Joumal of Advanced Nursing, 1977, 2, 92-96
Report of a working group on the use of operational research in European heaith services World Health Organization Sofia, 7-11 July 1975
This report has been prepared by the Regional Office for Europe of the World Health Organization for governments ofMcmkr States in the Region and for those who participated in the working group on the Use of Operational Research in European Health Services. A limited number of copies are available to persons officially or professionally concerned in this field of study from the WHO Regional Office for Europe, Scherfigsvej 8, 2100 Copenhagen o, Denmark. The report is also available in French and Russian.
Introduction The working group. The Regional Office for Europe, in collaboration with the Government of Bulgaria, convened a working group on the use of operational research in European health services in Sofia, from 7-11 July 1975. The purpose of the meeting was to review the application of operational research methods and the results obtained, with a view to providing guidance for their further application in health administration and planning. The meeting was attended by temporary advisers from 11 countries of the European Region (Austria, Belgium, Bulgaria, Czechoslovakia, Finland, France, Netherlands, Romania, Sweden, United Kingdom and the USSR), unpaid temporary advisers (Bulgaria), a consultant, and WHO staff members from the Regional Office for Europe and Headquarters. Where possible, the membership of the working group was biased towards decision-makers and planners in health services, since it is they who can provide the most appropriate guidance for the future development of operational research in public health. The Minister of Health of Bulgaria, Dr A. Todorov, personally welcomed participants to the meeting, emphasizing the need to develop new methods of management as health systems become increasingly complex and subject to evergrowing demands, and noting that operational research might also help to avoid the large costs which could result from administrative mistakes. Background. The working group had been convened because of the rapid growth of operational research and its widening applications to problems in health services. This growth had begun in the 1950s, but had accelerated only 92
Operational research in European health services after 1965, when technical discussions on the subject were held during the World Health Assembly. At the same time WHO began introducing specialists in the operational research field at Headquarters, training WHO regional staff in planning and operational research techniques of use to health administrators, advisers and teachers, and providing briefing on some of the uses and concepts involved in operational research so that a body of knowledge was gradually built up within WHO itself Side by side with this, a similar growth in operational research had occurred in national health services, and a number of studies had become available, mainly on different activities in hospitals. With the development of operational research a number of meetings were held, as individual countries and WHO began feeUng the need to investigate further how this relatively new discipline could be put to use. In addition to some eight earlier meetings on various fields of management which had begun in late 1964, a major seminar on health operational research was held in Bucharest in 1969 and this was followed up by a meeting, held in Copenhagen in 1970, which laid down a number of guidelines concerning training, the need to keep under review the competencies available in the different countries, and the main operational research work being done. Proceedings. To assist the deliberations of the working group, working papers on four case studies had been circulated beforehand, dealing with: (i) the development of a mass screening programme; (2) the care of the elderly; (3) the use of hospital beds and factors influencing hospital costs; and (4) the conceptual basis of a model for the optimization of a regional public health service. The working group examined not only the content of the studies, but also their context including: the influences and pressures leading to them; the factors included in them and reasons for their inclusion; the reasons for selecting a particular model or approach; and the manner of application of the results. A number of additional papers on operational research applications to health service problems were presented and have been summarized in the report. To provide a focus for discussion other working papers had been prepared on: a review of the development of operational research in health services; the relationship between the policy-maker and the operational research scientist; and the role of WHO. The nature of operational research Definition. A large number of definitions of the term 'operational research' have been put forward since it first came to be used some 30 years ago. The definition given in the report of the Bucharest Seminar describes operational research as 'the application of any or all of the disciplines of science to the problems of decisionmaking in organizations or systems. Its nature is: (a) to reach the best decision under uncertainty, (b) to be concemed with the system as a whole'. In discussion of this definition, it was noted that: operational research (i) is centrally concerned with the implementation of change rather than with the production of scientific theories; (2) undertakes studies according to scientific
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standards of measurement, observation, experimentation and validation; (3) is concemed with fields of study involving organized human activity; (4) aims to achieve a decision which is as good as possible, given various constraints; (5) takes into explicit account and explores the uncertainty surrounding decision problems; and (6) tries to deal with all relevant aspects of a decision-problem rather than touch on one particular aspect of it. The working group considered that the definition could be criticized on the grounds that it implies (i) that organizations are not systems; (2) the use of the word 'best', presumably intended to refer to an overall system point of view, butwhich avoids the issue of different interest groups; and (3) that it is impossible to consider the 'system as a whole' since all systems interact with their environment. Despite the limitations, it was agreed that the earlier definition quoted was a suitable basis for the ensuing discussions, provided some clarification of the terminology of operational research was made. Although it might not be possible to agree on the choice of terminology, or even on the definitions of terms, it was to be hoped that definitions could be based on commonly agreed criteria. The operational research team. Thus, operational research is science in the support of management, and is applicable in principle to the problems of decisionmaking in any field, including the health services. Because it makes use of any relevant scientific discipline, it is difficult to draw a sharp boundary between operational research and these disciplines. Depending on the nature of the problem under consideration, the operational research team may or may not need to include persons with various skills, ranging from mathematics, economics, statistics, demography,finance,social science to the health professions: medicine, nursing, etc. The term operational research scientist was used by the working group to refer to a person skilled in the use of the operational research approach, and who would have some knowledge of mathematics, economics, statistics and operational research techniques, while operational research specialist was used to refer to a person whose particular expertise lay in a knowledge of operational research techniques. Apart from such persons, the operational research team could also contain economists, doctors, nurses, etc. It was evident from discussion that no precise demarcation between 'operational research specialist', 'operational research scientist', 'economist' etc. was possible. Likewise, the boundary between operational research and other modern management methods was not clear and a number of participants suggested that consideration be given to holding a symposium to consider all modern management methods together.
Applications of operational research in the health services In order to provide a background for the deliberations of the working group, one of the working papers reviewed the historical development of health operational research. The review covers experience only in the United Kingdom, since it was not possible in the limited time available to describe the large number of applications of operational research to health services in other European countries.
Operational research in European health services
95
Education and training Elements of information on operational research techniques have been included in the series of training programmes in health planning which were initiated by WHO in Europe in 1968 but, owing to the short duration of courses, no very detailed practice in the use of techniques was possible. The discussions of the working group on the subject of education and training were mainly concerned with postgraduate activities. However, the inclusion of material on the operational research approach, including examples of its appplication in health services, was considered important for undergraduate education programmes because of the longer-term consequences. WHO assistance would be important in influencing medical schools and similar institutions as regards the value of incorporating such material. At the postgraduate level, discussions touched on the advantages and disadvantages of providing differentiated rather than generalized courses for studies with differing educational specializations. It was generally agreed that courses of four kinds should be considered: 1 Courses of an informative nature which explain briefly tlie nature of operational research and illustrate various applications to health services. 2 Courses for administrators, planners and professional health personnel who would be the users of the results of an operational research study. 3 Courses for those concerned with policy-making for health services. 4 Speciahst courses for operational research scientists. These would be concemed with developments in the operational research field, including operational research techniques and applications, and in related disciplines. The working group stressed the importance for operational research scientists to have a thorough understanding of the nature and context of health services in order to make an effective contribution. A number of participants expressed the value of mixed courses which included participants from several disciplines or perhaps operational research scientists and health professionals, such as physicians, nurses, social workers, etc. Problem-oriented courses in which a mixed team tackled a real problem were considered to be an effective method of achieving good results.
Conclusions and recommendations General. The working group put forward the following conclusions and recommendations : 1 There is a continuing need for the application of operational research to tactical problems in the health and welfare services. 2 In the five years since the meeting on the use of operational research in health services (Copenhagen, 1970) there has been significant development in the use of operational research at the strategic level in health and welfare services. 3 In the future, this development of strategic application should be further intensified.
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World Health Organization
4 At the strategic level, it may be difficult to draw a clear boundary between operational research and other scientific approaches such as economic or statistical analysis. 5 In order to achieve effective implementation of results, it is important to investigate and take into account not only the structure of decision problems but also the process by which such decisions are reached. 6 To the above end, the operational research scientist needs to be able to make use of social science skills as well as the traditional skills of mathematics, economics, statistics, etc. 7 There is a strong case for advancing the frontiers of operational research to tackle problems which are not clearly structured and lack precise information, but whose solution would provide the most significant benefits. 8 It is important to involve operational research expertise at the formulation stage of a project, particularly when the area of study is diffuse and not clearly structured. 9 In all operational research work in health and welfare problems, it is important to involve professional health personnel and administrators throughout the study. The involvement might be as part of the team itself or by continued liaison during the development of the study. 10 Operational research scientists need to review their terminology in order to clarify it and communicate more effectively v«th health professionals, policymakers, politicians and the layman. 11 Consideration should be given to the development of four types of operational research courses: for the operational research scientist; for the policy-maker; for the administrator; and for the various health professionals. coordinating role. The working group further recommended that WHO should provide coordination and guidance in this field through its Regional Office for Europe and, in doing so, should: 1 develop a terminology for operational research in health and welfare problems, based on clear-cut definitions and common criteria; 2 develop, maintain and make available to interested persons a register of groups competent in health operational research; 3 enlarge its information activity in the field of operational research, in particular by providing a regularly updated annotated bibliography of work in Europe; 4 encourage and support bilateral and multilateral studies on specific applications of operational research; 5 arrange working groups or seminars dealing with specific problem areas which can be tackled by operational research; and 6 continue to support short courses in operational research for the health professions, and encourage the inclusion of operational research in relevant basic and post-basic training for the health professions and other fields such as health planning. WHO'S
Report of a working group on the use of operational research in European heaith services World Health Organization Sofia, 7-11 July 1975
This report has been prepared by the Regional Office for Europe of the World Health Organization for governments ofMcmkr States in the Region and for those who participated in the working group on the Use of Operational Research in European Health Services. A limited number of copies are available to persons officially or professionally concerned in this field of study from the WHO Regional Office for Europe, Scherfigsvej 8, 2100 Copenhagen o, Denmark. The report is also available in French and Russian.
Introduction The working group. The Regional Office for Europe, in collaboration with the Government of Bulgaria, convened a working group on the use of operational research in European health services in Sofia, from 7-11 July 1975. The purpose of the meeting was to review the application of operational research methods and the results obtained, with a view to providing guidance for their further application in health administration and planning. The meeting was attended by temporary advisers from 11 countries of the European Region (Austria, Belgium, Bulgaria, Czechoslovakia, Finland, France, Netherlands, Romania, Sweden, United Kingdom and the USSR), unpaid temporary advisers (Bulgaria), a consultant, and WHO staff members from the Regional Office for Europe and Headquarters. Where possible, the membership of the working group was biased towards decision-makers and planners in health services, since it is they who can provide the most appropriate guidance for the future development of operational research in public health. The Minister of Health of Bulgaria, Dr A. Todorov, personally welcomed participants to the meeting, emphasizing the need to develop new methods of management as health systems become increasingly complex and subject to evergrowing demands, and noting that operational research might also help to avoid the large costs which could result from administrative mistakes. Background. The working group had been convened because of the rapid growth of operational research and its widening applications to problems in health services. This growth had begun in the 1950s, but had accelerated only 92
Operational research in European health services after 1965, when technical discussions on the subject were held during the World Health Assembly. At the same time WHO began introducing specialists in the operational research field at Headquarters, training WHO regional staff in planning and operational research techniques of use to health administrators, advisers and teachers, and providing briefing on some of the uses and concepts involved in operational research so that a body of knowledge was gradually built up within WHO itself Side by side with this, a similar growth in operational research had occurred in national health services, and a number of studies had become available, mainly on different activities in hospitals. With the development of operational research a number of meetings were held, as individual countries and WHO began feeUng the need to investigate further how this relatively new discipline could be put to use. In addition to some eight earlier meetings on various fields of management which had begun in late 1964, a major seminar on health operational research was held in Bucharest in 1969 and this was followed up by a meeting, held in Copenhagen in 1970, which laid down a number of guidelines concerning training, the need to keep under review the competencies available in the different countries, and the main operational research work being done. Proceedings. To assist the deliberations of the working group, working papers on four case studies had been circulated beforehand, dealing with: (i) the development of a mass screening programme; (2) the care of the elderly; (3) the use of hospital beds and factors influencing hospital costs; and (4) the conceptual basis of a model for the optimization of a regional public health service. The working group examined not only the content of the studies, but also their context including: the influences and pressures leading to them; the factors included in them and reasons for their inclusion; the reasons for selecting a particular model or approach; and the manner of application of the results. A number of additional papers on operational research applications to health service problems were presented and have been summarized in the report. To provide a focus for discussion other working papers had been prepared on: a review of the development of operational research in health services; the relationship between the policy-maker and the operational research scientist; and the role of WHO. The nature of operational research Definition. A large number of definitions of the term 'operational research' have been put forward since it first came to be used some 30 years ago. The definition given in the report of the Bucharest Seminar describes operational research as 'the application of any or all of the disciplines of science to the problems of decisionmaking in organizations or systems. Its nature is: (a) to reach the best decision under uncertainty, (b) to be concemed with the system as a whole'. In discussion of this definition, it was noted that: operational research (i) is centrally concerned with the implementation of change rather than with the production of scientific theories; (2) undertakes studies according to scientific
93
94
World Health Organization
standards of measurement, observation, experimentation and validation; (3) is concemed with fields of study involving organized human activity; (4) aims to achieve a decision which is as good as possible, given various constraints; (5) takes into explicit account and explores the uncertainty surrounding decision problems; and (6) tries to deal with all relevant aspects of a decision-problem rather than touch on one particular aspect of it. The working group considered that the definition could be criticized on the grounds that it implies (i) that organizations are not systems; (2) the use of the word 'best', presumably intended to refer to an overall system point of view, butwhich avoids the issue of different interest groups; and (3) that it is impossible to consider the 'system as a whole' since all systems interact with their environment. Despite the limitations, it was agreed that the earlier definition quoted was a suitable basis for the ensuing discussions, provided some clarification of the terminology of operational research was made. Although it might not be possible to agree on the choice of terminology, or even on the definitions of terms, it was to be hoped that definitions could be based on commonly agreed criteria. The operational research team. Thus, operational research is science in the support of management, and is applicable in principle to the problems of decisionmaking in any field, including the health services. Because it makes use of any relevant scientific discipline, it is difficult to draw a sharp boundary between operational research and these disciplines. Depending on the nature of the problem under consideration, the operational research team may or may not need to include persons with various skills, ranging from mathematics, economics, statistics, demography,finance,social science to the health professions: medicine, nursing, etc. The term operational research scientist was used by the working group to refer to a person skilled in the use of the operational research approach, and who would have some knowledge of mathematics, economics, statistics and operational research techniques, while operational research specialist was used to refer to a person whose particular expertise lay in a knowledge of operational research techniques. Apart from such persons, the operational research team could also contain economists, doctors, nurses, etc. It was evident from discussion that no precise demarcation between 'operational research specialist', 'operational research scientist', 'economist' etc. was possible. Likewise, the boundary between operational research and other modern management methods was not clear and a number of participants suggested that consideration be given to holding a symposium to consider all modern management methods together.
Applications of operational research in the health services In order to provide a background for the deliberations of the working group, one of the working papers reviewed the historical development of health operational research. The review covers experience only in the United Kingdom, since it was not possible in the limited time available to describe the large number of applications of operational research to health services in other European countries.
Operational research in European health services
95
Education and training Elements of information on operational research techniques have been included in the series of training programmes in health planning which were initiated by WHO in Europe in 1968 but, owing to the short duration of courses, no very detailed practice in the use of techniques was possible. The discussions of the working group on the subject of education and training were mainly concerned with postgraduate activities. However, the inclusion of material on the operational research approach, including examples of its appplication in health services, was considered important for undergraduate education programmes because of the longer-term consequences. WHO assistance would be important in influencing medical schools and similar institutions as regards the value of incorporating such material. At the postgraduate level, discussions touched on the advantages and disadvantages of providing differentiated rather than generalized courses for studies with differing educational specializations. It was generally agreed that courses of four kinds should be considered: 1 Courses of an informative nature which explain briefly tlie nature of operational research and illustrate various applications to health services. 2 Courses for administrators, planners and professional health personnel who would be the users of the results of an operational research study. 3 Courses for those concerned with policy-making for health services. 4 Speciahst courses for operational research scientists. These would be concemed with developments in the operational research field, including operational research techniques and applications, and in related disciplines. The working group stressed the importance for operational research scientists to have a thorough understanding of the nature and context of health services in order to make an effective contribution. A number of participants expressed the value of mixed courses which included participants from several disciplines or perhaps operational research scientists and health professionals, such as physicians, nurses, social workers, etc. Problem-oriented courses in which a mixed team tackled a real problem were considered to be an effective method of achieving good results.
Conclusions and recommendations General. The working group put forward the following conclusions and recommendations : 1 There is a continuing need for the application of operational research to tactical problems in the health and welfare services. 2 In the five years since the meeting on the use of operational research in health services (Copenhagen, 1970) there has been significant development in the use of operational research at the strategic level in health and welfare services. 3 In the future, this development of strategic application should be further intensified.
96
World Health Organization
4 At the strategic level, it may be difficult to draw a clear boundary between operational research and other scientific approaches such as economic or statistical analysis. 5 In order to achieve effective implementation of results, it is important to investigate and take into account not only the structure of decision problems but also the process by which such decisions are reached. 6 To the above end, the operational research scientist needs to be able to make use of social science skills as well as the traditional skills of mathematics, economics, statistics, etc. 7 There is a strong case for advancing the frontiers of operational research to tackle problems which are not clearly structured and lack precise information, but whose solution would provide the most significant benefits. 8 It is important to involve operational research expertise at the formulation stage of a project, particularly when the area of study is diffuse and not clearly structured. 9 In all operational research work in health and welfare problems, it is important to involve professional health personnel and administrators throughout the study. The involvement might be as part of the team itself or by continued liaison during the development of the study. 10 Operational research scientists need to review their terminology in order to clarify it and communicate more effectively v«th health professionals, policymakers, politicians and the layman. 11 Consideration should be given to the development of four types of operational research courses: for the operational research scientist; for the policy-maker; for the administrator; and for the various health professionals. coordinating role. The working group further recommended that WHO should provide coordination and guidance in this field through its Regional Office for Europe and, in doing so, should: 1 develop a terminology for operational research in health and welfare problems, based on clear-cut definitions and common criteria; 2 develop, maintain and make available to interested persons a register of groups competent in health operational research; 3 enlarge its information activity in the field of operational research, in particular by providing a regularly updated annotated bibliography of work in Europe; 4 encourage and support bilateral and multilateral studies on specific applications of operational research; 5 arrange working groups or seminars dealing with specific problem areas which can be tackled by operational research; and 6 continue to support short courses in operational research for the health professions, and encourage the inclusion of operational research in relevant basic and post-basic training for the health professions and other fields such as health planning. WHO'S
