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1. Introduction

6. Models

## 8. Operations Research In Hospitals

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Ä also known as operational researchÄ is an
interdisciplinary mathematical science that focuses on the
effective use of technology by organizations.

## Operational Research can be considered as being the application of

scientific method by inter-disciplinary teams to problems involving
the control of organized (man - machine) systems so as to provide
solutions which best serve the purposes of the organization as a
whole.
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  III century B.C) :During the II Punic war enemy
boats were set to fire by a catapultÄ and a system of mirrors and
focusing them with the Sun's rays.
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  !  (1503): In the war against Prisa used his
techniques to accomplish bombardmentsÄ construct shipsÄ armored
vehiclesÄ cannonsÄ catapultsÄ and many machines.
'    :Contributed in antisubmarine war by inventing
shields against torpedo for the ships.
'   " ÿ  #"
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maximums and minimums conditioned of certain functions.
' Ô 
\$   Ô  (1941 and 1942): Studied in
independent ways the Transport Problem for first time. For this
solutionÄ they used geometric methods.
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## 'During the Second World War 1Ä000 men and women in

Britain were engaged in operational research.

British Army.

## 'Patrick Blackett worked for Royal aircraft Establishment

during the war: Reduced number of anti-aircraft artillery rounds
needed to shoot the enemy aircraft.
'In 1941 Blackett moved from the RAE to the Navy where his
team at Coastal Command's Operational Research Section (CC-
ORS) included two future Nobel prize winners and many other
people who went on to be preeminent in their fields.
Britain introduced the convoy system to reduce shipping losses
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## With expanded techniques and growing awareness of the

field at the close of the warÄ operational research was no
longer limited to only operational but was extended to
encompass equipment procurementÄ trainingÄ logistics and
infrastructure.
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## ë Inter-disciplinary team approach

ë Systems approach
ë Helpful in improving the quality of solution
ë Scientific method
ë Goal oriented optimum solution
ë Use of models
ë Require willing executives
ë Reduces complexity
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'The model is a collection of logical and mathematical
relationships that represents aspects of the situation under
study.

## 'Models describe important relationships between variablesÄ

include an objective function with which alternative solutions
are evaluatedÄ and constraints that restrict solutions to feasible
values.

## 'A model is always an abstraction that is of necessity simpler

than the real situation.

## 'Models must be both tractableÄ capable of being solved and

validÄ representative of the original situation
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## Î ÿinear programming is a widely used model type that can solve

decision problems with many thousands of variables.
Î For a linear program the objective function and constraints are
required to be linearly related to the variables of the problem.

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åThere are many problems that might be posed regarding the PQ
situation.
åA linear expression of the amounts produced by the objective of
maximize profit.
åThe constraints specify that the amounts of time required on
each machine must not exceed the amount available. The amount
of time required of a machine is a linear function of the
production amounts.
åFinallyÄ we require that the amounts manufactured not exceed
the demand determined by the markets for the products

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åThe type of problem most often identified with the application
of linear program is the problem of distributing scarce resources
among alternative activities.
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åConsider a bus company scheduling drivers for its buses. The
requirement for buses varies from hour to hour because of
customer demand.
åThe problem is to determine how many drivers to schedule at
each starting time to cover the requirements for buses.
åOne feasible solution to this problem is to schedule 8 drivers at
a time this solution will cover all the requirements and use a total
of 30 drivers. The problem is to find the smallest number of
drivers.
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åAnother classic problem that can be modelled as a linear
program concerns blending or mixing ingredients to obtain a
product with certain characteristics or properties.
åThe problem is to find the composition of the feed mix that
satisfies these constraints while minimizing cost|

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åThe aggregate planning problem is interesting not only because
it represents an important application of linear programmingÄ but
because it also illustrates how multi period planning problems are
approached. For this model we use subscripted variables and
summations to simplify the model presentation. This is often
useful for multi period problems and for other problems that have
repetitive aspects.
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'The term network flow program describes a type of model that is
a special case of the more general linear program.

## åthe transportation problemÄ

åthe assignment problemÄ
åthe shortest path problemÄ
åthe maximum flow problemÄ
åthe pure minimum cost flow problemÄ and
åthe generalized minimum cost flow problem.
'It is an important class because many aspects of actual
situations are readily recognized as networks and the
representation of the model is much more compact than the
general linear program.

## 'When a situation can be entirely modelled as a networkÄ very

efficient algorithms exist for the solution of the optimization
problemÄ many times more efficient than linear programming in
the utilization of computer time and space resources
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'Integer programming is concerned with optimization problems
in which some of the variables are required to take on discrete
values. Only predetermined discrete values within the range are
permitted. In most casesÄ these values are the integersÄ giving rise
to the name of this class of models.

## 'They involve binary decisions such as yes-noÄ build-no build or

invest-not invest.

## 'Integer programming requires such a variable to be either 0 or 1Ä

but not in-between.
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'When expressions defining the objective function or constraints
of an optimization model are not linearÄ one has a nonlinear
programming model.
'The appeal of nonlinear programming (NÿP) is strong because
of the modelling richness it affords.
'UnfortunatelyÄ NÿP solvers have not yet achieved the same level
of performance and reliability associated with ÿP solvers.
'For all but the most structured problemsÄ the solution obtained
from an NÿP solver may not be globally optimal.
'This argues for caution. Before taking any actionÄ the decision
maker should have a full understanding of the nonlinearities
governing the system under study.
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'The word dynamic describes situations that occur over time and
programming is a synonym for planningÄ the original definition of
dynamic programming was "planning over time.³
'It is put to the best advantage when the decision set is bounded
and discreteÄ and the objective function is nonlinear.
'This section is primarily concerned with modelling of
deterministicÄ discrete systems.
'Modelling requires definitions of states and decisionsÄ as well as
the specification of a measure of effectiveness.
'To model with dynamic programmingÄ an abstraction or
reduction of complexity from the real world problem is necessary.
'There are two reasons for thisÄ one practical and the other
computational.
'Dynamic programming has been described as the most general
of the optimization approaches because conceivably it can solve
the broadest class of problems.

## 'Certain problemsÄ howeverÄ are particularly adaptable to the

model structure and lend themselves to efficient computational
procedures; in cases involving discontinuous functions or discrete
variablesÄ dynamic programming may be the only practical
solution methodology.
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'Stochastic programming explicitly recognizes uncertainty by
using random variables for some aspects of the problem.
' With probability distributions assigned to the random variablesÄ
an expression can be written for the expected value of the objective
to be optimized.
'Then a variety of computational methods can be used to
maximize or minimize the expected value.
'The mathematical programming modelsÄ such as linear
programmingÄ network flow programming and integer
programming generally neglect the effects of uncertainty and
assume that the results of decisions are predictable and
deterministic.
' This abstraction of reality allows large and complex decision
problems to be modelled and solved using powerful computational
methods.
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' The most general type of optimization problem applicable to
spreadsheet models is this.
' Spreadsheet models contain variables which are often
changed in an unstructured way to obtain the greatest or the
least of the measures.
' Combinatorial optimization provides tools for automating the
search for good solutions and is very useful for spreadsheet.
' Combinatorial optimization finds the member of the set that
optimizes an objective function.
' For ORÄ combinatorial optimization has come to mean
methods for finding or searching for the optimum of problems
with discrete solution spaces.
'
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:
o Minimal spanning tree.
o Shortest path tree.
o Traveling salesman.
o Quadratic assignment.
o Job sequencing.
o Vehicle routine problem.

## ' Mathematical programs for integerÄ network flowÄ

transportation and assignment optimization are COP's.

## ' The nonlinear program is a COP considering the problem of

finding the global optimum among multiple local optima.
' Models are constructed and solution methods are implemented
in the i and  
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## ' The i add-in is the most general and provides

solutions for several classes of problems.

## ' The  

   add-in takes advantage of features of
special case problems to provide faster solutions.

## ' Several application add-ins on

this siteÄ such as ( 
 Ä use COP solution methods to search for the best
solution.
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' When aspects of a process whose attributes may change over
a period of time and can be explained by probability theoryÄ
we have a stochastic process.
' The first step in modelling a dynamic process is to define the
set of states over which it can range and to characterize the
mechanisms that govern its transitions.
' It is an abstraction of reality that describes the attributes of the
system of interest.
' Using this informationÄ our goal is to predict the future
behaviour of the system in terms of a basic a set of attributes.
' From a modelling point of viewÄ state and time can be treated
as either continuous or discrete.
' To obtain computational tractability we assume that the
stochastic process satisfies the ð 
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## ' For the discrete time

system this leads to the Markov Chain
model. For the continuous time system the model is called a
Markov Process.

## ' The model of a stochastic process describes activities that

culminate in events. The events cause a transition from one
state to another.

## ' As activity durations are assumed to be continuous random

variablesÄ events occur in the continuum of time.
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## ' Here we investigate a finite-state stochastic process in which

the defining random variables are observed at discrete points in
time.

## ' When the future probabilistic behavior of the process depends

only on the present state regardless of when the present state is
measuredÄ the resultant model is called a ð   
. When
time is measured in discrete intervals the model is called the
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(DTMC).
'Often they are used to approximate quite complex physical
systemsÄ even when it is clear that the actual behavior of the
system being analyzed may depend on more than just the
present stateÄ or when the number of states is not really finite.

## 'To develop a model of a DTMC we need to define the system

states M and specify the one-step transition matrix . Given this
informationÄ computational procedures are available to answer
questions related to the steady-state behavior of the DTMC.
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## ' A natural extension of a DTMC occurs when time is treated as a

continuous parameter.

## ' In this sectionÄ we consider continuous-timeÄ discrete-state

stochastic processes but limit our attention to the case where the
Markovian property holds; that isÄ the future realization of a system
depends only on the current state and the random events that
proceed from it. This is called a 
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(CTMC).

## 'The Markov property is only satisfied in a continuous-time

stochastic process if all activity durations are exponentially
distributed.
' A primary example is a queuing system is in which customer
arrivals and service times follow an exponential distribution
because it is possible to compute the steady-state probabilities for
such systems.

## 'It is also possible to compute many performance-related statistics

such as the average wait and the average number of customers in
the queue and any critical design and operational questions can be
answered with little computational effort.
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'With simulationÄ the analyst creates a model of a system that
describes some process involving individual entities such as
personsÄ products or messages.
'The components of the model try to reproduceÄ with varying
degrees of accuracyÄ the actual operations of the real components
of the process.
'Mostly the system will have time-varying inputs and time-varying
outputs that are affected by random events.
'The components of the simulation are interconnected and can
often be viewed as a network with complex input-output
relationships.
'The flow of entities through the system is controlled by logic
rules that derive from the operating rules and policies associated
with the process being modelled.
' Within the limitations of the input and output interfacesÄ it can
also be duplicated with a high level of accuracy. Because of this
capacity for detailÄ simulation has become a very popular method
of analysis.

## ' Particularly appealing is its ability to model random variables

with arbitrary probability distributions and systems that have a
variety of interacting random processes.

## 'Reasons which encourage the use of simulation may be:-

Simulation may be the only alternative to provide solutions to the
problem under study. For exampleÄ it is not possible to obtain
transient (time-dependent) solutions for complex queuing models
in closed form or by solving a set of equationsÄ but they are
readily obtained with simulation methods.
'Models to be simulated can represent a real-world process more
realistically because fewer restrictive assumptions are required and
they are intractable.
'Examples include the use of nondeterministic lead times in an
inventory modelÄ non-Poisson arrivals or service times in a queuing
processÄ etc.
'In most casesÄ simulation is less costly than actual
experimentation; in other casesÄ it may be the only reasonable
initial approachÄ as when the system does not yet exist but
theoretical relationships are well-known. For exampleÄ solar energy
thermal collection systems for homes have been tested by
simulation prior to being built to help solve site-specific problems
or to explore new design issues.
'For many dynamic processesÄ simulation provides the only
means for direct and detailed observation within specified time
limits.
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'Simulation is time-consuming and costly compared to many analytic
approaches. For exampleÄ a simulation to estimate optimal reorder
levels and quantities for an inventory problem requires an extensive
search for optimal values of controllable variablesÄ whereas an
analytic solution would not.
'Because it attempts to reproduce significant amounts of detailÄ a
simulation model may require a large programming effortÄ its
accuracy may be difficult to verify.
'Simulation is a tool that requires the enumeration of alternatives to
determine an optimal design.
'Simulation does not yield expected values ratherÄ a simulation run is
like making an observation of a system in the real world and
recording the relevant statistics which themselves are random
variables.
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## ùFinding the problem and alternative courses of action are

discovered in this step.
ùÿengthy and time consuming.
ùThe activities constitute visitsÄ observations etc.
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## ù Thepurpose of this step is to have sufficient input to operate

the model.
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## ù Express the problem into a mathematical model that represents

systemsÄ processes or environment in the form of equationsÄ
relationships or formulas.

## ùThe proposed model may be field tested and modified in order to

work under stated environmental constraints.
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## ù If the model is not behaving properlyÄ updating and

modification is considered at this stage.

## ùResolving the issues involved in the implementation of the

process by using different operation research techniques.
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## ë Operations Research is the discipline of applying quantitative

methods to help make better decisions e.g. simulation and
optimisation.

## ë Operations Research tools can help hospitals improve qualityÄ

reduce costsÄ improve effectiveness and increase efficiency.
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Application 1: Bed allocation by specialties
Problem: Overflow (i.e. patients lodging at another speciality)
of patients in wards.

## Application 2: Outpatient Appointment Scheduling.

Problem: ÿong waiting time at outpatient clinics before
consultation.

## Application 3: Queue design.

Problem: Queue management and design.
Application 4: Health service capacity planning.
Problem: Project infrastructure and manpower demand.

## There are other healthcare areas where Operation Research

techniques will be usefulÄ such as reducing delay in healthcare
deliveryÄ smoothing of elective admissions to reduce peak bed
occupancyÄ and optimal deployment of ambulances.
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