On the challenges of healthcare modelling and a proposed project life cycle for successful implementation

OR methods and tools are being increasingly applied within the health services domain to support objective decision-making for the effective and efficient provision of resources. Healthcare modelling, however, is beset with many challenges and this paper examines a number of issues that define the primary challenges faced by the modeller in this field. It is fair to say that their resolution determines the likely success or failure of healthcare modelling in general. Working with a number of participating health service organizations, a proposed framework towards successful implementation has evolved and is presented in this paper     

System dynamics mapping of acute patient flows

Department of Health staff wished to use systems modelling to discuss acute patient flows with groups of NHS staff. The aim was to assess the usefulness of system dynamics (SD) in a healthcare context and to elicit proposals concerning ways of improving patient experience. Since time restrictions excluded simulation modelling, a hybrid approach using stock/flow symbols from SD was created. Initial interviews and hospital site visits generated a series of stock/flow maps. A ‘Conceptual Framework’ was then created to introduce the mapping symbols and to generate a series of questions about different patient paths and what might speed or slow patient flows. These materials formed the centre of three workshops for NHS staff. The participants were able to propose ideas for improving patient flows and the elicited data was subsequently employed to create a finalized suite of maps of a general acute hospital. The maps and ideas were communicated back to the Department of Health and subsequently assisted the work of the Modernization Agency.     

Supporting the strategy process: a survey of UK OR/MS practitioners

This paper reports the results of an online survey conducted with practitioner members of the UK Operational Research (OR) Society. The purpose of the survey was to explore the current practice of supporting the strategy process in terms of activities supported and tools used. The results of the survey are compared to those of previous surveys to explore developments in, inter alia, the use of management/strategy tools and ‘soft’ Operational Research/Management Science (OR/MS) tools. The survey results demonstrate that OR practitioners actively support the strategy process within their organisations. While a wide variety of tools, drawn from the OR/MS and management/strategy fields, are used to support the strategy process within organisations, the findings suggest that soft OR/MS tools are not regularly used. The findings also demonstrate that tools are combined to support the strategy process from both within and across the OR/MS and management/strategy fields. The paper ends by identifying a number of areas for further research.     

Operational Research for informed innovation: <Emphasis Type="Italic">NHS Direct</Emphasis> as a case study in the design,implementation and evaluation of a new public service

Delivering modern and responsive public services requires informed innovation drawing on a combination of design, planning and evaluative skills. The development of the national 24-hour telephone helpline service NHS Direct provides a case study demonstrating how, through using these skills, OR has been instrumental in achieving public service innovation. Firstly, OR analysts led strategic design and scenario-planning work, assessing the evidence on the performance of ‘direct’ services here and around the world and developing scenarios of an NHS where much greater use was made of modern communication technology, such as telephone call centres, to provide services. Secondly, we did modelling work to help determine the size, distribution and staffing of the call centres required in England to meet the likely demand and satisfy service performance targets. Thirdly, we set out evaluation criteria and developed performance-monitoring systems. NHS Direct has been one of the best-received innovations in the history of the NHS and Operational Research has made a crucial contribution to its development.     

Rethinking tradeoffs and OR/MS methodology

The purpose of this paper is to explore the role of a process known as the ‘evaporating cloud’ (EC) as a way of enhancing OR/MS modelling. While other authors have described the use of the EC process to explore the tradeoffs in a traditional Economic Order Quantity model, this paper demonstrates the use of the EC with a facilities location problem, which was originally solved via mixed integer programming. We relate our findings to OR/MS modelling in general, and argue that the EC could contribute effectively to different phases of the problem-solving process, for example, aiding the problem-structuring phase and helping to find better solutions in many OR/MS modelling situations. We demonstrate that the EC is a valuable tool to use in modelling practice as a problem-structuring tool, as a way of dealing specifically with tradeoffs, and that it can therefore be a useful complement to OR/MS methodology, and contribute to OR/MS practice and teaching.     

On the roles of OR/MS practitioners in supporting strategy

This paper presents an exploratory account of how Operational Research/Management Science (OR/MS) practitioners understand their role in supporting an organisational strategy process. The role of strategy support is characterised by five dimensions: the activities supported within the strategy process; the nature of support provided; the orientation of the support provided; the tools used in providing support; and the nature of the relationship between consultant and client. The research draws on case studies of four OR/MS practitioners working as internal and as external consultants. The work of the practitioners is mapped onto the framework and gaps are identified. The research proposes a further dimension, namely, ‘the purpose of the support provided’, and suggests four purposeful support roles adopted by practitioners in supporting strategy within organisations: sensemaking/sensegiving; decision support tool development; problem solving/solution exploration; and process facilitation. The paper concludes with suggestions for further research.     

Evaluating soft OR: some reflections on an apparently ‘unsuccessful’ implementation using a Soft Systems Methodology (SSM) based approach

This paper reflects on a case study in which a soft OR problem structuring approach, based on Soft Systems Methodology (SSM), was used to help in the design of an information system for health service users providing care in the community in a part of the South and West Health Region in the UK. The paper reflects on why an apparently ‘successful’ structuring led to an apparently ‘unsuccessful’ implementation. As part of this reflective process, the paper makes a contribution to the soft OR literature by reviewing some of the approaches taken in the literature to the evaluation of success of problem structuring using soft OR. This review reveals a lack of evaluative criteria, a lack of clarity over the identification of users, and a failure to differentiate criteria associated with ‘structuring’ and ‘implementation’ issues. An evaluative framework is proposed, which is applied retrospectively to the case study.     

The ‘invisible science’: operational research for the British Armed Forces after 1945

This paper presents an original account of the contribution of operational research (OR) to the formulation of tactics and strategy on behalf of the British Armed Forces in the four decades after 1945. The main focus is on the Cold War in the European theatre, where OR analysts devoted considerable time and effort to the modelling of warfare on behalf of the British Army of the Rhine. In the absence of combat data for nuclear weapons, OR analysts devised a sequence of war games which evolved in conformity with the development of NATO strategy in relation to the Warsaw Pact. Again in the context of the Cold War, the paper analyses the role of OR in relation to the early V bomber force and the introduction of ‘global war studies’ on behalf of the Royal Navy. The paper also comments on the organisational structure of British military OR following on the creation of a centralised OR facility within the Ministry of Defence in 1965. In conclusion, the paper notes the sea-change in military OR following the end of the Cold War in 1990 and the onset of a period of sustained ‘asymmetric’ military operations in the former Yugoslavia, the Middle East and Afghanistan.     

Cooperation between strands of practice: challenges and opportunities for the renewal of OR

Collaboration between OR groups following different ‘strands of practice’, namely adhering to different ways of conducting OR practice, is difficult. We demonstrate the existence of this problem in two contexts. Firstly, we found several different strands of practice within an independent, entrepreneurial OR firm. Though these strands had the potential to be highly complementary, their co-existence within one firm led to serious tensions and their potential synergy has not yet been realised. When the independent OR firm achieved successful renewal by transforming one of their strands of practice into a new approach to projects, this very success created a new set of competitive challenges. Secondly, an independent OR consulting firm working with a client's internal research group found that the latter's approach conflicted with its own, resulting in an unsuccessful project. We conclude that the ‘micro-level’ problems of collaboration between individual practitioners and between groups, though largely neglected in the OR literature, can be serious impediments to success and renewal of OR practice.     

Widening requirements capture with soft methods: an investigation of hybrid M&amp;S studies in health care

A simulation study consists of several stages: problem formulation, model implementation, verification and validation, experimentation and output data analysis. The application of multiple techniques in the model implementation stage is referred to as hybrid simulation, which we distinguish in this paper from a hybrid M&S study, the latter referring to studies that apply methods and techniques from disciplines like Operations Research (OR), Systems Engineering and Computer Science to one or more stages of a simulation study. Our paper focuses on the contribution of soft OR methods in the problem formulation stage of a simulation study (and by extension a hybrid M&S study). Soft Systems Methodology (SSM) has, arguably, been the most widely used qualitative approach for eliciting system requirements. In this paper, we present Qualitative System Dynamics (QSD), a soft systems method, as having potential use in the problem formulation stage of a healthcare M&S study. The contribution of this paper is thus twofold: (1) a review of the literature in SSM for healthcare operations management and (2) an examination of QSD as an additional soft OR method, complementing (rather than supplanting) existing approaches, which can further aid the understanding of the system in the problem formulation/conceptual modelling stage of a hybrid M&S study.     

Supporting strategic conversations: the significance of a quantitative model building process

This paper reports on the use of a quantitative system dynamics simulation model building process that followed on from a ‘soft OR’ strategy making intervention with a top management team. The work was carried out for the Chief Constable and top team of a UK police force. The output of the ‘soft OR’ strategy making process provided the reason for, and so focus of, the simulation model. The focus of the strategic conversation was on exploring the tension between the supply of resources (in this case police officers) and the demands placed on those officers. The project involved a series of strategic conversations with members of the top team that were stimulated through the process of building a system dynamics model. The process was facilitated by two modellers—one focussing on managing the strategic enquiry, while the other considered the implications of the conversation for the construction of the system dynamics model. Through the process of gradually building the system dynamics model, a number of issues and lessons were raised for the development and delivery of effective strategy making and the strategic management of public organisations. In addition there were implications for operational research model building processes, especially when operating at senior levels and within a strategic context.     

DEMO: Towards a discipline of organisation engineering

Dynamic Essential Modelling of Organisation (DEMO) is a theory about the ‘construction’ and the ‘operation’ of organisations, that is rooted in the Communicative Action Paradigm regarding human communication and action. In this theory, the ‘working principle’ of an organisation consists of the entering into and the complying with commitments between human beings, where authority, responsibility and competence play an important role. The ‘construction’ of an organisation consists of a coherent whole of transactions, i.e., recurrent patterns of communication and action in which the commitments are entered into and complied with.DEMO is also a methodology for modelling, (re)designing and (re)engineering organisations based on that theory. Up to now some thirty projects have been carried out with DEMO. These projects are of very different kinds and they have been carried out in various types of organisations. The success factor has been the same for all these projects, namely the practical relevance of the concepts of DEMO, as well as their clear and precise definitions. Both managers and employees appear to be able to participate readily in identifying and understanding problems, and in generating appropriate and feasible solutions.     

Holistic oil field value management: using system dynamics for ‘intermediate level’ and ‘value-based’ modelling in the oil industry

System dynamics has been seen primarily as a strategic tool, most effectively used at the highest level of strategy to identify robust policy interventions under a wide range of scenarios. However, an alternative, complementary and powerful role is emerging. This is at an ‘intermediate level’ in organisations to coordinate and integrate policies across the value chain. It is at this level where business value, as defined by the discounted value of future free cash flow, is both created and destroyed. This paper introduces the need for ‘intermediate-level’ and ‘value-based’ modelling and emphasises the natural role of system dynamics in supporting a methodology to fulfil the need. It describes the development of an approach and its application in the oil industry to coordinate the response of people and tools within operational, financial and commercial functions across the value chain to address a variety of problems and issues.     

Using Singular Spectrum Analysis to obtain staffing level requirements in emergency units

Many operational research (OR) techniques use historical data to populate model input parameters. Although the majority of these models take into account stochastic variation of the inputs, they do not necessarily take into account seasonal variations and other stochastic effects that might arise. One of the major applications of OR lies within healthcare, where ever increasing pressure on healthcare systems is having major implications on those who plan the provision of such services. Coping with growing demand for healthcare, as well as the volatile nature of the number of arrivals at a healthcare facility makes modelling healthcare provision one of the most challenging fields of OR. This paper proposes the use of a relatively modern time series technique, Singular Spectrum Analysis (SSA), to improve existing algorithms that give required staffing levels. The methodology is demonstrated using data from a large teaching hospital's emergency unit. Using time dependent queueing theory, as well as SSA, staffing levels are obtained. The performance of our technique is analysed using a weighted mean square error measure, introduced in this paper.     

Causal study of low stakeholder engagement in healthcare simulation projects

Stakeholder engagement plays a fundamental role in the success of ‘operational research’ initiatives including simulation projects. However, there is little empirical evidence of real engagement in the context of healthcare simulation. This paper principally examines this issue and aims to provide insights into the possible causes. The paper reports on the results of a literature review and 10 field studies within the UK healthcare settings, supplemented with the authors’ experience in order to arrive at an initial list of the causes, which will then be tested through a survey of expert opinions. Twelve primary and 26 secondary causal factors, which received statistically significant level of agreement from the experts, are presented in a fish-bone diagram. The findings indicate that communication gap between simulation and stakeholder groups is the top primary factor contributing the most to the poor stakeholder engagement in healthcare simulation projects, followed by ‘poor management support’, ‘clinician’s high workload’ and ‘failure in producing tangible and quick results’.     

Strategic operational research

Operational researchers have been slow to define and claim a strategic role for operational research (OR). This article discusses the OR activities of a number of leading-edge organisations, and argues that in several instances these activities have sustained a competitive advantage over a significant period of time, and are seen as a ‘strategic asset’ to the parent corporation. Finally, it is argued that OR people should begin talking about OR as a strategic asset, and that recognition of this strategic role provides a vision of a very exciting future for OR.     

On the nature of OR: taking stock

This paper argues that OR, having reached its maturity, must now play to its strengths. In strategic terms this means competing in those areas where OR's core competences can be brought to bear. Using a competence model it is suggested that OR's core products are (i) the development and implementation of the quantitative, algorithmic ‘smart bits’ and (ii) the ‘helpful ways’ of managing intervention processes. These core products are supported and sustained by three core competences labelled process, analytic, and context. Individuals and small groups of practitioners develop ‘strands of practice’ and larger groups ‘webs of practice’ on the basis of their core competences. It is argued that this is giving rise to the emergence of three archetypes of OR service, namely the OR technical consultancy, the OR process consultancy, and the full service OR consultancy. Both the technical and process consulting are built around ‘strands of practice’ of individuals and find their natural home in small service providers. The full service OR consulting practice, in the past located in internal OR groups, will in the future be located within the large management consultancies, which are capable of managing ‘webs of practice’. The implications for the worlds of OR practice and academia are examined.     

The Deployment of Personnel in a Branch Network—a Case Study in OR Methodology

This paper describes a successful study which was concerned with identifying appropriate levels of supernumerary staff in a branch network of a national service company. The case study is used to illustrate a number of OR methodology issues relating to problem identification, model design, implementation and choice of modelling approach:     

Examining the feasibility of using a modelling tool to assess resilience across a health-care system and assist with decisions concerning service reconfiguration

Changes in medical practice, demographic shifts and financial pressures are all examples of factors that may contribute to demand for periodic changes in the configuration of health services. When reconfiguring a service, health planners often take into account projected demand for services, patient access criteria and budgetary constraints (among other things), but typically give little consideration regarding its resilience to deliver services during and after external disruptions to its capability to deliver. In this paper we discuss a study conducted in response to a direct request from the National Health Service (NHS) Resilience Project within the Department of Health to explore the feasibility of assessing resilience across local services within the NHS and developing a computer software tool to assess resilience of different service reconfigurations. We give an account of the modelling process used, including the analytical framework we developed using both optimisation and heuristic methods, and an illustrative example of usage of a prototype software tool. We also highlight the key lessons that emerged during this project, which may be helpful to OR analysts working on similar projects regarding resilience in the public sector.