Operation research

OPERATIONS
RESEASRCH
“the science of better”
Dr. Mounica C
Guide: Dr Babitha Rajan

Contents
1. Introduction
2. History
3. Operations research (OR) in the field of health
4. Terminologies
5. How does OR differ from other types of Research?
6. Features of operations research
7. Operations Research process
8. Scientific methods in operations research
9. Applications of operations research
8/10/2018 Operations research
2

Contents Cont…
10. Benefits of OR
11. Techniques in operations research
12. Challenges of OR
13. Critical Review of OR in Public Health
14. How to measure the success of OR?
15. Conclusion
16. References
17. Exercise on OR
3

Introduction
4
• One of the popular managerial decision science tools
• Application of quantitative mathematical methods & logic to
find solutions to managerial problems
• Concerned with means of dealing with:
o Resource constraints
o Assignment and maximisation of values &
o Appraisal of alternatives in an uncertain, dynamic
environment

History ‘war baby’
5
• The Battle of Britain- 1940 (World War II)
• Gave effective assistance in missions - deploying radar,
searching for enemy submarines, and getting supplies
In India
• OR came into existence in 1949-OR unit was established at
Regional Research Laboratory, Hyderabad
• Prof. R.S.Verma - Defence Science Laboratory
• Prof. Mahalanobis - used OR in national planning

OR in the field of health
6
• Provides decision-makers with information to enable them to
improve performance of their programs
• Helps to identify solutions to problems that limit program
quality, efficiency and effectiveness, or to determine which
alternative service delivery strategy would yield the best
outcomes
• “the science of better”

OR in the field of health Cont…
7
• Seeks to improve number and quality of services and
program outcomes by optimizing program inputs (e.g.,
personnel, supplies) and processes (e.g., training, supervision,
and promotion of services)
• Determine cost-effective and sustainable ways to build
service delivery capacity

Terminologies
8
Operation: Set of activities – for desired outcome
Research
WHO (2003) defines OR as
“the use of systematic research techniques for program
decision-making to achieve a specific outcome”

Terminologies Cont…
9
A global meeting held in Geneva in 2008 resulted in a
consensus definition of OR in context of public health as
“Any research producing practically usable knowledge
(evidence, findings, information, etc) which can improve
program implementation (e.g. effectiveness, efficiency,
quality, access, scale up, sustainability) regardless of the type
of research (design, methodology, approach) falls within the
boundaries of OR”

How does OR differ from other
types of Research?
10
Basic
Reserach
Not
implement
ed in to
practice
Focusing
on an
individual
Routinely
collected
data can
be used
Deals
general
health
issues
Research
under
controlled
conditions
May be
only
researcher
/s involved

How does OR differ from other
types of Research?
11
OR
Examines a
system
Systematic
data
collection
Treating
the system
in its real
environme
ntCollaboration
b/w
researchers &
program
managers
Deals with
specific
health
issues
Successful
when results
implemented

Features of OR
12
Decision making
Scientific approach
Objective
Inter-disciplinary team approach
Digital computer

The OR Process
13
Defining the problem
Developing a model
Acquiring input data
Developing a solution
Testing the solution
Analyzing the results
Implementing the results

Scientific methods in OR: Phases
14
• Identification of problem
• Selection of appropriate goal
• Measurement
• Formulation of model
Judgement
phase
• Observation & Data collection
• Formulation of hypothesis
• Experimentation
• Analysis
• Generalisation
Research
phase
• Recommendations for decision
Action
phase

Applications of OR
15
OR
Finance,
Budgeting
&
Investment
Marketing
Physical
distribution
Purchasing,
Procurement
&
Exploration
Personnel
Production
Research
&
Developme
nt

Applications in hospital management
16
• Allocation problems
• Replacement problems
• Sequencing problems
• Placing jobs or activities in certain order
• Finding optimal route
• Inventory problems
• Quantum of holding or storing resources in the inventory
• Queuing problems
• Waiting line problems for service utilisation
• Searching information for decision making

Benefits of OR
17
Ability to deal in a
quantitative manner
with conditions of
uncertainty
Use of objective
methods to sort out in
complex situations
Capacity to illustrate
the likely outcomes of
alternative courses
Assist managers in
understanding many
inter-related factors
Provision of various
logical approaches to
make decisions
Ability to handle
masses of data with
help of computer

Management Techniques/ Methods in OR
A. Statistical techniques
1. Time trends & forecasting
2. Decision theory & tree
B. Activity analysis
1. Time motion studies
2. Work sampling & activity
analysis
3. Queuing theory
4. Gantt chart & work schedule
C. Mathematical techniques
1. Simulation study/models
2. System analysis
3. Linear programming
4. Inventory control
5. Network analysis - PERT &
CPM
D. Financial techniques
1. Monitoring expenditure
2. Cost accounting & analysis
3. DALY
4. Cost benefit analysis
5. Cost effectiveness analysis
6. Zero base budgeting
7. Input output analysis
8. Outcome budget
E. Miscellaneous
1. Management by exception
2. Situational analysis
3. Current state assessment
4. SWOT analysis
5. Log frame analysis
8/10/2018 Operations research 18

Time trends & forecasting
19
• Data gathered on a given characteristic over a period of time
at regular intervals
• Predictions can be made about expected occurrence, by using
mathematical methods
• If incidence of a disease exceeds expectation by certain limits,
epidemic can be anticipated, detected at the earliest and
appropriate steps taken for control

Time trends & forecasting Cont…
20
• Forecasting is defined as the science of predicting for future
• Forecasting the demand for supplies of materials like
vaccine, drugs etc, can also be similarly anticipated and a state
of preparedness maintained

Situation 1
21
As a medical officer in-charge of the hospital you have
observed that in the past 3 years, many measles cases are
coming to your hospital in the months of January till April
• Method applied: Time trends
Calculate the measles vaccine requirements for one month,
given the population being catered to is 36,000,
CBR=22/1000population and IMR=9/1000 live births
• Method applied: Forecasting

Decision theory & Decision tree
2
• Decision theory is the body of analytical tools, including logic
& mathematical models, using probability theory &
diagrammatic representation for use in decision making
• Decision tree is a diagram which depicts key interactions
among decisions & associated chance events
• The most rational decision can be taken in terms of resource
& the effectiveness

Decision tree for micro invasive cancer of the cervix showing selected
probabilities and possible utility calculations Available from URL:
http://ars.els-cdn.com/content/image/1-s2.0-S0140673601057099-gr1.jpg
23

Decision analysis
24
• Process of making choices from among several alternatives
• Includes many procedures, methods, and tools for identifying,
clearly representing, and formally assessing important
aspects of a decision
• Helps in prescribing a recommended course of action by
applying the maximum expected utility action

Time motion studies
25
• Consists of observing & timing by using stopwatches the
physical work & movements carried out by a worker
• The movements carried out in performance of a task are then
broken into segments, analyzed & redesigned so that task can
be accomplished more efficiently

Situation 2
26
Sisters in the ward always complained that the ward boys
were not available at the time of emergency.
Activities of the ward boy included shifting the patients to
x-ray/ USG department; helping during dressing; handing
over blood & urine samples to lab; collecting reports,
miscellaneous….
• Method applied: Time motion studies

Situation 3
27
In the hospital at reception counter patients arrive at an
interval of 5 minutes & reception desk takes 2 minutes for
servicing each patient. Under these conditions:
How long on an average a patient does wait in the queuing
system?
If the management is of the view that it can allow a waiting
time up to 5 minutes only, how much does the flow of
patients be to justify for opening a second counter in the
reception desk?
• Technique applied: Queuing theory

Queuing theory
28
• Concepts and parameters used in queuing theory
o Waiting time cost & service cost
o Mean arrival time of customers - 
o Mean service rate - 
• In the above scenario: Arrival pattern
o Mean inter arrival time=(1/ mean arrival time)=(1/)=5 mn
o Mean arrival rate per minute = (1/5) = 0.2 patients
o Mean arrival rate per hour = 0.2 x 60 = 12 patients per hour

Queuing theory Cont…
2
• Service pattern
o Mean service time per patient = (1/ Mean service rate) =
(1/) = 2 minutes
o Patients served per minute = (1/2) = 0.5
o Patients served per hour = 0.5 x 60= 30 patients
• Average waiting time of a patient in the queue E(w) = {/ 
(-)}= 12/30 (30-12)= 1/45 =0.22 hour or 1.33 minutes
• To open a second counter- how much should be the patient
inflow?

Queuing theory Cont…
30
• Mean arrival rate of patients E (w) = {’/  (-’)}where ’ -
expected arrival rate
E(w)=average waiting time of a patient in queue=5 min or
(1/12) hr, (1/12) = {’/ 30 (30-’)}
So ’ = arrival rate per hour = 21.43, nearly 3/min
• Hence mean arrival rate should go up to 21 from present 12
or nearly one patient for every 3 minutes, in contrast to one
patient for every 5 minutes, to justify for the setting up of
second counter

Linear Programming
31
• For use with a common management problem – the allocation
of resources in an optimum manner
• Mathematical or graphical technique - used to determine best
use of scarce resources to accomplish a defined objective
• Used when problems have these characteristics:
o mix
o needs an optimum solution
o Constraints
o linear relationship

Situation 4
32
Is it possible to predict number of nursing personnel of each
type needed for each nursing unit based on information
concerning the number and degree of illness of each patient?
• Method applied: Linear Programming
• This can be done immediately before each shift reports for
duty by computerized program matched against current
patient illness characteristics, and assignments of nursing
personnel can thus be made on a predicted patient care need
for next shift rather than just on number of patients on each
unit, or merely based on number of beds in each unit

Network Analysis
33
• Method of presentation of composite activities - diagrammatic
form recording their interdependence of an operation - total
view of situation from start to finish
• Depicts interdependency of activities, by splitting up the total
project into activities & assists in estimation of time for each
activity & enables in target achievement
• Enable better planning & evaluation of proposed schedule
of activities

34
Network Analysis
Critical Path Method (CPM)
Time required for completion of
activity is estimated
This estimation does not involve any
statistical methodology
Program Evaluation &
Review Technique (PERT)
Assumes 3 time estimates for each
activity in terms of optimistic,
pessimistic & most likely time for
completion of activity
Calculated using these 3 times
through statistical average approach
• Enables stricter control on completion of activity in time besides
enabling in estimation of men, money & material for completion
of program in scheduled time
• Depending on the situations, it also helps in modification of time
required for activities

Steps involved in drawing a network
35
List all activities to be performed with well defined end point
Schedule events in sequential order – merge/ burst events
Assess performance time for each event
Put events in sequential chain taking interdependence of events
Converted into graphic line from start to finish along with time
Each chain will have total time of completion - All chains
together form NETWORK
Chain with maximum required time is THE CRITICAL PATH

Situation 5
36
How to set up a laboratory in a hospital?
• Method applied: Network analysis
• CPM & PERT

Respective chains can be drawn as:
37
• A: Placing orders for equipment & furniture
• D: Supply of equipment & furniture
• G: Installation of for equipment &
laboratory
Chain 1
Related to
equipment
• B: Procurement of chemicals & reagents
• E: Stacking of chemicals & reagents
• H: Preparation of protocols for
investigations
Chain 2
Related to
chemicals
& reagents
• C: Advertise for personnel
• F: Recruitment of personnel
• I: Training of personal
Chain 3
Related to
staff

38
Ev
ent
Acti
vity
Description activity Predecesso
r activity
T(e)
(day)
1 A Placing orders for equipment &
furniture
- 3
1 B Procurement of chemicals &
reagents
- 5
1 C Advertise for personnel - 4
2 D Supply of equipment & furniture A 2
3 E Stacking of chemicals & reagents B 3
4 F Recruitment of personnel C 9
5 G Installation of for equipment &
laboratory
D,E 8
6 H Preparation of protocols for
investigations
B 7
7 I Training of personal G,H 9

Network Analysis
39
Critical path, slack time, non critical path, bottleneck/ critical activities,
EST, EFT, LFT, LST, floats

Network Analysis
40
CPM
• Advantages:
• Ascertaining time schedule
• Makes detailed planning
possible
• Identifies most critical
elements
• Limitations:
• May not be a true
assumption in practice
• Does not incorporate
statistical analysis
PERT
• Advantages:
• Ability to plan best possible
use of resources
• Presses for right action, at
right point, & at right time
• Limitations:
• Difficulty in way of time
estimates
• Does not consider resources
required at various stages
• Frequent updating &
revising calculations-costly
affairs

Inventory Control
41
• “Usable but idle resource having an economic value”
• ‘Pareto’s law’ - forms the basis
• Ultimate aim in healthcare setting - to ensure that adequate
and optimal essential items are properly stored, controlled,
are easily retrievable and distributed to points of uses so
that patient care does not suffer due to lack of these
essential medical supplies

Various selective inventory control measures
42
• ABC: Based on annual total cost of items
• VED: Based on criticality and importance of consumables,
items are classified as Vital (V), Essential (E) & Desirable (D)
• HML: Based on cost of individual item as High cost (H),
Medium cost (M) and Low cost (L)
• SDE: Based on ease of availability of items - classified as
Scarce (S), Difficult to obtain (D) and Easy to obtain (E)

Various selective inventory control measures
43
• GOLF: Based on source of supply & include Governmental
sources (G), Ordinary (O), Local (L) & Foreign (F)
• FSN: Based on rate of issue from the stores into Fast- moving
(F), Slow moving (S) & Nonmoving (N) items
• SOS: Based on Seasonal (S) & Off-seasonal (OS) availability
• XYZ: Based on value of stocks of items held

Situation 6
44
Have to indent essential drugs.
How much to indent?
How frequently to indent?
• Method applied: Inventory control
• In a hospital setting, combination of ABC analysis (based on
annual cost) and VED analysis (based on criticality of item)
is to be adopted
• Category I: Contain all the vital and costly items
• Category II: Items that are essential but are less costly
• Category III: Items that are desirable

Gantt chart
45
• Horizontal bar chart developed as a production control tool
in 1917 by Henry L. Gantt
• Provides a graphical illustration of a schedule that helps to
plan, coordinate, and track specific tasks in a project
• Useful tool for analyzing and planning complex projects
• Help to monitor whether the project is on schedule
• Assess how long a project should take, determine resources
needed, & lay out order in which tasks need to be carried out

Situation 7
46
Consider constructing a hospital in your district
• Method applied: Gantt chart

List of activities in
hospital construction project
47
Acti
vity
Description Predece
sors
Duration
(weeks)
A Select administrative and medical staff - 12
B Select site and do site survey - 9
C Select equipment A 10
D Prepare final construction plans B 10
E Bring utilities to the site B 24
F Interview applicants & fill positions in
nursing support staff, maintenance
A 10
G Purchase & take delivery of equipment C 35
H Construct the hospital D 40
I Develop an information system A 15
J Install the equipment E, G, H 4

Gantt chart for
hospital construction project
48

SWOT Analysis
49
• Strengths (S), Weaknesses (W), Opportunities (O) &Threats
(T) are identified in context of proposed program
• S&W - Permanent phenomena that exist within organization
• O&T - Temporary, often fleeting, phenomena that exist in
external environment
S: Powerful
attributes, which it
may possess
W: Actual or
potential liabilities &
weak points
O: Circumstances
conducive to its
flourishing &
growth further
T: Aspects which
may hinder its
growth &
development

Situation 8
50
Proposed programme for prevention & control of HIV in our
country
• Method applied: SWOT Analysis
S: Organizational &
constitutional philosophy
& political will of the
country
W: Common social
tendency not to encourage
talking about sexual health
O: Funds for developing
health educational
material & strongly in
favor of educating public
& high risk groups
T: Some recent resistance
and objection from parents
against sex education of
children

Financial Techniques
51
Cost Accounting/Cost Analysis – tool for measuring the cost of
health services.
• Ex: Unit cost of items like drug consumption/day/patient
• Costing also helps to assess the efficiency & effectiveness of
functions
Cost Benefit Analysis - evaluation method for comparing the
monetary value of all resources consumed (costs) in providing
a program or intervention with the monetary value of the
outcome (benefit) from the program or intervention

Financial Techniques Cont...
52
Cost effectiveness analysis - To determine which program
accomplishes given objective at least cost. Effectiveness is
measured in terms of non-monetary units that describe desired
objective (Lives saved/ disability days avoided/ cases treated)
Zero based budgeting (ZBB) - “Planning & budgeting process
which requires each manager to justify entire budget in detail
from ‘scratch’ (‘zero base’) thereby making it responsibility of
each manager to justify why he should spend any money at all
during budget period”

Challenges of OR
53
• Operate in absence of detailed, systematic research plan, with
clear linkages to programme priorities
• Implementing research studies in absence of a carefully conducted
situation analysis prevents from achieving their desired goals
• Appropriate external sources of support – financial, technical and
research mentoring – must be in place at all stages of planning and
implementation of research. Such resources are insufficient or
absent at some or all stages
• Training in OR methodology is required for both service providers
and academics

Critical Review of OR
in Public Health
54
• Gaining importance in public health programs and
interventions increasingly both nationally and internationally
• Guide program implementation to achieve best results
• Modulates inputs & processes involved & strive to produce
optimal gains in achieving targets & goals
• Identifies problems; often program managers encompass in
operation of public health goods and test the feasible
solutions for them

55
Approaches for OR in Public Health
Secondary data analysis Primary level research
Types of OR studies as defined by the Population Council
Exploratory study Field intervention
Monitoring &
Evaluation
Economic analysis

How to measure the success of OR?
56
• Results & new knowledge must also lead to action, which will
lead to changes in clinical or laboratory practice &
management & if possible, also to changes in policy
• All OR & new knowledge created by research should lead to
& be measured by:
o Publications
o Capacity development of service providers & academic
researchers
o Changes in practice and/or policy

Conclusion
57
• To survive & lead today’s highly competitive & demand
driven market, pressure is on management to make
economical decisions
• One of essential managerial skills is ability to allocate &
utilize resources appropriately in the efforts of achieving
optimal performance efficiently
• Translating outcomes of research into practice will lead to a
better health system in terms of 4 A’s – accessibility,
availability, affordability and acceptability bridging
prevailing inequities & disparities

References
58
1. WHO. Grunde F, Reinke WA. Health practice research and
formalised managerial methods. [serial online] Geneva: WHO;
1973. Available from URL:
http://apps.who.int/iris/bitstream/10665/40852/2/WHO_PHP_51_r
us.pdf
2. Sathe PV. Epidemiology and management for health care for all.
4th ed. Mumbai: Vora publications; 2009. p.173-190.
3. Vani C. Operation research. Seminar notes. Department of
community medicine.
4. Chetana T. Operation research.Seminar notes. Department of
community medicine.
5. Rao.NSN. Operation research techniques in health care
management. Unpublished material
6. Organization & management of hospitals. PGDHHM-03. New
Delhi: Akashdepp publishers;2009.

References Cont...
59
7. Agarwal S, Subramanian K R, Kapoor S. Operations research -
contemporary role in managerial decision making. IJRRAS [serial
online] 2010 May [cited 2017 Jan 2] Available from URL:
http://www.arpapress.com/Volumes/Vol3Issue2/IJRRAS_3_210.pdf
8. WHO. Foreit J, Schmid G. Guide to operational research in
programs supported by the global fund. [serial online] Geneva:
WHO. [cited 2016 Dec 26] Available from URL:
http://www.who.int/hiv/pub/operational/or_guide_gf.pdf
9. Swarup K, Gupta PK, Mohan M. Operations research. 13th ed New
Delhi: Sultan Chand & sons educational publishers; 2007.
10. Gantt chart. [serial online] [cited 2016 Dec 23] Available from
URL:http://www.improhealth.org/fileadmin/Documents/Improvem
ent_Tools/Gantt_Chart.pdf

References Cont...
60
11. WHO. Application of system analysis to health management.
Technical Report Series 596. [serial online] Geneva: WHO. [cited
2017 Jan 3] Available from URL:
http://whqlibdoc.who.int/trs/WHO_TRS_596.pdf
12. Bhalwar R, Vaidya R, Tilak R, Gupta R, Kunte R. Text book of
public health and community medicine. Pune: Department of
Community Medicine Armed Forces Medical College; 2009.
13. W. Durfee and T. Chase (2003), Brief tutorial on Gantt charts,
University of Minnesota
14. Malhotra S, Zodpey SP. Operations research in public health.
Indian Journal of Public Health July-September 2010; 54 (3): 145-
15
15. Korenromp E, Komatsu R, Katz I, Katz I, Xueref S, Low-Beer D.
Operational research on HIV/AIDS, tuberculosis and malaria
control in Global Fund-supported programmes: Round 1-6 grants.
In: Proceedings of the 5th European conference on tropical
medicine and international health, Amsterdam, 24–28 May 2007

References Cont...
61
16. HIV testing, treatment and prevention: generic tools for operational
research. Geneva: World Health Organization; 2009. 11.
17. The framework for operations and implementation research in
health and disease control programmes. Geneva: World Health
Organization; 2008. 20.
18. Trochim WM, Cabrera DA, Milstein B, Gallagher RS, Leischow
SJ. Practical challenges of systems thinking and modeling in public
health. Am J Public Health 2006; 96: 538-46 48.
19. Zachariah R, Harries AD, Ishikawa N, Rieder HL, Bissell K,
Laserson K, et al., et al. Operational research in low-income
countries: what, why, and how? Lancet Infect Dis 2009; 9: 711-7
20. Geoff Royston. Meeting global health challenges through
operational research and management science. Bulletin of the
World Health Organization 2011;89: 683-688.
21. Rama Murthy P. Operations research. 2nd edition. New Delhi: New
Age International Publishers; 2007.

References Cont...
62
22. Rais A, Viana A. Operations Research in Healthcare: a survey.
Intl Trans in Op Res. Jan 2010; 18: 1–31.
23. Boldy, D. Operational Research Applied to Health Services.
New York: St. Martin’s Press; 1981.
24. Brandeau, M., Sainfort, F., Pierskalla, W. Operations
Research and Health Care. A Handbook of Methods and
Applications. Kluwer’s International Series, Dordrecht; 2004.
25. Linda V. Using Operations Research to Reduce Delays for
Healthcare. Tutorials in Operations Research, 2008 INFORM.
26. Guide To Operational Research In Programs Supported By
The Global Fund. WHO.

Exercise: MR Campaign
8/10/2018 Operations research 63
Activity Activity Description Immediate
Predecessor
Te
A Establishment of surveillance --- 2W
B Local epidemiological information --- 2W
C Knowledge of public perceptions --- 2W
D To obtain funds for cold chain --- 4W
E Identification of staff A 3W
F Development of training materials B 4W
G Training staff E, F 3W
H Development of health education material C,B 4W
I Public acceptance H 2W
J Establishment of cold chain D 3W
K Availability of vaccine J 2W
Ending Vaccination programme on G,I,K ---

2

Operation research

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