Operations strategy in healthcare organisations

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Operations strategy in healthcare organisations

Shaping the operations strategy through the reconciliation process in

healthcare organisations

Master Thesis, Dual Degree in Operations Management

by

Twan Vinke

Student number: S2643529 (RUG), 170701725 (NUBS)

Email:

t.vinke@student.rug.nl

Supervisors:

Prof. Dr. J. de Vries (University of Groningen)

Dr. A. Small (Newcastle University)

Universities:

University of Groningen, Faculty of Economics and Business

Nettelbosje 2, 9747 AE Groningen

University of Newcastle, Newcastle University Business School,

5 Barrack Road, Newcastle upon Tyne, NE1 4SE

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Abstract

A large diversity of coercive stakeholders force healthcare organisations in the Netherlands to operate more efficient and effective. The process of shaping the operations strategy through the reconciliation of customer requirements with operations capabilities is proven to be successful for realising long term goals in the manufacturing sector. This research identifies the applicability of operations strategy in the healthcare sector and defines important factors to use in the formulation process of the operations strategy. An adapted framework for shaping the operations strategy is developed to investigate the effect the healthcare sector-specific characteristics have on the reconciliation process in healthcare organisations. The case study with data from informal conversations, interviews and observations showed that the operations strategy in healthcare organisations is shaped through the reconciliation of patient needs and the requirements of other stakeholders with operations capabilities. Overall, shaping the operations strategy in healthcare organisations turned out the be far more complex than shaping process in manufacturing organisations.

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Preface

This master thesis represents the last part in completing the dual degree programme in Operations Management at the University of Groningen and Newcastle University. I would like to use this section to express my gratitude to a few people.

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1. Introduction

Over the last centuries, healthcare cost in the Netherlands have increased (Krabbe-Alkemade et al., 2017). The total cost of the healthcare sector in the Netherlands have shown an increase of more than 26 billion euros from 70.3 billion euros in 2006 to 96.7 billion euros in 2016 (CBS, 2018). Due to the increasing level of competition, patient service alternatives, joint ventures, quality initiatives and emphasis on continuous improvement, the focus of operations in the healthcare sector has changed (Purbey et al., 2007). Operations can be defined as the part of a healthcare organisation that creates and/ or delivers products and services (adapted from Butler et al. 1996). Governments and taxpayers invest large amounts of money in the healthcare sector, either directly or indirectly, and expect a high-quality service (Purbery et al, 2007; Hewko and Cummings, 2016). Therefore, the healthcare sector continuously faces pressure to improve performance while reducing cost (Butler et al., 1996; Dobrzykowski et al., 2014). Healthcare organisations have tried to enhance their performance, but a number of healthcare organisations are missing a long-term plan to succeed (Dobrzykowski et al., 2014 and Jha et al., 2016). One of the biggest reasons behind this is the lack of clear understanding of problems existing in organisations (Jha et al., 2016). Therefore, the rise in overall cost of the healthcare organisations is quite high when compared to the improvement in overall performance (Jha et al., 2016).

The challenge for healthcare organisations is to operate more efficiently while improving the quality of care. According to Kim et al. (2014) and Fiorentino (2016), operations strategy can be used as a tool for organisation to realise long-term goals. In essence, according to Dangayach and Deshmukh (2001) and Slack and Lewis (2015), the operations strategy of an manufacturing organisation is shaped through the reconciliation of market requirements with strategic operations decision areas. However, since operations strategy in the manufacturing sector is primarily concerned with addressing the needs of customers (Slack and Lewis, 2015), the terminology customer needs is used in this study instead of market requirements. Extensive research has shown that operations strategy in the manufacturing industry can be critical for the success of an organisation (e.g. Ahmed et al., 1996; Butler et al., 1996; Brown et al., 2007; Gorm Rytter et al., 2007; McDermott and Stock, 2011; Kim et al., 2014; Fiorentino, 2016). However, other authors have concerns regarding the generalizability of operations strategy to other sectors (Abernethy et al, 2006; Machuca et al., 2007; Cardinaels and Soderstrom, 2013; de Blok et al., 2013; Mahdavi et al., 2013; Dobrzykowski et al. 2014; Jagoda & Kiridena, 2015; Jha et al., 2016). Radnor and Noke (2013) and Dobrzykowski et al. (2014) mention that knowledge from the manufacturing sector can be used to improve the performance in the healthcare sector as long as the sector-specific characteristics are understood. Further, Radnor and Noke (2013) mention that during the usage of knowledge from the manufacturing sector to another sector, the focus must be on adaption instead of adoption.

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2013; Dobrzykowski et al., 2014; Jha et al., 2016; Yu, 2017). Further, it is expected that due the large diversity of coercive and influential stakeholders of the healthcare sector, the requirements of the other stakeholders play a more important role in the reconciliation process than in the manufacturing sector (Abernethy et al., 2006; Chenhall, 2006; Gaynor et al., 2015; Dobrzykowski et al., 2014; Jha et al., 2016). The reconciliation process is critical for shaping the operations strategy, because it increases the understanding of the relative importance of the operation’s performance objectives and it increases the understanding of the influence the decision areas have on the performance objectives related to resource deployment (Slack and Lewis, 2015). Therefore, the process of shaping the operations strategy through the reconciliation of customer requirements and operations capabilities in manufacturing organisations have to be adapted to healthcare organisations. However, little is currently known in literature about the reconciliation process in healthcare organisations and how this process is influenced by the patient (customer of the healthcare sector) needs, the operations capabilities of healthcare organisations and the requirements of other stakeholders (Shah et al., 2008; Gunasekaran and Ngai, 2012; Dobryzkowski et al., 2014; Jha et al., 2016).

In this study, first the sector-specific characteristics of the healthcare sector which are relevant for this study are analysed. These characteristics are the patient needs, the operations capabilities of healthcare organisations and the requirements of other stakeholders in the healthcare sector. After that, the effects of the sector-specific characteristics on the reconciliation process in healthcare organisations are researched. In doing so, this study aims at giving insights in the reconciliation process of patient needs and the requirements of other stakeholders with the operations capabilities in healthcare organisations. This resulted in the following research question:

How do the healthcare sector-specific characteristics affect healthcare organisations in shaping their operations strategy through the reconciliation process?

This research question is investigated by conducting a single case study at a healthcare organisation located in the Netherlands. The academic relevance of this paper can be found in the enrichment of operations strategy literature specified for healthcare organisations. From a managerial perspective, this study can be used by managers to formulate their operations strategy of their healthcare organisation through the reconciliation process. This gives managers more insights in whether it is necessary to redesign their operations. In the long-term, redesigning operations can result in better overall performance (Fiorentino, 2016). The remainder of this study is be structured as follows. In section 2, the theoretical background is be described. In the third section, the methodology in order to conduct this research is be discussed. In section 4, the findings of the case research are presented. In section 5, these findings are discussed, and the results are presented in the form of a conclusion in the last section.

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2. Theoretical background

In the theoretical background, operations strategy is further discussed. Section 2.1. outlines the origins of operations strategy and describes the reconciliation process in the manufacturing sector. In section 2.2, the difference between the manufacturing sector and the service sector is explained. Further, the healthcare sector-specific characteristics, which are relevant for this study, that distinguish the healthcare sector from the service sector are presented. In section 2.3., the reconciliation process adapted to the healthcare sector is discussed. The framework for shaping the operations strategy in the healthcare organisations and the research questions are presented in section 2.4.

2.1. Operations strategy

The origins of manufacturing strategy and operations strategy can be found in the work of Skinner (1969). Skinner (1969) discussed the importance of explicit linkages between manufacturing choices and the firm’s environment and corporate strategy. He criticizes the short-term view of manufacturing management. According to Skinner (1969) the manufacturing management is more focused on their day-to-day business instead of following a long-term strategy. In order to focus on the long-term, Skinner (1969) suggested five important decision areas for the manufacturing strategy of company: factory and equipment, production planning and control, labour and staff, product design/ engineering and organization and management. In the following years, the body of literature on manufacturing strategy evolved and different definitions of operations strategy were formulated. For instance, Hayes and Wheelwright (1987) defined the manufacturing strategy as a consistent pattern of decision making in the manufacturing function which is linked to the business strategy and its objectives. Hayes and Wheelwright (1987) identified the following manufacturing decision areas: Capacity, Facilities, Equipment and Process Technologies, Vertical integration, Vendors, New Products, Human Resources, Quality and Systems.

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The existence of trade-offs among the main performance aims of operations are widely analysed in literature (Anderson et al., 1989; Rosenzweig, 2009; Fiorentino, 2016). The main performance aims of operations mentioned in several articles slightly differ, but overall, they are quite similar. These targets are identified primarily in terms of quality, speed, reliability, flexibility and costs (Vos, 1995; Rosenzweig, 2009; Slack and Lewis, 2015; Fiorentino, 2016). Companies have to address potential trade-offs between performance objectives by making a choice in the pursuit of corporate targets, moving toward selected targets (Fiorentino, 2016). These decisions should be based on the importance of the performance objectives within the overall corporate strategies (Slack et al., 2009). Similarly, some objectives are focussed on the reduction of costs, whereas others are primarily oriented towards achieving advantages of differentiation (Jacobs et al., 2004). However, in the manufacturing sector the performance objectives are primarily related to customer needs (Slack and Lewis, 2015). Another area of research has investigated the underlying factors of the strategic operations decision areas (Hayes and Wheelwright, 1987; Dangayach and Deshmukh, 2001; Slack and Lewis, 2015; Fiorentino, 2016; Yu,2017). The decisions areas frequently named are: capacity, facilities, technology, vertical integration, staff, quality, production planning and organization (Anderson et al., 1989; Slack and Lewis, 2015). In order to manage the resources of operations, insights in these operations areas are required. According to Anderson et al. (1989), the operations decision areas can be seen as strategic opportunities. Operations capabilities can allow organisations to take up an attractive market position and protect it from a competitive threat (Slack and Lewis, 2015). However, due to the environment a firm operates in, the operations capabilities can differ per company (Yu, 2017).

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9 2.2. Product, service and healthcare environment

The first literature regarding operations strategy only focused on the manufacturing sector (Anderson et al., 1989). Therefore, the term manufacturing strategy was used. However, according to Anderson et al. (1989) it makes little sense to confine most of the research to the manufacturing sector of the economy. Anderson et al. (1989) emphasize the importance of the service industry and suggest using the term operations strategy instead of manufacturing strategy. In the following years, due to emerging notions of ‘servitization’ and product-service combination, the body of literature regarding operations strategy in the service industry grew (Voss et al., 2008). ‘Servitization’ is the process of transforming manufacturers to compete through manufacturing and service capabilities instead of manufacturing capabilities only (Baines et al., 2009). However, according to Spring and Araujo (2009) operations strategy in the service industry differs from operations strategy in the manufacturing industry. This can be explained by the difference in four characteristics between products and services (Spring and Araujo, 2009). The first difference between services and products is that products are often tangible, and services are intangible. The second difference is that services are inseparable and products not. This means that the delivery and consumption of the service happen at the same time (Spring and Araujo, 2009). The third difference Is the heterogeneity of services. The output of services is heterogenic, because it is produced by people and service have a degree of customisation which is offered in the service (Spring and Araujo, 2009). Heterogeneity is less valid for products, because standardization is easier to implement. The last difference between services and products is perishability. Services cannot be stored or transported, and products are.

The scope of this research, healthcare organisations, can be typed as a service provided to patients. The service offered in the healthcare organisations is intangible. Further, the delivery and consumption of the service happens at the same time. Therefore, the service of healthcare companies can be seen as inseparable. Moreover, the service of healthcare organisations is heterogenic, because the service is patient-specific and provided by an employee of a healthcare organisation. Besides the service characteristics discussed, the healthcare sector has some specific characteristics that distinguish the healthcare sector from the manufacturing sector. According to Radnor and Noke (2013) and Dobrzykowski et al. (2014), knowledge from the manufacturing sector can be used to improve the performance in the healthcare sector as long as the sector-specific characteristics are understood. The sector-specific characteristics, which are relevant to this study, are the patient needs, the operations capabilities of healthcare organisations and the requirements of the other stakeholders in the healthcare sector. Before these healthcare sector-specific characteristics are discussed, first the healthcare sector in the Netherlands is explained.

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mandatory healthcare insurance, supplementary insurance policies (e.g. for dental care) are optionally available at healthcare insurance companies. The regulations regarding supplementary insurances are made by the healthcare insurance company themselves. The insurance companies can decide whether to provide a consumer a supplementary insurance or not. Competition in the healthcare insurance market should result in an affordable premium for the consumers (Boot, 2013). Moreover, it is allowed for insurance companies and healthcare providers to discuss prices (Halbersma et al., 2011).

The first healthcare sector-specific characteristic is the patient needs (customer needs of the healthcare sector). In this research, the patient needs are defined as: the needs of the patients regarding healthcare organisations (adapted from Fiorentino, 2016). According to Radnor and Noke (2013), it is important to know that during transferring knowledge from one sector to another sector, the focus must be on adaption instead of adoption. Further, in the literature is suggested that the content of the patient needs is different than the content of the customer needs in the manufacturing sector. The reason behind this is that healthcare organisations provide services which are more complicated for patients than products provided by manufacturing organisations (Abernethy et al., 2006; Chenhall, 2006; Cardinaels and Soderstrom, 2013; Dobrzykowski et al., 2014; Jha et al., 2016). Therefore, it is assumed that the customer needs in the manufacturing sector have to be adapted to the healthcare sector. Moreover, it is assumed that the content of the adapted patient needs is different than the content of the customer needs in the manufacturing sector. However, literature regarding the patient needs is nascent and further research is necessary (de Blok et al., 2013; Dobrzykowski et al., 2014; Jha et al., 2016). For this reason, this study investigates the patient needs and their content..

The second healthcare sector-specific characteristic of the healthcare sector is the operations capabilities of healthcare organisations. In literature, many researchers have used a variety of terms to define operations capabilities (Hayes and Wheelwright, 1987; Dangayach and Deshmukh, 2001; Peng et al., 2008; Slack and Lewis, 2015; Fiorentino, 2016). In this research operations capabilities are defined as the realized strengths of operations (adapted from Peng et al., 2008) According to Radnor and Noke (2013), it is important to know that during transferring knowledge from one sector to another sector, the focus must be on adaption instead of adoption. Moreover, in literature it is suggested that the content of the operations capabilities in the healthcare organisations is different than the content of operations capabilities in the manufacturing organisations. The reason behind this is that the healthcare sector is in another environment than the manufacturing sector (Blok et al., 2013, Dobryzkowski et al.,2014; Jha et al., 2016; Yu, 2017). Therefore, it is assumed that the operations capabilities in the manufacturing organisations have to be adapted to the healthcare organisations. Further, it is assumed that the content of the adapted operations capabilities of healthcare organisations is different than the content of operations capabilities in the manufacturing sector. However, little is currently known about the operations capabilities of healthcare organisations. For this reason, this study investigates the operations capabilities of healthcare organisations.

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11 diverse and complex objectives are involved (Abernethy et al., 2006; Chenhall, 2006; Gaynor et al., 2015). The stakeholders exert pressure on the healthcare sector in order to shape how the resources are managed and allocated (Braithwaite, 2004; Cardinaels and Soderstrom, 2013). Therefore, it is assumed that healthcare organisations often have to deal with more powerful stakeholders that have more effect on the reconciliation process than in the manufacturing sector. For this reason, this study investigates the requirements of the other stakeholders. In this research, stakeholders are defined as: a person, group or organization that can affect or is affected by the healthcare organization (Olmedo-Cifuentes et al., 2014). Further, according to Olmedo-Cifuentes et al. (2014) it is important to understand the difference between internal and external stakeholders. Internal stakeholders are stakeholders within an organisation that can apply internal pressure (Olemdo-Cifuentes et al., 2014). External stakeholders are stakeholders outside an organisation that can apply external pressure (Olemdo-Cifuentes et al., 2014). Hoek (2007) and Boot (2013) made a list of the stakeholders in the Dutch healthcare sector. An overview of the stakeholders identified by Hoek (2007) and Boot (2013), divided in internal and external stakeholders can be found in table 1.

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2.3. Reconciliation process in the healthcare sector

The operations strategy in the manufacturing sector is shaped trough the reconciliation process of customer needs and the operations capabilities (Dangayach and Deshmukh, 2001; Slack and Lewis, 2015). Due to the healthcare sector-specific characteristics, other factors play a role in the reconciliation process in healthcare organisations compared to the manufacturing sector. As explained in section 2.2., these sector-specific characteristics are the patient needs, the operations capabilities of healthcare organisations and the requirements of other stakeholders. Therefore, it is assumed that the operations strategy in the healthcare organisations is shaped by the reconciliation process of the patient needs, the operations capabilities of healthcare organisations and the requirements of the other diverse stakeholders. Before the role of these sector-specific characteristics on the reconciliation process are researched, first the patient needs, the operations capabilities of healthcare organisations and the requirements other stakeholders have to be identified. In order to identify the patient needs, operations capabilities and the requirements of other diverse stakeholders, themes are used as starting-points. These themes are formulated based upon the most recent literature reviews in healthcare operations management and strategy of Dobrzykowksi et al. (2014) and Jha et al. (2016).

The formulated themes for patient needs are: quality of the service, financial aspect and patient satisfaction. The first theme focusses on the patient needs regarding the quality of the service provided by healthcare organisations are investigated (Dobrzykowski et al., 2014; Jha et al., 2016). Further, the financial aspect plays an important role in the healthcare sector (Dobrzykowski, 2012; Gaynor et al., 2015). In this theme, the focus is at the patients need regarding the financial aspects of the healthcare organisations are researched. Patient satisfaction is chosen because it is an overarching goal of healthcare organisations (Dobrzykowski et al., 2014; Jha et al., 2016). Patient satisfaction is important, because it can lead to gains for an organisation in the form of patient loyalty and positive worth of mouth (Dobrzykowski et al, 2014; Jha et al., 2016). The theme patient satisfaction addresses the patient needs regarding patient satisfaction of the healthcare organisations are examined. Furthermore, the formulated themes for operations capabilities are information technology, organisation & development and process technology. Within the first theme, the focus is on the operations capabilities of healthcare organisations regarding information technology. Healthcare organisations are high-contact service organisation (Dobrzykowski et al., 2014; Jha et al., 2016). The theme organisation & development addresses the operations capabilities of healthcare organisations regarding the employees’ skillset and trainings are examined. Within the theme process technology, the focus is on the operations capabilities of healthcare organisations regarding the usage of advanced technologies for the services (Dobryzkowski et al. 2014).

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13 healthcare organisations are addressed. Within the theme patient satisfaction, the focus is on requirements of the other stakeholders related to patient satisfaction regarding the healthcare organisations.

After the patient needs, the operations capabilities of healthcare organisations and the requirements of the other stakeholders are identified, the effect of these sector-specific characteristics on the reconciliation process are addressed. The reconciliation process is defined as the ongoing process in healthcare organisations of aligning the patient needs and requirements of other stakeholders to the operations capabilities of the healthcare organisations (adapted from Slack and Lewis, 2015). A tool that can be used to display the operations strategy of an organisation through the reconciliation process is the operations strategy matrix (Slack and Lewis, 2015). The operations strategy matrix emphasises what is required from the operations and how the operations try to achieve this with their capabilities. Since, this is crucial for this research, the operations strategy matrix is used. The operations strategy matrix consists of two dimensions. These are the requirements of the operations and the operations capabilities. In the healthcare organisations, the requirements of the operations consist of both the patient needs and the requirements of the other stakeholders. The dimension operations capability is related to the operations capabilities of healthcare organisations.

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2.4. The adapted framework

In the manufacturing sector, the operations strategy is shaped through the reconciliation process of customer requirements and operations capabilities (Dangayach and Deshmukh, 2001; Slack and Lewis, 2015). According to Radnor and Noke (2013) and Dobrzykowski et al. (2014), the healthcare sector-specific characteristics have to be understood in order to use the knowledge from the manufacturing sector improve the performance in the healthcare sector. Further, Radnor and Noke (2013) mention that during the usage of knowledge from the manufacturing sector to another sector, the focus must be on adaption instead of adoption. In line with Radnor and Noke (2013) and due to the complexity and the environment of the healthcare sector, it is assumed that the customer needs and the operations capabilities in the manufacturing sector have to be adapted to the healthcare sector (de Blok et al., 2013; Dobrzykowski et al., 2014; Jha et al., 2016; Yu, 2017). Further, it is assumed that due the large diversity of coercive and influential stakeholders of the healthcare sector, the requirements of the other stakeholders play a more important role in the reconciliation process than in the manufacturing sector (Abernethy et al., 2006; Chenhall, 2006; Gaynor et al., 2015; Dobrzykowski et al., 2014; Jha et al., 2016). Therefore, the process of shaping the operations strategy through the reconciliation of customer requirements and operations capabilities in manufacturing organisations is adapted to healthcare organisations. This resulted in the following framework (figure 1.). The framework tries to explain how healthcare organisations shape their operations strategy through the reconciliation process of the patient needs and the requirements of the other stakeholders with the operations capabilities of healthcare organisations.

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15 The framework provides interesting areas that need investigation. The aim of this study is to give insights in the reconciliation process of the patient needs and the requirements of other stakeholders with the operations capabilities in healthcare organisations. Therefore, the following research question is formulated:

How do the healthcare sector-specific characteristics affect healthcare organisations in shaping their operations strategy through the reconciliation process?

In order to answer this research question, supporting sub-questions are formulated. These sub-questions are focused on the constructs in the framework. First of all, this research examined the patient needs, the operations capabilities of healthcare organisations and the requirements of the other stakeholders. Second, it is investigated how the patient needs and the operations capabilities are reconciled in the healthcare organisations. Last, this study investigates how the requirements of the other stakeholders affect this reconciliation process. The sub questions are formulated below:

1. What are the patient needs, the operations capabilities of healthcare organisations and the requirements of the other stakeholders?

2. How are the patient needs with the operations capabilities of healthcare organisations reconciled in healthcare organisations?

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3. Methodology

In the methodology, the design of this research is explained first. Second, the data collection is discussed. In section 3.3, the data analysis method is presented. In the last section, the quality criteria for this research are discussed.

3.1. Research design

This research used a qualitative approach to answer the main research question, which was done by using case research. To the extent that the author knows, little is currently known in literature about shaping the operations strategy through the reconciliation process in healthcare organisations. Therefore, this research can be seen as an explorative study. In order to explore and build new theories, case research has been one of the most powerful tools in operations management (Karlsson, 2016). Furthermore, case studies have been identified as the most favourite research methods for investigating the formulation of operations strategy (Barnes, 2001). One advantage of case research is that it allows the researcher to study the phenomenon in its natural setting, which can result in a better understanding of the nature and the complexity of the complete phenomenon (Karlsson, 2016). According to Karlsson (2016) an important choice within case research is the number of cases. In this research, a single case study is used. Single case studies allow the research to investigate the phenomenon in depth, but it limits the generalizability of conclusions (Karlsson, 2016). Further, when only one case is used, there may also be other potential problems. These include the risks of biases such as misjudging the representativeness of single event and exaggerating easily available data. In order to choose the case for this study, convenience sampling is used. Convenience sampling is a type of non-probability sampling where a case is chosen based on certain criteria. These criteria were size, geographical location and availability. For the single case study, a dental organisation located in the Netherlands was chosen. The chosen organisation has several locations in the Netherlands and due to its size, it is more likely that operations strategy is perceived as important within the organisation. Furthermore, conducting the interviews fits in their planning. In this research, the unit of analysis is healthcare organisations located in the Netherlands.

3.2. Data collection

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17 between locations and the data of the fourth location, compared to the three before, had diminishing returns. Therefore, the total amount of interviews conducted is twelve. All these interviews were semi-structured. According to Ryan et al. (2009), semi-structured interviews involves a standard set of open-ended question that allow for spontaneous and in-depth responses. Further, semi-structured interviews can reduce the difficulty of finding similar themes and codes during the coding process (Karlsson, 2016). Therefore, all the interviewees were asked the same questions. In order to support this process and increase reliability, an interview protocol is used. The usage of an interview protocol reduces the possibilities for researcher bias. The interview protocol was developed around the conceptual framework and can be found in Appendix A (in Dutch) and Appendix B (in English). The interview protocol starts with general questions about the employee and the organisation. After that, more specific questions regarding the elements of the framework, presented in section 2.4., were asked. These elements are: patient needs regarding quality of the service, financial aspect and patient satisfaction; the operations capabilities of the healthcare organisation regarding information technology, organisation & development and process technology; the requirements of the other stakeholders regarding quality of service, financial aspect and patient satisfaction; and the effects these elements have on the reconciliation process. All the interviews were conducted in face-to-face conditions. Since the interviews were conducted by one researcher, the interviews were recorded. This also guarantees high quality transcripts of the interviews afterwards. All the interviews were conducted in Dutch, because the native language of the interviewees is Dutch. This allows the interviewees to express themselves in the most natural way. Due to the usage of semi-structured interviews the time necessary per interviewee fluctuated. In discussion with the healthcare organisation the interviews were planned for one hour. This allows the researcher to anticipate and get a deeper understanding of the given responses. The given responses of the interviewees are validated during the interview by asking and summarizing answers in order to avoid misinterpretation. Eventually, all the interviews took between 40 and 55 minutes. The experience of the employees working at the healthcare organisation varied from 8 months to 5 years. For ethical reasons the interviewees are anonymized. Further, the data collected is confidential between the researcher and the interviewees. Transcripts will not be provided in an appendix. The interviews were conducted on entirely voluntary participation and interviewees were offered to stop the interviews at any time.

3.3. Data analyse method

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autonomy of each location. In this research, the coding scheme suggested by Strauss and Corbin (1990) is used, because it is respected and used by many researchers (Karlsson, 2016). Open coding, the first step, is used to identify concepts and corresponding properties. This is executed by using line-by-line analysis, which provides the best understanding in order to discover concepts, categories and uncover relationships in the beginning of a study (Strauss and Corbin, 1990). Since the interviews were conducted in Dutch during the coding phase a conversion to English was made. An overview of the codes, the number of occurrences and the definitions of the codes is presented in Appendix C. The second and third step of the scheme, suggested by Strauss and Corbin (1990), is to group the identified concepts into categories (axial coding) and select core categories and relating to other categories (selective coding). These categories were mainly formed based upon the theoretical background. Examples are the stakeholders, the financial performance objectives and the quality of the service. A complete overview of these core groups and corresponding concepts can be found in Appendix D. Atlas.ti was used as supportive software for this analysis. Findings retrieved from the data reduction were visualized and expressed in the form of tables, diagrams and interview quotes.

3.4. Quality criteria

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4. Findings

In this section, the main findings related to sub-questions are presented. These findings are retrieved from informal conversations, observations and interviews with employees of the chosen healthcare organisation. As mentioned in the methodology, the ch sen healthcare organisation is a dental organisation. This organisation has several locations in the Netherlands. The locations provide complete dental care, including general dentistry, dental hygiene, endodontics, orthodontics and implantology. Further, for ethical concerns the chosen organisation is anonymized. In section 4.1., the patient needs are discussed. In section 4.2., the requirements of the other stakeholders are discussed. In section 4.3, the operations capabilities of the healthcare organisation are presented. In section 4.4, the findings regarding the reconciliation process of patient needs and the requirements of the other stakeholders with the operations capabilities are explained.

4.1. Patient needs

During the interviews the patient needs regarding the healthcare organisation have been researched. As a starting point the themes quality of service, financial aspect and patient satisfaction are used. Further, the interviewees were asked whether there were patient needs that could not be placed within the themes. According to the interviewees this was not the case. Due to the time and the maximum word constraints, the factors that are mentioned by less than four interviewees are not presented as main findings. An overview of the factors related to the themes can be found in table 2. An overview of all the factors related to the themes of patient needs can be found in Appendix E.

Theme Factors Mentioned

Quality of service Communication 12

Long-term solutions 6 Pain during treatment 5 Financial aspect Financial information 12

Insurance budget 5

Patient satisfaction Quality of service 12

Financial aspect 12

Communication at the location 12

Accessibility 9

Waiting times 8

Clean location 7

Availability 4

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The first theme that is discussed with the interviewees is the patient needs regarding the quality of the service. All the interviewees mention that due to missing expertise, the average patient is not able to measure the quality of the service delivered by the care provider. For example, an employee who mentioned this, said the following:

“Quality is not measurable to the average patient. The average patient for example does not know whether a filler is correctly placed and whether there is dirt under the filler.”

However, the interviewees identified other patient needs that are related to the quality of the service provided. All the interviewees mention that patients require good communication between them and their care provider. Within the factor communication, the patients demand information regarding their treatments, including other options and risks. Moreover, the patients desire to discuss together with the care provider which solution fits them best. Furthermore, the interviewees mention that the kindness of the care provider during communication is also important. Patients desire a personal connection with the care provider. According to the interviewees, the patients judge their care providers based on their communication skills and not their technical skills. The following quote is an example of an employee that explains this:

“Due to missing expertise, patients rather choose a care provider who has strong communication skills and a bit less technical skills than a care provider who has better technical skills but less communication skills.”

Moreover, six interviewees identify the factor long-term solutions as a need of patients related to the quality of service. Further, five of the twelve interviewees mention that no pain during the service is also a factor of patient need regarding the quality of service.

The second theme that is discussed with the interviewees is the patient needs regarding the financial aspect. According to all the interviewees, the patients desire to receive financial information regarding their treatments. The patients require no financial surprises. The patients want to know how much a treatment costs; how much is covered by their insurance company; how much budget they still have and what their actual costs are. For instance, an employee who mentioned this, said the following:

“Patients ask the care providers for the cost of a treatment. If the actual costs are eventually higher, due to for example extra treatment that is necessary, the patients start to complain.”

Further, five interviewees mention that the patients’ insurance is another factor of patient needs regarding the financial aspect. The patients in general avoid exceeding their insurance budget. Patients rather choose alternative solution, which do not cost them money. Even when, this solution is not best one. In the long-term this negatively affects the dental health of patients. The following quote is an example of an employee that explains this:

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cleaning underneath the gum is not. Therefore, the patients rather want the treatment cleaning above the gum. Even when they need the other treatment.”

The last theme discussed with the interviewees is the patient needs regarding patient satisfaction. According to all the interviewees, the patients see patient satisfaction as an overarching construct, which also includes the quality of the service and the financial aspect. Further, all the interviewees mention communication at the locations as a factor of patient satisfaction. For example, if their appointment is delayed or cancelled, the patients want to know it. Further, nine interviewees identify accessibility as a factor of patient satisfaction. According to the interviewees, this includes both the transport accessibility and the telephone accessibility of the healthcare organisation. For example, an employee who mentioned this, said the following:

“Further, patients require accessibility of the healthcare organisation, both telephone accessibility as transport accessibility.”

Moreover, eight interviewees indicate that the patients have needs related to waiting times. Patients despise waiting at the locations. Further, seven interviewees explain that the patients require clean locations. Furthermore, four interviewees indicate that the patients have requirements related to the availability of the locations. The patients desire that it is easy to make an appointment in the short term. The following quote is an instance of an employee that explains that some interviewees care more about availability than a personal connection with the care provider:

“Some patients do not care about their personal connection with the dental care provider, the

only want to plan appointments in the evenings.”

4.2. The requirements of the other stakeholders

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Type

stakeholder Stakeholder. Mentioned Theme Factors Internal Headquarter 12 Quality of

service

Right treatment

Compliance related protocols Financial

aspect Compliance related protocols Patient

satisfaction Collaboration _Accessible Cleaning protocol Waiting times Care

providers 6 Quality of service Discussed treatment _{Compliance related protocols} Financial

aspect Patient discussion

Compliance related protocols Patient

satisfaction Waiting time _{Accessibility} Clean location

External NZA 12 Financial

aspect Compliance financial directives Dental

associations 10 Quality of service Compliance dental directives Government 9 Financial

aspect Compliance rules and regulations Quality of

service Compliance rules and regulation Health

insurance companies

9 Financial

aspect Force contract

IGJ 8 Financial

aspect Compliance to the directives, rules and regulations Quality of

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23 The headquarter of the organisation is identified by all the interviewees as an internal stakeholder. The headquarter has different roles within the organisation. Their main role is to support and facilitate all the locations. Further, the headquarter creates and organises trainings for the employees of the locations. Moreover, the headquarter formulates all the protocols for the locations. These protocols are based upon dental directives from the dental associations, financial directives from the NZA and rules and regulations from the government. According to the interviewees, the most important requirements of the headquarter to the locations related to the quality of the service are that the care provides give the right treatment to the patients and that these treatments fully comply with the dental, hygiene and cleaning protocols for each specific service. The requirements of the headquarter related to the financial aspect is that the locations comply with the financial protocols. The requirements of the headquarter related to patient satisfaction are that locations listen to the patients. Further, the locations should work together with the patients. Moreover, a requirement of the headquarter is that the locations are accessible for the patients. The locations also have to minimalize waiting times. Last, the locations have to comply to the cleaning protocols.

Further, the interviewees indicate the care providers as internal stakeholders. The care providers are dentists, dental hygienists, paro-prevention assistants and the prevention assistants. According to the interviewees, the most important requirements of the care providers related to the quality of the service are that patients receive the treatments which they discussed with the care providers. Further, all the treatments have to comply with the protocols of the headquarter. The requirements of the care providers regarding the financial aspect is that they discuss the financial aspects with the patients. Further, an requirement of the care providers is that they comply to the financial protocols of the headquarters. The following quote is an instance of a interviewee that mentioned that discussing the financial aspect is important to care providers:

“It happens often that patients do not want to exceed their insurance budget. In those cases, the care providers always discuss with the patient, for example, postponement of a specific treatment.”

According to the interviewees, the main requirements of the care providers related to the patient satisfaction is that the patients do not have long waiting times. Moreover, the locations should be accessible and clean.

The first external stakeholder all the interviewees mention is the NZA. The NZA is an independent organisation, which is part of the Dutch government, that sets the maximum treatment prices for all the healthcare organisations and health insurance companies in the Netherlands. Further, the NZA controls the healthcare organisations and health insurance companies in the Netherlands. The NZA only has a requirement related to the theme the financial aspect. Their requirement is that the healthcare organisation complies with their financial directives.

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dental associations are an important stakeholder. Their requirement is related to the theme quality of service. The organisation has to comply with the dental directives formulated by the dental associations.

Third, the interviewees indicate that the government is an external stakeholder. The government can change rules and regulations, which can affect the healthcare organisations. According to the interviewees, these rules and regulations are related to the themes, the quality of the service and the financial aspects. The employees mention that within both themes the organisation has to comply with the AVG law, which is concerned with data protection regulations.

Fourth, nine interviewees also indicate health insurance companies as external stakeholder. The health insurances companies affect the healthcare organisation both directly and indirectly. The health insurances companies are covering the treatment cost of patients. They have to comply to the maximum treatment cost of the NZA. However, they can also decide to cover less than the maximum treatment cost for more complex treatments. This affects the patients, who on their turn affect the healthcare organisation by avoiding expensive treatments. According to the interviewees the health insurance companies have a requirement related to the theme financial aspect. They require the organisation to sign a contract with them. Otherwise the cover less than the maximum treatment costs.

In addition, eight interviewees indicate the IGJ as an external stakeholder. The IGJ is an organisation that is part of the government. According to the interviewees, it is an powerful stakeholder. The IGJ controls the healthcare organisation regarding the dental directives and other rules and regulations related to the services of healthcare organisations. The requirements of the IGJ relate to the themes, the quality of the service and the financial aspect. Their main requirement is that the chosen healthcare organisation complies to the directives, rules and regulations formulated by the dental associations, the NZA and the government. The power of the IGJ is explained in a quote of one of the employees:

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25 4.3. Operations capabilities of healthcare organisations

During the interview the operations capabilities of the healthcare organisation have been studied. As a starting point the themes information technology, organisation & development and process technology are used. Further, the interviewees were asked whether there were operations capabilities that could not be placed within these themes. According to the interviewees this was not the case. Due to the time and the maximum word constraints, the factors that are mentioned by less than four interviewees are not presented as main findings. An overview of the factors related to the themes can be found in table 4. An overview of all the factors related to the themes of patient needs can be found in Appendix G.

Theme Factors Mentioned

Information technology Information system on patient level 12 Information system on employee level 12 Employee information system 12 Information system for enchiridion 12 Organisation &

development Mix employees 12

Case discussion 7

Educational background 5

WIP training 4

X-ray training 4

Process technology Microscope 9

Dental operating chair 7

3d scanner 5

X-ray tube 5

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The first theme discussed with the interviewees is the operations capabilities of the healthcare organisations regarding information technology. According to the interviewees, the same information systems are used in all the locations of the healthcare company. The most important system is the information system on patient. Within this system the patients and treatment rooms are planned. Due to the required dentists with specialisms, special treatment rooms and special tools for the more complex services, patient planning in the locations is crucial. Moreover, in the information system on patient level the patients’ dossiers are stored. Furthermore, within the information system on patient level, there is also a sub-system which can show patients’ information regarding their insurance budget, based on only the healthcare organisation, their dental insurance and coverages can be found. The following quote is an instance of an employee that explains this:

“Within the information system on patient level, we have a system that allows us to give the patients an indication of their insurance budget, but only based on the treatments that happened at this organisation. If the patient wants to be sure, he has to call his health insurance company.”

Further, there is an information system on employee level. Within this system the employees are planned, and the vacation hours and absence are administered. Since the patient planning is crucial, the planning of the care providers is also important. It is important for the locations to plan the dentists with the right specialisms in the right treatment rooms. Closely related to the information system on employee level is the employee information system. Within this information system all the other information of the employees can be found. The interviewees mention that the information system on employee level and the employee information system have overlap. However, the information systems are not integrated. Some interviewees mention that this results in frustrations. This shows an important fact regarding information systems, if a healthcare organisation chooses to use specific software, a good understanding is required of the possibilities and limitations of these software packages. Especially, the integration with other information systems. Last, there is an information system for enchiridion. The interviewees mention that this information system includes all the protocols related to the healthcare organisation. The protocols in this information system are dental protocols, employee protocols, cleaning protocols, hygiene protocols and financial protocols. Each kind of service provided by the location has its own dental protocol. The other protocols are related for the all the activities in the locations. For example, an employee who mentioned the information system for enchiridion, said the following:

“The information system for enchiridion is a system that is mainly used to look up protocols. Not only dental protocols, but also protocols related to hygiene and employees.”

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27 regarding dental hygiene is categorized in three classes based on the DPSI-score (Dutch periodontal screening index). The class with the highest DPSI-score, the worst dental health, is treated by the dental hygienist. The class with the middle DPSI-score is treated by the paro-prevention assistants. The class with the lowest DPSI-score, the best dental health, is treated by the prevention assistants. Further, the locations have receptionists and other employees. Moreover, eight interviewees mention that the dentists of the organisation discuss cases. These case discussions are organised by the dentists. In these case discussion sessions, the dentists discuss treatment plans and explain their preferred treatment plan among each other. The preferred treatment plans of the dentists can differ due to their experience and specialisms. The following quote is an instance of an employee that explains this:

“A dentist with a particular specialism would maybe tend earlier to a treatment plan related to that specialism.”

Furthermore, five of the interviewees indicate all the employees who practice clinical work at the locations have an educational background. The dentists have studied dentistry at the university. The dental hygienists have studied dental hygiene, which is higher professional education. The paro-prevention and prevention assistants completed an intermediate vocational education. For example, an employee who mentioned this, said the following:

“All the employees working clinical at the locations have a background education. The prevention assistants, para prevention assistants, dental hygienist and dentist.”

Last, four interviewees mention that all new employees of the organisation have to do a WIP-training and a x-ray WIP-training. The WIP-WIP-training is concerned with infection prevention. The new employees can follow the WIP-training online. The x-ray training is concerned with making x-ray pictures, using the x-ray machines and the risks of x-ray.

The last theme discussed with the interviewees is the operations capabilities of the healthcare organisations regarding the process technology. Nine of the interviewees mention the microscope as capability of the organisation related to process technology. The microscope is mainly used for root canal treatments. This treatment is related to the endodontics service of the healthcare organisation. The microscope enables the care provider to see the canals of the tooth better. This increase the quality of the root canal treatment. For instance, an employee who explains the microscope, said the following:

“During a root canal treatment, all the canals of the tooth are hardly visible to the naked eye. The microscope eases this process and also enables the care provider to work more specific.”

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x-ray tubes. In every treatment room an x-ray tube is installed. Therefore, all the treatment rooms are also provided with x-ray protection. The x-ray tubes allow care providers to make bitewings within the treatment room. With the bitewings, dental caries can be identified more easily. Dental caries is cavity formation in the teeth. The x-ray tubes are mainly used for the services regarding general dentistry. The following quote is an example of an employee that explained this:

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29 4.4. Reconciliation process

During the interview the reconciliation process in the healthcare organisation of the customer needs and the requirements of the other stakeholders with the operations capacities have been extensively studied. For the healthcare organisation, it is possible to find some kind of relationship between each performance objective and every operation capability. However, due to time and word constraints, the findings are confined to some critical issues described by the interviewees. An overview of these issues can be found in the operations strategy matrix (figure 5.). In this section these issues are in-depth analysed.

Quality of service

Under-utilization of microscope WIP training open to multiple interpretations Misfit of the implants Financial performance objectives Minimising financial surprises

Customer satisfaction Decrease waiting

time

Information

technology Organisation & development Process technology

Figure 5. Operations strategy matrix healthcare organisation.

The first critical issue analysed is the under-utilization of the microscope. As explained in section 2.3., the microscope is mainly used for root canal treatments, but also for treatments related to implant. This treatment is related to the endodontics service of the healthcare organisation. The microscope enables the care provider to see the canals of the tooth better. This increase the quality of the root canal treatment. The microscope is introduced by the headquarter, because it increases the quality of root canal treatments. However, the usage of a microscope is not compulsory according to the dental directives formulated by dental associations. The interviewees indicate that the usage of the microscope in the dental

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organisations will be mandatory in the future. Before introducing the microscopes to the locations, the headquarter had discussions with the locations. After these discussions, the first microscopes were placed. In the agreeing locations, one microscope was placed at the ceiling of one treatment room. The interviews revealed that the microscopes were large investments, but after a period the headquarter and the locations realised that the microscope underutilized. The following quote is an example of an employee that mentioned this:

“The new microscope was not used often for root canal treatments in the locations”.

This resulted in a dilemma for the organisation. In order to meet the customer need of long-term solutions and the requirement of the headquarter that the microscope should be used more often, the organisation eventually adapted their information system on patient level and their information system on employee level. The reasoning behind this is that the microscope is fixed to the ceiling. The microscope was only available in one treatment room, but the root canal treatments were provided by dentist in different treatment rooms. Therefore, the microscope was under used. The organisation made the choice to plan all the service related to endodontics in the treatment room with the microscope on one day of the week. In line with this planning, the dentists with the specialism in endodontics were scheduled in the same treatment room for that specific day. All the root canal treatments are now performed with the usage of the microscope. For instance, an employee who mentioned the change, said the following:

“The patient planning and employee scheduling in the information systems was changed. All the root canal treatments could only be planned in the treatment room with the microscope on Wednesdays.”

The second critical issue analysed is the WIP training. The WIP training is concerned with infection prevention. Before new employees can start working at dental organisations, they have to complete the WIP training. This is an compulsory regulation, created by the government. The IGJ controls, among other rules and regulations, the compliance of dental organisations. According to the interviewees, the general WIP training consists of wordy information. Further, there are many ways to interpret this information. The following quote is an example of an employee that mentioned this:

“The information of the WIP training is really wordy and can interpreted in different ways.”

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31 overall risk of infection. For instance, an employee who mentioned the change, said the following:

“The headquarter designed and developed an online version of the WIP-training”.

The third critical issue analysed is the misfit of dental preparations. First, the dental preparations for the services related to implantology were made by using mouldings. The prints of the mouldings were made in the locations of the healthcare sector. After the prints are made, these prints are sent to the supplier. The supplier, a dental lab, makes the dental preparations based on the prints received from the dental organisation. The supplier, on their turn, send back the dental preparations. Some of these dental preparations do not perfectly fit in the mouth of the patients. In line with the dental directives of the dental associations, which are controlled by the IGJ, the dental preparations need further adjustments at the dental organisation. The main reason behind this problem is that in the process of making prints by using the mouldings, mistakes which result in imperfect prints are easily made. The following quote is an example an employee that explains this:

“Sometimes a dentist is unsatisfied with the dental preparations provided by the dental lab, but didn’t they make a good moulding print themselves.”

This resulted in a dilemma for the dental organisations. To deal with this problem the dental organisation looked in options to avoid making prints by using mouldings. In discussion with the dental labs, the dental organisation made the choice to introduce 3d-scanners some locations. The 3d-scanner uses a toothbrush with censors and cameras to make a digital three-dimensional print of the teeth and jaws. The introduction of the 3d-scanners changed the overall process in the service related to implantology. Currently, the dental prints are made by using the 3d-scanner. After these prints are made, the dental preparations can be digitally designed by the dentists with the specialisms in implantology. Next, the dental prints with the designs for the dental preparations are digitally sent to the dental labs. Within the dental labs, the digital prints are directly milled by a machine. This new process enormously reduces the time to make dental preparations. By making the choice to introduce 3d-scanners, the dental organisation increases the quality of their service related to implantology. The dental preparations produced with the 3d-scanner fit perfectly. Therefore, the pain of the patients during the placing of the dental preparations decreases. Further, the dental preparations last longer due to their perfect fit. Moreover, the process of making the dental preparations are faster. Therefore, the waiting times of the patients are reduced. In addition, the dental preparations which are made by using the 3d-scanners are perfectly in line with the directives of the dental associations.

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organisations. Therefore, the care providers always mention that the patient should contact their insurance company for the exact amount of insurance budget. The costs of all the treatments in the dental care are determined by the NZA. These are the maximum treatment cost the healthcare organisations and insurance companies in the Netherlands can apply. In all the dental organisations in the Netherlands, the treatments cost always equal these maximum costs determined by the NZA. According to the rules and regulations of the government and the NZA, the dental organisations in the Netherlands are obligated to give a treatment tender to the patients when the treatment costs for the created plan exceed 250 euros. However, the interviewees indicate that treatment costs under 250 euros also can be perceived as expensive for the patient. Most complains the dental organisation receives are related to the financial surprises of the patients. The following quote is an instance of an interviewee that mentions this:

“90% of the complaints we receive as organisation are related to the financial aspect of the services”.

In order to overcome this dilemma, the dental organisation made changes in their information system for enchiridion. In this information system all the protocols of the dental origination can be found. In the financial protocols, which are based on the financial directives of the NZA and government, the dental organisation made the choice to provide the patients tender agreements when the actual cost for a treatment is higher than 150 euros. The interviewees indicate that the reason behind the minimum of 150 euros is that the treatments which cost more than 150 euros are related to the more specific services provided by the dental organisation. The treatments related to general dentistry, for example, do not exceed 150 euros. By making this choice, the dental organisation enhances patient satisfaction and also complies to the government and the NZA.

The fifth critical issue analysed is related to reducing waiting time. Within the dental organisation, x-ray tubes used are to make bitewings. With the bitewings, dental caries can be identified. Dental caries is cavity formation in the teeth. In the past, the dental associations formulated a new directive which indicated that x-ray photos of the patients’ mouths have to be made every two years. The interviewees mention that due to changes in the dental directives, problems related to waiting times in the dental organisation arose. In the dental organisation several locations had a specific room where the x-ray photos were made. In line with the rules and regulations of the government, these specific rooms were also provided with x-ray protection. However, due to the change in dental directives, the amount specific rooms for x-ray photos could not comply with the demand for x-ray photos. Therefore, waiting times arose. This resulted in a dilemma for the dental organisation. The choice the dental organisation made, was to place an x-ray tube in every treatment room. By doing this, the dentists did not have to transfer their patients to the special rooms for x-ray photos. By making this choice, the dental organisation had to provide every treatment room with x-ray protection in order to comply with the rules and regulations of the government. After, placing the x-ray tubes and x-ray protection the dilemma regarding the waiting times is solved. The following quote is an example of an employee that mentions this:

Operations strategy in healthcare organisations