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VSM and
Integration of value stream agent-based
mapping and agent-based modeling
modeling for OR improvement
585
Yikun Xie and Qingjin Peng
Department of Mechanical and Manufacturing Engineering,
University of Manitoba, Winnipeg, Canada

Abstract
Purpose The purpose of this paper is to present the research for improvement of the operating
room in a hospital, to reduce patient waiting time and increase the resource utilization.
Design/methodology/approach Value stream mapping (VSM) is used to represent the entire
operating room (OR) process and patient flow to identify problems. Agent-based simulation (ABS) is
applied to model human behaviors in the OR operation. Agents perform human factors in the
simulation model with autonomous and interactive functions actively.
Findings The research outcomes prove the effectiveness of integrated VSM and ABS to improve
decision making in human-centred healthcare environments.
Research limitations/implications Because the state is dynamically changed, the task priority
needs to be updated dynamically. The nurse schedule to transport patients between different units is
to be detailed.
Practical implications Long waiting lists in hospitals lead to patient dissatisfaction and care
quality reduction. It is crucial to identify inefficiency and to improve the healthcare delivery effectively.
Originality/value The paper shows how VSM and ABS are integrated in the modeling for the
dynamic OR planning. It improves the simulation modeling of healthcare delivery.
Keywords Simulation, Modelling, Healthcare, Operating theatres, Resource efficiency,
Value stream mapping, Agent-based system
Paper type Research paper

1. Introduction
Operating room (OR) in hospitals is a highly demanded healthcare unit. It faces challenges
to reduce patient waiting list and to improve the operation efficiency. The inefficiency not
only wastes OR resources but affects overall patient safety, care and satisfaction.
In the previous research, we built a simulation model for the OR in a local hospital to
improve the operation from the OR patient admitting to discharge. The model uses
historical data to locate the system bottleneck by analyzing the input and output of the
OR. The simulation analyzed what-if scenarios to allow the exploration of multiple
options without much expense on staffing and resources. As doctors and nurses
different decisions may lead to a variation of patient flow, the challenge is to optimize the
patient flow and allocate resources reasonably to reduce the patient waiting time. There
are following problems in the simulation model to improve: Business Process Management
Journal
Vol. 18 No. 4, 2012
The authors are grateful to the Winnipeg Regional Health Authority and Winnipeg Health pp. 585-599
q Emerald Group Publishing Limited
Sciences Centre for the research support, assistance and valuable constructive remarks during 1463-7154
the research. DOI 10.1108/14637151211253747
BPMJ .
Human behavior related decision-making. The human behavior plays an important
18,4 role in the OR operation. The activities in each care unit have the close relationship
with human factors. The existing model cannot address these factors in the
process such as admitting, pre-operation, and operation. It is not accurate to
simply set a fixed process time or schedule for operations in the OR system.
.
The systematic process management. OR functions systematic operations with a
586 series of processes, such as admitting, consulting, and treatment. It requires that
the entire system works not only for each units performance, but also for the
whole systematically. The risk evaluation of decision-making is to be included in the
model.
. The systematic analysis to identify problems. The processing is defined based on
the patient flow in the existing model. There is a need to increase efficiency of the
optimal search using value stream mapping (VSM) and agent-based
decision-making. VSM can represent a process to realize lean in a system. It
is proposed using VSM to combine processes and related data to locate the
improvement for the agent-based decision-making.

Therefore, this research uses the VSM and agent-based simulation (ABS) modeling for
the analysis and decision-making in the interdependent OR operation. VSM is to identify
the non-value added process or problems in OR. Agents represent human factors for the
care quality and patients satisfaction in the OR operation. General functions and
characters of agents used in the ABS modeling are as follows:
.
Agent is an individual with a set of rules governing its behaviors and
decision-making capability.
.
Agent is autonomous an agent can function independently and can interact
with other agents.
.
Agent can be set as goal-directed to achieve the goal.
.
Agent has the ability to learn and adapt its behavior from experience and the
previous decision.

In following parts of the paper, literature in the healthcare simulation modeling, VSM
and ABS research and applications is reviewed in Section 2. Section 3 introduces VSM
and OR planning. Proposed agents and interactions are described in Section 4. Section 5
discusses the system implementation, simulation solution and analysis, followed by
conclusions and further work in Section 6.

2. Literature review
Operation research has been applied in healthcare systems for decades. The research
has successfully guided the healthcare resource planning, system evaluation and
redesign. Simulation is one of the most popular operation research methods used in
healthcare systems (Davies and Davies, 1994).
Healthcare systems are often complex with multiple decision makers (Bertolini et al.,
2011). As uncertain and variable features of healthcare systems, healthcare modeling can
be very complicated. The modeling has to deal with complexity effectively. Simulation is
capable of interaction and communication required between the model and users
(Brailsford et al., 2010). Simulation can also be used for dynamic analysis of the situation
(Bertolini et al., 2011). Simulation can help to identify bottlenecks, and adjust resources or VSM and
staff without disturbing the actual system (Wang et al., 2009). Simulation is an effective agent-based
decision support tool in modeling process and evaluating effects of changes in healthcare
(Shim and Kumar, 2010). modeling
Simulation modeling has been used extensively in the research of healthcare
operations (Davies and Davies, 1994). The waiting time of patients and usage of
resources are common performance measures in healthcare systems. The simulation 587
provides tools to find the mechanism of conflicting factors and balanced load for
bottlenecks (Williams et al., 2010). It has been applied to model and analyze problems
that would not be successfully approached by other analytical techniques. Several
studies reported the benefit and cost saving of applying simulation in hospital planning
and scheduling (Duguay and Chetouane, 2007; Lowery et al., 1994). A number of
simulation models have been developed to reduce patient waiting time and to improve
OR efficiency, such as the flow simulation of surgical patients to test a master surgical
schedule on inpatient nursing workload, and to test the potential for increasing OR
utilization (Bertolini et al., 2011; Duguay and Chetouane, 2007).
The simulation has also been used for capacity planning with the constantly changing
complexity of surgical delivery process (Kumar, 2011). The performance modeling and
simulation for the design of healthcare systems has contributed to the improvement of
the quality, efficiency and effectiveness of healthcare (Maglogiannis et al., 2007).
There are mainly four approaches applied in the healthcare simulation modeling,
including discrete-event simulation (DES), system dynamics (SD), Monte Carlo
simulation (MCS), and ABS modeling (Mustafee et al., 2010).
DES is the most widely used simulation approach in healthcare research. It models
systems individual entities, characteristics, and flows with queues and processes
(Brailsford et al., 2010; Mustafee et al., 2010). DES has been applied in many
applications of improving hospital systems (Wang et al., 2009; Shim and Kumar, 2010).
It uses the medical historical data. Processing time distributions are based on the
previous history. Logical rules can be used to determine patients routing through the
system (Williams et al., 2010). Randomness and variability can be modeled. There is a
variety of DES software packages available in the market, such as Witness, Lanner
Group (2011) and Flexsim Software Products, Inc. (2011).
SD is a continuous simulation approach. It adopts a holistic system perspective and
uses feedback to study complex systems (Brailsford et al., 2010; Mustafee et al., 2010).
MCS uses a sequence of random numbers to generate values from a known probability
distribution associated with a source of uncertainty (Mustafee et al., 2010). This
approach may be difficult to evaluate the best and worst case scenarios for each input
variable (Raychaudhuri, 2008; Mustafee et al., 2010).
ABS is the most recent simulation method. It is particularly useful in modeling the
system behavior with autonomous and interactive abilities (Macal and North, 2008;
Bonabeau, 2001). Agents have certain characteristics including attributes, behavioral
rules, memory, resources, and decision-making rules (Stiglic and Kokol, 2005).
Applications of ABS in the healthcare sector are not yet widespread (Mustafee et al., 2010).
The simulation model in healthcare is more complex than the model used in
manufacturing simulation. Compared to the human beings in healthcare with materials
in manufacturing, human behavior affects the simulation outcomes greatly (Duffy,
2011). Human behavior plays a significant role in healthcare. For instance, patients may
BPMJ not be able to complete a prescribed medication because of the side-effect. Research
18,4 of evaluating the medication that ignores such behavioral factors may generate
unreliable results. Schmidt (2000) suggested an approach considering the physical,
emotional, cognitive and social aspects of human behavior. Sykes (2007) built a model
of the human behavior for womans probability of attending breast cancer screening.
An ABS can evaluate the impact of various physician staffing configurations
588 on patient waiting time (Jones and Evans, 2008). Physicians often represent a critical
path for the primary bottleneck constricting the patient flow (Naesens and
Gelders, 2009).
Agents can have elementary rules for scheduling patients based on their criticality.
Agents are self-directed for varying OR time based on the severity of patient illness.
Agents can set doctors to work faster or over lunch periods to reduce excessive queues
in waiting rooms (Kanagarajah et al., 2010). Agent-based modeling can also be used for
healthcare supply networks to identify their impact on patient safety, economics, and
workloads (Kanagarajah et al., 2010). The non-linear behaviors of a health service unit
and its complexities can be modeled. The safety dynamic model can evaluate the
various policy and design aspects of healthcare.
VSM was formed from Toyota production system and lean manufacturing principles
(Womack et al., 1990). It is a technique to visualize an entire process, and represent
information and material flow to improve the process by identifying waste and
its sources (Rother and Shook, 1999). A value stream consists of materials and
information in a system. VSM is simply transferring information about the value stream
to a map, which represents either the current or future state of the system
(Chen et al., 2010).
VSM has many successful applications to identify the non-value added process or
problem in a system. Lean principle can be substantiated in a systematic manner with
VSM (Sahoo et al., 2008). For example, VSM was used to improve productive systems in six
companies. VSM was presented as an original and practical method to design and create
efficient and flexible productive environments (Serrano Lasa et al., 2009). VSM can support
dynamic modeling for the changing process and resources (Agyapong-Kodua et al., 2009).
The integration of simulation and VSM can achieve the better system performance
(McDonald et al., 2002). VSM can also enable leanness in an organisation (Vinodh et al.,
2010).
Resulting from the review of extant literature, there is no solution demonstrated
capability to consider dynamic scenarios in healthcare environments. There is much
research for OR improvement. However, the direct applicability of the solutions from
one healthcare system to the other is difficult or even impossible as the difference of
healthcare operations and environments (Kanagarajah et al., 2010).
Based on the challenges in the OR delivery of safe, effective, patient satisfaction,
timely, and efficient, we proposed to use VSM and ABS modeling to simulate the
human behavior in the OR decision-making. VSM is used as a tool to identify problems
in the decision-making process. This will enable OR management to analyze the impact
of operational situations.

3. VSM and OR planning

VSM identifies the OR process and activity for the further what-if analysis and
simulation to assess the OR performance and improvement.
3.1 VSM for problem identification VSM and
VSM provides a tool for the system decision-making. VSM indicates intricate details of
facilities for improvements. VSM here is used in the static analysis for agent-based
agent-based
modeling. The dynamic decision is made in ABS. The integration of VSM and ABS modeling
helps modeling of the OR improvement.
The system current state and future state are mapped using VSM. It can track
historical data of the time record of patients through the OR in each processing. The data 589
include waiting time for each processing, different staff groups and units involved, and
other related information about the existing process to identify bottlenecks. After the
current state map is constructed, improvement alternatives of the future state can be
proposed. The future state is then validated and evaluated using the simulation model.
As shown in Figure 1, the OR patient flow is mapped to identify problems. Figure 2 is the
detailed unit processing in VSM. The information obtained from the mapping is used in
the ABS model for following decision-making.

3.2 OR capacity and schedule planning

OR provides care service to patients with the personal, complex, and intangible outcome.
Different units may play different roles in the process. The capacity planning and
schedule control are two most important issues to determine the process setting and OR
performance. Therefore, a dynamitic schedule is planned to control unit activities of
the patient flow based on the mapping information. Following goals are used in the
planning:

Figure 1.
OR patient flow mapping
BPMJ
18,4

590

Figure 2.
Process unit VSM

.
meeting patient satisfaction to reduce the time stay of patients in the hospital;
.
increasing resource utilization to balance the resource, load and usable time to
improve the efficiency; and
.
improving the system performance to use fixed target to measure the performance
such as the utilization of time and resources, and number of patients processed.

Algorithm is developed to process patient quantity, arrival time and OR scheduling for
each day. The schedule is dynamically modified by agents based on the current
situation with following two steps:
(1) The previous patient quantity and schedule are initially used in the daily
planning based on the historical data and model. The schedule is then modified
based on the patient arrival time and operation room assigned to the patient.
(2) Demand is determined for each day according to the total patients and available
OR time.

Objectives of schedule planning are to reduce the daily ending time and to improve the OR
utilization. As the importance of OR in the hospital, the planning will start at OR based on
the operation duration. The planning executes for each day. The simulation evaluates the
plan to show the process and results. The algorithm is coded using Flexscript in Flexsim
simulation tool. Following assumptions are applied in the scheduling:
.
if a surgeon has more than one operation, the operations will be assigned in the
same operation room;
.
the time stay in an individual unit is based on the distribution of the historical data;
 .
the ending time is set similarly for all operation rooms; VSM and
.
operations are scheduled using available time as much as possible, continuously agent-based
if possible; and modeling
.
the arrival time is scheduled at n times of 15 minutes, n is a positive integer.
Following notations are used in the objective function:
591
PN total number of patients in one day.
SN total number of surgeons in one day.
ON total operation rooms available.
MR Music room or patient holding area before operation.
PACU Post Anaesthesia Care Unit before patient discharge.
PreN total chairs in the pre-operation unit.
PostN total number of beds in the post-operation unit.
EODi expected operation duration of patient i.
EPreT expected time before operation (from arrival to operation beginning).
EPostT expected time from an operation end to discharge.
EIT expected interview time stayed in holding area.
ATi patient i arrival time, i follows the arrival sequence.
mi,t 1 means the patient i stays in pre-operation unit at time t, 0 otherwise.
hi,t 1 means the patient i stays in operation room at time t, 0 otherwise.
li,t 1 means the patient i stays in post-operation unit at time t, 0 otherwise.
pj,l 1 means the surgeon j is assigned with an operation room, 0 otherwise.
The objective function is formed as follows:
X
PN
Min ATi EBO EODi EPostT
i1

Subject to:
ATi3 2 ATi $ 15 1

X
i21
mi;t , PreN; t ATi EBO 2 EPreT 2
i1
X
i21
hi;t , ON; t ATi EBO 3
i1
X
i21
li;t , PostN; t ATi EBO EODi 4
i1
BPMJ X
ON
pj;l 1 5
18,4 l1

where: the constraint (1) limits the patient to stay in a pre-operation unit for waiting.
592 The patient needs the hospital staff to transfer from Pre-OP to MR; constraint (2)
specifies time when a patient i is expected to entry a holding area for interview, MR
should have at least one available chair; constraint (3) specifies when a patient i is
expected to entry the operation room, it should have at least one available room;
constraint (4) specifies when a patient i is expected to entry the post-operation unit,
it should have at least one available bed; constraint (5) requires that one surgeon is
assigned for only one operation room.
Figure 3 shows the flow chart of the capacity and schedule planning. Following are
the detailed planning steps:

Start

Retrieve data from Excel sheet to global table

Create doctor's table from raw data

Create OR table

Use equal allocation algorithm to initialize the OR table

Constraint 1 No Generate the block time

(AT(i+3)-AT(i)> = 15) ? between patients until it fits
constraint 1

Yes

Constraint 2 No
(AT(i+MR_number)-A Generate the block time
T(i) > = between patients until it fits
Interview_time? constraint 2

Yes
Generate the
No No block time
Constraint 3 Any patient fits
(LOTm > LOTn > = DTm)? between patients
constraint 3 ? until it fits
Yes constraint 3
Yes
Figure 3.
Switch 2 patients and
Flow chart of the capacity End reinitialize the OR,
and schedule planning
reinitialize arrival time
 .
Step 1. Pick the intraday patient information related to schedule planning, import VSM and
the data from the data base. Generate a patient table including information of agent-based
patient ID, operation duration, surgeon name and other schedule items.
.
Step 2. Generate a surgeon table including information such as surgeon ID,
modeling
surgeon name, operation time, patient ID to be processed and other related date.
Count the surgeon number according to the name, assign them with ID. Add up
each surgeons operation time and record patients ID. Sort the table by total 593
operation time.
.
Step 3. Produce an operation table including the operation group ID, surgeon
name, total time and other related data. Divide the operations into ON groups.
Fill up these groups with an equal allocation rule according to the surgeons and
their total operation time. Record operation sequence of each group and sort the
table by group ending time.
.
Step 4. Based on the operation table, modify the patient table with initial arrival
time, entry MR time, entry OR time, leave OR time and discharge time.
.
Step 5. Using the rule of the latest group ending time and first arrival time, the
patient arrival time can be modified. For each patient arrival time, check
constraints (1), (2) and (4). If there is one constraint that is not satisfied, postpone
the arrival time to satisfy all of them.
.
Step 6. For each patient, check any other OR is available before the time of
expected entry OR. If yes, this patient arrival time could be moved up. Therefore,
the constraints (1), (2) and (4) are used to check the possibility of the moving up.
If not, this operation is changed to another group and then equally to allocate the
following operations in theses two groups. Repeat this procedure until a final
optimized result is achieved.
.
Step 7. Assign an operation room to each operation group. As the distance
difference between holding area and operation rooms, assign OR number using
rules of the latest end and the shortest distance.

4. Proposed agents and interactions

Healthcare is highly human involved with staff resources and patients (Duguay and
Chetouane, 2007). Agent-based techniques model the system with autonomous entities.
Each agent is capable of acting independently and is guided by a set of programmed rules
(Jones and Evans, 2008). Agents are designed for the OR operation as a dynamic system
with complex interactions among various components and processes. The agents are used
for the critical processes and relevant resource planning. These agents are as follows:
.
Agent.Admitting for primary schedule for patient arrival time and operation
room assignment.
.
Agent.Pre-OP for patient waiting for transferring to music room or holding areas.
.
Agent.MR for patient interview before operation in the holding area.
.
Agent.OR for surgery operation.
.
Agent.PACU for patient waiting for discharge.
.
Agent.Schedule for day schedule based on the scheduling strategy.
. Agent.data for real-time information provided to agents.
BPMJ Each agent assigned in the ABS model has its own function with resources, behavior
18,4 rules for decision, and interaction with other agents. The detailed definition can be found
from the publication Peng et al. (2009). Figure 4 shows the agents and interactions.

5. System implementation, simulation solution and analysis

5.1 OR modeling
594 The simulation model is built based on the OR patient flow in the hospital using
Flexsim modeling tool. The modeling follows the patient flow mapping to analyze
scenarios to shorten the waiting time and improve the resource utilization.
Choosing the optimal OR configuration is complicated as the fact that the patient
arrivals are inherently unpredictable. However, the consistent intraday model for
reduction of patient waiting time can be made if physician staffing appropriately
accounts for the model.
The ABS model was verified by staff in the OR department before the simulation
runs. The simulation results were shown to the staff after the simulation runs. The
confidence intervals of the simulation outputs were compared to the actual values for
validating the simulation model. The ABS model was run in two different scenarios,
the changes made before and after for the OR improvement.
The agents are coded using Flexcript in the simulation model. Figure 5 is the OR
layout model. Figure 6 shows the part of OR simulation.

5.2 Agent-based dynamic planning

Doctors skill, experience and even personalities are main human factors in the OR
process. Each doctor is assigned a level to determine the weight for the operation time.
Staff is a group of workers with the same job assignment, the different busy time and
moving distance will affect their working enthusiasm. As the main goal is to reduce the
LOS, the effort is to balance the staff daily working load.

Figure 4.
Agents and interaction
 VSM and
agent-based
modeling

595

Figure 5.
Layout of the OR

Figure 6.
OR simulation

The fixed schedule and dynamic schedule are examined using the OR simulation.
Figure 7 shows the comparison between fixed schedule and dynamic schedule. The
column unit is minute. It can be seen that time is reduced from 150 to 130 minutes for
patient arrival to OR, the time is reduced from 89 to 72 minutes for patient ToMR to
ToOR. There is no improvement for the time of patient arrival to ToPostOp, it is because
the time increase of patient ToOR to ToPosOp by 6 percent, and OR time is increased by
6 percent.
From the patient stay time in the hospital based on the proposed schedule generated
in the simulation for a period of six weeks, the longer stay time (. 1,000 minutes) of
patients is reduced and shorter stay time (, 1,000 minutes) is increased to get the
working load balanced. The resource utilization is improved using the dynamic
planning in the OR scheduling.

5.3 The result analysis

The main objective of this research is to reduce the patient time of stay in the hospital.
The measure used for the system performance is the time from patient arrival to discharge.
BPMJ
18,4

596

Figure 7.
Comparison between fixed
schedule and dynamic
schedule

In order to investigate details of patient time spent in the hospital related to the
available recourses, different time ranges are considered to measure the OR
performance, including time from patient arrival to OR, time from patient holding room
to OR, time from patient arrival to post-operation, time from OR to the post-operation,
and OR stay time. The proposed dynamic scheduling considers uncertainties in the
operation. The agent-based decision-making can adjust a pre-decided schedule to best
fit the current state of the operation. Ideally, if the system can perform as good as we
expected, the OR resources will be fully utilized leading to a high efficient OR
operation. Although the overall system performance is improved with more balanced
stay time of patients, there is no improvement for the time spent in some operation
stages. It may results from the fixed task priority used in the proposed method, which
constrains nurses operation to transport patients from OR to the post anaesthesia care
unit after the operation. The nurse resource seems playing a major role for the time
stay as patients waiting for the TP transferring to following processing unit. The
longer time after OR indicates the bottleneck existed in PACU.

6. Conclusions and further work

Simulation modeling is an effective method for the healthcare improvement. The model
can be used to forecast the outcome of a change in strategy, or predict and evaluate an
alternative policy. Simulation modeling generally entails the representation of certain key
characteristics or behaviors of a system. It uses random variation to capture uncertainty
and to show the eventual real effects of alternative conditions and courses of action.
In this research, VSM and ABS modeling are integrated to optimize the OR operation.
The modeling is based on the specific circumstances, processes, and the human decision
behavior of the OR in the hospital. The system can analyze alternatives for problems of
capacity planning and schedule control. The obtained results are proved that the model
can simulate a series of alternative scenarios to identify bottlenecks of patient flow and
to examine potential solutions.
Because the state is dynamically changed, the task priority needs to be updated
dynamically. Another problem is the nurse scheduling to transport patients from MR to
OR and from OR to PACU. The priority rule is also required when there are two tasks to VSM and
call staff at the same time. Different priorities are required for different scenarios agent-based
to reduce the patient stay time.
modeling
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About the authors

Yikun Xie is a Master student of the Department of Mechanical and Manufacturing Engineering,
University of Manitoba, Canada. He received his Bachelors degree from Anhui University
of Science & Technology. He worked for Siemens Ltd, China, Industry Sector, Industry
Automation & Drive Technologies (SLC I IA&DT) for five years and GEA Group, Division of
Process Engineering for four years. His research interests are agent-based systems and
simulation applications in healthcare systems.
 Qingjin Peng is a Professor in the Department of Mechanical and Manufacturing Engineering VSM and
at the University of Manitoba, Canada. He received his Doctorate at the University of
Birmingham, UK in 1998. His research is in the areas of virtual manufacturing, system modeling agent-based
and simulation, and healthcare delivery improvement. He has published over 100 refereed papers modeling
in international journals and conferences. He is a registered professional engineer and member of
ASME and SME. Qingjin Peng is the corresponding author and can be contacted at: pengq@cc.
umanitoba.ca
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