Journal of the Operational Research Society (2002) 53, 387–396 #2002 Operational Research Society Ltd.

td. All rights reserved. 0160-5682/02 $15.00

www.palgrave-journals.com/jors

Analysis via goal programming of the minimum

achievable stay in surgical waiting lists
M Arenas1, A Bilbao1, R Caballero2*, T Gómez2, MV Rodrı́guez1 and F Ruiz2
1
University of Oviedo, Oviedo, Spain; and 2University of Málaga, Málaga, Spain
In this paper, a Goal Programming model is developed in order to study the possibility of decreasing the length of stay on
the waiting list of a hospital that belongs to the Spanish Health Service. First, a problem is solved to determine the
optimal planning for one year, so as to make the maximum waiting time decrease to six months (at present, some
operations have a waiting list of more than a year). Afterwards, two other problems are solved in order to determine the
impact that a further reduction of the waiting time (four months) would have on the requirements of extra resources for
the hospital. The particular problem for the Trauma service is described in detail, but global results are shown and
commented.
Journal of the Operational Research Society 53, 387–396. DOI: 10.1057=palgrave=jors=2601310

Keywords: goal programming; hospitals; health service

Introduction redistributed among the different services. There are two

main ways of reducing the waiting list at a hospital: to
In this paper, a Goal Programming model is developed as an
increase the activity levels at the centre itself, or to redirect
information system in order to plan and manage in an
patients to other health centres.
optimal way the surgical activity demand of a middle-
In order to carry out a thorough study of the model, two
sized hospital of the INSALUD (Spanish National Health
Goal Programming problems, denoted by GP1 and GP2
Service). Both a theoretical analysis and a practical valida-
respectively, have been solved. In GP1, the first goal consists
tion of the model are carried out. The activity program of the
in ensuring that no patient will stay on the waiting list for
hospital is modulated according to the relation between its
more than six months. The second goal is to maintain the
offer, the demand, and the waiting times.
level of the so-called extraordinary interventions (which
The main aim of this application is the optimal activity
refer to both operations in the hospital taking extra time,
planning and management during 1999 in the aforemen-
or referrals to other centres) below certain levels.
tioned hospital. The model is constructed using data from
In GP2, the maximum waiting time is reduced to four
this particular hospital, but it obviously can be extended to
months. After testing that no solutions satisfying this goal
any INSALUD hospital, which has the same functional
exist for the current resources of the hospital, a modified
requirements for the given planning period. Similar
model is built incorporating the operating theatre availability
models can be developed in order to study the possibility
as a goal. This way, the impact of this reduction of the
to satisfy other kind of goals, by introducing a few changes
waiting list is studied. Namely, the additional requirements
in the basic model.
of operating theatres or the additional number of extra-
A linear problem has been formulated using dynamic
ordinary operations are determined.
constraints which describe the monthly evolution of the
All these problems have been solved for all the services of
waiting list for each process and service. The availability
the hospitals, and the results are commented on at the end
of the operating theatres is the strongest functional limita-
of the paper. Nevertheless, for the sake of clarity, only the
tion of the surgical services, given that nowadays many
statement of the problems for one particular service
surgical processes are ambulatory. Moreover, one of the
(Trauma) is shown in full detail.
main limitations of the current system is the fact that
The intermediate linear problems are solved by the
the total available operating theatres’ time cannot be
simplex algorithm, using the computational package
HYPERLINDO. However, the exchange of data between
the decision centre and the analyst is complicated, and the
*Correspondence: R Caballero, Universidad de Málaga, Departamento de model would be useless if this information is not transferred
Economı́a Aplicada (Matemáticas), El Ejido s=n, 29701 Málaga, Spain. in an adequate way.
388 Journal of the Operational Research Society Vol. 53, No. 4
For this reason, a connection support between the avail-
able data at the hospital and the resolution program
described has been developed. The system automatically
generates all the problems that have to be solved, and reports
are generated after solving the problems, which allow any
user to understand the solutions of the problems. The reports
are issued as tables (in the real problem, graphics have also
been used, although they are not shown in this paper), so
that the information given to the hospital decision centre is
easy to handle.
A mathematical programming treatment of the efficiency
concept in Health Care Institutions can be found in Bitran
and Valor-Sabatier.1 Lee2 already applied a Goal Program-
ming formulation to problems in the health care field, and
showed that the flexibility of choosing the priorities of the
model is a special advantage because it permits the decision
maker to make different choices to find the one that repre-
sents the best option under each circumstance. Rodrı́guez
et al3 present a GP model to design the optimal performance
of a surgical service at a local general hospital, taking into
account different kinds of goals. From the point of view of
the Government, Martı́n et al 4 study, via GP, the budget
assignment to the hospitals of a regional health system.
Description and formulation of the model
The main priority with respect to surgical activity for the
1999 planning year is that no patient should stay on the
waiting list for more than six months. Therefore, the hospital
will try to determine the maximum surgical activity level,
taking into account its estimates of incoming patients, as
well as its current resources. This way, the extraordinary
activity will also be determined, that is, the patients that
have to be referred to other centres or operated on in the
hospital using overtime.
Data and variables of the problems
The number of monthly incoming patients has been
estimated using the available activity levels of the two
preceding years and real data have been used for the first
trimester of 1999.
Table 1 Activities and variables corresponding to the Trauma service
Code Name of the process
239 Neoplasia
354 Mononeuritis
715 Osteoarthrosis
717 Interior ligaments of the knee
727 Sinovial/tendon diseases
735 Hallux Valgus
736 Other acquired malformations
The initial planning for the current year does not neces-
sarily have to be respected throughout the whole year.
Reality requires a permanent re-planning process. Thus, it
is necessary to carry out a monthly update, once the activity
reports and the new admissions and exclusions are known.
For this reason, the model has been designed so that the
starting point, or initial value of the state variables, as well
as the corresponding parameters, can be related to this
update at a specific moment of the process. As an example,
it will be assumed in this paper that the update is carried out
at the end of the first trimester, that is, index j which
corresponds to the months that follow the current one,
will range from 4–12.
As has been previously stated, the model developed
handles all the services of the hospital. In order to make a
simpler presentation, a specific service will be considered:
Trauma. The variables considered are grouped in two main
blocks: ordinary activity and extraordinary activity, which
can be carried out on overtime at the hospital or in other
health centres.
The variables are denoted according to the corresponding
service, using its initials (for example, T for Trauma); let us
observe that each variable has a subscript and a superscript.
The subscript denotes the specific activity or process, while
the superscript denotes the month when the operation is
carried out. An X precedes the extraordinary activity vari-
ables. For example, the number of ordinary and extraordin-
ary osteoarthrosis operations which are carried out in May
are denoted by T35 and XT35, respectively.
Table 1 displays the format of the names assigned to each
variable of the model. Other data are also shown, such as the
code number or the average operating theatre time required.
Constraints
The model constraints can be grouped as follows:

state equations

available operating theatre time for the service

inferior limit on the overall ordinary activity

bounds on the extraordinary activity levels.
Variable
Ordinary Extra Time (min)
T01 XT01 87
T02 XT02 79
T03 XT03 164
T04 XT04 118
T05 XT05 75
T06 XT06 85
T07 XT07 129
 M Arenas et al—Minimum achievable stay in surgical waiting lists 389

Using a compact notation when possible, these service due to intern agreements, and cannot be changed at
constraints can be explicitly described as follows. this stage of the process.
The duration of each process, ti (which can be seen in
(a) State equations. Table 1), has been determined using the mean data obtained
½C1 ij LTijþ1 ¼ LTi j þ ATi j  ETi j  XTi j  Ti j ; from the operating theatre reports, plus twenty minutes,
which is the time needed to prepare the theatre for the next
i ¼ 1; . . . ; 7; j ¼ 4; . . . ; 12
operation. Thus, the constraint corresponding to month j
where LTi j denotes the state of the waiting list for process i takes the following form:
at the beginning of month j, ATi j is the estimated number of X
7
admissions for process i during month j and ETi j represents ½C2 j
ti Ti j 4 TQ j
j ¼ 4; . . . ; 12
the estimated number of exclusions without surgical opera- i¼1
tion for process i, each month j. The values of ATi j , ETi j
where the right-hand side, TQ j , is the total operation theatre
and the initial values of the waiting lists are displayed in
available time for the trauma service in month j, and it can
Tables 2–4, respectively.
be found in Table 5. For example, the constraint correspond-
Thus, for example, the dynamic equation that gives the
ing to May is the following:
state of the waiting list for osteoarthrosis operations at the
beginning of September (given that AT38  ET38 ¼ 2Þ is 87T15 þ 79T25 þ 164T35 þ 118T45 þ 75T55 þ 85T65 þ 129T75
LT39  LT38 þ T38 þ XT38 ¼ 2 4 5388

(b) Monthly operation theatre availability. The available
operation theatre times are computed, considering that the
maximum daily activity is six and a half hours, which is
more realistic than assuming that the seven daily available
hours are fully used. Besides, it is assumed that the
operating theatre sessions are previously assigned to each
(c) Lower bound on the global ordinary activity
level. This constraint is formulated as the overall sum of
the ordinary activity along the planning period. The right-
hand side has been fixed to 378 operations, which is the
minimum operation number that was obtained in Rodrı́guez.5
In this study, several efficient solutions (regarding the

Table 2 Expected admissions during the planning period in the Trauma service

Code Variable 4 5 6 7 8 9 10 11 12
239 T01 5 16 12 6 11 12 6 15 9
354 T02 6 4 14 7 4 5 13 22 15
715 T03 12 28 30 16 15 30 25 25 57
717 T04 8 13 11 9 19 35 21 21 20
727 T05 11 14 16 9 16 12 4 13 19
735 T06 18 34 46 32 39 16 35 27 18
736 T07 7 6 4 2 4 4 11 1 6

Table 3 Expected exclusions without operation during the planning period in the Trauma service

Code Variable 4 5 6 7 8 9 10 11 12
239 T01 7 9 6 6 4 4 2 4 9
354 T02 2 1 0 1 1 2 2 2 3
715 T03 7 9 7 7 13 9 12 6 18
717 T04 7 10 13 4 2 7 8 2 4
727 T05 7 8 3 20 4 4 8 3 11
735 T06 15 13 29 24 20 10 11 6 18
736 T07 1 2 1 3 2 2 2 1 2

Table 4 Initial state of the waiting lists in the Trauma service

T01 T02 T03 T04 T05 T06 T07

29 58 97 78 40 118 27
390 Journal of the Operational Research Society Vol. 53, No. 4

maximization of the ordinary activity and the minimization Goals

of the extraordinary activity) were shown to the decision
makers, who chose the most appropriate one. Thus, the
constraint is the following:
X
7 X
12
½C3 Ti j 5 378
i¼1 j¼4
Given that the problem is solved using a Goal Programming
scheme, as will be seen afterwards, the number of extra-
ordinary operation is not minimized. Rather than that, a
target value is set on this number. This fact, together with
the possible existence of multiple solutions of the problem,
makes it necessary to assure a minimum number of ordinary
operations, so as not to waste the resources of the hospital.
(d) Bounds on the extraordinary operations. In all the
services, there exist bounds on the extraordinary activity,
due to contractual and/or technical reasons. In the Trauma
service, the decision makers took into account the foresee-
able cost of the extraordinary operations, and the capacity of
other health centre to carry them out. After that, it was
decided that:

no extraordinary osteoarthrosis operations can be done:
½C4 j XT3j ¼ 0 j ¼ 4; . . . ; 12

there must be at least 21 monthly extraordinary Hallux
Valgus operations, and actually they have been contracted
with the other centres:
½C5 j XT6j 5 21 j ¼ 4; . . . ; 12
No integrality conditions are imposed in the model, given
that the estimated times per process are average times, and,
thus, just an approximated planning is required.
As has been previously stated, two problems have been
solved, which have been denoted by GP1 and GP2,
respectively.
In problem GP1, the goals are to reduce to six months the
maximum stay on the waiting lists, and to limit the number
of extraordinary operations. Thus, these goals are divided
into two priority levels. The first level contains the waiting
list goal, while the extraordinary activity limitation is in the
second level.
Next, let us build the equations that reduce the maximum
stay on the waiting list to six months. To this end, it must be
assumed that the sum of the ordinary and extraordinary
operations performed between April 1999 and the jth month
must be greater than the number of patients that would be on
the waiting list for six months or longer for each process i in
month j:
X
j
 
Tik þ XTik 5 sij
k¼4
The meaning of these equations is setting a lower bound
on the global activity level of each process, so as to
accomplish the maximum stay requirements. These lower
bounds must be fixed for each process and month.
The right-hand parameters per process, which are
displayed in Table 6, have been determined taking into
account the data of Tables 2, 3 and 4, as well as the time
of stay in the waiting list of the patients at the beginning of
the planning period. Therefore, the formulation of these
goals is the following:
X
j
 
½G1ij Tik þ XTik þ nij  pij ¼ sij
k¼4
i ¼ 1; . . . ; 7; j ¼ 4; . . . ; 12

Table 5 Operating theatre minutes assigned to the Trauma service

Apr May Jun Jul Aug Sep Oct Nov Dec

4449 5388 6114 4449 4021 4828 5388 5388 4894

Table 6 Parameters sij corresponding to Trauma

Code Variable 4 5 6 7 8 9 10 11 12
239 T01 1 4 9 14 22 26 27 34 40
354 T02 9 18 29 34 43 58 62 66 80
715 T03 5 13 36 54 77 97 102 121 144
717 T04 9 18 30 41 57 78 79 85 89
727 T05 1 5 7 16 26 40 44 50 62
735 T06 3 17 34 53 92 118 121 136 153
736 T07 1 2 6 9 18 27 33 37 40
 M Arenas et al—Minimum achievable stay in surgical waiting lists 391

where nij and pij are the corresponding negative and positive Anyway, the setting of target values is always a complex
deviation variables, respectively. Thus, for example, the goal process, and, of course, the GP model itself is not affected
which states that at least all these osteoarthrosis patients by this particular value, although the final solution would be
who have been on the waiting list at the end of August for different. Thus, denoting the negative and positive deviation
six months should have been operated by the end of this variables by xn and xp, respectively, the second goal takes
month is the form:
T34 þ XT34 þ T35 þ XT35 þ T36 þ XT36 þ T37 þ XT37 7 X
X 12  
þ T38 þ XT38 þ n83  p83 ¼ 77 ½G2 a j XTi j þ xn  xp ¼ 1582
i¼1 j¼4
This way, 63 goals are considered, that is, one per process
and month. The achievement function corresponding to the where the positive deviation variable is the non-desired one:
first priority level is the sum of the corresponding negative
deviation variables: h2 ðn; pÞ ¼ xp:
7 X
X 12
h1 ðn; pÞ ¼ ni j Obviously, any other cost-decreasing cost structure can be
i¼1 j¼4
used for this goal in order to achieve the above-mentioned
The second goal, as previously mentioned, sets a limita- purpose. In this case, the study would have to be carried out
tion on the total extraordinary activity. Due to its functional again, in order to set the target value, which depends on the
design, the program used to solve the linear problems, values of a j .
HYPERLINDO, tends to assign the maximum possible In problem GP2, an attempt is made to reduce the stay in
values to the initial variables. For this reason, a cost is the waiting lists to a maximum of four months. That means
assigned to each extraordinary activity variable, which is that the target values of the goals placed on the first priority
decreasing in time, so that the final solution does not level change, in order to assure a maximum stay of four
accumulate all the extra activity at the beginning of the months instead of six. These new target values (which are
planning period. This way, the activity is carried out at a obtained in the same way that sij ) are denoted by s ij (see
higher cost only if it is necessary in order to accomplish the Table 7), the formulation of the goals is
waiting list requirements.
The function corresponding to this goal is the following: h ij X
j
 
G1 Tik þ XTik þ nij  pij ¼ sij i ¼ 1; . . . ; 7;
X
7 X
12 
j
i
k¼4
j
a XTi
j ¼ 4; . . . ; 12
i¼1 j¼4

Namely, the condition a j þ j ¼ 14 is imposed, where a j is and the corresponding achievement function remains
the cost assigned to month j, independent of the service and unchanged.
process. This condition implies that such cost decreases as In this problem the hard constraint corresponding to the
the months pass, and therefore the extraordinary activity is monthly operation theatre availability is removed, and it is
done at high cost only when it is strictly necessary. In considered as a goal. Therefore, denoting the negative and
Rodrı́guez,5 a study was carried out in order to determine a positive deviation variables by tn j and tp j respectively, the
set of efficient solutions relative to the objectives of decreas- formulation of this new block of goals is the following:
ing the waiting lists and minimizing the number of extra-
ordinary operations. These results were shown to the X
7  
decision makers when they were asked to give a target ½G3 j ti Ti j þ tn j  tp j ¼ TQ j j ¼ 4; . . . ; 12
value for this second goal, and the value 1582 was chosen. i¼1

Table 7 Parameters sij corresponding to Trauma

Code Variable 4 5 6 7 8 9 10 11 12
239 T01 9 14 22 26 27 34 40 40 44
354 T02 29 34 43 58 62 66 80 86 88
715 T03 36 54 77 97 102 121 144 153 155
717 T04 30 41 57 78 79 85 89 94 110
727 T05 7 16 26 40 44 50 62 62 74
735 T06 34 53 92 118 121 136 153 163 182
736 T07 6 9 18 27 33 37 40 42 44
392 Journal of the Operational Research Society Vol. 53, No. 4

and the corresponding achievement function is the sum of The formulation of problem GP2-l is the following:
the positive deviation variables:
½GP2-1
X
12 8
h3 ðn; pÞ ¼ tp j > lexmin fh1 ðn; pÞ; h2 ðn; pÞ; h3 ðn; pÞg
>
>
j¼4 >
> h ij
>
> j
>
> s:t: ½C1 ; G1 i ¼ 1; . . . ; 7 j ¼ 4; . . . ; 12
>
>
i
i
It should be noted that variables n and p, which appear in >
>
<
the formulation of the achievement functions, denote the ½C4 j ; ½C5 j ; ½G3 j j ¼ 4; . . . ; 12
vectors formed by all the negative and positive deviation >
>
>
> ½C3; ½G2
variables, respectively, corresponding to all the goals of the >
>
>
>
problem. >
> Tji ; XTi j ; nij ; pij ; xn; xp; tn; tp 5 0
>
>
>
:
i ¼ 1; . . . ; 7 j ¼ 4; . . . ; 12
Problems solved
while problem GP2-2 is formulated in the same way, with h2
As has been mentioned before, three different versions of
and h3 in the opposite order.
the described problem have been solved. First, problem GP1
This way. the impact of this reduction of the waiting time
has been considered, whose formulation is the following:
on both the additional requirements of operating theatres
½GP1 and the number of extraordinary operations is studied.
8
>
> lexmin fh1 ðn; pÞ; h2 ðn; pÞg
>
>
>
> Results and conclusions
>
> s:t: ½C1ij ; ½G1ij i ¼ 1; . . . ; 7 j ¼ 4; . . . ; 12
>
>
>
> The solutions obtained for problem GP1 are displayed in
< ½C2 j ; ½C4 j ; ½C5 j j ¼ 4; . . . ; 12
Table 8. Namely, the evolution of the waiting list, and the
>
> ½C3; ½G2 ordinary and extraordinary activity levels are shown. Also,
>
>
>
> Table 9 presents some significant results for the rest of the
>
> Tji ; XTi j ; nij ; pij ; xn; xp 5 0
>
> services.
>
>
: The solution of this problem satisfies all the goals; that
i ¼ 1; . . . ; 7 j ¼ 4; . . . ; 12
is, with an adequate distribution of the ordinary and
As a result, a satisfying solution was obtained. That is, it extraordinary operations, it is possible to accomplish the
is possible, with the currently available resources, to ensure desired levels. In this solution, there is no spare capacity
that the maximum waiting time will not exceed six months, within the service. This can be seen by multiplying,
without having to carry out an excessive number of extra- within each month, the number of ordinary operations
ordinary operations. In the next sections, the results will be of each process (Table 8) by the mean duration of these
commented on in further detail and a full list of them can be operations (Table 1). The results for each month differ
found in Tables 8 to 11. from the total assigned times (Table 5) in just a few
The setting of the maximum stay in the waiting lists is a minutes. Therefore, a redistribution of the resources has
political decision, and thus it can change; logically, it will been achieved, and, as a result, there is an improvement
tend to decrease. This is why the possibility to reduce even of the ordinary activity. On the other hand, there is spare
more the waiting time (not more than four months) has been capacity in other services, as can be seen in Table 9,
considered, in an attempt to analyse the functional require- which would suggest a redistribution of the installed
ments derived from this reduction. As a non-satisfying capacity (especially the operation theatres’ time) in order
solution was obtained with this new target value (four to get a more efficient performance. This fact is shown in
months), a problem, GP2, has been considered, where the Rodrı́guez et al 6 where it was proved that, if it was
constraint corresponding to the available operating theatre possible to reassign the global available operating theatres
time was considered as a goal. With these three goals, two time of the hospital, so that the Trauma service could
problems have been solved, depending on how these goals increase its availability, then the problem would have a
are ordered in priority levels: satisfying solution without having to increase the current
resources. The residual waiting lists of the solution are
Problem GP2-1: Level 1—waiting lists;
lower than the current ones, and the extraordinary activity
Level 2—extraordinary operations;
is kept to the minimum possible values. Namely, there
Level 3—operating theatre times.
are 265 extraordinary operations, out of which 189
Problem GP2-2: Level 1—waiting lists; ( ¼ 9  21) are fixed by the hard constraints imposed by
Level 2—operating theatre times; the decision makers (thus, part of the decision, although
Level 3—extraordinary operations. not part of the goals). The costs of this activity are not
 M Arenas et al—Minimum achievable stay in surgical waiting lists 393

Table 8 Solution of problem GP1

Process 1 Process 2 Process 3 Process 4 Process 5 Process 6 Process 7

Evolution of the waiting list
Apr 23 53 97 70 25 100 32
May 28 47 108 52 23 100 35
Jun 31 36 108 50 36 96 34
Jul 18 42 99 44 20 83 30
Aug 25 45 78 45 29 81 23
Sep 29 33 79 52 32 66 16
Oct 25 22 81 64 24 69 19
Nov 36 42 83 73 28 69 12
Dec 30 54 103 89 24 44 16
Ordinary activity
Apr 4 9 5 9 19 0 1
May 2 9 8 21 8 0 1
Jun 3 25 23 0 0 0 1
Jul 13 0 18 0 5 0 0
Aug 0 0 23 0 3 0 0
Sep 0 15 20 0 5 0 0
Oct 8 22 11 1 4 0 6
Nov 0 0 17 10 6 0 7
Dec 6 0 19 0 12 4 0
Extraordinary activity
Apr 0 0 0 0 0 21 0
May 0 0 0 0 0 21 0
Jun 0 0 0 0 0 21 3
Jul 0 0 0 11 0 21 3
Aug 0 0 0 16 0 21 9
Sep 4 0 0 21 0 21 9
Oct 0 0 0 0 0 21 0
Nov 0 0 0 0 0 21 0
Dec 0 0 0 0 0 21 0
Goals
Level 1 (Maximum stay on the waiting list) Level 2 (Extraordinary activity)
Satisfying Satisfying

Table 9 Free operating theatres’ time and total extraordinary activity for all the services in problem GP1

Service Unused operating theatres’ time Total extraordinary activity

General surgery 14 212 0
Gynecology 0 32
Ophthalmology 16 082 0
Otorrino 0 119
Urology 13 701 0
Trauma 
available so far, but politically speaking, it is necessary to
carry it out, almost at any cost.
In the second problem, an attempt is made to make the
length of stay in the waiting list decrease to a maximum of
four months. Logically, this new target value requires an
increase of the global activity of the service.
In its first formulation, GP2-1, the goal corresponding to
the extraordinary activity is assigned to the second priority
level, with the same target value that was set in GP1. In the
0 265
third priority level, the current operation theatre availability
is required to stay at the same level that was set in the
constraints of problem GP1. That is, the impact of the
reduction of the waiting lists on the extra requirements of
operating theatres is studied. The solution of the problem,
which is shown in Table 10, does satisfy all the goals.
In this solution, it can be observed that the reduction in
the waiting time is accomplished thanks to a significant
increase of the ordinary activity, while the extraordinary
394 Journal of the Operational Research Society Vol. 53, No. 4

Table 10 Solution of problem GP2-1

Process 1 Process 2 Process 3 Process 4 Process 5 Process 6 Process 7

Evolution of the waiting list
Apr 18 33 66 49 37 87 24
May 20 31 67 41 34 87 28
Jun 14 36 67 13 37 67 22
Jul 14 27 56 7 12 49 12
Aug 20 26 45 23 20 47 4
Sep 21 25 55 45 10 32 3
Oct 19 22 45 58 6 35 3
Nov 30 36 55 50 16 35 1
Dec 26 46 74 66 12 14 3
Ordinary activity
Apr 9 29 36 30 7 13 9
May 5 5 18 11 9 0 0
Jun 12 9 23 0 10 16 0
Jul 0 15 20 0 14 5 0
Aug 1 4 13 1 4 0 9
Sep 7 4 11 6 18 0 0
Oct 6 14 23 0 0 0 0
Nov 0 6 9 27 0 0 2
Dec 4 2 20 0 12 0 2
Extraordinary activity
Apr 0 0 0 0 0 21 0
May 0 0 0 0 0 21 0
Jun 0 0 0 16 0 21 9
Jul 0 0 0 21 0 21 9
Aug 0 0 0 0 0 21 0
Sep 0 0 0 0 0 21 1
Oct 0 0 0 4 0 21 3
Nov 0 0 0 0 0 21 0
Dec 0 0 0 0 0 21 0
Goals
Level 1 (Waiting list) Level 2 (Ext. activity) Level 3 (Operating theatres)
Satisfying Satisfying Non-satisfying:
PT04 ¼ 10 824
PT05 ¼ 367
PT06 ¼ 1523
PT07 ¼ 1491

activity remains at very similar reduced levels to
the solution of GP1. In order to achieve this increase of
the ordinary activity, it would be necessary to increase the
operating theatres’ availability by 30% with respect to the
current situation.
Finally, the same model is considered but with the two last
priority levels in the opposite order (see Table 11). This way,
the impact of the reduction of the waiting lists on the
extraordinary activity is studied. It can be observed that the
goals of the second priority level cannot be achieved. This
means that it would be necessary to increase the operating
theatres’ availability even if the number of extraordinary
operations increased to its maximum. Namely, the extraor-
dinary activity significantly increases (up to 394 operations),
but a 3% increase of the available operating theatre time is
still necessary to reduce the waiting time to the desired level.
This is due to the existence of processes, in this case the
osteoarthrosis (T03) whose extraordinary activity is set to 0,
and so it is necessary to have more operating theatre time
available to increase the ordinary activity.
From a technical point of view, it can be affirmed that
Goal Programming offers a highly valuable analysis tool to
solve decision problems, when the set of possible decisions
is determined by a set of constraints that affect several
simultaneous objectives. It is well known that achieving
such multiple objectives is usually impossible, and thus
Goal Programming establishes the set of satisfying solutions
for given target values.
This fact makes Goal Programming highly suitable for
problems like the one that has been studied. That is, a
problem where the relations among the different variables
and data are complex, and make it difficult for the decision
 M Arenas et al—Minimum achievable stay in surgical waiting lists 395

Table 11 Solution of problem GP2-2

Process 1 Process 2 Process 3 Process 4 Process 5 Process 6 Process 7

Evolution of the waiting list
Apr 18 33 66 49 32 82 27
May 20 31 67 41 34 67 28
Jun 14 36 67 23 37 63 22
Jul 14 27 56 7 12 49 12
Aug 20 26 40 23 20 47 8
Sep 21 25 53 45 10 32 6
Oct 15 22 45 54 6 35 12
Nov 26 36 55 46 16 35 10
Dec 26 46 79 62 2 14 12
Ordinary activity
Apr 0 0 36 0 0 0 0
May 5 5 18 11 4 0 0
Jun 10 9 23 0 10 0 0
Jul 0 0 20 0 14 1 0
Aug 1 4 18 1 4 0 2
Sep 7 4 8 6 18 0 4
Oct 10 14 21 0 0 0 0
Nov 0 6 9 27 0 0 2
Dec 0 2 15 0 26 0 2
Extraordinary activity
Apr 9 29 0 30 12 39 6
May 0 0 0 0 0 36 3
Jun 2 0 0 16 0 21 9
Jul 0 15 0 21 0 21 9
Aug 0 0 0 0 0 21 4
Sep 0 0 0 0 0 21 0
Oct 0 0 0 4 0 21 3
Nov 0 0 0 0 0 21 0
Dec 0 0 0 0 0 21 0
Goals
Level 1 (Waiting list) Level 2 (Operating theatres) Level 3 (Ext. activity)
Satisfying Non-satisfying: —
PT04 ¼ 1455

makers to establish their wishes via a single objective. In our
particular case, it was clear that the reduction of the waiting
list was in conflict with the limitation of the extraordinary
activity.
Given these facts, the decision makers were satisfied with
the methodology, due to its inherent flexibility. This
allowed them to study, through the establishment of differ-
ent target values and/or goals, the impact of determined
policies on some other aspects of the problem. In this
sense, it must be pointed out that Goal Programming, and,
particularly the setting of the goals and their corresponding
target values, is not in practice carried out ‘once and
forever’ (that is, they are not set at the beginning of the
problem, and kept until the end). Quite the contrary they
are the result of an interactive process, where the para-
meters are actualized as the decision makers learn more
about their problem. This is why this study is connected to
the previous one that was carried out in Rodrı́guez,5 where
a complete efficiency analysis of the problem was
performed.
Decision makers also felt satisfied with the possibility to
readapt the model to the reality monthly in such a comfor-
table and quick way. This process lets them keep track of the
real evolution of the waiting list, and to react to possible
unexpected changes in the initial previsions.
Finally, it is important to point out that, during the
elaboration process of this work, some new questions have
arisen. They open new research lines which may allow us to
keep on with this application, enriching the results, in the
frame of other paradigms that explain in a better way the
behaviour of the dynamic system under study. First, it would
be interesting to take costs, whether real or not, into
consideration, because this would allow us to make a
better distinction between the ordinary and extraordinary
activity of each process. Second, if data from several
hospitals were available, it would be possible to carry out
comparative performance and efficiency analyses. Third, it
is possible to study the problem under the framework of
Fuzzy Programming, given that the information available is
not certain, but is not fully probabilistic either.
396 Journal of the Operational Research Society Vol. 53, No. 4
Acknowledgments—The authors wish to thank the anonymous referees for
their helpful comments, which have contributed to improving the quality of
the paper.
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Received April 2000;
accepted October 2001 after two revisions