{"status":"ok","message-type":"work","message-version":"1.0.0","message":{"indexed":{"date-parts":[[2026,4,19]],"date-time":"2026-04-19T09:10:34Z","timestamp":1776589834254,"version":"3.51.2"},"reference-count":47,"publisher":"MDPI AG","issue":"2","license":[{"start":{"date-parts":[[2022,4,22]],"date-time":"2022-04-22T00:00:00Z","timestamp":1650585600000},"content-version":"vor","delay-in-days":0,"URL":"https:\/\/creativecommons.org\/licenses\/by\/4.0\/"}],"content-domain":{"domain":[],"crossmark-restriction":false},"short-container-title":["Informatics"],"abstract":"<jats:p>Healthcare facilities require flexible layouts that can adapt quickly in the face of various disruptions. COVID-19 confirmed this need for both healthcare and manufacturing systems. Starting with the transfer of decision support systems from manufacturing, this paper generalizes layout re-design activities for complex systems by presenting a simulation framework. Through a real case study concerning the proliferation of nosocomial cross-infection in an intensive care unit (ICU), the model developed in systems dynamics, based on a zero order immediate logic, allows reproducing the evolution of the different agencies (e.g., physicians, nurses, ancillary workers, patients), as well as of the cyber-technical side of the ICU, in its general but also local aspects. The entire global workflow is theoretically founded on lean principles, with the goal of balancing the need for minimal patient throughput time and maximum efficiency by optimizing the resources used during the process. The proposed framework might be transferred to other wards with minimal adjustments; hence, it has the potential to represent the initial step for a modular depiction of an entire healthcare facility.<\/jats:p>","DOI":"10.3390\/informatics9020035","type":"journal-article","created":{"date-parts":[[2022,4,23]],"date-time":"2022-04-23T08:14:06Z","timestamp":1650701646000},"page":"35","update-policy":"https:\/\/doi.org\/10.3390\/mdpi_crossmark_policy","source":"Crossref","is-referenced-by-count":7,"title":["Lean ICU Layout Re-Design: A Simulation-Based Approach"],"prefix":"10.3390","volume":"9","author":[{"ORCID":"https:\/\/orcid.org\/0000-0001-6184-4416","authenticated-orcid":false,"given":"Elpidio","family":"Romano","sequence":"first","affiliation":[{"name":"Management Engineering Faculty, Uninettuno University, 00186 Rome, Italy"}],"role":[{"role":"author","vocabulary":"crossref"}]},{"ORCID":"https:\/\/orcid.org\/0000-0002-9179-0372","authenticated-orcid":false,"given":"Andrea","family":"Falegnami","sequence":"additional","affiliation":[{"name":"Management Engineering Faculty, Uninettuno University, 00186 Rome, Italy"}],"role":[{"role":"author","vocabulary":"crossref"}]},{"ORCID":"https:\/\/orcid.org\/0000-0002-6283-1518","authenticated-orcid":false,"given":"Anna Corinna","family":"Cagliano","sequence":"additional","affiliation":[{"name":"Department of Management and Production Engineering, Politecnico di Torino, Corso Duca Degli Abruzzi 24, 10129 Turin, Italy"}],"role":[{"role":"author","vocabulary":"crossref"}]},{"given":"Carlo","family":"Rafele","sequence":"additional","affiliation":[{"name":"Department of Management and Production Engineering, Politecnico di Torino, Corso Duca Degli Abruzzi 24, 10129 Turin, Italy"}],"role":[{"role":"author","vocabulary":"crossref"}]}],"member":"1968","published-online":{"date-parts":[[2022,4,22]]},"reference":[{"key":"ref_1","doi-asserted-by":"crossref","first-page":"102505","DOI":"10.1016\/j.omega.2021.102505","article-title":"Quality assessment of the Portuguese public hospitals: A multiple criteria approach","volume":"105","author":"Rocha","year":"2021","journal-title":"Omega"},{"key":"ref_2","doi-asserted-by":"crossref","first-page":"2163","DOI":"10.1097\/CCM.0b013e31821f0522","article-title":"Clinical and economic burden of postoperative pulmonary complications: Patient safety summit on definition, risk-reducing interventions, and preventive strategies","volume":"39","author":"Shander","year":"2011","journal-title":"Crit. Care Med."},{"key":"ref_3","doi-asserted-by":"crossref","first-page":"e18080","DOI":"10.2196\/18080","article-title":"Intention to use Medical Apps Among Older Adults in the Netherlands: Cross-Sectional Study","volume":"22","author":"Askari","year":"2020","journal-title":"J. Med. Internet Res."},{"key":"ref_4","doi-asserted-by":"crossref","first-page":"509","DOI":"10.3233\/THC-150919","article-title":"A patient centered electronic health: EHealth system development","volume":"23","author":"Schiza","year":"2015","journal-title":"Technol. Health Care"},{"key":"ref_5","doi-asserted-by":"crossref","unstructured":"Marsilio, M., Pisarra, M., Rubio, K., and Shortell, S. (2022). Lean adoption, implementation, and outcomes in public hospitals: Benchmarking the US and Italy health systems. BMC Health Serv. Res., 22.","DOI":"10.1186\/s12913-022-07473-w"},{"key":"ref_6","doi-asserted-by":"crossref","first-page":"160","DOI":"10.1177\/003335490712200205","article-title":"Estimating health care-associated infections and deaths in U.S. Hospitals, 2002","volume":"122","author":"Klevens","year":"2007","journal-title":"Public Health Rep."},{"key":"ref_7","doi-asserted-by":"crossref","unstructured":"Wickramasinghe, N., Al-Hakim, L., Gonzalez, C.M., and Tan, J. (2014). Lean Thinking for Healthcare, Springer.","DOI":"10.1007\/978-1-4614-8036-5"},{"key":"ref_8","doi-asserted-by":"crossref","unstructured":"Souza, D.L., Korzenowski, A.L., Alvarado, M.M., Sperafico, J.H., Ackermann, A.E.F., Mareth, T., and Scavarda, A.J. (2021). A systematic review on lean applications\u2019 in emergency departments. Healthcare, 9.","DOI":"10.3390\/healthcare9060763"},{"key":"ref_9","doi-asserted-by":"crossref","unstructured":"Gabow, P.A., and Goodman, P.L. (2014). The lean prescription: Powerful medicine for our ailing healthcare system. The Lean Prescription: Powerful Medicine for Our Ailing Healthcare System, CRC Press, Taylor & Francis.","DOI":"10.1201\/b17564"},{"key":"ref_10","doi-asserted-by":"crossref","first-page":"8875902","DOI":"10.1155\/2020\/8875902","article-title":"Healthcare Engineering: A Lean Management Approach","volume":"2020","author":"Abdallah","year":"2020","journal-title":"J. Healthc. Eng."},{"key":"ref_11","doi-asserted-by":"crossref","first-page":"640","DOI":"10.1002\/joom.1153","article-title":"A lean view of lean","volume":"67","author":"Browning","year":"2021","journal-title":"J. Oper. Manag."},{"key":"ref_12","doi-asserted-by":"crossref","first-page":"4","DOI":"10.1111\/j.1945-1474.2005.tb00571.x","article-title":"Chaos and complexity: Applications for healthcare quality and patient safety","volume":"27","author":"Benson","year":"2005","journal-title":"J. Healthc. Qual."},{"key":"ref_13","unstructured":"Zimmerman, B. (2011). How Complexity Science Is Transforming Healthcare. The SAGE Handbook of Complexity and Management, SAGE."},{"key":"ref_14","doi-asserted-by":"crossref","first-page":"496","DOI":"10.1126\/science.1227079","article-title":"Detecting causality in complex ecosystems","volume":"338","author":"Sugihara","year":"2012","journal-title":"Science"},{"key":"ref_15","doi-asserted-by":"crossref","first-page":"11","DOI":"10.1179\/2047971915Y.0000000016","article-title":"Complexity in healthcare management: Why does Drucker describe healthcare organizations as a double-headed monster?","volume":"9","author":"Cinaroglu","year":"2016","journal-title":"Int. J. Healthc. Manag."},{"key":"ref_16","doi-asserted-by":"crossref","first-page":"193","DOI":"10.1007\/s12553-020-00504-8","article-title":"Systems modelling to support the complex nature of healthcare services","volume":"11","author":"Engelseth","year":"2021","journal-title":"Health Technol."},{"key":"ref_17","unstructured":"Zeigler, B.P., Muzy, A., and Kofman, E. (2018). Theory of Modeling and Simulation: Discrete Event & Iterative System Computational Foundations, Academic Press."},{"key":"ref_18","doi-asserted-by":"crossref","unstructured":"Kennedy, O.G. (1973, January 17\u201319). The use of computer simulation in health care facility design. Proceedings of the Winter Simulation Conference, San Francisco, CA, USA.","DOI":"10.1145\/800293.811575"},{"key":"ref_19","doi-asserted-by":"crossref","first-page":"49","DOI":"10.1007\/s10729-005-5216-3","article-title":"Modeling patient flows using a queuing network with blocking","volume":"8","author":"Koizumi","year":"2005","journal-title":"Health Care Manag. Sci."},{"key":"ref_20","doi-asserted-by":"crossref","first-page":"1","DOI":"10.1007\/s10729-006-9001-8","article-title":"Modeling patient service centers with simulation and system dynamics","volume":"10","author":"Rohleder","year":"2007","journal-title":"Health Care Manag. Sci."},{"key":"ref_21","doi-asserted-by":"crossref","first-page":"83","DOI":"10.1080\/17477778.2020.1751570","article-title":"How simulation modelling can help reduce the impact of COVID-19","volume":"14","author":"Currie","year":"2020","journal-title":"J. Simul."},{"key":"ref_22","doi-asserted-by":"crossref","unstructured":"Ozkaynak, M., Sircar, C.M., Frye, O., and Valdez, R.S. (2021). A systematic review of design workshops for health information technologies. Informatics, 8.","DOI":"10.3390\/informatics8020034"},{"key":"ref_23","doi-asserted-by":"crossref","first-page":"109237","DOI":"10.1016\/j.drugalcdep.2021.109237","article-title":"Insights from system dynamics applications in addiction research: A scoping review","volume":"231","author":"Naumann","year":"2022","journal-title":"Drug Alcohol Depend."},{"key":"ref_24","first-page":"275","article-title":"Linking approaches for multi-methods simulation in healthcare systems planning and management","volume":"26","author":"Abdelghany","year":"2017","journal-title":"Int. J. Ind. Syst. Eng."},{"key":"ref_25","doi-asserted-by":"crossref","first-page":"77","DOI":"10.1080\/17434440.2019.1561269","article-title":"Embracing simplexity: The role of artificial intelligence in peri-procedural medical safety","volume":"16","author":"Patriarca","year":"2019","journal-title":"Expert Rev. Med. Devices"},{"key":"ref_26","doi-asserted-by":"crossref","unstructured":"Abdullah, S.S., Rostamzadeh, N., Sedig, K., Garg, A.X., and McArthur, E. (2020). Visual analytics for dimension reduction and cluster analysis of high dimensional electronic health records. Informatics, 7.","DOI":"10.3390\/informatics7020017"},{"key":"ref_27","doi-asserted-by":"crossref","unstructured":"Ola, O., and Sedig, K. (2017). Health literacy for the general public: Making a case for non-trivial visualizations. Informatics, 4.","DOI":"10.3390\/informatics4040033"},{"key":"ref_28","doi-asserted-by":"crossref","first-page":"102120","DOI":"10.1016\/j.omega.2019.102120","article-title":"The problem of the last bed: Contextualization and a new simulation framework for analyzing physician decisions","volume":"96","author":"Azcarate","year":"2020","journal-title":"Omega"},{"key":"ref_29","doi-asserted-by":"crossref","unstructured":"Brailsford, S.C., Desai, S.M., and Viana, J. (2010, January 5\u20138). Towards the holy grail: Combining system dynamics and discrete-event simulation in healthcare. Proceedings of the Winter Simulation Conference, Baltimore, ML, USA.","DOI":"10.1109\/WSC.2010.5678927"},{"key":"ref_30","doi-asserted-by":"crossref","first-page":"50","DOI":"10.1108\/17410391311289541","article-title":"A conceptual framework for hybrid system dynamics and discrete event simulation for healthcare","volume":"26","author":"Chahal","year":"2013","journal-title":"J. Enterp. Inf. Manag."},{"key":"ref_31","doi-asserted-by":"crossref","unstructured":"G\u00f6n\u00fcl-Sezer, E.D., and Ocak, Z. (2016). Comparison of System Dynamics and Discrete Event Simulation Approaches. Simulation and Modeling Methodologies, Technologies and Applications, Springer.","DOI":"10.1007\/978-3-319-31295-8_5"},{"key":"ref_32","doi-asserted-by":"crossref","unstructured":"Zulkepli, J., and Eldabi, T. (2016, January 11\u201314). Towards a framework for conceptual model hybridization in healthcare. Proceedings of the Winter Simulation Conference, Washington, DC, USA.","DOI":"10.1109\/WSC.2015.7408280"},{"key":"ref_33","doi-asserted-by":"crossref","unstructured":"Mielczarek, B., and Zabawa, J. (2016, January 11\u201314). Modeling healthcare demand using a hybrid simulation approach. Proceedings of the Winter Simulation Conference, Washington, DC, USA.","DOI":"10.1109\/WSC.2016.7822204"},{"key":"ref_34","doi-asserted-by":"crossref","unstructured":"Alvarado, M., Lawley, M., and Li, Y. (2016, January 11\u201314). Healthcare simulation tutorial: Methods, challenges, and opportunities. Proceedings of the Winter Simulation Conference, Washington, DC, USA.","DOI":"10.1109\/WSC.2016.7822092"},{"key":"ref_35","doi-asserted-by":"crossref","first-page":"401","DOI":"10.13189\/ujph.2021.090607","article-title":"Modeling in Healthcare: Selection of Simulation Types","volume":"9","author":"Nawawi","year":"2021","journal-title":"Univers. J. Public Health"},{"key":"ref_36","unstructured":"Romano, E., and Assante, D. (2013, January 27\u201329). A Management of Intensive Care Unit based on the System Dynamics Model. Proceedings of the 5th International Conference on Applied Economics, Business and Development, Chania, Greece."},{"key":"ref_37","first-page":"65","article-title":"Transformation of a production\/assembly washing machine lines into a lean manufacturing system","volume":"4","author":"Romano","year":"2009","journal-title":"WSEAS Trans. Syst. Control"},{"key":"ref_38","first-page":"464","article-title":"Optimal size of kanban board in a single stage multi product system","volume":"5","author":"Murino","year":"2010","journal-title":"WSEAS Trans. Syst. Control"},{"key":"ref_39","first-page":"141","article-title":"A decision support tool, implemented in a system dynamics model, to improve the effectiveness in the hospital emergency department","volume":"8","author":"Romano","year":"2015","journal-title":"Int. J. Procure. Manag."},{"key":"ref_40","first-page":"53","article-title":"A simulation\/optimisation approach to support the resource allocation in service firms","volume":"11","author":"Romano","year":"2018","journal-title":"Int. J. Procure. Manag."},{"key":"ref_41","doi-asserted-by":"crossref","first-page":"213","DOI":"10.1007\/s10100-021-00779-w","article-title":"Hospital preparedness during epidemics using simulation: The case of COVID-19","volume":"30","author":"Esparza","year":"2022","journal-title":"Cent. Eur. J. Oper. Res."},{"key":"ref_42","unstructured":"Zupick, N.B. (2015). Simulation with Arena, McGraw-Hill Education."},{"key":"ref_43","doi-asserted-by":"crossref","first-page":"2307","DOI":"10.1007\/s00134-003-2019-1","article-title":"The relationship between labour cost per patient and the size of intensive care units: A multicentre prospective study","volume":"29","author":"Bertolini","year":"2003","journal-title":"Intensive Care Med."},{"key":"ref_44","doi-asserted-by":"crossref","unstructured":"Zulkepli, J., Eldabi, T., and Mustafee, N. (2012, January 9\u201312). Hybrid simulation for modelling large systems: An example of integrated care model. Proceedings of the 2012 Winter Simulation Conference (WSC), Berlin, Germany.","DOI":"10.1109\/WSC.2012.6465314"},{"key":"ref_45","first-page":"419","article-title":"Continuous quality improvement in intensive care medicine. The GiViTI Margherita Project-Report 2005","volume":"72","author":"Boffelli","year":"2006","journal-title":"Minerva Anestesiol."},{"key":"ref_46","doi-asserted-by":"crossref","first-page":"109","DOI":"10.1016\/j.jcrc.2021.08.010","article-title":"Incidence, outcomes, and predictors of Acinetobacter infection in Saudi Arabian critical care units","volume":"66","author":"Kharaba","year":"2021","journal-title":"J. Crit. Care"},{"key":"ref_47","doi-asserted-by":"crossref","first-page":"1612","DOI":"10.1097\/CCM.0b013e31819efac0","article-title":"Epidemiology, management, and risk factors for death of invasive Candida infections in critical care: A multicenter, prospective, observational study in France (2005\u20132006)","volume":"37","author":"Leroy","year":"2009","journal-title":"Crit. Care Med."}],"container-title":["Informatics"],"original-title":[],"language":"en","link":[{"URL":"https:\/\/www.mdpi.com\/2227-9709\/9\/2\/35\/pdf","content-type":"unspecified","content-version":"vor","intended-application":"similarity-checking"}],"deposited":{"date-parts":[[2025,10,10]],"date-time":"2025-10-10T22:58:44Z","timestamp":1760137124000},"score":1,"resource":{"primary":{"URL":"https:\/\/www.mdpi.com\/2227-9709\/9\/2\/35"}},"subtitle":[],"short-title":[],"issued":{"date-parts":[[2022,4,22]]},"references-count":47,"journal-issue":{"issue":"2","published-online":{"date-parts":[[2022,6]]}},"alternative-id":["informatics9020035"],"URL":"https:\/\/doi.org\/10.3390\/informatics9020035","relation":{},"ISSN":["2227-9709"],"issn-type":[{"value":"2227-9709","type":"electronic"}],"subject":[],"published":{"date-parts":[[2022,4,22]]}}}