Performance Evaluation of the Hospital's Emergency Department: An Integrated Approach based on Resilience Engineering and Lean Management

Document Type : Original Article


1 M.Sc., Iran University of Science and Technology.

2 Instructor, University of Eyvanekey.

3 M.Sc., University of Tehran.


The emergency department is one of the crowded wards of a hospital, so improving the performance of this ward has a significant impact on improving the quality of hospital services. Recently, researchers have paid more attention to resilience engineering (RE) and lean management approaches, because of their focus on performance improvement. The aim of this study is to present an integrated performance evaluation model for evaluation performance of the emergency wards of a private hospital, based on simultaneous applying resilience engineering and lean management. For this purpose, first by identifying the effective factors, a conceptual model of the problem was designed. Then the required data were collected using a standard questionnaire. In the next step, using the algorithm based on data envelopment analysis (DEA) and with the presence of all indicators, performance values were calculated. Also, the performance values were recalculated after removing each of the factors. The results show that the indicators of engineering commitment in the group of RE and operational improvement in the group of lean management; have the most impact; Therefore, by focusing on these factors, significant improvements can be made in the level of staff satisfaction and as a result, the performance of the organization.


Main Subjects

  1. Al-Balushi, S., Sohal, A. S.. Singh P. J, Al Hajri, A. Al Farsi, Y.R. & Al Abri, J. J. o. h. o. (2014). Readiness factors for lean implementation in healthcare settings–a literature review.
  2. Aminuddin, W. M. W. M. & Ismail, W. R. (2016). Integrated simulation and data envelopment analysis models in emergency department. AIP Conference Proceedings, AIP Publishing LLC.
  3. Andersen, P., & Petersen, N. C. J. M. s. (1993). A procedure for ranking efficient units in data envelopment analysis. Management science, 39(10), 1261-1264.
  4. Azadeh, A., Bonab, N. A., Salehi ,V. & Zarrin, M. (2015). A unique algorithm for the assessment and improvement of job satisfaction by resilience engineering: Hazardous labs. International Journal of Industrial Ergonomics, 49, 68-77.
  5. Azadeh, A., Nasirian, B., Motevali Haghighi S. J. T. Q. M., & Excellence B. (2019). An intelligent framework for performance optimisation of integrated management system and resilience engineering in pharmaceutical plants. T. Q. M., & Excellence B. 30(9-10), 953-989.
  6. Azadeh, A., Salehi, V., Ashjari, B. & Saberi, M. (2014). Performance evaluation of integrated resilience engineering factors by data envelopment analysis: The case of a petrochemical plant. Process Safety and Environmental Protection 92(3), 231-241.
  7. Azadeh, A., Yazdanparast, R., Zadeh, S. A., & Keramati, A. (2018). An intelligent algorithm for optimizing emergency department job and patient satisfaction. International journal of health care quality assurance, 31(5), 374-390.
  8. Azadeh, A., Yazdanparast, R., AbdolhosseinZadeh, S., & EsmailZadeh, A. (2017). Performance optimization of integrated resilience engineering and lean production principles." Expert Systems with Applications, 84, 155-170.
  9. Azadeh, A., Zarrin, M., & Hamid, M. (2016). A novel framework for improvement of road accidents considering decision-making styles of drivers in a large metropolitan area. Accident Analysis & Prevention, 87, 17-33.
  10. Azizi B. L., Bastan M., & Ahamdvand, A. (2017). Occupational Health and Safety Management System Development: A Qualitative System Dynamics Approach. The 13th International Conference on Industrial Engineering (IIEC 2017), Babolsar, Iran, Iranian Institute of Industrial Engineering.
  11. Azizi, F., Tavakkoli-Moghaddam, R., Hamid, M., Siadat, A., & Samieinasab M. (2021). An integrated approach for evaluating and improving the performance of surgical theaters with resilience engineering. Computers in Biology and Medicine 141, 105148.
  12. Babajani, R., Abbasi, M., Azar, A. T., Bastan, M., Yazdanparast, R., & Hamid, M. (2019). Integrated safety and economic factors in a sand mine industry: a multivariate algorithm. International Journal of Computer Applications in Technology, 60(4), 351-359.
  13. Bastan, M., Azizi B., L., Grösser S., & Sheikhahmadi, F. (2018). Analysis of Development Policies in Occupational Health and Safety Management System: A System Dynamics Approach. The 2nd IEOM European International Conference on Industrial Engineering and Operations Management, Paris, France, IEOM Society.
  14. Bastan, M., Grösser, S. & Zadfallah, E. (2018). Model-Based Risk Assessment to Clinical Risk Management Policies. The 36th International Conference of the System Dynamics Society, Reykjavík, Iceland, System Dynamics Society.
  15. Bastan, M. & F. Soltani K. (2016). System Analysis of user satisfaction in healthcare services with system dynamics methodology. The 1st International Conference on Industrial Engineering, Management and Accounting Tehran, Iran, University of Applied Science and Technology.
  16. Carvalho, P. V., dos Santos, I. L., Gomes J. O. & Borges, M. R. (2008). Micro incident analysis framework to assess safety and resilience in the operation of safe critical systems: a case study in a nuclear power plant. Journal of Loss Prevention in the Process Industries. 21(3), 277-286.
  17. Cinca, C. S. & Molinero, C. (2002). Mar; GARCÍA, F. Chaparro. Behind DEA efficiency in financial institutions. University of Southampton.
  18. Clarke, D. M. (2005). Human redundancy in complex, hazardous systems: A theoretical framework. Safety science, 43(9), 655-677.
  19. Clegg, C. W. (2000). Sociotechnical principles for system design. Applied ergonomics, 31(5), 463-477.
  20. Cronbach, L. J. (1951). Coefficient alpha and the internal structure of tests. psychometrika 16(3), 297-334.
  21. Da Mata, T. F., Gajewski, D. W., Hall, C. K., Lacerda, M. C., Santos, A. G., Gomes, J. O., & Woods, D. D. (2006). Application of resilience engineering on safety in offshore helicopter transportation. 2006 IEEE Systems and Information Engineering Design Symposium, IEEE.
  22. Daultani, Y., Chaudhuri, A., & Kumar, S. (2015). A decade of lean in healthcare: current state and future directions. Global Business Review, 16(6), 1082-1099.
  23. De Souza, L. B. (2009). Trends and approaches in lean healthcare.
  24. Dijkstra, A. J. K. R. D. A. T. D. (2007). Resilience engineering and safety management systems in aviation.
  25. Dinh, L. T., Pasman, H., Gao, X., & Mannan, M. S. (2012). Resilience engineering of industrial processes: principles and contributing factors. Journal of Loss Prevention in the Process Industries, 25(2), 233-241.
  26. Douillet, D., Caillaud, A., Riou, J., Miroux, P., Thibaud, E., Noizet, M., Oberlin, M., Léger, M., Mahieu, R., & Riquin, E. (2021). Assessment of physicians’ resilience level during the COVID-19 pandemic. Translational Psychiatry, 11(1), 1-8.
  27. Elnadi, M., & Shehab, E. (2014). A conceptual model for evaluating product-service systems leanness in UK manufacturing companies. Procedia CIRP 22, 281-286.
  28. Gharoun, H., Hamid, M., Iranmanesh S. H., & Yazdanparast, R. (2019). Using an intelligent algorithm for performance improvement of two-sided assembly line balancing problem considering learning effect and allocation of multi-skilled operators. Journal of Industrial and Systems Engineering, 12(4), 57-75.
  29. Ghasemi, S., Aghsami, A. & Rabbani, M. (2021). Data Envelopment Analysis for Estimate Efficiency and Ranking operating rooms: A case study. International Journal of Research in Industrial Engineering, 12(4), 57-75.
  30. Groover, D. (2007). Creating a culture where employee engagement Thrives.
  31. Habibifar, N., Hamid, M., Bastan, M., & Azar, A. T. (2019). Performance optimisation of a pharmaceutical production line by integrated simulation and data envelopment analysis. International Journal of Simulation and Process Modelling, 14(4), 360-376.
  32. Hamid, M., Barzinpour, F., Hamid, M. & Mirzamohammadi, S. (2018). A multi-objective mathematical model for nurse scheduling problem with hybrid DEA and augmented ε-constraint method: a case study. Journal of Industrial and Systems Engineering 11(Special issue: 14th International Industrial Engineering Conference Summer), 98-108.
  33. Hamid, M., Hamid, M., Nasiri, M. M., & Ebrahimnia, M. (2018). Improvement of operating room performance using a multi-objective mathematical model and data envelopment analysis: A case study. International Journal of Industrial Engineering & Production Research, 29(2), 117-132.
  34. Hamid, M., Tavakkoli-Moghaddam, R., Golpaygani, F. & Vahedi-Nouri, B. (2020). A multi-objective model for a nurse scheduling problem by emphasizing human factors. Proceedings of the Institution of Mechanical Engineers, Part H: Journal of Engineering in Medicine, 234(2), 179-199.
  35. Hollnagel, E., Woods, D. D. & Leveson, N. (2006). Resilience engineering: Concepts and precepts, Ashgate Publishing, Ltd.
  36. Huber, S., van Wijgerden, I., de Witt, A. & Dekker, S. W. J. P. S. P. (2009). "Learning from organizational incidents: Resilience engineering for high‐risk process environments. Process Safety Progress, 28(1), 90-95.
  37. Improta, G., Romano, M., Di Cicco, M. V., Ferraro, A., Borrelli, A., Verdoliva, C., Triassi, M. & Cesarelli, M. (2018). Lean thinking to improve emergency department throughput at AORN Cardarelli hospital. BMC health services research, 18(1), 1-9.
  38. Iranmanesh, S. H., Tavakoli, M., Heydari, K., Bastan, M., & Yazdanparast, R. (2019). An integrated resilience engineering algorithm for performance optimisation of electricity distribution units. International Journal of Computer Applications in Technology, 60(3), 254-266.
  39. Jafarnezhad Chaghooshi, A., Kazemi, A., & Arab, A. (2016). Identification and Prioritization of Supplier’s Resiliency Evaluation Criteria Based on BWM. Journal of Industrial Management Perspective, 6(3), 159-186 (in persian).
  40. Jahani, M., Moghbel Baarz, A., & Azar, A. (2017). Designing a Model for the Measurement of Supply Chain Resilience through SEM Approach. Journal of Industrial Management Perspective, 7(1), 91-114 (in persian).
  41. Kadarova, J., Demecko, M. J. P. E.& Finance (2016). New approaches in lean management, 39, 11-16.
  42. LaGanga, L. R. J. J. O. O. M. (2011). Lean service operations: reflections and new directions for capacity expansion in outpatient clinics. Journal of Operations Management, 29(5), 422-433.
  43. Ling-Ling, F., & Yong-Duan, S. (2010). On fault-tolerant control of dynamic systems with actuator failures and external disturbances. Acta Automatica Sinica, 36(11), 1620-1625.
  44. López, C., & Ruiz-Benítez, R. (2020). Multilayer analysis of supply chain strategies’ impact on sustainability. Journal of Purchasing and Supply Management, 26(2), 100535.
  45. Lunardini, D., Arington, R., Canacari, E. G., Gamboa, K., Wagner, K., & McGuire, K. J. J. S. (2014). Lean principles to optimize instrument utilization for spine surgery in an academic medical center: an opportunity to standardize, cut costs, and build a culture of improvement. S., 39(20), 1714-1717.
  46. Namvar, H., & Bamdad, S. (2021). "Resilience-Based Efficiency Measurement of Process Industries with Type-2 Fuzzy Sets. International Journal of Fuzzy Systems, 23, 1-15.
  47. Nasiri, A., Mansory, A., & Mohammadi, N. (2022). Developing an Integrated Model for Evaluating the Performance of Green and Resilient Suppliers by Combining Path Analysis, Sawara and TOPSIS Decision-Making Techniques. Journal of Industrial Management Perspective, 12(2), 227-251 (in persian).
  48. ayar, P. & Ozcan, Y. A. (2008). Data envelopment analysis comparison of hospital efficiency and quality. Journal of medical systems, 32(3), 193-199.
  49. Nemeth, C., Wears, R., Woods, D., Hollnagel, E., & Cook, R. (2008). Minding the Gaps: Creating Resilience in Health Care Advances in Patient Safety: New Directions and Alternative Approaches. Performance and Tools, 3, Rockville MD.
  50. Nunnally, J. C. & Bernstein, I. (1978). Psychometric Theory McGraw-Hill New York. The role of university in the development of entrepreneurial vocations: a Spanish study, 387-405.
  51. O'Dwyer, G., Konder, M. T., Machado, C. V., Alves, C. P.& Alves, R. P. (2013). "The current scenario of emergency care policies in Brazil. BMC health services research, 13(1), 1-10.
  52. Poksinska, B. (2010). The current state of Lean implementation in health care: literature review. 19(4), 319-329.
  53. Putra, Y., Yusof, M. M. (2021). A Lean Approach to Evaluating Prescribing Errors in Medication Reconciliation. 281, 814-815.
  54. Rabbani, M., Yazdanparast, R. & Mobini, M. (2019). An algorithm for performance evaluation of resilience engineering culture based on graph theory and matrix approach. International Journal of System Assurance Engineering and Management 10(2), 228-241.
  55. Radnor, Z. J., Holweg, M., & Waring, J. (2012). Lean in healthcare: the unfilled promise? Social science & medicine, 74(3), 364-371.
  56. Rouyendegh, B. D., Oztekin, A., Ekong, J., & Dag, A. (2019). Measuring the efficiency of hospitals: a fully-ranking DEA–FAHP approach. Annals of Operations Research, 278(1), 361-378.
  57. Rundall, T. G., M. Shortell, S., Blodgett, J. C., Henke, R. M. & Foster, D. J. H. C. M. R. (2021). Adoption of Lean management and hospital performance: results from a national survey. 46(1), E10-E19.
  58. Sarkis, J. (2000). A comparative analysis of DEA as a discrete alternative multiple criteria decision tool. European journal of operational research, 123(3), 543-557.
  59. Schull, M. J., Slaughter, P. M., & Redelmeier, D. A. (2002). Urban emergency department overcrowding: defining the problem and eliminating misconceptions. Canadian Journal of Emergency Medicine, 4(2), 76-83.
  60. Shirali, G., Motamedzade, M., Mohammadfam, I., Ebrahimipour, V. & Moghimbeigi, A. (2012). Challenges in building resilience engineering (RE) and adaptive capacity: A field study in a chemical plant. Process safety and environmental protection, 90(2), 83-90.
  61. Tazi, D. & R. Amalberti (2006). Resilience of maintenance organization in a refining plant. Proceedings of the second resilience engineering symposium, Ecole des mines de Paris, France.
  62. Urban, W. J. P.-S. & Sciences, B. (2015). The lean management maturity self-assessment tool based on organizational culture diagnosis, 213, 728-733.
  63. Verelst, S., Wouters, P., Gillet, J.-B. &Van den Berghe, G. (2015). Emergency department crowding in relation to in-hospital adverse medical events: a large prospective observational cohort study. The Journal of emergency medicine 49(6), 949-961.
  64. Yazdanparast, R., Hamid, M., Azadeh, A., & Keramati, A. (2018). An intelligent algorithm for optimization of resource allocation problem by considering human error in an emergency. Journal of Industrial and Systems Engineering, 11(1), 287-309.
  65. Yazdanparast, R., Tavakkoli-Moghaddam, R., Heidari, R., & Aliabadi, L. (2021). A hybrid Z-number data envelopment analysis and neural network for assessment of supply chain resilience: a case study. Central European Journal of Operations Research, 29(2), 611-631.
  66. Yousefi, M., & Ferreira, R. (2017). An agent-based simulation combined with group decision-making technique for improving the performance of an emergency department. Brazilian journal of medical and biological research, 50(5).
  67. Zadfallah, E., Bastan, M., & Ahmadvand, A. (2017). A Qualitative System Dynamics Approach to Clinical Risk Management. The 13th International Conference on Industrial Engineering (IIEC2017), Babolsar, Iran, Iranian Institute of Industrial Engineering.
  68. Zarrin, M., & Azadeh, A. (2017). Simulation optimization of lean production strategy by considering resilience engineering in a production system with maintenance policies. Simulation, 93(1), 49-68.