Monitoring, Evaluating, Planning Health Services

The following sections are included:

• PREFACE

• CONTENTS

Health services throughout Europe present a constant challenge to deliver acceptable services within cost constraints. Operations researchers strive to understand the determinants of system performance and provide support to identify and implement solutions. In the UK recently, measures of health performance have been endorsed nationally by Government. This paper reviews the issues and the interventions taking place Europe-wide. A categorisation of the ways in which O. R. can address performance issues is presented, and compared with evidence from recent publications and from the programme of the present ORAHS conference. The focus of OR on implementation and of ORAHS on sharing experiences of Health Services across Europe are regarded as a good basis for collaboration and communication and the focusing of future research. Success is always partial, and more research is always necessary.

Most developed countries aim for health services which are basically egalitarian. Thus equity and equality are important factors in the monitoring, evaluating and/or planning of health services. However, the achievement of equity in health and health-care is problematic. Inequalities in health status arise from a wide range of social, environmental, economic and genetic factors. Inequity in access to health care can result from inherited inequalities in financial and physical provision of health care, geographical problems of access, and different medical values and priorities. For many reasons, which are well documented, achieving total equality in health status is probably impossible. However, even the achievement of equity in access to health care raises a number of problems. Further, recent interest in reforming health-care systems and the debates on priority-setting and rationing in different countries have raised new fears of increasing inequalities in access to health care. This paper presents a critical analysis of a number of different approaches to conceptualising, measuring and operationalising equity in access to health care. In particular, it explores which inequalities in health-care provision are consistent with, and which indeed are necessary for, equity in access to health care. It also examines a particular problem of inequality in the UK: “rationing by post-code”.

The introduction of large-scale databases creates new opportunities for the monitoring, evaluation and planning of medical programmes. It also creates new obstacles. The existing tools of the trade that are based on strictly designed, well controlled, small experiments and their inferential statistics become insufficient. The sensible analysis of huge databases demands for a new approach, new tools and new indicators. This document presents one new approach that is based on data warehousing, benchmarking, a micro-macro approach and graphic user interfaces. The opportunities for medical programme monitoring, evaluation and planning are illustrated for the case of all cardiovascular surgery in Belgium.

This paper focus on health and care systems operation and provides an innovative approach towards improving performance, by offering tools to help an existing working group in the project of a new hospital facility at the Federal University of Rio de Janeiro. A simulation platform, devised and developed by the author, is described. The platform provides a patient-oriented modelling process and allows one to formulate a particular problem, to conduct a discrete event simulation experiment showing the possible outcomes within a 3D virtual scenario. Four standard queuing models are used to demonstrate the potentiality of the method. It is argued that the method is useful to the planning of facilities, training and teaching.

Present hospital development plan is the result of the activities set in motion by the Ministry of Welfare’s wish to lay the foundations for decisions on the future geographical organisation of the provision of health care in the republic of Latvia. The work has been funded by the Latvian Ministry of Welfare and by a grant from the Danish Government. A pilot area was established, after application to the Ministry of Welfare, in the districts of Cesis, Limbazi, Valka and Valmiera with a total amount of approximately 200,000 inhabitants. The project work has been performed as a cooperation between working groups comprising professionals from the involved hospitals and Latvian and Danish Technical Assistance Consultants. The following issues have been taken into consideration in the proposal: prognosis for need of beds, working group proposals, technical assistants (TAs)' knowledge about links between specialities, need for securing high standards of care, preparation of one regional hospital able to counteract the export of patients to state capital clinics, investment needs in building and equipment, supposed socio-economic situation in the urban and rural areas in 2005, supposed transportation possibilities in 2005. The project recommendations are: to implement a change in the bed allocation and specialities allocation between the hospitals in the pilot area; to establish a Regional Health Board as a decision making body consisting of politicians appointed by the hospital owners and including a regional central technical service organisation. As to the implementation, only few recommendations have been implemented. Instead of establishing the Regional Health Board, District Sickness Funds have been merged to one Regional Sickness Fund, which is the organisation responsible for the distribution of the health care budget among health care providers. It will be possible to implement other project proposals after establishing the health management organisation in the region. There are a lot of objective and subjective factors, which affect the implementation of the project recommendations.

Two years ago, the Belgian Ministry for Social Affairs asked the departments of Operational Research (SMG) and Applied Economics (DULBEA) of the Université Libre de Bruxelles to develop methodological tools aimed at helping to understand health care budgets consumption. The first step of this research concerns the identification of “pathological channels” defined from mathematical programs and through the correlation between cares expenditures time series. The paper will deal with the second step, which is dedicated to the construction of a multicriteria fuzzy assignment procedure of the insured to these channels. The multicriteria sorting problematic, also called P.β problematic (in contrast to the P.α choice problematic and the P.γ ranking problematic), consists in assigning a set of alternatives, described by their profile of performances according to k criteria, to some predefined categories characterised by one or several reference point(s), also called prototype(s). The assignment to a category is based on the type of relation existing between the action to be assigned and the category prototype(s). When applying these concepts to the analysis of Belgian health care budgets, the concordance and non-discordance aggregation functions of the available methods and software (mainly inspired by the crisp or valued outranking approach, and more precisely by the ELECTRE methods) did not seem appropriate to solve the problem. Therefore, inspired by the particular characteristics of our application, we investigate the definition of multicriteria weighted operators aggregating a valued non compensatory (conjunctive) measure of similarity in the case of non ordered categories for which the criteria rather look like assignment constraints.

Modelling-based health care management ought to become just as popular as evidence based medicine. Making managerial decisions based on evidence by modelling efforts is certainly a step forward. Examples can be given of many successful applications in different areas of decision making: disease process modelling, screening and prevention policy development, resource allocation, waiting lists and waiting times, patient scheduling. Also examples can be given which would have benefited by prior modelling, for example adverse effects of health care system reform decisions. This contribution aims at giving an overview of health care management modelling areas, and observations from a European perspective on developing successful health care management models. The overview is created by presenting different reference frameworks for mapping health care management modelling applications. We report a development from an almost arbitrary list of applications used for bibliographic purposes (scheduling, simulation, queuing, etc.) towards frameworks that focus on the process of delivery. The advantage of mapping modelling applications in this way is that we are able to position contributions within a reference framework with a focus on processes, with the patient process at the top. The acceptance of process-orientation as a basis for modelling has consequences for the way models are developed. Close cooperation between modeller and manager and a profound insight into the dynamics of the modelling area concerned are important requirements for developing successful models.

New residential aged care standards in Australia, linked to an accreditation process, require evidence that appropriate quality management systems are in place that permit continuous quality improvement (CQI) to be demonstrated across all operations. This requires that aged care facilities adopt a cycle of monitoring, assessment (“evaluation”), action and follow-up (“planning”). A particular example given of evidence of CQI is that “customers are more satisfied” in addition, it is indicated that CQI activities should be “responsive to inputs from management, staff and residents”. This paper describes the development of an approach by which managers of aged care facilities can explore in detail the needs and concerns of their residents. A comprehensive manual provides relevant practical tools (interview schedules and self-complete questionnaires) and guidelines for their use and interpretation, within a CQI philosophy. As well as its use for internal monitoring and assessment purposes, the manual also provides the basis for longer term planning. A related research project has also been initiated to model the relationship between resident satisfaction in aged care facilities and: i) organisational factors (e.g. size, location and age of facility); ii) staff factors (e.g. number, mix, satisfaction, experience); and iii) resident factors (e.g. age, sex, dependency level).

While considerable attention has been given to the development of patient satisfaction measure in acute care and mental health, existing measures of older patients' satisfaction with home care services suffer from several shortcomings. Against this background, interest has arisen in the development of an instrument to measure satisfaction that is able to catch the various aspects of service quality that is called in Italy “Integrated Home Care”. This paper describes the development of Home Care Satisfaction Measure, that covers three dimensions of service quality following the Article 14 of the Law 502/1992 that emphasises the so-called “perceived quality”. The three dimensions are accessibility, efficiency, and effectiveness. A composite index of perceived quality of care based on the patients' evaluations of different domains of service and specific items within domain, was built. Finally, the instrument was able to assess the ability to measure, through relatives (and/or other delegates), the satisfaction of mentally disabled patients. The instrument can be used for program evaluations, quality assurance or improvement systems, clinical research or general population surveys.

Sarah Network Hospitals are composed by 4 rehabilitation units located in 3 Brazilian areas (Northeast, Southeast, and Centre). Main pathologies assisted by Sarah Hospitals are spinal cord injury, cerebral palsy, orthopaedic diseases/trauma, muscle/bone tumours, congenital anomalies, etc. Since January 1997 a program of quality control has been implemented in all Sarah hospitals. This program includes monitoring and evaluation of the hospitals main sectors. Evaluation indicators were classified in four groups: Hospital Bed Utilisation, Production and Productivity, Technical Quality, User Satisfaction. Besides monitoring the above indicators, other studies on quality are always carried out such as: productivity of doctors, number of needed nurses, analysis of waiting lists, follow-up of patients, epidemiological profiles of main pathologies, inquiries on incidence of spinal cord injuries, etc.

A multiobjective multiperiodal linear programming model has been built as a contribution to a good management of a blood donations-transfusions system in order to make the best usage of the blood resource and to minimise the quantity of blood imported from outside the system. The model has been applied to the Italian Red Cross (CRI) blood donations-transfusions system in Rome and to each hospital belonging to such a system, producing interesting results.

The following paper reviews the provision of Intensive Therapy Unit (ITU) beds in the City of Glasgow. The review utilises data made available by Greater Glasgow Health Board which covers the years 1995 and 1996 and 4 out of the 5 ITUs in Glasgow. The paper looks at various issues including the number of beds available as opposed to the “official bed complement”, the idea of a collaboration theory between the units and the extent to which the Midnight Bed State (a traditional measure of bed occupancy) can be used as a predictor of bed occupancy. In conclusion, a central bed bureau is required for the collaboration to be effective, and the rules for the operation of this require further study relating to the number of beds available. These cannot be realistically forecast for more then 12 hours using the Midnight Bed State.

The objectives of this paper are to give insight into medical multi-disciplinary patient flows, to quantify the occurrence of this phenomenon in Dutch general hospitals and to make a first step towards a solution. The approach to this problem is based on logistic analyses of these patient flows, as a control system needs to be based on the characteristics of the underlying processes.

In the past, Operational Research methods have been successfully applied to road traffic control problems associated with granting priority to public transport. Such methods translate well into the evaluation of prioritising hospital admissions from a waiting list. A modelling method used by the author in the context of traffic engineering has been reformulated so that it can be used to evaluate potential hospital admission policies that take account of priority ratings. The method can be used to compare the consequences of different strategies for patient admission in terms of features such as: mean waiting time for different patient priority groups, maximum waiting times and overall patient throughput.

Cardiology patient flows in hospitals are difficult to manage. Many patients are admitted via the emergency department, and go straight to the cardiocare unit (CCU). The bed capacity of the CCU is limited. If new patients arrive for the CCU, and the beds are full, the pressure on the cardiology subsystem increases. Decisions have to be made to transfer patients from the CCU to the regular ward, and to discharge patients from the regular ward. These early transfers and discharges are a worry to those working in this subsystem: emergency department, CCU staff, cardiologists and nursing staff. The paper reports on a case-study performed in a hospital in the Netherlands that was faced with this problem. A decision support model was developed for the hospital to support decision making on improving the logistic management of cardiology patient flows. The paper describes the model as well as results of applying the model for different scenarios of improvement.

For some decades radiation therapy - external beam radiation therapy as well as brachytherapy - has been proved successful in cancer treatment. It is the major task of clinical radiation treatment planning to realise on the one hand a high level dose of radiation in the cancer tissue in order to obtain maximum tumour control. On the other hand it is obvious that it is absolutely necessary to keep in the tissue outside the tumour, particularly in organs at risk, the unavoidable radiation as low as possible. No doubt, these two objectives of treatment planning – high level dose in the tumour, low radiation outside the tumour – have a basically contradictory nature. Therefore, it is no surprise that inverse mathematical models with prescribed dose distributions tend to be infeasible in most cases. Thus, there is need for approximations compromising between overdosing the organs at risk and underdosing the target volume. Differing from the currently used time consuming iterative approach, which measures deviation from an ideal (non-achievable) treatment plan using recursively trial-and-error weights for the organs of interest, we go a new way trying to avoid a priori weight choices and consider the treatment planning problem as a multiple objective linear programming problem: with each organ of interest, target tissue as well as organs at risk, we associate an objective function measuring the maximal deviation from the prescribed doses. We build up a data base of relatively few efficient solutions representing and approximating the variety of Pareto solutions of the multiple objective linear programming problem. This data base can be easily scanned by physicians looking for an adequate treatment plan with the aid of an appropriate online tool.

At present in the United Kingdom most babies are born in hospitals. A more woman-centred approach, with choices available to women, is now accepted as being appropriate for the provision of maternity care. A detailed model for the provision of maternity care, and illustrative results, will be discussed.

The NHS White paper (The new NHS modern dependable) was published in December 1997. This strategic document, endorsed by a new Government, promotes integrated care, national standards of care and easier and swifter access to the NHS, in a ten year programme which proposes that local doctors and nurses will shape local primary and secondary care services. The opinions of a small group of General Practitioners were surveyed from a structured questionnaire as part of a seminar / discussion session. The GPs' knowledge and views of the White Paper were obtained, together with data on their own practices' clinical performance, their priorities and their use of information. The differences between their views and experience and the national strategy identify constraints to change in the extent of collaboration, of clinical consistency, and of information use. The findings are important because an effective national health strategy relies on full support from those whose work is affected, especially general practitioners, and these proposals will involve them in more planning and management than is currently the case. The currently little collaboration reported between GPs and other care agencies conflicts with the Government proposals. GPs also said that they did not use information much in planning and delivering services. They were not confident in accessing, analysing and understanding information, and felt that there was insufficient relevant information to help them plan and deliver services to major patient care groups. It is hoped that exposure to, and support with, information management methods should increase the amount of shared relevant information, and the use to which it is put. GPs' current focus on their individual practice, rather than on the envisaged larger, multiprofessional PCGs, may limit the preparation of agreed rational plans and the introduction of effective collaboration.

In this work we will present methods and instruments for the evaluation of the Institutional Benchmark in Health Care and in every other field of public interventions. In particular we will see the methods for goal optimisation in a problem of resources allocation and the known methods for the definition of goal functions. We can define the Institutional Benchmark in a problem of resources as the ratio between the value obtained of the goal function and the maximum value that could be obtained using the same resources. In resources allocation problems there are n goals that are often conflicting with each other so we have to deal with a multiobjective optimisation. Moreover, the evaluation of the priority of one goal over another must be a political decision and must be taken by the political institutions. For this reason we have to speak of non-inferiority rather then optimality. There are different ways to define non-inferiority; we propose the concept of Pareto-optimality adapted to services. We will discuss the advantages that this definition of noninferiority can achieve. We will formulate the multiobjective programming defining the objective functions (utility functions) and the constraint functions. The hardest part of the work is to express the objective functions in terms of resources, that is, to define the functional link between the resources used and the objective achieved. We will spend part of this work presenting the available methods to generate the utility functions automatically from historical data and we will see advantages and disadvantages of each method. Once defined the multiobjective programming problem, we will recall the known methods available for solving it, in particular we will present the weights method and the constraints method. The utility functions will be in a non-analytical form so we will discuss briefly about methods dealing with this kind of functions. In particular we will see the advantages of genetic algorithms. We will conclude our work with a critical evaluation on an application in the local health care field, presenting our conclusions and suggesting future work.

First, we briefly discuss different approaches for inpatient reimbursement systems. Then, we outline the way from the old per diem payment system in Austria to the new performance-oriented reimbursement strategy called performance-oriented hospital financing (abb. LKF) with limited budget. The LKF-system is split into two main parts: the national core part and the regulation part defined by each federal state. Whereas the core part generally contains the reimbursement of performances for inpatients, the regulation part takes into account the structure-specific quality criteria of hospitals. Consequently, one and the same performance is differently reimbursed in each federal state and in each hospital. Then, we accurately analyse the underlying formulas for reimbursement for general inpatients derived from our system dynamics model illustrated by a numerical example. We close the paper by summarising the limitations and benefits of the LKF-system.

In this paper a new discrete event simulation model will be proposed for the analysis of patient flows in a hospital. The model has been developed as a part of a project funded by the Italian Ministry of Health and will be used by healthcare managers to study the effect of changes both in the population and in the organisation of the hospitals. One of the main characteristics of the model is the fact that patient flow into the hospital is split into several streams, each characterised by a specific diagnostic code (or DRG).

Operational Research (OR) and health services research are recognised in the academic world and in health care management as valid tools for health needs assessment, services evaluation and problem solving. If any benefits are expected from the application of this type of research to the health care sector, it is important to have a clear definition of the characteristics, potentialities and limitations of the OR. OR is based on the use of mathematical models. It goes through the stages of: definition of the problem, construction of the model, identification of the solution, validation of the model and the solution, implementation and evaluation of the solution The analysis of the methodology used in OR highlights the use of descriptive, analytical, experimental and “quasi-experimental” designs, techniques of economic, statistical, demographic, social and anthropological analysis. These techniques may not be always strictly “operational”. OR turns out to be very useful when the variables determining the issue (or the problem) under study, can be identified and described in their interrelationships and iterations. Studying the problem leads to identifying the solution. As long as OR focuses on problem solving, it will contribute to the improvement of health services management.

I confess I am a little embarrassed because of the simple reason that my experience is a very recent and pragmatic one with a group of OR operators in common action, as you know from the report that was presented in this Congress, about supporting Roman Emergency System in view of the Jubilee 2000…

To be perfectly honest, the invitation that I received to this scientific event, beyond making me feel honoured and genuinely pleased, did cause me some embarrassment.

Due to my qualifications as an expert in the field of health services planning and organisation and also to my current role as director of a regional health executive (Agenzia Sanitaria Regionale dell'Assessorato alia Sanità dell'Emilia Romagna), which is responsible for the diffusion of preliminary information and data for the implementation of health care policy processes, I was asked to develop and convey some ideas about what we can expect from activities in the field of Operational Research (OR). I was asked to talk about those aspects that may be useful and appropriate in supporting decisionmaking especially with regards to the allocation of resources…

The following sections are included:

• Introduction

• Definitions and links

• Concluding comment

• References

1. Professor Zanetti said that OR is not well known in Italy: that it was regarded as a “closed circle”, and that it was difficult to convince clinical clients of the benefits they might gain from using OR. This is a European wide experience - that change is difficult. Communication and open minds are the basis of these ORAHS meetings, as we believe that no change is possible without engaging minds in the presence of evidence. Unfortunately, stereotypes of the scientist in the white coat, with a computer under their arm, speaking in specialist terms endure, and remain valid in some individual cases. This description might apply to a doctor as much to an operations researcher! The essential issue is that these weird people need to share their knowledge and their information for managed beneficial change to occur. OR provides some tools and some skills to enable multidisciplinary groups of health services professionals work together. The “closed circles” need to open for us all to benefit…

The following sections are included:

• ADDRESSES