Enabling better management of patients: discrete event simulation combined with the STAR approach

Squeezed budgets and funding cuts are expected to become a feature of the healthcare landscape in the future, forcing decision makers such as service managers, clinicians and commissioners to find effective ways of allocating scarce resources. This paper discusses the development of a decision support toolkit (DST) that facilitates the improvement of services by identifying cost savings and efficiencies within the pathway of care. With the help of National Health Service and commercial experts, we developed a discrete event simulation model for deep vein thrombosis (DVT) patients and adapted the socio-technical allocation of resources (STAR) approach to answer crucial questions like what sort of interventions should we spend our money on? Where will we get the most value for our investment? How will we explain the choices we have made? The DST enables users to model their own services by working with the DST interface allowing users to specify local DVT services. They can input local estimates, or data of service demands and capacities, thus creating a baseline discrete event simulation model. The user can then compare the baseline with potential changes in the patient pathway in the safety of a virtual environment. By making such changes key decision makers can easily understand the impact on activity, cost, staffing levels, skill-mix, utilisation of resources and, more importantly, it allows them to find the interventions that have the highest benefit to patients and provide best value for money.     

Exploring the use of DEA for formative evaluation in primary diabetes care: An application to compare English practices

Primary care is currently at the heart of the UK National Health Service policy. Primary care trusts have the crucial role of improving the efficiency and equity in primary care delivery. However, few studies have focused on performance assessment in primary care provision. In this paper, we examine the role of data envelopment analysis (DEA) in helping decision makers to understand and improve the performance of primary care practices. We discuss the results from a study of 14 practices in England in terms of their delivery of diabetes services. In order to take into account the multiple values that underlie public services provision, we have considered several different perspectives for evaluation. These were: technical, allocative and cost efficiency, clinical and patient-focused effectiveness, and equity. The approach adopted involved a deep engagement with the practices. The purpose was to understand the structures and processes supporting effective practice using DEA in a formative role rather than the more usual summative role with a large data set. This approach is in the tradition of the developmental engagement approach of operational research.     

Health visitors revisited

Cambridgeshire Area Health Authority commissioned a team from the University of Aston Management Centre to carry out an operational research project in order to assist in planning the provision of health visitor services in Peterborough health District. Since Peterborough is a Development Area there has been a rapid increase in population which it is planned will continue for some years. This change in size and age-distribution of the population poses considerable problems for planning the provision of health visitor services.Health visitors are trained nurses who have highly independent roles in the National Health Service. They are largely concerned with preventive work, traditionally with children and increasingly with the elderly, in which it is difficult to set quantitative objectives and measure outputs.This paper will describe the research plan and the models developed. Considerable attention will be paid to the relationship of the research team to the client system, consisting of the Area and District managers and the individual health visitors. The implications of this type of study in extending the practice of O.R. will be considered.     

Data envelopment analysis applied to quality in primary health care

The performance of primary care should ultimately be judged on its effect on the health outcome of individual patients. However, for the foreseeable future, it is inconceivable that the outcome data necessary to come to a judgement on performance will be available. And in any case, specification of the statistical model necessary to analyze outcome is fraught with difficulty. This paper therefore sets out a model of primary care performance which is based on the premise that certain measurable quality indicators can act as proxies for outcome. This being the case, a model of performance can be deduced which takes into account the effect of resources and patient characteristics on outcome. The most appropriate analytic technique to make this model operational is data envelopment analysis (DEA). It is argued that DEA can handle multiple dimensions of performance more comfortably, and is less vulnerable to the misspecification bias that afflicts statistically based models. The issues are illustrated with an example from English Family Health Service Authorities.     

Community Health Care in Rochdale Family Health Services Authority

The National Health Service and the Social Services are engaged on a massive transfer of resources in which, wherever possible, care will be delivered to vulnerable patients in their own homes. This paper deals with two pilot medical practices in Rochdale. The needs of patients are considered on a subjective scale in five categories. It was confirmed that there was a consistency of subjective measurement between the nurses involved but there was no relation between these particular measures and the amount of nursing care being delivered. However, there was a strong relationship between age and the probability of being on the nursing care list, with a significant difference between the sexes. The model can lead to the identification of categories of patients who might have slipped through the net and also to estimates of the total home care nursing list in a practice.     

A multi-objective model to determine efficient resource levels in a medical assessment unit

This paper details models that determine the efficient allocation of resources on a medical assessment unit (MAU) of a general hospital belonging to the National Health Service (NHS) UK. The MAU was established to improve the quality of care given to acute medical patients on admission, and also provide the organizational means of rapid assessment and investigation in order to avoid unnecessary admissions. To analyse the performance of the MAU, doctors, nurses and beds are considered as the three main resources. Then a model is developed using the goal programming approach in multiobjective decision making and solved to deal with MAU performance. The developed model is solved under three different sets of patient admissions with the same resource levels using past data from the MAU. The results of the model are used to analyse the needed resource levels. Conclusions as to the appropriate staffing levels and functions of the MAU are drawn.     

Hospital bed requirements planning

Within the current environment of British government public spending cuts, the effective use of National Health Service resources is now probably more important than at any time since its formation. For this reason the Management Science Department of University of Swanswa have developed a simulation model to aid decision making in the area of operating theatre time tables and the resultant hospital bed requirements. It has already have agree that the model be adopted in one large South Wales hospital. This paper describes the formulation of the model, the results obtained and its applications within the hospital service.     

Proposing a systems vision of knowledge management in emergency care

This paper makes a case for taking a systems view of knowledge management within health-care provision, concentrating on the emergency care process in the UK National Health Service. It draws upon research in two case-study organizations (a hospital and an ambulance service). The case-study organizations appear to be approaching knowledge (and information) management in a somewhat fragmented way. They are trying to think more holistically, but (perhaps) because of the ways their organizations and their work are structured, they cannot ‘see’ the whole of the care process. The paper explores the complexity of knowledge management in emergency health care and draws the distinction for knowledge management between managing local and operational knowledge, and global and clinical knowledge.     

On comparing the performance of primary care providers

In the past few years primary health care has been characterised as central to the development of the National Health Service in the United Kingdom. Furthermore, performance assessment is seen as a way of achieving care of high standards. Performance indicators and targets are being developed to assess primary care providers, and to develop financial incentives. However, the number of studies that have compared the performance of primary care providers is limited and the existing approaches to evaluation are open to improvement.     

One hundred years of Operational Research in Health—UK 1948–2048

This paper presents a personal view, drawing on some 30 years of working in this area, of past, present and future contributions of operational research (OR) in health in the UK. It considers developments in health and care and in OR contributions to these at local and national level since the creation of the National Health Service 60 years ago; likely future developments in health and care; and associated priorities for preparing now for OR to make a major impact on health and care in the next 40 years. The aim is to stimulate reflective thinking and promote anticipatory action among health OR practitioners of the future.     

Utilizing buffer management to improve performance in a healthcare environment

For over 50 years, the United Kingdom’s National Health Service has aspired to provide universal access to quality health care. However, as evidenced by huge backlogs and lengthy waiting times for many services, the NHS is showing the strain of accommodating rising contemporary expectations within a constrained budget. This paper describes the concept of buffer management, its origins in manufacturing applications, and how it can be applied to generate improvements in health care systems. The successful implementation of buffer management is illustrated with recent applications in the Accident and Emergency departments and the hospital admissions process of three NHS facilities.     

Balancing the NHS balanced scorecard!

In the UK, the split between opposition and supporters views of the National Health Service (NHS) performance ratings system is growing. Objective argument and consensus would be facilitated if a methodology was developed which showed the cause and effect relationships between the components of the performance rating system. The NHS hospital trust performance ratings data used in 2002 and 2003 were downloaded from the Department of Health performance rating website. Structural equation modelling was used to construct a causal-loop diagram showing the cause and effect relationships between the 16 common performance indicators in the two years. Scenario testing suggests that indicators of delayed transfer of care and of data quality are compromised if emergency readmissions performance is improved.     

Involving Users in the Development of Decision-Analytic Aids: The Principal Factor in Successful Implementation

Decision-analytic techniques and aids have been used successfully in a wide range of settings to help decision makers sytematically evaluate alternative means of resolving a problem. On the basis of this success. it is anticipated that organizations will increasingly desire decision-analytic aids with stand-alone capabilities for routine use without outside consultation. The paper's thesis is that decision-analytic aids will seldom achieve stand-alone capabilities unless eventual users are involved throughout the development process. User involvement develops the understanding and commitment necessary for implementing a different decision-making approach and tailors aid characteristics to the users' needs within their organizational context. Although the need for user involvement appears obvious, it has often been neglected in the development of analytical decision aids, with the result being unsuccessful implementation.     

Choice of modelling technique for evaluating health care interventions

Economic evaluation, such as cost effectiveness analysis, provides a method for comparing healthcare interventions. These evaluations often use modelling techniques such as decision trees, Markov processes and discrete event simulations (DES). With the aid of examples from coronary heart disease, the use of these techniques in different health care situations is discussed. Guidelines for the choice of modelling technique are developed according to the characteristics of the health care intervention.The choice of modelling technique is shown to depend on the acceptance of the modelling technique, model ‘error’, model appropriateness, dimensionality and ease and speed of model development. Generally decision trees are suitable for acute interventions but they cannot model recursion and Markov models are suitable for simple chronic interventions. It is further recommended that population based models be used in order to provide health care outcomes for the likely cost, health benefits and cost effectiveness of the intervention. The population approach will complicate the construction of the model. DES will allow the modeller to construct more complex, dynamic and accurate systems but these may involve a corresponding increase in development time and expense. The modeller will need to make a judgement on the necessary complexity of the model in terms of interaction of individuals and model size and whether queuing for resources, resource constraints or the interactions between individuals are significant issues in the health care system.     

Population needs assessment and access modelling for cardiac services

The National Service Framework (NSF) for Coronary Heart Disease (CHD), recently published by the Department of Health, specifies Government target rates for different cardiac procedures. This paper describes how the Eastern Regional Office of the Department of Health, with current rates approximately half the NSF target levels, designed a strategy to plan rationally for increases in service provision. A bottom-up needs assessment model was used to predict the population requirements for these CHD procedures and accounts for the effects of demographic change, anticipated reduction in the incidence of heart disease due to primary prevention programmes and the expected improvement in cardiology and cardiac surgery technologies. It is predicted that excess procedures would be required across the region over the next 20 years, and so a geographical access model was developed and used to recommend the building and location of a new tertiary cardiac centre to meet the increased demand. These tools have successfully been used in the Eastern Region to plan long-term increases in CHD rates in order to achieve Department of Health targets.     

Bayesian decision making and military command and control

We discuss firstly the problem of military decision, in the context of the more general development of ideas in the representation of decision making. Within this context, we have considered a mathematical model—Bayesian Decision—of decision making and military command. Previous work has been extended, and applied to this problem. A distribution of belief in outcome, given that a decision is made, and a Loss function—a measure of the effect of this outcome relative to a goal—are formed. The Bayes' Decision is the decision which globally minimises the resultant bimodal (or worse) Expected Loss function. The set of all minimising decisions corresponds to the surface of an elementary Catastrophe. This allows smooth parameter changes to lead to a discontinuous change in the Bayes' decision. In future work this approach will be used to help develop a number of hypotheses concerning command processes and military headquarters structure. It will also be used to help capture such command and control processes in simulation modelling of future defence capability and force structure.     

Planning for a Single Specialty in a Health District

This paper discusses planning in the National Health Service. An outline of a general method for planning at the district level is illustrated with a case study in which a strategic plan was produced for the maternity services in Cambridge Health District. Some of the problems of ensuring implementation of proposals are then discussed.     

A multiattribute GDSS for aiding problem-solving

This study proposes a group decision support system (GDSS) with multiattribute to help solve problems in the real world. The problems are usually characterized as a multiattribute decision making (MADM) for selections, and shall be the responsibility of an expert group. On a regular basis, experts within that group will meet and conduct discussions on the web. After each individual make efforts of judgments, comparisons, and rankings, they shall determine, collectively as a group, the final rankings of all possible alternatives. Furthermore, aimed at insuring the decision quality of the collective decisions, an integrated procedure will be applied to make any modifications as necessary. Based on the geometric aspects of decision quality, the disparity of each individual member's preferences on attribute can be filtered out by the suggested bounded indicators. And then the outliers related to attributes' weights will be identified through a different set of consensus indicators, thus, further improving the decision quality while maintaining a quantitative level of consensus. Finally, using a car-selection problem herein, the proposed integrated procedure is implemented on a network-based PC system with web interfaces.