Journal of the Operational Research Society

, Volume 61, Issue 2, pp 255–264

A system dynamics-based simulation study for managing clinical governance and pathways in a hospital

Case-Oriented Paper


This paper examines the development of clinical pathways (CP) in a hospital in Australia based on empirical clinical data of patient episodes. A system dynamics (SD)-based decision support system is developed and analysed for this purpose. The study highlights the scenarios that will help hospital administrators to redistribute caseloads among admitting clinicians with a focus on multiple diagnostic-related groups (DRGs) as the means to improve the patient turnaround and hospital throughput without compromising quality patient care. DRGs are the best known classification system used in a casemix funding model. Casemix is a DRG-based government funding model for hospitals with a mix of performance measures aiming to reward initiatives that increase efficiencies in hospitals. The classification system groups inpatient stays into clinically meaningful categories of similar levels of complexity that consume similar amounts of resources. Policy explorations reveal various combinations of the dominant policies that hospital management can adopt. With the use of visual interfaces, executives can manipulate the DSS to test various scenarios. Experimental evidence based on focus groups demonstrated that it can enhance group learning processes and improve decision making. The findings are supported by other recent studies of CP implementation on various DRGs. These showed substantial reduction in length of stay, costs and resource utilization.


clinical pathways system dynamics decision support system diagnostic-related groups (DRG) 


  1. Cardoen B and Demeulemeester E (2007). Evaluating the capacity of clinical pathways through discrete-event simulation. KU Leuven Department of Decision Sciences and Information Management Working Paper No. KBI 0712. Available at SSRN:
  2. Chalmers I (1993). The Cochrane collaboration: Preparing, maintaining and disseminating systematic reviews of the effects of health care. In Warren KS and Mosteller F (eds). Doing More Good Than Harm: The Evaluation of Health Care Interventions. Annals of the New York Academy of Sciences, NY USA, 703: 156–165.Google Scholar
  3. Dickinson RA, Thomas SM and Naughton BB (1999). Rethinking specialist integration strategies . J Healthcare Finan Mngt Assoc 53(1): 42–47.Google Scholar
  4. Ellrodt AG, Conner L, Riedinger M and Weingarten S (1995). Measuring and improving physician compliance with clinical practice guidelines . Ann Int Med 122: 277–282.CrossRefGoogle Scholar
  5. Guadagnino C (1998). Does standardization equal quality? Physician's News Digest, April.Google Scholar
  6. Hindle D (1998). Classifying the care needs and services received by Home and Community Care (HACC) clients. Aged and Community Care Service Development and Evaluation Reports, Commonwealth Dep. of Health and Family Services, April, No. 33.Google Scholar
  7. Holt P, Ward JE and Wilson A (1996). Clinical Practice Guidelines and Critical Pathways: A Status Report on National and NSW Development and Implementation Activity. NSW Health Department: Sydney.Google Scholar
  8. Jordens CFC, Hawe P, Irwig LM, Henderson-Smart DJ, Ryan M, Donoghue DA Gabb RG and Fraser IS (1998). Use of systematic review of randomised trials by Australian neonatologists and obstetricians. Med J Austral 168: 267–270.Google Scholar
  9. Jung M, Böchers K, Wasem J, Stolke D and Gasser T (2007). Improvement in quality – Reduction of costs: Clinical pathways prove cost-effectiveness of neuronavigation . Deutsche Gesellschaft für Neurochirurgie. 58. Jahrestagung der Deutschen Gesellschaft für Neurochirurgie e.V. (DGNC). Leipzig, 26.-29.04.2007. German Medical Science GMS Publishing House: Düsseldorf 2007. Doc P 022.Google Scholar
  10. Leape LL (1990). Practice guidelines and standards: An overview. Qual Rev Bull 16(2): 42–49.Google Scholar
  11. Lomas J (1989). Do practice guidelines guide practice? New Engl J Med 321: 1306–1311.CrossRefGoogle Scholar
  12. Lugon M and Secker-Walker J (1999). Clinical Governance: Making it Happen . Royal Society of Medicine Press: London.Google Scholar
  13. Maliapen M (1998a). Visual interactive modeling. In: Rahn J (ed.) Proceedings of 16th International System Dynamics Conference, Quebec, Canada. Systems Dynamics Society: Albany, NY.Google Scholar
  14. Phillips PA (1998). Disseminating and applying the best evidence. Medical J Austral, 168(6): 267–270.Google Scholar
  15. Porter GA, Pisters PWT, Mansyur C, Bisanz A, Reyna K, Stanford P, Jeffrey EL and Evans DB (2000). Cost and utilization impact of a clinical pathway for patients undergoing pancreaticoduodenectomy . Ann Surg Oncol 7(7): 484–489.CrossRefGoogle Scholar
  16. Ranjan A (2003). Effectiveness of the clinical pathway in the management of congestive heart failure. Southern Med J 96(7): 661–663.Google Scholar
  17. Saeed K (1998). Defining a problem or constructing a reference mode. In: Rahn J (ed.) Proceedings of 16th System Dynamics Conference, Quebec, Canada. System Dynamics Society: Albany, NY.Google Scholar
  18. Scally G and Donaldson LJ (1998). Clinical governance and the drive for quality improvement in the new NHS in England . Brit Med J 317: 61–65.CrossRefGoogle Scholar
  19. Secretary of State for Health (1997). The New NHS. Stationery Office: London (Cmd 3807).Google Scholar
  20. Sterman J (2000). Business Dynamics: Systems Thinking and Modeling for a Complex World. Irwin/McGraw-Hill, New York.Google Scholar
  21. Thomson R, Lavender M and Madhok R (1995). How to ensure that guidelines are effective . Brit Med J 311: 237–242.CrossRefGoogle Scholar
  22. Vissers J and Beech R (2005). Health Operations Management . Routledge: London.Google Scholar

Copyright information

© Palgrave Macmillan Ltd 2009

Authors and Affiliations

  1. 1.University of Central LancashireLancashire
  2. 2.University of SalfordManchesterUK

Personalised recommendations