The effect of self-service kiosks in Dutch hospitals

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The effect of self-service kiosks in Dutch hospitals

Matthijs van der Wielen, BSc.

1

_{Master Medical Informatics, Amsterdam University Medical Centers, location}

AMC, University of Amsterdam

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Master Thesis

The effect of self-service kiosks in Dutch hospitals Author

M.J.L. van der Wielen (Matthijs), BSc.

Department Medical Informatics, University of Amsterdam Meibergdreef 9, 1105 AZ Amsterdam

Supervisor Dr. F. Voorbraak

Department Medical Informatics, University of Amsterdam Meibergdreef 9

1105 AZ Amsterdam Mentor

A. van Eldik (Armand), MSc. Furore Bos en Lommerplein 280 1055 RW Amsterdam SRP Duration: May 2019 – November 2019 SRP Location: Furore Bos en Lommerplein 280 1055 RW Amsterdam 1

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Preface

In front of you lies the Master Thesis: “The effect of self-service kiosks in Dutch hospitals”, the basis on which publicly available information was gathered from two hospitals and kiosk suppliers. This Thesis has been written to fulfill the requirements for completing the Master Medical Informatics at the University of Amsterdam. The research and writing of this Thesis was conducted from May to October 2019.

The research was conducted under the supervision of Furore Informatica, where I performed my scientific research internship. My internship supervisors were very helpful in narrowing the focus and direction of my research. Gathering all the information required to answer my research ques-tions proved to be a tedious and time consuming endeavour. Thankfully my supervisors were there to provide guidance and assistance where needed.

I would like to thank everyone who provided me with guidance and support that allowed me to complete this Thesis. I would sincerely like to thank Armand van Eldik and Frans Voorbraak for providing continuous feedback throughout this scientific research project. Furthermore I would like to thank Jos Vliegenthart for proposing this research direction and providing introductions to the key stakeholders of this research project.

Of course I would like to especially thank my partner in crime Jolien van der Wielen for your inexhaustible positivity and support.

I hope you enjoy reading this.

Sincerely,

Matthijs van der Wielen. October 16, 2019

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Abstract

Introduction: Several Hospitals in the Netherlands have implemented self-service kiosks in their organizations. Suppliers offer these kiosks based on certain promises they make about their func-tions and effects. Hospitals have expectafunc-tions when it comes to the benefits the kiosks will provide. The aim of this study is to determine if the promises and expectations meet reality. For this study two hospitals and two suppliers are studied.

Method: To get a full picture of the promises made by the suppliers, publicly available information and information the suppliers are willing to share is gathered and analyzed. In order to determine the expectations from both hospitals, publicly available information from the hospitals is requested. To study the actual results of the kiosks data is gathered from the hospital and kiosk systems. All the sections are enriched with information gathered from interviews with the self-service kiosk project managers from both hospitals. In addition a case-study on an outpatient clinic in one of the hospitals is performed.

Result: The promises, expectations and outcomes were extracted from the available information. On most aspects the promises and expectations are met by the outcomes. Universal check-in pro-cesses for outpatient clinic patients and live waiting times are realized. There are some points where the expectations aren’t met by the outcomes. Differences are seen in management information and administrative workload decrease.

Discussion: In many cases the expectations of the hospitals have been met by the kiosk suppli-ers. However, slight differences remain when it comes to outcomes and expectations. Both hospital managers indicated that they would have liked to be better prepared for the implementation of the kiosks.

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Samenvatting

Introductie: Verschillende ziekenhuizen in Nederland gebruiken aanmeldzuilen in hun organizaties. De aanmeldzuilen leverancies bieden deze aan met een aantal beloftes over de functies en effecten die de aanmeldzuilen veroorzaken. Ziekenhuizen hebben bepaalde verwachtingen over de voordelen die de aan-mdelzuilen met zich meebrengen. Deze studie onderzoekt of de realiteit overeenkomt met deze beloftes en verwachtingen. Er wordt gekeken naar de aanmeldzuilen in twee ziekenhuizen van twee verschillende leveranciers.

Methode: Om een volledig beeld te krijgen van de beloftes die de leverancies over hun aanmeldzuilen maken, is publiekelijk beschikbare informatie gebruikt. Deze informatie is aangevuld met informatie die de leveranciers bereid waren te delen. Om achter de verwachtingen van de ziekenhuizen te komen zijn zij gevraagd om publiekelijk beschikbare informatie te delen. Om de uitkomsten en effecten van de aan-meldzuilen te bepalen is er data verzameld uit de aanaan-meldzuilen en ziekenhuis systemen en zijn er interviews gedaan met project managers. Aanvullend is er op een polikliniek een case-study uitgevoerd.

Resultaten: De beloftes, verwachtingen en uitkomsten zijn vergaard uit de aangeleverde en beschikbare informatie. De interviews zijn een grote informatiebron gebleken om de uitkomsten van de aanmeldzuilen te bepalen. Op de meeste vlakken komen de beloftes en verwachtingen overeen met de uitkomsten. Er zijn wel enkele aspecten waar de beloftes en verwachtingen niet overeen komen. De grootste verschillen zitten in de verwachtingen over managementinformatie en de administratieve werkdruk verlaging

Discussie: In de meeste gevallen komen de verwachtingen van de ziekenhuizen overeen met de uitkom-sten. Alhoewel, in een aantal gevallen zijn er toch kleine verschillen. Beide project managers van de aanmeldzuilen geven aan dat ze achteraf een betere voorbereiding zouden willen op het implementeren van aanmeldzuilen.

Steekwoorden— Aanmeldzuilen, aanmeldzuilen leveranciers, ziekenhuis verwachtingen, interviews, case-study

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1 Introduction

"Computers make excellent and efficient servants, but I have no wish to serve under them." — Spock (Leonard Nimoy)

Several hospitals in the Netherlands have implemented self-service kiosks [1,2,3], but what are the results of these implementations? This paper will examine the implementation of self-service kiosks in two different hospitals further referred to as Hospital A and Hospital B. This is examined by looking at the promises made by suppliers, expectations from hospitals and results.

1.1 Context

When deciding to implement self-service kiosks, the hospital will have certain expectations that will justify the costs and effort it takes to implement them. Usually the goal of implementing self-service is to provide patients with a service without using human resources [4,5]. The kiosk suppliers promise certain effects and improvements. From a hospital perspective, the implementation of self-service kiosks provides several beneficial effects. The administrator’s workload decreases because the kiosks allow patients to check themselves in at the hospital and outpatient clinic. The kiosks allow the hospital to monitor patient flow** throughout the hospital and available data retrieved from the kiosks provide the hospital indicators to improve patient flow throughout the hospital.

The use of self-service kiosks also provides benefits from a patient’s perspective. The kiosks provide improvements in the logistic process of moving though the hospital and increases patient participation. Self-service technology is a way to get patients more involved in their care process. One of these technologies is self-service kiosks [6]. The kiosks let patients check-in, inform patients about their appointment and lets them answer a short questionnaire [7]. The kiosks increase patient participation providing benefits to the care patients receive and increasing trust in the care provider [8].

The Dutch government is stimulating patient participation by funding research into ways to increase patient participation. Increased patient participation is seen as beneficial to the care patients receive [9,

10]. One way to do this is by using patient portals, these allow patients to review their medical records and in some cases even add to- or alter them [11].

Increased customer involvement and self-service is seen in all sorts of businesses nowadays. Examples of this can be seen in mobile banking applications, self-service checkout at IKEA and supermarkets and self-service check in at airports [12]. These applications require the customer to participate in the service they want.

1.2 Previous research

There is extensive research available about the effects of self-service in airports and hospitality settings. Most of this research suggests that the use of self-service can lead to cost savings [13]. When self-service is implemented with success it can lead to reduced waiting times [13,14]. Use of self-service kiosks can have a positive effect on customer satisfaction [15]. Customer satisfaction is also dependent on the option for an alternative to self-service [16]. When an alternative is offered the feeling of forced self-service decreases [16]. Personal assistance and communications are important factors in order to improve kiosk adoption [12]. Careful preparation is important to prevent adverse effects of kiosk implementation [14].

There is little research available on the effect of self-service kiosks in healthcare. Kiosks have the potential to improve logistics and flexible use of hospital resources, this flexibility will increase patient satisfaction, reduce delays and improve patient flow [6]. In the general practitioners office the use of self-service kiosks resulted in time saving for the GP’s staff, nurses and patients [17]. Research into the effect of self-service check-in in Hospitals in the UK suggest that there is a benefit to be obtained by implementing kiosks if done correctly [18].

There are several blogs and opinion pieces available from people working in the field of Medicine. It is suggested that the kiosks can execute several information checks during patient check-in. These checks have the potential to reduce workload for administrative staff [19]. However there is no evidence found in earlier research. Research on patient flow is found, but these studies did not look at situations where self-service kiosks are used [20,21]. Previous research has some parts in common with this research but none of them can be directly compared.

*A self-service kiosk is a pillar with a touchscreen powered by a small computer [6]. **Patient flow is explained in detail in the background section.

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1.3 Focus of this research

In order to incorporate different facets of the use of self-service kiosks this study will look at three different areas. First, this study focuses on different functionalities and effects as stated by the kiosk suppliers. This gives a better picture of the possibilities of implementing self-service kiosks. This part identifies the different functionalities and possibilities stated by the kiosk suppliers, including future possibilities. Second, this study aims to determine what the hospitals expectations are with regards to implementing self-service kiosks. This part looks at the hospitals motivation for acquiring and investing in self-service kiosks. Third, the effectiveness of the self-service kiosks is researched. By observing patient throughput, performing interviews and data analysis, the situation after kiosks implementation is researched. This determines whether the suppliers claims and the hospitals expectations are met by the result of implementing the kiosks.

The use of Self-Service technology leads to increased customer satisfaction [22]. However, due to the scope of this paper, the benefits for the patients will not be included in this research other than through kiosk data analysis.

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2 Background

2.1 Patient-flow without self-service kiosks

We distinguish two types of patients in the outpatient clinic, new and already registered patients. New patients are patients that visit the hospital for the first time. They receive a letter with necessary in-formation about their appointment prior to their first visit. On arrival at the hospital they first need to complete their registration at the central desk. Thereafter they continue in the same way as already registered patients.

Registered patients receive a letter prior to their visit with information about their scheduled appoint-ment. In the letter, the hospital requests the patient to arrive at the hospital 15 to 30 minutes early depending on the department and hospital. Patients are expected to go to the outpatient clinic directly and check themselves in at the outpatient administrators desk. A simplification is shown in Figure1.

Figure 1: Traditional patient-flow without self-service kiosks.

2.2 Patient-flow with self-service kiosks

When a hospital uses self-service kiosks, patients still receive a letter prior to their visit but with the additional request to check themselves in at the central kiosk prior to their appointment. After the pa-tient scans their identification at the kiosk, the kiosk executes several automated checks. All new papa-tients receive a drop-out ticket that sends them to the central administrators desk to complete their hospital registration. For already registered patients the kiosks performs automated checks regarding insurance and personal information. When their information is correct and all the checks are performed the patient receives a day-ticket. The ticket provides information about the outpatient clinic where they need to go. When any of the automated checks fail, or the identification document is unreadable the patient receives a drop-out ticket sending them to the central administrators desk to update their information.

The only patient related reason for receiving a drop-out ticket is if they refuse to add an identification photo to their EHR. When the patient arrives at the outpatient clinic the patient scans his or her ticket and if no additional information is required prior to treatment the patient is asked to take place in the waiting area. When the patient scans his or her ticket they are checked-in for their appointment and don’t have to report at the administrators desk. If additional information is required they are asked to go to the outpatient clinic’s administrator desk. A simplification of this process is shown in Figure2

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Figure 2: Patient-flow with self-service kiosks.

Patients that only follow the green sections in the flowchart are patients that go through a happy flow. Happy flow consists of patients that only interact with a self-service kiosk before entering the waiting area.

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3 Method

This paper examines three different aspects that play a part in self-service kiosks implementations: 1. To determine the promises made by the suppliers, publicly available information about the features

and functions of two different kiosks suppliers is gathered. Via email both suppliers are asked to provide any additional information they are willing to share for this research.

2. To determine the expectations from the hospital, self-service kiosk project managers from each hospital is asked to provide documentation about the expectations of the hospitals.

3. In order to determine the outcomes, output data from the kiosks and HiX electronic health record (EHR) is gathered.

In order to get more information on all aspects, semi-structured interviews are held with the project managers.

3.1 Self-service kiosk suppliers

To get a full picture of the features and functions promised by the suppliers, publicly available information is used. This information is collected from the websites of Supplier 1 and Supplier 2. Additional information the suppliers are willing to provide is requested through email. Information requested in the email are whitepapers, sales presentations and information folders. It was clearly mentioned that the information they provide is used in this paper.

3.2 Hospital organization expectations

In order to understand the hospitals expectations, publicly available information from the hospitals is requested. The hospitals self-service kiosk project managers are asked to provide information about the public tender and other available documentation. The request was done via email or face-to-face, the goal and intended use of this information was clearly stated in the emails. Additional information is acquired by holding interviews with both project managers, the interviews are held in a semi-structured way in order to accomplish homogeneity [23], more information about the interviews can be found in section 3.3.3.

3.3 Self-service kiosk outcome

To identify and examine the outcomes of the self-service kiosk implementation information already gathered and information acquired from the hospitals is used. Information acquired during the interviews is used to identify outcomes in addition with data analysis performed on data the hospitals is willing to share. During the research internship an opportunity arose to perform a case-study in the Hospital B at the outpatient clinic of operative surgery. The outpatient clinic is about to implement the kiosks in their process. This case-study provides additional information about the effects of implementation of self-service kiosks on an outpatient clinic. Output data from the kiosks and case-study data is used to identify results, this is complemented with information extracted from the interviews.

3.3.1 Data analysis

The self-service kiosks provide output data which is used for management information. Data from the kiosks and management information is requested from the project managers. The management information is used to identify effects of using self-service kiosks.

3.3.2 Case-study

During the study the opportunity presented itself to study the effects of self-service kiosks on a specific outpatient clinic. The outpatient clinic is about to implement the kiosks in their process. A case study is performed to see how the implementation of kiosks affects the outpatient clinic administrators work process. This case-study provides additional information about the effects of implementation of self-service kiosks on an outpatient clinic. To set up the case-study the manager of the operative surgery clinic was asked what their expectations would be with regards to implementation of the kiosks. It was concluded that it would be interesting to see how many and what kinds of interactions take place at the outpatient clinics desk before and after the kiosks were implemented.

The interactions at the administrators desk are measured at three moments. The first moment, the baseline measurement, is taken before the kiosks are implemented. After kiosks implementation two follow-up measurements are performed. The first follow-up measurement is performed 1 week after imple-mentation, the second follow-up measurement is taken 12 weeks after implementation. The two different follow-up measurements are done to identify the effects of the kiosks and if this changes over time. The baseline measurement and the follow-up measurements are performed by a Medical Informatics master

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student. The baseline measurement consists of counting the amount of relevant factors present during consultation hours. The sheet used for counting the relevant factors is seen in AppendixC.

Data generated by the self-service kiosks in the different databases is analyzed to determine what checks are performed by the kiosks and in what quantity. The data will be used to determine if the quality of the registration improves by the use of the kiosks.

3.3.3 Interviews

In addition to the research, the project manager from the Hospital A and B are interviewed. The interviews are performed in a semi-structured way in order to accomplish homogeneity in the output [23]. A list of themes and questions is used to address the same topics in both interviews [24]. The managers will be asked to address their initial expectations, problems encountered during implementation, satisfaction with the end product and any future changes or improvements they would like to see. All these parts of the HOT-fit framework are addressed. The set-up of the semi-structured interviews can be found in Appendix

D. The interviews are recorded and transcribed. The information retrieved from the interviews is added to the different sections of the framework.

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4 Results

The results section exists of three parts:

1. The promises about the features and functions made by the suppliers.

2. The expectations the hospitals have about the outcomes of implementing kiosks. 3. The outcomes identified from data analysis and conducting the interviews.

Two pairs are analyzed, Hospital A acquired the kiosks from Supplier 1 and Hospital B acquired the kiosks from Supplier 2. The results for all three parts are summarized for each pair in Table (1and2).

Table 1: Hospital A with Supplier 1

Sections Aspects Promised Expected Outcome

Features and functions Improved patient registration Yes Yes Yes

Information output

Management information Yes Yes Yes

Patient throughput duration Yes Yes Yes

Live waiting times No** Yes No*

Service quality Staff training Yes Yes Yes

Implementation support Yes Yes Yes

Process changes

Universal check-in procedure No Yes No* Universal outpatient clinic procedure No Yes No* Administrative workload decrease Yes Yes No* Patient satisfaction Increased patient satisfaction Yes Yes Unknown * Not yet, ** Not specified, *** Not fully functional

Table 2: Hospital B with Supplier 2

Sections Aspects Promised Expected Outcome

Features and functions Improved patient registration Yes Yes Yes***

Information output

Management information No Yes No

Patient throughput duration No** No** No

Live waiting times Yes Yes Yes

Service quality Staff training Yes No** Yes

Implementation support Yes No** Yes

Process changes

Universal check-in procedure No** Yes Yes Universal outpatient clinic procedure No** Yes Yes Administrative workload decrease Yes Yes No* Patient satisfaction Increased patient satisfaction Yes Yes Unknown * Not yet, ** Not specified, *** Not fully functional

The tables show for each hospital-supplier pair the promises made by the supplier, the expectations from the hospitals and the outcome of implementation. Every aspect for the suppliers, hospitals and outcomes is explained in the following sections. Every aspect is highlighted to indicate where each aspect is addressed.

4.1 Self-service kiosk suppliers

Both kiosk suppliers were so kind to provide documentation about the possibilities that their product provides for a hospital. The first section will be about Supplier 1. This is a company that delivers full service applications for self-service and hospitality [25]. Supplier 1 is active in several sectors and branches. They provide services for municipality, education and examination, client reception and patient flow management in healthcare. The second supplier is Supplier 2. They have a partnership with Chipsoft and has fully integrated their kiosk in HiX EHR [26]. Both kiosk suppliers deliver a standalone touchscreen pillar with integrated computer.

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4.1.1 Supplier 1

Supplier 1 states on their website that they are convinced that organizations are more successful by digitization and using self-service [25]. This puts the organizations and patients in charge of the service processes [25].

4.1.1.1 Supplier 1 features and functions.

Improved patient registration. The process of patient-kiosk interaction as stated on the website of Hospital A is as follows: Scan ID, check appointment information, print day-ticket, go to outpatient clinic as directed and check-in at outpatient clinic using ticket. On the central kiosks the hospital can add short questionnaires for the patient to answer. The answers of these questionnaires are directly entered in the patient’s ERH. During the patient’s interaction with the central kiosks several checks are automatically performed: check the validity of the provided ID, check if insurance information is correct, check if there is a patient photo added in the patient’s EHR and check if the patient has any appointments. When the patient scans their day-ticket at the outpatient clinic kiosk the patient’s status in HiX is updated to ‘waiting’ indicating that they are present on the clinic. On both the central and the outpatient clinic kiosks there are several features and functions available.

Supplier 1 can be integrated in any EHR, this makes it possible for their system to be integrated in different and even several Health Information Systems (HIS). This provides the hospital with a lot of flexibility when it comes to implementing self-service kiosks in their processes. Individual outpatient clinic kiosks can also be linked to multiple HIS so that different outpatient clinics can have different procedures.

4.1.1.2 Supplier 1 information output.

On the supplier’s website it says that reports lead to insight. Live management information and reports allow organizations to continuously improve their service.

Management information. The data generated by the kiosks provides the organization with live management information. This information can be used to build management reports. The management information can be used to continuously improve services [25].

Patient throughput duration. Supplier 1 states they have a market leading position in the domain of Patient Flow Management [25]. Patient Flow Management has several benefits for both patients and the organization: Patients are better informed, less no-shows, increased hospitality, shorter queues, less stress for patients, patients on-time arrival increases and reports about processes.

4.1.1.3 Supplier 1 service.

Staff training and Implementation support. Supplier 1 provides support with business consultancy, advice about processes, implementation and configuration of systems. They provide consultants who can answer questions about the system. Even after implementation Supplier 1 provides service as desired by the client [25].

4.1.1.4 Supplier 1 process changes.

Administrative workload decrease. On the website of the supplier it says that by using a large scale of applications, Supplier 1 helps to increase efficiency in the hospital. They support many registration and check-in processes. By using ID-scanners in the registration process they can perform several direct checks. In the administrative process the use of ID-scanners can provide a significant increase in efficiency leading to administrative savings [25].

4.1.2 Supplier 2

Supplier 2 states that well organized self-service systems are valuable resources in healthcare. The possi-bilities are: better informed patients, increased hospitality, increased patient safety and a higher quality patient registration process [26,7].

4.1.2.1 Supplier 2 features and functions.

The patient information brochure from Hospital B shown in Figure3 provides an infographic with the actions a patient performs at the kiosk. Supplier 2 is fully integrated in HiX EHR, this means that the kiosk provided by Supplier 2 scans the patient’s identification document and then retrieves the patient’s electronic health record from HiX.

Improved patient registration The central kiosk features and functions will be examined in the same order as the patient encounters them in use. The patient arrives at the kiosk, selects the desired legal identification document and scans this at the kiosk. The kiosk verifies that it is a valid identification document and a sequence of automated checks are performed to see if all information in the patient’s EHR is complete and up-to-date: The social security number registration is checked, insurance information is checked and the personal information is retrieved, verified and shown. The patient then has the option to change their personal and contact information in case it has changed since the last visit. Chipsoft

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Figure 3: Hospital B patient folder.

HiX allows the hospital to decide what information can be changed by the patient [7]. If the patient has not added a patient identification photo to their EHR the patient is asked permission to add the photo from the identification document to the patient’s EHR. Furthermore, patients can change their general practitioners, pharmacy and dentist information if needed and allowed by the hospital.

Chipsoft HiX allows hospitals to perform questionnaires on the kiosk. An example would be MRSA-risk questionnaire [7,6]. The answers to these questionnaires are directly entered in HiX EHR.

4.1.2.2 Supplier 2 information output.

Supplier 2 does not mention anything about management information output in the documents available. Management information. Their website only mentions that the kiosk provides information for the patient regarding their appointment. The project manager in Hospital B stated that Supplier 2 told them that they would provide the hospital with reports on kiosk use.

Live waiting times. If every check is performed and verified, the patient gets an overview of their appointments and live waiting times. The appointment information is printed on a day ticket. How the waiting time is calculated is not specified

4.1.2.3 Supplier 2 service.

Staff training and Implementation support. The kiosks from supplier 2 are constantly monitored by the supplier to see it they are turned on and functioning properly. A consultant from the supplier helps with implementation and provides training for the staff that work with the kiosks.

4.1.2.4 Supplier 2 process changes

Administrative workload decrease. On the website of Supplier 2 is says that the use of self-service in a hospital will increase service for the patient. Self-service allows the patients to check-in without the intervention of hospital staff. When patients check-in using self-service the hospital employees can provide these patients with more assistance and have time for other tasks.

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4.2 Hospital expectations

Information about the decision to implement self-service kiosks is requested from the project managers at each hospital. Both project managers were so kind to provide documentation about their decision process regarding the kiosk acquisition. Expectations from Hospital A and Hospital B, based on their supplied documentation, are explained in detail in the following sections. First the expectations of Hospital A are addressed, followed by the expectations of Hospital B.

Hospitals in the Netherlands are stimulated by the government to implement new strategies and sys-tems to decrease healthcare costs [27]. Financial incentive is provided for hospitals if they can exchange information with the patient in a standardized form [28]. This initiative is called the “Versnellingspro-gramma Informatie-uitwisseling Patiënt en Professional” (VIPP). The goal of this initiative is that patient information exchange will be standardized, self-service kiosks can play an important role in this. Only hospital B is eligible for this financial incentive.

4.2.1 Hospital A expectations

The self-service kiosk project manager from Hospital A was kind enough to give an interview and provide the documents “Aanbestedingsleiddraad” and “Business case”. The documents contain information about the procurement details and information about the goals the hospital wants to achieve with the self-service kiosks. The information from the documents is supplemented with information extracted from the interview. All this information is used to determine Hospital A’s expectations with regards to the implementation of self-service kiosks.

Patient satisfaction. Based on the provided documents, the overall goal of Hospital A is to increase the service for patients. Increasing of service entails shorter throughput times, improved information about the destination and route in the hospital and automated check-in at the outpatient clinics. By calling in patients in an automated and anonymous way their privacy is better protected. The hospital wants the supplier to continuously improve the processes and functionality of the kiosks. The registered timestamps of actions completed at the kiosks allows the hospital to continuously improve their processes. By using the kiosks and continuously improving the hospital’s processes the service provided to patients increases.

Improved patient registration. Implementing self-service kiosks is expected to provide quality improvements. The quality improvements are expected in registration and verification of patient data. Self-service kiosks scan patient identification and perform automatic checks, the patient is verified and their EHR is retrieved. After the patient’s EHR is retrieved the system confirms if the patient’s registration is complete and if the patient has an appointment. In order to reduce the risk for fraud the kiosk checks if the insurance provider and personal information is up-to-date and if the patient has an identification photo in their EPD. The qualitative improvements expected by Hospital A are mostly due to automatization of the check-in process.

4.2.1.1 Hospital A expected features and functions.

The hospital wants the kiosk system to be integrated in their current system and have the option to add new systems in the future. In addition to HiX EPD, Hospital A is operating several other systems that are imperative to their operating processes. Hospital A needs all those systems to be connected with a Customer Flow Management (CFM) system provided by the kiosk provider. A future application the hospital wants is narrowcasting of live waiting times, narrowcasting is the system that shows broad and local information about delays to patients through the outpatient clinic kiosks.

During the interview with the project manager we learned that they expected quality improvements as a result of the kiosks. Before the kiosk implementation the percentage of patients with full and up-to-date registration was lower than the hospital desires. The kiosks should perform an automated check to see if the patient is registered at the hospital and if the patient’s information is up-to-date.

4.2.1.2 Hospital A information output expectations.

Hospital A expected Supplier 1 to provide the hospital with the CFM, this system should register all the interactions that happen at the kiosk.

Management information and Patient throughput times. Hospital A expects the CFM to connect all the necessary systems with the kiosk system. The CFM then generates information for hospital management and patients. Information provided to patients entails the time and place of the appointment accompanied with directions to the outpatient clinic. The appointment information is printed on a ticket at the central kiosk. During the interview the project manager said that in the procurement procedure the hospital made very clear what they wanted to receive from, and achieve with the kiosks. One of the goals of the kiosks was to decrease patient throughput and waiting times. For this they want information to be available on every step of the patient’s flow through the hospital. The kiosks register several points with accompanying timestamps. This information is needed to generate management information and live waiting times. When the CFM works as expected the information should be available for both patients and the hospital.

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Live waiting times. Having the information about the live waiting times available is especially important to Hospital A because they scored below average on this in the Customer Quality(CQ) Index 2015. The CQ Index is a method to measure patient experience and satisfaction in University Medical Centres [29].

4.2.1.3 Hospital A service expectations.

Staff training and Implementation support. Hospital A has several desires when it comes to Service Quality. Hospital A desires that the IT-staff and key-users are trained in such a way that the system can be used optimally for the duration of the system life-cycle. Besides staff training an e-learning and a digital learning environment is expected in order to train users. The hospital wants governance and maintenance by the kiosk supplier in order to continuously improve and update the system.

4.2.1.4 Hospital A expected process changes.

The implementation of self-service kiosks is expected to result in changes in the check-in procedures throughout the hospital.

Universal check-in procedure and universal outpatient clinic procedure Hospital A wants the kiosks to lead to a standardized check-in procedure at the central hall and at every outpatient clinic. This creates a situation where the patient is subjected to the same registration process on every outpatient clinic visit. The kiosks allow the hospital to provide patients with information in a uniform way.

Administrative workload decrease. The goal of automating the check-in processes throughout the hospital is to decrease the workload for administrators and improve patient satisfaction.

4.2.2 Hospital B expectations

The kiosk project manager in Hospital B was kind enough provided the “Projectvoorstel aanmeldzuilen poliklinieken”. This document provides the information regarding the decision to implement self-service kiosks in Hospital B.

Patient satisfaction. When the Hospital B started their remodel in 2015 they set up a document with plans for the future. A part of this was patient-oriented logistic process from check-in to the end of their visit. Hospital B decided that the implementation of self-service kiosks would help achieve these goals. They expect self-service kiosks to lead to: quick patient self-service supported by volunteers if needed, universal patient identification, the possibility for patients to update and alter their personal information, efficient routing for patients, overview of appointments, employees will have more time for patients that require extra service at the administration desk and JUST IN TIME patient-flow. The kiosks are set-up in a way so that the patient feels welcome and that the patient throughput is performed in the best and fastest way possible.

4.2.2.1 Hospital B expected features and functions.

Improved patient registration. Hospital B wants unequivocal and structured patient identification warranted by the use of self-service kiosks. During the interview with the project manager from Hospital B we learned that the hospital wanted the insurance information check to be performed for every patient. Before for the kiosks the insurance information was checked at the end of the day for the next day. This could only be done for patients with a scheduled appointment. The radiology and laboratory departments worked mostly with walk-in patients, so patients without an appointment. These patients could go to these departments without having their insurance information checked. This was an undesirable situation for the hospital. Implementing the kiosks would provide the structure where all patients who arrive for outpatient clinic appointments and walk-ins would go through the same registration process. In this situation the insurance information for all patients is up-to-date prior to their appointment.

4.2.2.2 Hospital B information output expectations.

In the documents provided by the hospital no information about desired information output was found. Management information. During the interview we learned that the project manager expected reports on the use of the kiosks. This information should be usable for management information. They wanted monthly reports which shows amount of check ins for every hour, throughput times and amount of check ins at every outpatient clinic.

Live waiting times and patient satisfaction. For the patients Hospital B expected that the use of kiosks would provide patients with better and more information. Clear directions should be provided to the patients. Information about the location and time of their appointment should be printed on a ticket. With the use of the kiosks, patients should be informed about the live waiting times on the kiosks. The improved information is expected to lead to increased patient satisfaction.

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4.2.2.3 Hospital B service expectations.

Service quality. Because Supplier 2 is integrated in Chipsoft’s HiX EHR, the level of service quality is expected to be the same as with any HiX issues.

4.2.2.4 Hospital B expected process changes.

Universal check-in procedure, universal outpatient clinic procedure and administrative work-load decrease. For all patients, the use of kiosks should lead to a universal way of checking-in and to universal processes at every outpatient clinic. By automating the check-in procedure the workload for the administrative staff decreases.

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4.3 Outcome

The outcomes are summarized in Table1and2. The information about the outcomes is largely based on interviews with both project managers and if possible enriched with information retrieved from the kiosk system. Outcomes for both hospitals are further explained in the following sections.

4.3.1 Hospital A outcomes

4.3.1.1 Hospital A features and functions outcome.

As mentioned before, the system and the kiosks provide a large degree of freedom when it comes to setting up the kiosks for different outpatient clinics. This allowed Hospital A to add MRSA risk questions to the central kiosk. Now, all patients that check-in using the kiosks have answered the questions. On each outpatient clinic a short questionnaire specific for that clinic can be added. The central kiosks and all individual outpatient clinic kiosks can be customized. This is done only when necessary in order to keep the check-in procedure universal throughout the hospital.

4.3.1.2 Hospital A information output.

The kiosk system generates data for all patient-kiosk interactions, that data is stored in a database. Improved patient registration and management information. The central kiosk generates data about the amount of successful check-ins, the amount of patients that drop-out with specific reasons and the duration of the kiosk interaction. The amount of check-ins and drop-outs are shown in AppendixA. The frequency of different drop-out reasons in shown in AppendixB. The different drop-out reasons are selected by the hospital with the goal to improve patient registration. The outpatient clinic kiosks generate information about successful outpatient clinic check-ins. The generated information is available and used for management information so they get an insight in the usage of the kiosks.

Patient throughput duration. The system registers a timestamp for every interaction at the central and outpatient clinic kiosk which allows the hospital to measure the time it takes patients to get from the central kiosk to the outpatient clinic.

Management information and live waiting times. During the interview we learned that the information generated by the kiosk, combined with registrations in HiX EHR, can be used for showing live waiting times in the outpatient waiting rooms (narrow-casting). Currently this system is not operational. When the registrations in HiX EHR are performed the management information can be enriched with information about appointment durations. The project manager said that this information will be used to identify any mismatches in scheduled appointment start time and realized start time, further reducing the patient’s waiting time.

4.3.1.3 Hospital A service.

Implementation support. Supplier 1 offers continuous support during the implementation phase. As mentioned before there is a large degree of freedom when configuring the kiosk. Supplier 1 assists in setting up the kiosks and where necessary add customizations for specific outpatient clinics.

4.3.1.4 Hospital A process changes.

The project manager said that because they place the kiosks at a few outpatient clinics at a time they can get a full picture of every outpatient clinic’s processes before implementing a kiosk.

Universal check-in procedure and Universal outpatient clinic procedure. Because they get a full picture before implementing a kiosk they can see what processes should be included in the kiosks and what processes should change in order for the kiosks to function optimally. The offered flexibility is a gift and a pitfall at the same time. The flexibility provides a large amount of freedom when configuring outpatient clinic kiosks. At the same time the goal is to get a universal check-in procedure throughout the hospital. This requires careful consideration at every outpatient clinic. Some issues could be solved by the kiosk and other should be solved by changing the clinics processes. The implementation of self-service solutions requires standardization in the administrative processes. Some small customizations can solve a lot of outpatient clinic specific problems but the goal remains that the check-in procedure becomes universal on all clinics.

Live waiting times. During the interview we learned that in order for narrowcasting of live waiting times to be possible, appointment registration by care providers on the outpatient clinics need to change. The care providers need to register in HiX EHR when an appointment starts and when it is completed. This information combined with the timestamps from the kiosks can provide the patients with live waiting times through narrowcasting.

4.3.1.5 Hospital A Operative surgery case-study.

With the implementation of the self-service kiosks on the outpatient clinic the administrative process changed. The administrative process at the moment of the baseline measurement and the process for the follow-up measurements are explained in the activity diagram in Figure4.

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Figure 4: Activity diagram Operative Surgery check-in. Left diagram is the situation before kiosk implementations. Right is situation after kiosk implementation. Green path on the right indicates happy-flow.

The left activity diagram illustrates the situation before kiosk implementation: The patient arrives at the outpatient clinic and reports at the clinics administrative desk. There are two desks for Operative Surgery with two accompanying waiting areas. The patient is informed via letter at which of the two desks they should check-in. When the patient arrives at the correct desk the patient is checked-in by the administrator. If the patient happens to go to the wrong desk, they are asked to go to the other desk to complete their check-in. After the check-in is complete the patient takes place in the correct waiting area. The right activity diagram shows the new situation with the kiosk. In the happy-flow(indicated by green), the patient arrives at the outpatient clinic, scans their day ticket at the clinics kiosk and is auto-matically checked-in and directed to the correct waiting area. Only if additional actions are required at the outpatient clinic desk, the patient is directed there instead of the waiting area. By automating the location check and check-in procedure the workload of the outpatient clinic administrator should be lightened.

The baseline measurement of the Operative Surgery outpatient clinic was performed by observing and counting activities at the outpatient clinic administrators desk. The baseline measurement and the follow-up measurements are shown in Table3.

This table shows the comparison between the situations explained in Figure4. In this table the amount and percentages of patients are shown for the outpatient clinic from 08:30 until 12:00. This time interval is chosen because at this time the most consultation hours are held.

From Table3can be concluded that the total amount of interactions at the administrator’s desk has decreased. However, on the Thursday of the two month follow up there were three physicians absent. This Thursday is not representative of a normal Thursday. Between the baseline measurement and the two month follow ups there is a decrease in the percentage of patients that need their MRSA risk questions asked at the administrator’s desk. These questions are now asked and updated at the central kiosk.

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Table 3: Operative surgery case-study

Day Moment (n) RAD/LAB (n (%)) MRSA (n (%)) Ticket (n (%)) Other (n (%)) On Time (n (%)) Kiosk Q’s (n (%)) X Desk (avg) Monday Before (n=28) 3 (12,5%) 5 (20,8%) 8 (33,3%) 20 (45,8%) 11 (83,3%) NA 1,4 1 week (n=11) 0 (0%) 0 (0%) 5 (45,5%) 1 (9,1%) 11 (100%) 4 (36,4%) 1,3 2 month (n=6) 2 (33,3%) 1 (16,7%) 1 (16,7%) 0 (0%) 5 (83,3%) 2 (33,3%) 1,2 Tuesday Before (n=30) 5 (16,7%) 12 (40,0%) 8 (26,7%) 2 (6,7%) 26 (86,7%) NA 1,2 1 week (n=35) 0 (0%) 2 (5,7%) 11 (31,4%) 8 (22,9%) 35 (100%) 6 (17,1%) 1,2 2 month (n=12) 0 (0%) 3 (25,0%) 2 (16,7%) 1 (8,3%) 10 (83,3%) 2 (16,7%) 1,3 Wednesday Before (n=14) 1 (7,1%) 0 (0%) 5 (35,7%) 0 (0%) 13 (92,9% NA 1,1 1 week (n=10) 0 (0%) 0 (0%) 5 (50%) 1 (10%) 10 (100%) 5 (50%) 1,1 2 month (n=11) 0 (0%) 0 (0%) 2 (18,2%) 3 (27,3%) 11 (100%) 2 (18,2%) 1,0 Thursday Before (n=45) 0 (0%) 10 (22,2%) 14 (31,1%) 8 (17,8%) 43 (95,6% NA 1,3 1 week (n=37) 0 (0%) 7 (18,9%) 14 (37,8%) 5 (13,5%) 35 (94,6%) 4 (10,8%) 1,2 2 month (n=11) 0 (0%) 1 (9,1%) 2 (18,2%) 4 (36,4%) 10 (90,9%) 1 (9,1%) 1,0 Friday Before (n=30) 0 (0%) 5 (16,7%) 8 (26,7%) 3 (10%) 26 (86,7%) NA 1,2 1 week (n=33) 0 (0%) 10 (30,3%) 12 (36,4%) 4 (12,1%) 32 (97,0%) 10 (30,3%) 1,2 2 month (n=20) 0 (0%) 0 (0%) 5 (25%) 6 (30%) 18 (90%) 6 (30%) 1,2 Average Before (n=29) 7,3% 19,9% 30,7% 16,1% 89,0% NA 1,3 1 week (n=25) 0% 11,0% 40,2% 13,5% 98,3% 28,9% 1,2 2 month (n=12) 6,7% 10,2% 18,9% 20,4% 89,5% 21,5% 1,1

4.3.2 Hospital B hospital outcome

4.3.2.1 Hospital B features and functions outcome.

Improved patient registration. During the interview with the project manager in Hospital B we learned that the features and functions are working as expected. The checks for patient identification photo and insurance information are working as intended. It is not possible for patients to alter their personal information. This was a deliberate choice from the hospital in order to minimize the time spent at the kiosk. The social security number (SSN) check to see if the SSN is complete and correct is not turned on at the time of the interview. The project manager said this will be turned on in the near future. The SSN check was not turned on at go-live because an analysis of patient registration showed that a large part of the patient population did not have this information correctly registered. At the go-live this would result in a too large number of patients dropping-out leading to patient and employee dissatisfaction. Now that the current kiosk features and functions are working as intended, the hospital wants to turn the SSN check function on and add MRSA risk score questionnaires in order to further improve patient registration.

4.3.2.2 Hospital B information output.

Management information. From the interview with the project manager in Hospital B we learned that there are several information outputs available from the kiosks. The kiosk from Supplier 2 provides a weekly overview of kiosk interactions, this shows the amount of patients that check-in using the kiosk on a hospital level. The project manager said that they can build more detailed reports on their own from the HiX EHR. However, this is a cumbersome process and therefore is not feasible to perform on a daily or weekly basis. The project manager would like to receive a more detailed overview.

4.3.2.3 Hospital B service.

Staff training and Implementation support. Based on the interview, the service quality is similar to other HiX related ICT issues: a problem is reported to Chipsoft and they address the issue. Problems with the kiosks itself(hardware) are solved by the company that installed the kiosks.

4.3.2.4 Hospital B process changes.

During the interview with the project manager we learned that a great deal is going the way they expected. Universal check-in procedure. The central check-in process is improved, after go-live it was unclear who should check in and why. There were many patients who made their appointments up to a year ago. These patients had received a letter informing them they could go straight to the outpatient clinic of their appointment. Because of these letters most of those patients walked past the kiosks and went straight to their respective outpatient clinic. After the go-live patients became more aware of the kiosks the usage vastly increased over time. The project manager expects that over time this will continue to improve.

Universal outpatient clinic procedure. Before kiosk implementation all outpatient clinics were informed about the consequences of working with the kiosks. Their processes needed to change in order to profit optimally from the kiosks. Patients now scan their day ticket on the outpatient clinic and can take place in the waiting room. Some outpatient clinics have underestimated the effects of these patients directly

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taking place in the waiting rooms without interacting with the administrative desk. Some outpatient clinics still need to alter their processes to optimally profit from the kiosks.

Administrative workload decrease. The project manager said that the administrative staff notices a workload reduction. Initially there was more work, because patients did not understand what to do. The administrator had to explain why it was beneficial for them to check-in using the kiosks. The project manager said that it is expected to take up to a year before administrators will say they have freed up time for other activities as a result of the workload reduction.

Live waiting times. One of the benefits of using the kiosks is the possibility to show the patient the live waiting times for their appointments. Before this was possible, all outpatient clinics needed to correctly register when a patient is called in and when the patient’s appointment is finished in HiX EHR. This required a change in the processes at the outpatient clinics and research departments affecting the care providers. When this process was changed, the patient could be informed about live waiting times on the outpatient clinic kiosk when they scan their day-ticket.

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5 Discussion

5.1 Main Findings

In many cases the expectations of the hospitals have been met by the kiosk suppliers. On the features and functions the kiosks have delivered according to the promises made by the suppliers. The expectations from the hospitals are met on the features and functions as well. The check-in process in both hospitals is more universal now that they started working with self-service kiosks. However, there are some aspects where the outcome do not match the promises and expectations. The outcome of the information output in Hospital B does not meet their expectations. Also, the administrative savings promised by the suppliers is not yet measurable. Both suppliers and hospitals expected a workload decrease of administrative savings. However, it is unclear how this will be realized in practice. On hindsight both project managers said they would have liked to be better prepared prior to the kiosk implementation.

5.1.1 Hospital A

Not all outpatient clinics are currently working with self-service kiosks. This can be confusing for patients. Eventually all outpatient clinics in Hospital A will work with the kiosks. The hospital expects that this will make the check-in process universal throughout the hospital.

Hospital A specified in their procurement documentation what information output they expected from the kiosks. This resulted in supplier 1 being selected to implement the kiosks in Hospital A. Supplier 1 delivered the data as requested by Hospital A, allowing the hospital to build the desired reports.

Hospital A wants to inform patients through narrowcasting live waiting times on outpatient clinic kiosks. For this to be possible, the care providers need to register when they start with a patient appoint-ment and when they finish that appointappoint-ment. The project manager expects that when this information is shown on the kiosk that the care providers see the usefulness of working with kiosks and the additional registration. Eventually the care providers can benefit from the management information. The informa-tion can be used to identify scheduling issues. This can identify when care providers structurally need more time then scheduled. It remains to be seen that the improved information provision for patients and available management information will be seen as useful by the care providers. Their registration burden slightly increases, but they don’t directly benefit from this.

From the kiosk data in AppendixAyou can see that the percentage of patients needing to complete their registration or update their information is decreasing over time. This data suggests that an increasing amount of patients has up-to-date information.

The kiosk project manager said they would have liked to prepare better for what needed to be done when implementing a kiosk on an outpatient clinic. For them it has been a learning process, now they have a list with points to check-off.

5.1.2 Hospital B

Hospital B went live with the self-service kiosks on their all their outpatient clinics at the same time. The initial implementation was a success. However, there are still some problems at the central check-in with patients that have received letters with their appointment information in the old setting. It is expected that when all these patients have been in for their appointment all patients know how to check-in using the kiosk system. After some startup problems the central and outpatient clinic check-in procedure is universal.

During the procurement the project manager said they would like reports about the usage of the kiosk. Supplier 2 said they would provide the hospital with information reports about the kiosks. However, the expectations about the reports and the actually produced reports don’t match. The project manager would like a more detailed report about the usage on an hourly basis and specific for each outpatient clinic kiosk. The project manager said that at Chipsoft they are working on building reports like this. Currently the hospital can build reports of their own, but they don’t have the time and manpower to do this on a continuous base.

Before the kiosk there was an issue with checking the insurance information for patients that went to the radiology or laboratory departments. These patients did not have a scheduled appointment. Now that the self-service kiosks are operational all the patients have to check-in using the kiosks. This solved the issue of checking the insurance information for unscheduled patients at the radiology or laboratory department.

The kiosk project manager said that they would have liked a playbook from the kiosk supplier. They would have liked to know what to do and organize before and during kiosk implementations.

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5.2 Strengths and Limitations

The aim of this research was to compare pairs of hospitals and suppliers. This paper compared two different types of hospitals with two different kiosk suppliers. A strength of this paper is that different settings and products are compared. Another strength of this research is that little research is available about self-service kiosks in healthcare.

This study had limitations as well. The researcher had no prior experience with self-service kiosk implementations and hospital processes. The research is only performed in two hospitals making it difficult to generalize the outcomes. A big part of the results is based on interviews with the project managers of both hospitals.

5.3 Implications

This paper has implications for hospitals that wish to implement self-service kiosks. Both the project man-agers said that preparation is very important. Both hospitals had expectations about different aspects, but in some aspects it was not specified what outcome was desired. In future self-service kiosk implementations it would be advisable to specify beforehand what outcomes the organization desires. It is also advisable to develop measurements to see to what degree the expectations and desires are met. This way the chance of a mismatch between expectations and outcome can be reduced.

For the suppliers this has some implications. They should assist the hospital in realizing their expec-tations. The suppliers should provide hospitals with a playbook or checklist containing all the necessary preparations and considerations. This will help the suppliers cater to the needs and expectations of the hospitals.

5.4 Future Research

Future research directions are: outcomes 1 year after go-live, patient satisfaction, realized administrative workload decrease and future possibilities with the self-service kiosks.

Because both systems are not yet working to their full potential it is difficult to say what the effects of the kiosks are. A follow up study a year after implementation could provide an insight into the effects of the fully operational kiosk system.

Patient and hospital staff satisfaction has not been included in this research. When the kiosks are working to their full potential it would be interesting to measure user satisfaction in both hospital staff and patients. Both suppliers state that because of the administrative workload decrease the staff has more time for hospitality. It would be interesting to study if there is increased hospitality and how patients experience this.

The administrative workload decrease can lead to a reduction in administrative staff, however this was not measured in this study. Future research could focus on measuring the realized administrative workload decrease.

Other research could focus on the possibilities the realized administrative workload decrease provides. When (part of) a job gets replaced by a computer it allows the employee to evolve their job into something new [30]. The administrative staff could relieve part of the administrative duties from care providers [31]. In the Netherlands physicians say they spend up to 40% of their time on administrative duties and of that time only 36% is deemed useful[32]. In other fields secretaries ended up doing tasks which were only reserved for managerial and professional staff [30]. Research could focus on the possibilities the expected workload reduction provides for the hospital and their care providers.

Another research direction is combining self-service kiosks and dynamic planning. Other research suggests that by moving the doctor to the patient instead of the patient to the doctor efficiency will increase [33]. Incorporating this in hospital processes can potentially save both patient and care provider a lot of time. Future research could focus on how self-service kiosks can play a role in dynamic planning and further increase the efficiency.

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Abbreviations

EHR = Electronice Health Record HIS = Health Information Systems PFM = Patient Flow Management CFM = Customer Flow Management CQ = Customer Quality

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Appendices

A

Hospital A information output

Figure 5: Central kiosk drop-out percentage December 2018 - July 2019.

Figure 6: Central kiosk check-in and drop-out output December 2018- July 2019.

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B

Hospital A Drop-out reasons

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C

Case-study set-up

The questions the Operative Surgery manager had where: How many patients arrive at the outpatient clinic but need laboratory or radiology diagnostics prior to their appointment? How many patients need to update or answer the MRSA contamination risk questions? How many patients arrive with a ticket from the central kiosk? How many patients have questions unrelated to their appointment? How many patients arrive on time? How many times to patients interact at the Operative Surgery administrators desk? How many patients have questions about the use of the self-service kiosks?

These were scored in the following form:

Patient Rad/Lab MRSA Ticket Overig Op tijd X balie Zuil vragen

1 2 3 4 5 6 7 8 9 10 29

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D

Semi-structured interviews

What to bring:

• Recording equipment

• Checklist with interview subjects Explanation before start of interview:

• Explanation of students research and importance of interviewee input

• Explain that the interview will be used in my thesis, and that it will be anonymous • Get consent for recording the interview

Interview strategy:

• Wat was de verwachting van het ziekenhuis over de functies van de aanmeldzuilen? • Zijn die verwachtingen ook uitgekomen?

• Zijn jullie tevreden over de informatie die de aanmeldzuilen voorziet aan de patiënten? • Wat voorinformatie krijgt het ziekenhuis uit/door de aanmeldzuilen?

• Zijn jullie hier tevreden over?

• Hebben jullie het idee dat de patiënten tevreden zijn over de aanmeldzuilen? • Zijn de baliemedewerkers tevreden over de aanmeld zuilen?

• En de zorgverleners?

• Zijn jullie tevreden over de aanmeldzuilen?

• Is er veel veranderd in het aanmeldproces nu er met de aanmeldzuilen gewerkt wordt? • Kunnen patiënten nu beter de weg vinden in het ziekenhuis?

• Hoe ging de implementatie?

• Als je het hele proces opnieuw zou kunnen doen, zou je dan dingen anders gedaan hebben? • Waren de zuilen gelijk een succes?

• Was de timing goed?

• Waren de verwachtingen realistisch? • Zijn jullie tevreden over de aanmeldzuilen?

The effect of self-service kiosks in Dutch hospitals