A PORTER-SCOR MODELING APPROACH FOR THE HOSPITAL SUPPLY CHAIN

C. DI MARTINELLYa, F. RIANEa, A. GUINETb Centre de Recherche en Gestion Industrielle, FUCAM, Mons-Belgique, dimartinelly@fucam.ac.be b Laboratoire PRISMA, INSA de Lyon, Lyon-France, alain.guinet@insa-lyon.fr

Abstract: This article proposes a conceptual approach to model the pharmaceuticals supply chain. In a first time, we position it towards the hospital supply chain to ensure that the changes made lead to a global improvement. To apprehend this complex reality we need a modeling framework. In a first time, we use the Porters model to identify the best strategy to follow according to the market context. We then identify activities that generate value for care. To go further in our analysis, we need a modeling tool. We tend to apply the SCOR model to describe processes, to make comparisons between practices to get benchmarks and to define performance measures. The description of activities is made through logical diagrams to allow for simulation. Keywords: pharmaceuticals supply chain, modeling, Porter, SCOR

Introduction

European hospitals are facing today challenges similar to those faced by industrial firms twenty years ago. The healthcare organizations have to deal with a changing environment and accelerated technological development both in medical equipments and in managing tools. There is now competition between hospitals and Governments force them to rationalize expenses by cutting subsidizes. Therefore, logistics has gained much attention in the sense that they may increase efficiency and flexibility of organizations as logistical costs make up a significant part of annual budget, up to 40% according to a study lead by Landry (Landry and Beaulieu, 2000) in several countries. The main logistics activities are patient oriented, clinic pharmacy, laundry, catering, administrative and technical support (AS GHC, 2002). Its objective is to determine the most efficient way to dispense care (Dallery, 2004). Among these activities, the pharmacy amounts for half of the logistic expenses. Therefore, the optimization of its working can lead to interesting cost savings. Before claiming to optimize the pharmaceuticals supply chain while considering the hospital working, it is first necessary to analyze and diagnose the current situation. We thus need a modeling framework to apprehend the complex reality of a hospital. In this paper we adapt global approaches from the enterprise modeling to the healthcare sector. We use the current working of a Belgian hospital as starting point to our study. In a first time, we use the Porters model to identify activities that generate value for care. In a second time, we use the SCOR model to describe the processes of the supply chain and to define performance indicators. Finally, activities are described through logical diagrams to allow for simulation.

Problem description

The purpose of the pharmaceuticals supply chain is to guarantee a safety and traceable dispense of drugs in each hospital department, under regulation constraints.

The illustration 1 highlights the different steps to put medicine at patients disposal and the specificities of the supply chain. The different actors are also identified.
Care units and medico-technical units Specialists

Care process

Patients
Prescribe Administer

Nurses

Patients

Prescription Advanced inventories

Dispense - prescriptions analysis - medicine preparation - information

List consumption List of patients consumption

Pharmacists

Deliver

General inventory

Fix the price of pharmaceuticals Prices of pharmaceuticals

Supply

Order form

Pharmacy Suppliers

Illustration 1: The pharmaceuticals supply chain

Providers: the pharmaceuticals market is dominated by few firms providing a large

range of products from medical equipment to drugs. The pharmaceuticals selling prices to patients are imposed by INAMI (Institut National dAssurance Maladie Invalidit) in Belgium. Inventory and general pharmacy: there are numerous legal constraints on pharmacist activities and pharmaceuticals dispensing, storage and reimbursement. Furthermore, the drugs inventory management is made more complex by the wide variety of products, volume and packaging, the use-by date management, the specific storage conditions (fridge, secured space for narcotics). Advanced inventories: each medical unit has a pharmaceuticals inventory locally managed by nurses. The management process is different from care unit to medico-technical unit. These stocks tend to be oversized because the care process cant be delayed and the nurses take extra stocks to prevent from any shortage. Care process: like advanced inventories management, the care process is different from care unit to medico-technical unit. For instance, pharmaceuticals dispense should be nominative in a unit of care but the prescription is made after the dispensing in a medico-technical unit. In addition, the care process, which is at the root of drugs demand, is highly influenced by the human factor.

 Information flows: These flows are of primary importance to ensure a proper

dispensing. There are several softwares on the market that manage the pharmacy and pharmaceuticals dispensing but in most cases they dont manage magistery preparations, total parenteral nutrition and cytostatics. These products amount for more than 30% of drugs dispensing in some hospitals. The information flow should allow prescriptions, contraindications of a medicine, traceability (for instance for products such as blood), finance activities (invoicing, third party payers information, insurance),... . Actors: there are numerous people involved in the process and they should have a technical and a medicine competence. The pharmaceutical flow is therefore managed independently. Pharmaceuticals demand: it is initiated by a prescription or a medical order. The demand is therefore dependent on the patient flow and is twice random because both the patients number and the patients characteristics are unknown. We have found few papers on the pharmaceuticals supply chain in the literature. This lack of researches can be due to legal aspects, numerous constraints and human factor influence (Beretz, 2002). Table 1 summarizes the researches done on the healthcare supply chain. We use a classification system based on the decision level and the problem scope.
Organisational design Information system Resources sizing Inventory management Timetabling Planning Distribution Banerjea et al. , 1998 Hassan et al. , 2003 strategic Chabrol et al ., 2005 Ducq et al. , 2004 Staccini et al. , 2004 Staccini et al. , 2004 Colin et al. , 2004 Romeyer et al ., 2004 tactical Besombes et al. , 2004 operational

Rossetti et al. , 1998 Rossetti and Selandari, 2001 Beaulieu and Patinaude, 2004 Taher H., 2006

Baboli et al. , 2003 Dellaert and Van De Poel, 1996 Epstein and Dexter, 2000 Lapierre and Ruiz, 2003 Lapierre et al. , 2003 Fontan et al. , 2004

Table 1: Classification of healthcare supply chain researches

Most of the articles related to the pharmaceuticals supply chain mainly focus on a single problem such as inventory management, distribution or sizing and dont take into account the rest of the supply chain. However some recent papers on the hospital supply chain adopt a process-oriented view to design the information system (Colin et al., 2004; Staccini et al., 2004) or to set up a new organizational design (Besombes et al., 2004; Chabrol et al., 2005; Staccini et al., 2004). These researches are based on the patient flow and adopt a modeling transverse to the organizational and functional design. The identified problematics have been already studied in industrial management and can potentially be adapted to the healthcare sector. Authors like Groot et al. (1993) and Flagle (2002) considered a hospital like a production centre with specificities but enough

common characteristics, the timely deployment of scarce resources to meet a critical and partly uncontrollable demand, to applied OR techniques largely used in industrial management. The literature reviews provided by Thomas (Thomas and Griffin, 1996) and Slats (Slats et al., 1995) enhance the numerous studies already made on these problems. The taxonomy used by Min (Min and Zhou, 2002) to classify the recent works done highlights the lack of researches done on the whole supply chain. These studies are however needed to lead to a global optimization: local optimization does indeed not strive for the optimization of the whole. The same problem occurs in healthcare management. We need to study the whole hospital supply chain to be sure that the changes made to the pharmaceuticals supply chain lead to a global improvement. 2.1 Modeling approach

Before attempting to analyze and claim to optimize a complex organization like a hospital, it is first advisable to understand its working. Therefore, the modeling approach is well suited and can also be used as tool of representation, communication, and analysis. This will enable a better comprehension of the way the real system work, the nature and the logics of interactions between the various actors around actions and operations and to identify malfunctioning. There are numerous modeling approaches based on common methodologies but using different point of views and analysis levels. However, as far as we know, there is no methodology or referent dedicated to the healthcare sector. We choose a process modeling approach that seems well suited for the healthcare sector (Artiba et al., 2004) and that had been successfully applied to hospital projects (Besombes et al., 2004; Chu et al., 2000; Fontan et al., 2004; Staccini et al., 2001; Staccini et al., 2004, Su et al., 2003). We use the Porters model (Porter, 1985) as framework to support our approach. The model is indeed process-oriented and has been already applied to diagnose the American healthcare system (Porter and Teisberg, 2004). It has also been used as framework model to design a medico-technical unit (Besombes et al., 2004). It helps us to identify and structure the processes that we model to analyze the value creates for care. 2.1.1 The adapted Porters model The value chain is a tool to diagnose the competitive advantage of a firm and plays a valuable role in designing its organizational structure. There are two steps in the approach. In a first time, an analysis of the industry and competitors determines the strategy appropriate for gaining a competitive advantage. In a second time, the use of Porters model will help a firm to put the generic strategy into practices. The structural analysis of the industry is needed to evaluate the collective strength of five forces: the entry of new competitors, the threat of substitutes, the bargaining power of buyers, the bargaining power of suppliers and the rivalry among existing competitors. These five forces determine the industry profitability (influence on costs, prices and required investments) and the appropriateness of a firm strategy and activities that can contribute to performance. The five forces identified for our problematic are:

 The pharmaceutical groups are the main suppliers of hospitals. They provide them

with drugs and medical materials. Their bargaining power is relatively high although the prices of pharmaceuticals are fixed by state. The threat of new entrants is relative light because of the investments needed to set up a hospital and of governments policies. The healthcare sector in Belgium is highly regulated and partly subsidized by public funds. The new legislation released in 2002 ultimately reduced the number of subsidized beds. The patients are the buyers. They have limited information on care partly because services are highly customized. Furthermore, the care prices are in great part fixed by state. The buyers choice is mainly based on the quality perceived and their sensitivity. The threat of substitutes, like unconventional medicine, is in our opinion, relatively low. Furthermore, the costs of these unconventional medicines are high for the patients because they are not reimbursed. The rivalry between hospitals is mainly based on services, reputation and quality. There are very few private hospitals in Belgium (mainly for esthetical care). However, the Porters model has been designed for the private sector (in the United States, the healthcare sector is largely private as a majority of American activities). On the contrary, the healthcare sector is state-controlled in Belgium, as in many other European countries: a great part of hospitals annual budget is funded by State. Government and paragovernmental agencies play an active role and influence competition between hospitals. Among other things they impose cost of care, cost of pharmaceuticals products, they define the rules of competition between the hospitals, . To take into account this reality, we add a sixth competitive force, the regulator, which has an influence on each of the five other forces, as shown in illustration 2. In the private sector, the sixth competitive force is mainly played by the market that regulates the competition between firms. However, Governments also intervene by setting commercial rules. Hospitals provide a service as base product. As researches done by Langlois (Langlois and Tocquer, 1992) show it, firms providing a service as base product can gain a competitive advantage by developing clients relations and reducing costs. However, sole cost cutting objectives are not the solution on the long term. The American health system, largely private and subject to more competition than virtually any place in the world, has unsatisfactory performance in both costs and quality partly because of this wrong objective of cost reduction (Porter and Teisberg, 2004). The clients relations are influenced by the perceived quality of care and prices. Hospitals have therefore to improve the quality of care while maintaining costs under control. Hospitals can work on medical and/or managerial activities to implement this strategy.

Potential entrants Regulator

Threat of new entrants

Suppliers

Bargaining power of suppliers

Industry competitors
Threat of substitute products

Bargaining power of buyers

Buyers

Substitutes

Regulator

Illustration 2: The six competitive forces of the healthcare sector

From the medical point of view, numerous studies show that when physicians or teams treat a high volume of patients who have a particular disease or condition, they create better outcomes and lower costs. In healthcare, as in most industries, cost and quality can improve simultaneously as providers prevent errors, boost efficiency and develop expertise. The idea is to develop hospitals networks, each specialized, to provide an efficient geographic cover at lower cost for each care service. Furthermore, the collaboration between hospitals can increase their bargaining power towards pharmaceuticals groups and therefore lead to better sales conditions. However the development of such networks will take time and the results will only be significant on the long term. From the managerial point of view, we will interest to the supply chain. We apply the value chain analysis to identify activities that create value for care and to configure them in order to minimize costs, given the hospital competitive strategy, the improvement of care quality while maintaining costs under control. The notion of value in the healthcare sector is composed of two elements: the quality of care for the patient and the economical value in the sense of productivity and competitiveness of the production system of care (Besombes et al., 2004). The performance of the system is measured by the efficiency and effectiveness of activities that use technical, human and financial resources to produce care of quality for the patient (Lebas, 1995). The links between activities have an impact on hospital performance and costs. The model will help us to highlight links between the hospital main activity, patients care, and one of hospital support activities, the pharmaceuticals supply chain and to estimate the impact of a pharmaceutical process modification on the care process. The illustration 3 is our adaptation of the Porters model to the hospital, based on the study of a Belgian healthcare center. We rename each of the categories to be closer to the hospital terminology. The primary processes are activities devoted to care patients. The support processes support primary activities by providing human, technical and material resources. Primary activities are divided into 5 sub-categories.

 Admission logistics: processes associated with patients admission and management

of their documents. Care: processes associated with care dispensing and their management. Discharge logistics: processes associated with patients discharge. Marketing and sales: processes associated with the financial return of care: invoicing to patient and third party payers, information exchange with statecontrolled organization, price setting activities. Service: processes associated with care activities and that can add value to care. As we mentioned it earlier in this paper, the objective of the pharmaceuticals supply chain is to put medicine at patients disposal. Patients receive drugs under treatment. The demand coming from a unit of care triggers the activity of the pharmaceuticals supply chain and occurs during the patients stay. Among these processes, the different Porters categories can also be identified.
Inbound logistics: processes associated with pharmaceuticals purchase and

reception.
Production: processes associated with pharmaceuticals preparation. Outbound logistics: processes associated with the distribution throughout the

hospital.
Price setting: processes associated with the pharmaceuticals price setting,

reimbursement demand, ... .

Service: processes associated with pharmaceuticals testing, pharmaceuticals care.

These activities produce value for the medical staff, third party payer and patients and are for the most part legally defined. They come intrinsically within the competences of the pharmacists. Pharmacy support processes are less specific and are mainly the same as those of the hospital. Among them, the information system has to support a perfect coordination between the patients flow and the pharmaceuticals flow to allow an optimal management and a correct invoicing. Value is based on the ability to coordinate the activities from the pharmaceuticals and hospital supply chain. As we mentioned it earlier in this paper, the starting point of our study is the case of a Belgian hospital that set up a new organizational structure for its pharmacy. The application of the Porters model (illustration 3) helps us to identify processes that create value for care and to identify some malfunctioning, for instance, repeated activities. All activities directly implied in the ordering, preparation, warehousing, delivery and traceability of drugs (primary activities) add value to care and are specific to the clinic pharmacy. We also identified some repeated activities like invoicing (invoicing for hospital stay and invoicing for pharmaceuticals). We have to reorganize processes. To do so and because of the complexity of the hospital working, a global approach is needed to apprehend the reality. A modeling tool is needed to communicate, to use a common language, to make comparisons between practices to get benchmark. Furthermore, performance measures must be defined to characterize the situation and evaluate the impact of process modifications. We therefore choose to apply the SCOR model (Supply Chain Operations Reference model) that is a global approach to analyze, evaluate and improve the supply chain and that is largely used in industrial management.

Hospital
Hospital infrastructure
Recruiting and training people for admission Recruiting and training emergency medical technicians Recruiting and training nurses and physicians Recruiting pharmacists Recruiting and training administrative personnel Decision support system for diagnoses Automated prescription software Planning and scheduling sofware Automated dispensing system Linen Cattering Waste management

Human Resource Management

Technology development
Care value

Procurement
CARE
Patients diagnostic Prescription Patient treatment in care units and in medicotechnical units Planning and scheduling for patient treatment Planning and scheduling for medico-technical units Analyses Drugs dispense Drugs management

ADMISSION LOGISTICS
Patient admission Emergencies

DISCHARGE LOGISTICS
Patients discharge Patient s tranfert to other medical establishments

MARKETING & SALES

Invoicing Insurance

SERVICE
Taxi service home hospitalisation Ambulatory Office visit

Clinic pharmacy
Hospital infrastructure Human Resource Management Technology development Procurement
INBOUND LOGISTICS
Pharmaceuticals and materials ordering Pharmaceuticals and materials reception and control Inventory management of parts products

Care value

OPERATIONS
Pharmaceuticals preparation and control pharmaceuticals packaging Inventory management of final products Pharmaceuticals return management

OUTBOUND LOGISTICS
Pharmaceuticals and materials distribution in care unit and medicotechnical units Fill in cabinets for medecines

MARKETING & SALES

Pricing

SERVICE
Validation of prescription

Illustration 3: Porters model adapted to hospital

2.1.2 The SCOR Model (SCC, 1996) The Supply Chain Council (SCC), a not-for-profit organization established in 1996 that now has over 650 organizations members worldwide, has developed the SCOR model, a framework that takes into account the whole supply chain and integrates the strategic decision making. It is a process reference model which is intended to be an industrial standard and that provides a structure for linking business objectives to supply chain operations. It contains a standard description of management processes, a framework of relationships among the standard processes, standard metrics to measure process performance, management practices that produce best-in-class performance, and a standard alignment to software features and functionality (Huang et al., 2005). We apply SCOR to our problematic to make operational our first analyze made with the Porters model. It is well suited for our problematic for three main reasons. Firstly, the SCOR model has been already applied to the healthcare sector and more precisely to the downstream pharmaceuticals supply chain (Baboli et al., 2005) as a diagnostic tool. Secondly, the healthcare sector needs standards to communicate. As we mentioned it earlier, the development of care network should allow providing better outcomes in care at

lowest costs. European governments favor this strategy as it can rationalize the offer of care. SCOR provides standard processes and indicators. The performance measures defined on the basis of standard processes will allow comparisons between hospitals, benchmarks and the definition of best practices that yield the optimal overall performance. Thirdly, our ultimate goal is to tend to optimize the pharmaceuticals supply chain. We therefore need to reorganize some processes and the SCOR description provides us a framework model to redesign them given strategic objectives. We adapt the model used by Baboli et al. (2005) to describe the pharmaceuticals supply chain and we add a layer, the hospital supply chain. In fact, the pharmaceuticals supply chain is part of the hospital supply chain and is not isolated. The supply chain working of the hospital has an influence on the pharmaceuticals supply chain. There is numerous information coming from the patients treatment that determine the drugs flow. The type of drugs is conditioned by the hospital strategy: if a hospital gets a specialization in cancer research, the clinical pharmacy will contain more cytostatics and there will be more fridges to store them. The hospital physical organization determines the delivery frequency. Illustration 4 shows our adaptation of SCOR model on process categories. We rename process categories to be closer to the healthcare reality. Admit: processes that describe patients admission in a hospital. We identify 4 main types of admission processes. Treat: processes that apply a treatment to care patients. Treatment processes take place in a unit of care or in medico-technical units. Discharge: processes that discharge patient to another medical establishment or to home. Return: processes associated with patients transfer to a more appropriate medical establishment or with a new treatment for a patient. Plan: processes that balance care demand and care supply/capacity to develop a course of actions which best meets admission, treatment and discharge requirements. The definition of performance indicators takes place at level 3 with the description of process elements. For each process elements, input and output information are identified and five types of performance attributes can be defined. Illustrations 5 and 6 give an overview of a process element description. The description and the identification of indicators will help us to diagnose and to quantify the current pharmaceuticals supply chain organization. It is a prerequisite before tempting to optimize its working. The level 4 of the SCOR Model is the implementation level where each process element is decomposed into activities. The SCOR model doesnt provide a framework to make this description. We therefore use logical diagrams (Cattan et al., 1998) to describe activities. We identify actors, inputs and outputs, activities, their logic and sequence. Illustration 7is a logical diagram of one process element.

Plan Patients flow

Admit Treat Discharge

A1: in-patient planned A2: in-patient in emergency A3: outpatient planned A4: outpatient in emergency

T1: in-patient planned T2: in-patient in emergency T3: outpatient planned T4: outpatient in emergency

D1: in-patient planned D2: in-patient in emergency D3: outpatient planned D4: outpatient in emergency

Return treat
RT1: transfer to another medical establishment

Return discharge
RD1: new treatment

Enable

Plan Materials and pharmaceuticals flow

Source Make Deliver

S1: source specialities S2: source medical materials S3: source pharmaceuticals bulk products

M1: make specialities M2: make medical materials M3: make pharmaceuticals bulk products

DE1: deliver specialities DE2: deliver medical materials DE3: deliver pharmaceuticals bulk products

SR1: return defective pharmaceuticals SR3: return excess pharmaceuticals

Return

DR1: return defective pharmaceuticals (useby-date, damaged packaging,) DR3: return excess pharmaceuticals

Return

Enable
Illustration 4: Level 2 description of hospital supply chain.
Patients flow
Hospital supply chain
Admission types plan Hospital organisation framework Medico-technical units organisation

Materials and pharmaceuticals flow

Input

Pharmaceuticals sourcing plan Production pharmaceuticals schedule Replenishment signal (inventory management rules) Defective pharmaceuticals Excess pharmaceuticals

Sourced pharmaceuticals

Product pull signals Pharmaceuticals inventory location

Payment terms

Schedule product delivery

Receive product

Verify product

Transfer product

Authorize supplier payement

Output

Scheduled receipts Sourced pharmaceuticals on order

Receipt verification

Receipt verification

Inventory availability Daily replenishment requirements

Illustration 5: SCOR level 3 description: source specialties.

Schedule specialities delivery Performance attributes Reliability Responsiveness Flexibility Costs Assets Metric % Schedules generated within supplier's lead time Schedule specialities deliveries cycle time N.I. Schedule deliveries costs as a % of specialities acquisition costs Return on SC assets

Illustration 6: Performance attributes for a level 3 process element description

The logical diagrams allow us for identifying responsibilities, adding information on event-driven aspects of activities and the rules of resources availability. This description is necessary to model the working of the pharmaceuticals supply chain and to use a simulation tool, RAO (Di Martinelly, 2004). The use of a simulation model will allow us to test different organization scenarios and to follow the variation of performance indicators during the system walk. This approach has been used several times to reorganize or to size care units before implementing the solution (Cahill and Render, 1999; Dumas, 1984; El Darzi et al., 1998; Vissers et al., 1998;).

Conclusion

Healthcare organizations are currently facing new challenges similar to those faced by industrial firms twenty years ago. Logistics activities have therefore gained much attention in the sense that it may increase efficiency and flexibility. Among them, the pharmaceuticals supply chain activities amount for half of the total costs. The optimization of their working could lead to interesting cost savings. However, we have to be sure that the changes made lead to a global improvements. The pharmaceuticals supply chain has to be considered in relation with the hospital supply chain. Before claiming to optimize the working of the pharmaceuticals supply chain while considering the hospital activities, it is first necessary to analyze and diagnose the current situation. We thus need a modeling framework to apprehend this complex reality. In a first time, we use the Porters model to identify the best strategy to follow according to the market context. We then identify activities that generate value for care. All activities directly implied in the ordering, preparation, warehousing, delivery and traceability of drugs (primary activities of the pharmaceuticals supply chain) add value to care and are specific to the clinic pharmacy. The support processes are less specific and are mainly the same as those of the hospital and have to support a perfect coordination between the patients and the pharmaceuticals flows. To go further in our analysis, we need a modeling tool. We tend to apply the SCOR model to describe processes, to make comparisons between practices to get benchmarks and to define performance measures. The processoriented approach is well adapted to our problematic because it describes processes transverse to the organizational and functional design. Links between activities are therefore more obvious. The SCOR model gives a modeling framework that allows clear communication. However the definition of performance indicators should be made cautiously and should be filled in by a decision view to clearly identify responsibilities to ensure coherence between objectives definition and performance measurement. We also use logical diagrams to describe each process element. We identify responsibilities, we add information on event-driven aspects of activities and the rules of resources activities. The

use of logical diagrams will allow us to simulate the working of the hospital supply chain, to follow the variation of performance indicators during the system walk and to test different reorganization scenarios for optimization.
Schedule products delivery
Providers Pharmacy Care units Medico-technical units

Consultation plan

Intervention plan

Prescriptions

Prescriptions

Collect prescriptions for pharmaceuticals ordering Prescriptions

Manage local inventories

Replenishment signal?

Yes Order pharmaceuticals Make (SCOR level 2 process) Pharmaceuticals Medical orders

Deliver pharmaceuticals (SCOR level 2 process)

Return defective or excess pharmaceuticals Pharmaceuticals

Return defective or excess pharmaceuticals Pharmaceuticals

Manage inventories

Replenihment signal?

Yes

Order pharmaceuticals Orders

Order Pharmaceuticals Receive pharmaceuticals (SCOR level 3 process)

Illustration 8: Description of a process element: schedule product delivery

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Biography

CHRISTINE DI MARTINELLY studied business at the Catholic University of Mons. Since 2002, she is PHD student and teaching assistant at the group of Prof. RIANE. She is mainly interested in healthcare management and supply chain. FOUAD RIANE is professor at the Catholic University of Mons. He is director of the CREGI. His main research interests are supply chain management and maintenance. ALAIN GUINET is professor at Institut National des Sciences Appliques de Lyon. His main research interests are operating theatre planning, staffing and scheduling, hospital logistics.