This paper is based on the keynote address given by the paper's first author at EURO 2021. We draw on our experience over more than three decades to define the critical challenges of healthcare implementation. We do not address issues pertaining to technical quality of a solution. Rather, we focus on five general characteristics of the problem that should be carefully considered for any healthcare project that requires implementation. The problem needs an internal Champion; there should be a current Critical Issue; one must understand and adapt to the Cultural dynamics of the organization; appropriate Data exists; and we need to manage Expectations. We illustrate each with examples of our successes, failures, and mixed results. Finally, we summarize what short and long-term steps we believe the operational research community can take that will lead to improvement in each of these areas.
Healthcare offers many opportunities for improvement through operational research. However, while there is a great deal of literature on operational research (OR) applied to healthcare including multiple reviews over the years (Klein et al., 1993; Wilson, 1981; Smith-Daniels et al., 1988; Arisha & Rashwan, 2016; Bhattacharjee & Ray, 2014; Brailsford & Vissers, 2011; Brailsford, Harper, Patel & Pitt, 2009; Davahli et al., 2020; Fakhimi & Probert, 2013; Fone et al., 2003; Gunal & Pidd, 2010, Vanberkel et al., 2010; Hulshof et al., 2012; Jun et al., 1999; Katsaliaki & Mustafee, 2011; Mielczarek & Uziałko-Mydlikowska, 2012; Rais & Viana, 2011; Roy et al., 2021; Zhang, 2018), there is also a shared and consistent concern that evidence of successful, impactful implementation is lacking (Bowers et al., 2012; Brailsford, 2007; Brailsford & Vissers, 2011; Brailsford, Harper et al., 2009, 2013; Eldabi, 2009; Fone et al., 2003; Forsberg et al., 2011; Jahangirian et al., 2012; Jun et al., 1999; Katsaliaki & Mustafee, 2011; Lagergren, 1998; Lame et al., 2020; Naseer et al., 2009; Wilson, 1981) even as the volume of published work increases (Davahli et al., 2020; Fakhimi & Probert, 2013; Gunal & Pidd, 2010; Katsaliaki & Mustafee, 2011; Roy et al., 2021). Operational research literature in healthcare is often either intentionally theoretical (Brailsford, Bolt, Connell, Klein & Patel, 2009; Eldabi, 2009) or, if grounded in a practical problem, lacks documentation on the implementation and final impact (Brailsford, Bolt et al., 2009; Fone et al., 2003; Katsaliaki & Mustafee, 2011; van Lent et al., 2012). In addition, most literature describes small, local, incremental operational improvements, rather than systemic, strategic, or tactical level changes (Brailsford, 2007; Gunal & Pidd, 2010; Jun et al., 1999; Vanberkel et al., 2010).
7. Discussion and conclusion
We have outlined the five key areas we believe, based on our experience, are fundamental to successful implementation of operational research models in healthcare: an internal champion, a critical issue, healthcare cultural insight, Data quality, and expectations management.
It is instructive, as a simple case study, to consider each of these areas with respect to the Covid-19 pandemic. We clearly have a crisis, and there are plenty of champions (and funding sources). However, there is essentially no data from previous epidemics, the culture has experts in every domain arguing their position at length with very little consensus, and public expectations of the modeling efforts are unrealistic. The models that are shown regularly are typically based on SEIR models with relatively simple assumptions. OR has not taken a lead role.
While we have examined each of these five key elements independently it is clear there is significant cross-over between them as well. For example, a strong champion inside the organization can galvanize resources to find or collect better quality data, can ensure expectations are aligned, manage internal power struggles, bring in operational research teams early to tackle a critical issue, and keep focus on a project over the long-term even if the urgency fades. Likewise, robust data sources can make it easier to meet short timelines required for critical issues, convince people that the model works as intended, while helping to build future champions. A thorough understanding of, or immersion in, the healthcare culture by the operational research team can help to avoid miscommunications and misalignment of expectations, understand the priorities of each stakeholder in the organization and better understand the context in which the data being used is collected. Designing and creating models that are transparent and accessible to decision makers will not only help with managing expectations but will also help to integrate modeling into the healthcare culture, create awareness for the necessity for reliable patient flow data, and increase the number of potential champions. Therefore, as well as being individually important, there is also clearly synergy between each of these five elements. Being able to excel in one of these five areas can make it easier to excel in or mitigate issues in the other areas