is very extensive,
aTEXT ('shifts.TXT') I Requirement; but since the interesting part was the embedding of the ILP
ZNCDATA model, Figure 4 provides the subset of the VBA code that
[OBJECTIVE1 MIN = Cost 1Cl)'Requirement ISH1) + triggers and controls LINGO.
:ostlcZ) 'Requirement (SNZ) +
3ost (c3)'Requirement(SH3) + 1 Get the goal (LOS) from user
zostlC4)*Requi+ement(SH4) + t Load files (schedules)
Iost (C5)*RequirementiSH5); Change = 0
1 Run simulation
SINIRequirement ISH1)) i I At end of Simulation run,
SIN(Requirement iSH2)) ; For i = 1 to iI (Number Of periods per day)
aGIN(Requirement (SH3)1 ;
aGIN(Requirement lSH4)) i Calculate 95% CI on LOS f o r nperiods
aGIN(Requirement (SH5)) ; I€ Goal c ~nxllos,I then RN,=Rh',+I
Requirement (SH3) + Requirement (SH4) >= De-
nand(RN1); Change = 1
Requirement (SH4) + Requirement (SH5) 5= De- Next i
nand(RN2); 5 If Change, = I , then
Requirement (SH1) + Requirement lSH5) >= De-
nand(RN3); Stop Simulation
Requirement iSH1) + Requirement (SH5) >= De- Update physical model (SCHEDULES)
mandIRN4) ; Go to step 3
Requirement (SH1) + Requirement (SH5) )= De- Else
mand(RN5); Export RN, from SCHEDULES to file
Requirement lSH1) + Requirement lSH2) + Rewire- End If
nent (SH5) >= Demand(RN6) ; 5 Trigger Lingo ILP model
Requirement (SH1) + Requirement (SH2) + Require-
ment(SH3) >= DemandlPS7); Load Files (cost, )
Requirement (SH1) + Requirement (SH2) + Require- Get solution, transfer to a file
mentlSH3) + RequirementlSH4) >= DemandiRNB); 3 Pause simulation execution, retain control
Requirement(SH2) + Requirement(SH3) + Require- 9 Trigger Lingo ILP model
mentlSH4) >= Demand(RN9);
END
Load Files IcoBt, mi)
Solve ILP model,
! Terse Output mode transfer results to an ASCII file
SET TERSE0 1 10 Read ILP results f i l e
! Open a file I1 Display final Results.
DIVERT Shifts.TXT Figure 3: Steps in the Integration Process
! Send solution to the file
SOLUTION
! Close solution file At the conclusion of the simulation run, the number of
RVRT nurses is exported from the SCHEDULES element to a text
! Quit LINGO
QUIT
file. A VBA routine (LingoContro[) triggers LINGO to
run the pre-formulated LINGO ILP model. The LINGO
Figure 2: The LINGO ILP Model model is programmed to read the text file containing the
number of nurses required per time period VBA for
components of the tool are: a simulation model and an in- ARENA funs the ILP model, via the DDE facility of Send-
teger linear program. The tools used to develop these two keys. The results are then exported to a text file. that is in
components are ARENA and LINGO. These tools have a tum read by VBA for ARENA to exhibit the final results
master-slave relationship, with ARENA retaining the mas- through a user form.
ter role because of its VBA capability. Figure shows the
macro steps of the heuristic that enable the communication
between tbe user and ARENA and ARENA and LINGO.
The user never interacts directly with LINGO, only with
ARENA through a simple and friendly interface.

1935
 Centeno, Giachetti, Linn, and Ismoil

Sub Lingocontrol 0 7 CONCLUSIONS

Dim LingoConnector, thefile, Start
D i m PaueeTime
Dim Totalcost, TOtalHOurs As Integer This work presents a tool that integrates two proven tools,
simulation and integer linear programming to help ER
t Triggering Lingo managements to staff their departments correctly without
thefile = "ataffing.lg4"
over-spending.
LingoConnector=Shell("lingo.EXE",11 The value of this tool had to be ascertained by answer-
AppActivate Lingoconnector ing one question: Is the heuristic at least os good as the
SendKeys 'OFo", True ALT+F and 0 empirical method currently used ? This implies that even
SendKeys thefile, True ' sending file name tc
be Opened if the heuristic is as good as the empirical approach there is
SendKeys -{tab 2)(enter)", True 'click 01 an intrinsic value in using it, namely that the process of
OPEN in dialog box" generating the schedule is automated; hence, the schedules
SendKeys "%LS", True r running the
are less prone to errors and can be generated faster.
model
Since this heuristic was established for staff schedul-
'pausing to allow solver to finish ing in ER, the total nurse-hours per day for the empirical
approach and the heuristic were calculated at different de-
PauseTim: = 3 ' set duration. mand levels. Table 8 shows the total nurse hours for each
Start I Timer ' set start time.
Do While Timer < Start + PauseTime of the two methods. For the empirical method an ER
DOEvents manager was consulted to perform the staffing of nurses at
LOOP the different patients levels. As can be seen in Table 8, the
'Resume control from Lingo
SendKeys "C", true schedule is fmed between 40 and SO patients, the total of
SendKeys "IFX", True 'Close Lingo nurse-hours are then increased proportionally based on the
number of patients.
open 'Shifts.txt" For Input A8 #15
I = O
While Not EOF(151 Table 8: Total Nurse-Hours
Input #15, My
I = 1 + 1
Wend
~~~~

Close #15
ObsNum = I
ReDim mIobsNum1 As Integer
open -Shi€ts.fXt" For Input AB #15 0 Oper
file.
Do While Not EOF(151
For I = 1 TO ObsNum
Input #15, z
m(I1 = z
Next I
LOOP
Close #15

RNSHl = m ( l 1 : RNSH3 = m ( 3 1 : RNSH2 = m ( z 1 64 w I 120 I 168

RNSH4 = m(41 : RNSHS = m ( 5 )
6S U 111 I
Totalcost = 3 0 0 * RNSHl + 345 RNSH2 + 375
FNSH3 + 3 7 5 * RNSH4 + 400 * RNSHS A t-test was used to answer the question. The hy-
TOtalHOUrs = 12 (RNSH1 + RNSH2 + RNSH3 i pothesis test is set up as follows:
RNSH4 + FNSH51

Load ResultForm H , : TE TH
ResultForm.Shiftl.Text = FNSHl
ReaultForm.Shift2.Text = RNSH2 H , : TE 2 TH.
ResultForm.Shift3.Text = RNSH3
ResultForm.Shift4.Text = RNSH4
ResultForm.Shift5.Text = RNSH5 where,
ReBultFOm.Hour8.Text = TotalHOurs TH =Total person-hours for Heuristic
ResultForm.Objective.Text = Totalcost
ResultForm.Show TE = Total person-hours for Empirical
End Sub Since the resulting confidence interval (24.67, 44.13)
Figure 4 VBA Code to Control LINGO does not contain zero, and the two tail significance level is
less than 0.005, we reject the null hypothesis. Thus, there

1936
 Centeno, Giachetti, Linn, andlsmoil

is sufficient evidence to conclude that there is a difference Conference Proceedings, Institute of Industrial Engi-
between the two populations. Furthermore, because the neers, 343-349.
difference TE - TH is positive (34.4), schedules generated Hammond, D. and S. Mabesh, 1995, “A Simulation and
using the heuristic requires less person hours than the Analysis of Bank Teller Manning,” Proceedings of the
schedules generated using the empirical method. There- 1995 Winter Simulation Conference, C. Alexopoulos,
fore, the heuristic is better than the empirical approach. K. Kang, W. R Lilegdon, and D. Goldsman (eds),
The mean improvement in the total person-hours is 1077-1080.
34.40 hours per day, that is a 28% improvement. Estimat- Hanmk, W. M.and T. J. Chan, 1988, ”Productivity and
ing nursing hourly rate to be at $35.00, the 28% improve- Staffig of Hospital Units with Uncertainty in the De-
ment, for a 15 beds emergency room, will result in an an- mand for Service,” IIE Tmactions, 20(4), 346-353.
nual savings of approximately half a million dollars (34.4 Hospital Statistics, 2000 Edition, Health Forum LLC, an
hourslday*$35.00ihour * 365 dayslyear = $439,460). If a affiliate of the American Hospital Association.
hospital decides to implement this heuristic, they must own Isken, M. W. and W. Hancock, 1998, “Tactical Staff
ARENA and LINGO software packages, which implies an Scheduling Analysis for Hospital Ancillaq Units,”
investment of approximately $25,000.00. Given the ex- Joumalof the Society for Health Systems, 5(4), 11-23,
pected savings, investing in the s o h a r e is profitable. Ismail, A. M. and N. D. Miville, 1999, “Flexible Staffmg
This tool will aid ER management in determining the for Ancillary Departments in Hospitals,” Industrial
exact number of staff required to achieve a specific goal, Engineering Solutions 99 Canference Proceedings, B.
which is the time in the system that a patient spends in ER. Bopaya, and P. H. Cohen (eds), 79-83.
With this tool, ER management would be able to determine Khan, Z.A.,1991, “A Note on a Network Model for Nurs-
the number of nurses by shift based on a specific time that ing Staff Scheduling Problems,” Information and De-
they would l i e to have the patients out of the system. cbions Technologies, 17 (1991), 63-69.
They would also be able to calculate based on their labor Klein, R. W., M. A. Dame, R. S . Dittus, and D.J. DeBrota,
rates, the cost associated with a specific time in the system. 1990, “Using Discrete Event Simulation to Evaluate
They also can use t!is tool to experiment with three differ- Housestaff Work Schedules,” Proceedings of the 1990
ent important factors; labor cost, time in the system and Winter Simulation Conference, 0. Balci, R P.
number of nurses. Sadowski, and R. E. Name (eds),738-742.
Lewin Report, 1999. “The Balanced Budget Act and Hospi-
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1937