A supply chain perspective on the influence
of integration on variability: A case study
Master Thesis, Supply Chain Management
University of Groningen, Faculty of Economics and Business
June 24, 2019
Christel de Winter
s2729032
k.b.m.de.winter@student.rug.nl
Supervisor: prof. dr. J. T. van der Vaart
Co-assessor: R. E. Gifford
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ABSTRACT
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TABLE OF CONTENT
1. Introduction ...3 2. Theoretical background ...5 2.1 Variability ...5 2.2 Integration ...6 2.3 Conceptual model ...8 3. Methodology ...10 3.1 Research design ...10 3.2 Case selection ...10 3.3 Research setting ...12 3.4 Data collection ...13 3.5 Data analysis ...16 4. Findings ...17 4.1 Within-case analysis ...17 4.2 Cross-case analysis ...22 5. Discussion...305.1 Variability within the hierarchical levels ...30
5.2 Differences between flows ...31
5.3 Obstacles within the relationship ...32
6. Conclusion ...34
6.1 Theoretical implications ...35
6.2 Managerial implications ...35
6.3 Limitations and further research ...35
7. References ...37
8. Appendices ...41
Appendix A: Interview protocol ...41
Appendix B: Questionnaire...42
Appendix C: Coding tree ...46
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1. INTRODUCTION
Hospitals are critical in our society, as they play a vital role in the improvement of the quality of our lives. However, hospitals are very complicated as well, with all kinds of inefficiencies (Amony et al., 2015). One of the inefficiencies that hospitals deal with is the high level of variability in the patient flows (Bittencourt et al., 2018). Variability in the patient flow can be caused by the hospital itself, called artificial variability. For instance, an unstable planning caused by variability in capacity, which in turn leads to peaks and valleys by treating each day a different number of patients (Litvak et al., 2005; Lega et al., 2013). This variability can over time lead to delays, queues, and unnecessary waiting times (Bittencourt et al., 2018; Eriksson et al., 2011; Villa et al., 2009; Salzarulo et al., 2011). So, changes are needed, because patients are affected by the discontinuity of the flow as it causes uncertainties and endangers the quality of care. (Villa et al., 2014; Drupsteen et al., 2013; Litvak et al., 2005).
Improving the patient flow is not something that is done easily, since patients have to go through different interrelated departments. However, proper integration in terms of coordination, information sharing, and interaction between the different departments can enhance the patient flow (Abraham and Reddy, 2010). As those activities give more insights in the different steps of the patient flow and help find the cause of variability. Moreover, once found an attempt can be made to eliminate the source of variability (Drupsteen et al., 2013; Keel et al., 2017).
In practice, variability reduction is not as easy as it occurs. Indicated is that this is due to the complexity in capacity planning (Litvak et al., 2005). This makes it interesting to explore the impact of integration on the reduction of variability within the patient flow, in order to better understand why the reduction is still difficult and what the role of integration contains.
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In addition, literature makes distinctions in integration in the form of the scope, the span, and the intensity of integration (Drupsteen et al., 2013). However, integration is not yet considered in terms of different hierarchical levels, which can be operationalized in the strategical, tactical, and operational level (Vissers et al., 2001). It adds value to the study as it distinguishes the decision-making on each level in terms of the time that it covers. What relates to the detail of information that is available on the moment of the decision. This influences the extent of their opportunities to control capacity problems (Hans et al., 2012).
Therefore, the contribution of this study will be twofold. First, it gives an overall perspective on the interdepartmental integration on each hierarchical level, which is currently unexposed. Secondly, it explains how integration helps with the reduction of artificial variability per hierarchical level and what the differences contain. Where the variability reduction is viewed by the proposed steps of Smith et al. (2013); (1) identification, (2) quantification, and (3) elimination. This provides structure in the analysis of how variability is reduced, and it gains a better understanding of how variability is handled. More knowledge on this phenomenon is essential as it can provide more insight in how to stabilize the patient flow. This led to the following research question:
How does integration on different hierarchical levels contribute to the reduction of artificial variability?
In order to gain an understanding of this relationship, an in-depth multiple-case study will be conducted in a medium-sized hospital in the Netherlands. The case study will have an explorative nature in order to gain insights into the ways of integration and its influence on variability reduction in the patient flow.
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2. THEORETICAL BACKGROUND
This chapter explains the key concepts of this study. First, the concept of variability will be explained, where the three steps of variability reduction will be discussed. Next, the concept of integration at the different hierarchical levels is explored. Lastly, the conceptual model will be presented.
2.1 Variability
The patient flow can be disrupted due to variability. Literature distinguishes two main types of variability, natural variability and artificial variability (Litvak et al., 2005). Natural variability is difficult to control as it results from the random needs of individual patients (McManus et al., 2003). In principle, it should be possible to control artificial variability, which is defined by Roemeling et al. (2017) as: “artificial variability is created by one’s own actions, such as introducing rules and legislation.” This type of variability is controllable and non-random. It can be caused by capacity scheduling that causes peaks and valleys in the flow (Litvak et al., 2005; McManus et al., 2003). For instance, poor allocation of operating room (OR) time results into distortion in the flow when sessions are divided unevenly throughout the week, which in turn leads to variability in the demand for staff and beds (Villa et al., 2014). Therefore, a stable capacity planning causes more regularity. However, variability may still arise in the volume of patients treated. When a double amount of patients had surgery on one day versus the day before, by scheduling shorter surgeries at that day (Litvak et al., 2005). This is related to patient mix variation when more difficult patient groups are treated at certain days, which cause a higher duration of surgery time.
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impact, with the final step of reducing the variability. This study will use this terminology to investigate how variability is reduced.
So, the first step in the reduction of variability is the identification stage. Which is about knowing the forms and sources of artificial variation. It is a necessity to be aware of where variability has its origin, in order to make sure the source is artificial and not natural variability (Litvak and Long, 2000).This provides a foundation of being able to deal with the variability in the patient flows.
The next stage is quantification. Quantification is necessary to determine the quantity, size and impact of the variability that is present. This can be measured, by taking into account the deviation of a stable pattern (Litvak and Long, 2000). This can be seen in the number of new patients, radiology requests, or the outflow of patients from the OR. Measures that can be performed are queue overviews, monitoring capacity by using control charts (Eriksson et al., 2011; Bittencourt et al., 2018), or by process mapping (Molema et al., 2007). This step is important in deciding whether or not the occurring variability has an impact that is worth mentioning.
Lastly, variability should be eliminated. This contains the actions that are taken by the hospital in order to actually reduce variability. Hence, when it is clear where the variability originates and the impact is evident solutions must be found. Therefore, the management of resources is essential (Litvak and Long, 2000). Besides, the elimination must contain a solution for capacity variability as well as for the scheduling of patient volume and patient mix.
2.2 Integration
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and the amount of information will be different on each hierarchical level (Hans et al., 2012). Furthermore, the time period concerning the responsibilities differentiates between the strategic, tactical and operational layers (Vissers et al., 2001).
This study will work with those hierarchical levels to investigate the integration practices and their interaction with variability reduction.
2.2.1 Strategic integration
The first level that is discussed is the strategic level. Vissers et al. (2001) argue that the strategic level is the responsibility of the higher management and the scope in which they act is on the long run, from two till five years. The strategical layer comprises two components. First, the corporate responsibility of an overall strategy for the hospital, involving a mission to pursue (Hans et al., 2012). Where the complete in- and outflow of patients is considered, and close attention is paid to the lead times. Secondly, a more functional responsibility is forecasting the necessities for the different specialisms and determining the long-term capacity (Butler et al., 1992). The capacity should be arranged for each process step, in order for supply to meet demand. How effective the capacity planning is for the patient flow depends on the interaction between the different departments. Meetings could be arranged and information shared in order to create alignment. Such cross-management interactions may help to structure capacity plans (Hans et al., 2012).
2.2.2 Tactical integration
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can be discussed. What will provide clarity about staffing, planning and scheduling to allocate the right materials and resources (Roth and Van Dierdonck, 1995).
2.2.3 Operational integration
Lastly, integration on the operational level. This layer can be explained by Vissers et al., (2001) as: “operational control involves short term activities, typically executed by lower levels of management and non-managerial personnel to carry out efficiently the day-to-day activities of the organization.” The functionality is twofold; (1) it concerns short-term decision making, and (2) reactive operations control (Hans et al., 2012). The former covers dealing with capacity in terms of patient and resource scheduling and operational planning for their unit. The latter concerns dissolving occurring problems, for instance in bed occupancy (Roth and Van Dierdonck, 1995). At this point more information is available about the patient and whether or not the patient will go to a subsequent department. The departments should depend on each other in order to make decisions that contribute to a more stable flow (Hans et al., 2012). Integration by having short gatherings can create opportunities to discuss problems.
2.3 Conceptual model
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The problems mentioned above are based on decisions, procedures and actions on a certain hierarchical level. All the hierarchical levels have, to a certain extent, influence on the capacity. The capacity for an independent department is controlled by the strategic level. Where the tactical and operational level control the capacity per department for a certain specialism. The planning activities on each level have in the end influence on the operational execution (Hans et al., 2012). Each level should know how their decisions cause variability, what the impact is throughout the chain, and find solutions to eliminate it. However, each level has to deal with different complexities and has different information available. By sharing and discussing all available information and considering variability on each level it is more likely to reduce variability (Drupsteen et al., 2013). Integration in terms of communication can help find sources of variability as it would be beneficial for clearing out misunderstandings, because consistent decisions are needed to make the capacity plans work (Butler et al., 1992).
In conclusion, this study will explore the relationship, while involving the variability reduction steps. This in order to know how the hospital deals with the process of reduction. The relation is shown in the conceptual model (figure 1).
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3. METHODOLOGY
This chapter provides insights into the research design of this study. The structure, approach, and methods that were used will be discussed. In addition, the data collection is explained followed by the analysis that is performed to be able to answer the research question.
3.1. Research design
The aim of this study is to find out how the relationship between integration and variability is established on the different hierarchical levels. A case study design allows for further exploration of this relationship in a real-life setting. Case studies prove to be suitable as it is a method in which ‘what’, ‘how’, and ‘why’ questions can be answered extensively (Voss et al., 2002). An embedded multiple-case design was taken, as multiple cases of specialisms within one hospital were explored (Yin, 2003; Yin, 1981). Voss et al. (2002) distinguished four types of contribution that a case study can provide; exploration, theory building, theory testing, and theory extension/refinement. This paper has an explorative nature to gain more understanding of this phenomenon, whereby an abductive approach was followed. What first of all led to an expansion of the theory, by gaining new insights. And secondly, through empirical observations, unexplored areas in literature were identified (Dubois and Gadde, 2002). This research is conducted in a Dutch teaching hospital, where suitable cases were selected and additional data was gathered.
3.2. Case selection
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Selection criteria were used to find the specialisms that are most suitable to explore the relationship. Explanations that were predictable, such as complexity and size differences, were excluded by selecting cases that are similar. More complexity entails differences in the arrangement of integration and makes it harder to reduce variability (Litvak et al., 2005). The size of the flow is related to the capacity needed, since fewer physicians are needed if there are less patient to treat. What entails that the absence of one physician causes more variability if, for instance, one out of four is absent than if one out of twelve is absent. So, a simple linear flow and large chains were selected expecting that the effect of the integration can be discerned better and other influences could be found. Another criterion was based on variability in the patient flows presented in figure 2 and 3. The theoretical replication logic was used, as searched was for cases with a different degree of variability. The cases were expected to give different outcomes (Karlsson, 2016). Looked was at both variability within the week and among weeks, as both can cause flow fluctuations in other departments. For instance, variability in capacity within the week can lead to problems with combination appointments. And variability among weeks can cause more requests, for example, in the radiology department in one week than the week after that. The different flows were deliberated based on the criteria set, whereby the ear-nose-throat (ENT) and the orthopedics flow seemed appropriated for the above mentioned standards.
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Outpatient
clinic
Radiology
room (OR)
Operation
Nursing
ward
Figure 3: Variability of new patients among weeks. Source: Hospital
3.3 Research setting
So, chosen is for the ENT and the orthopedics flow. The course of the general patient flow of the orthopedics and ENT is illustrated in figure 4. The different departments that a patient flow passes are important for this study. This is due to the integration in terms of interaction and communication needed to get the patient from one department to another department with as less variability as possible.
Figure 4: schematic overview of the patient flow
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more use of the CT scan for their patient groups, in which the former last longer. The time spend in the OR and the length of stay can be explained by the difficulty and intensity of the surgery. Those characteristics are dependent on the type of patient, and therefore on natural variability. However, it is evident that the way of dealing with variability in schedules can weaken or strengthen the effect of natural variability (Litvak and Long, 200). Therefore, it is interesting how both chains handle the different characteristics in their flow and how this manifests in the relationship between the integration practices and the attempt to reduce variability. Besides, those differences build on the earlier mentioned theoretical replication (Karlsson, 2016).
Characteristics of the chains ENT Orthopedics
Use of radiology Less More
Average time spend at the operating room
Less More
Length of stay Short Long (relatively)
Patient flow Linear Linear
Table 1: Overview of characteristics
3.4 Data Collection
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the planning and control of the capacities. Their coordination and decision-making directly influences the variability experienced in the flow.
Figure 5: Organizational chart. Source: Hospital
Semi-structured interviews were prepared in order to gain as much information. In this way the possibility for more depth is still accessible. An interview protocol was made in order to ensure validity (Appendix A). In total twelve interviews were conducted to gather information from different perspectives (table 2). Two versions of the interview were prepared to be able to ask targeted questions (Appendix B). One at the strategic and tactical level for the care process managers, the capacity managers and medical coordinators. And another version for the unit heads, as they operate on a tactical level and coordinate the operational level. The questions of the different versions were relatable.
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Interviewees Interviewed for Available for interview
1 Care process manager basic care Strategic and tactical level Yes 2 Care process manager expertise areas Strategic and tactical level Yes 3 Capacity manager outpatient clinic Strategic and tactical level Yes 4 Capacity manager medical support
departments
Strategic and tactical level Yes
5 Capacity manager medical specialist capacities
Strategic and tactical level Yes
6 Capacity manager inpatient clinic Strategic and tactical level Yes 7 Medical coordinator ENT Strategic and tactical level Yes 8 Medical coordinator orthopedics Strategic and tactical level No 9 Unit head outpatient clinic ENT Tactical and operational level Yes 10 Unit head inpatient clinic ENT Tactical and operational level Yes 11 Unit head outpatient & inpatient clinic
orthopedics
Tactical and operational level Yes
12 Unit head CT & MRI Tactical and operational level Yes 13 Unit head admission scheduling Tactical and operational level Yes
Table 2: Interviewees
Every interviewee was asked permission for recording, while the confidentiality was assured. Besides, they were informed about the time it would take, which was around 50 minutes. Furthermore, to make sure that every interviewee understood the purpose of the study, the flows were visualized and showed to the interviewee. Besides, all the terminology used in the interview was defined beforehand. In this way, the interviewees were aware of how the concepts are used in the research.
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information about the way integration is done at a strategic level. This data can be a supplement or comparison material for the information gathered from the interviews.
3.5 Data analysis
After conducting the interviews, the analysis of the data followed. All recordings were transcribed verbatim and were subsequently uploaded into Atlas.ti. In order to accomplish a well-structured analysis, the content of the data was coded. For this an abductive approach was chosen. The coding process has two main goals, organizing the data and uncovering additional connections (Bradley et al., 2007). The data was reviewed whereby the coding process of Corbin and Strauss (1990) was followed; open coding, axial coding, and selective coding. First, important segments were highlighted and given a code. Those first order codes were partly existing codes and partly open codes, in order to gain new insights. In this way fragments of the interview were grouped into categories. Thereafter, the relations between categories made in the first coding round were explored. Comparisons were made between the multiple interviews, and segments with comparable categories were given the same axial code. The axial codes were partly based on the experience of existing theory and partly on new insights. Those first two steps were performed in an iterative way in order to be able to categorize the codes in the best way possible. The last step in the process was selective coding. In this step the categories of the axial codes were merged into themes that characterize that group of codes. From those main themes conclusions were drawn.
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4. FINDINGS
This chapter is structured as follow; section 4.1 provides the within-case analysis, where an overview is given on the concepts of integration and variability separately for both the ENT and orthopedics flows. Section 4.2 describes the relationship between integration and variability and the differences between the flows in the cross-case analysis. Besides, it shows the obstacles encountered in this relationship.
4.1 Within-case analysis
4.1.1 Strategic hospital policy
The organization of the strategic level is equal for both flows. The integration in the form of meetings and communication structures in which issues can be discussed are represented in table 3. There is the corporate side at which the long-term plans for the complete hospital are discussed. Therefore, portfolio- and production choices and multiannual production budget plans are needed that indicates the direction for the hospitals’ future. The first four rows of table 3 represent mostly the integration of this corporate side. Based on the corporate plans the hospital’s capacity managers make sure that the capacities are in place in order to ensure that supply meets demand, which is the functional side of the strategic level. The integration practices engaged with the capacities are represented in the bottom three rows of the table.
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Type of strategic integration
Parties involved in strategic integration
Description
Multiannual production budget
Board of directors, staff, care process managers
Long term view on the production
Portfolio agreements Board of directors, medical managers, care process managers
Strategic choices on the hospital policies
Production considerations
Medical coordinators, capacity managers, care process managers
Estimation budget and production
S&OP Care process managers, staff Production agreements Multidisciplinary
decisions
Staff, care process managers, capacity managers, medical coordinators
Supportive information concerning important issues (e.g. quality and security)
Service level agreements (SLA's)
Capacity managers, care process managers
Agreements about governance and the production chain
Annual plan Capacity managers, unit heads Strategic plan per cluster SPO Staff, care process managers,
capacity managers
Long term view on capacity demand
Table 3: Integration at strategic level
4.1.2 ENT flow
Tactical
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Parties involved in tactical integration Description
UH outpatient clinic, with: TPM
OR Communication of the operation schedule Admission schedule Communication of the operation schedule Medical coordinator Communication of the physician planning
UH inpatient clinic, with: TPM
OR Communication of the operation schedule Admission schedule Communication of the bed capacity
UH admission schedule TPM
OR Communication of the operation schedule
Table 4: Integration at tactical level, ENT flow
Operational
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Parties involved in operational integration Description
UH outpatient clinic, with:
Personnel Coordination, in line with physician planning OR Feedback moment
UH inpatient clinic, with:
OR Coordination of different flows into the clinic Clinic Consultation with other clinics
UH admission scheduling, with:
Physicians OR scheduling approval
Table 5: Integration at operational level, ENT flow
Variability
The organization of the capacities influence the variability in the flow (Appendix D, I & II). This flow is performing well in comparison with the other specialisms. Taking a closer look indicates that the inflow shows fluctuations. The ENT flow performs on average well on the variability of new patients within the week. As their coefficient of variation is 0,22, which is just slightly higher than the hospital norm of 0,20. However, The variability among weeks is 0,22 as well, which is desired by the hospital at 0,10. Therefore, there is still room for improvement when it comes to the elimination of variability. As this affects the patient flow towards the radiology and the OR. The outflow from the OR towards the inpatient clinic shows a stable pattern. Based on the number of surgeries it is well predictable what the total amount of bed days will be (Appendix D, III).
4.1.2 Orthopedics flow
Tactical
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causes capacity problems. The integration creates the opportunity to respond to the proposed planning. However, only information of the amount outpatient clinic time is available, while more information is needed.
Parties involved in tactical integration Description
UH outpatient clinic and inpatient clinic, with: TPM
Radiology Discussing the bottleneck problems OR Communication of the operation schedule Admission schedule Communication of the operation schedule Medical coordinator Discussing the physician planning
ICM assist with problems
UH admission schedule, with: TPM
OR Discussing the operation schedule
Table 6: Integration at tactical level, orthopedics flow
Operational
Table 7 describes little operational integration in this flow. The operational planning of patients is done in the unit itself as well. And those effects are not discussed between units. Indicated is that they want to stabilize patient inflow in the OR. The outpatient clinic has to adjust its capacity accordingly. Experienced is that this leads to a variable inflow of patients, also in mix and volume, which in turn affects the patient planning of the radiology. Structural communication between departments could clear out misunderstandings and problems that are caused by other departments.
Parties involved in operational integration Description
UH outpatient clinic and inpatient clinic, with:
Personnel Coordination, in line with physician planning Radiology Merging flows
OR/Admission scheduling Coordination irregularities
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Variability
Problems with variability are found within the orthopedics flow. Within the week there is a variation of new patients of 0,36 compared to the desired norm of 0,20. Among weeks the variability measured is 0,20 compared to the hospital norm of 0,10. Especially when zooming in huge fluctuations are found (Appendix D, I & II). This can explain the trouble encountered in the outpatient clinic itself and the sequential process steps. For instance, scheduling combination appointments could directly amplify the variability towards the radiology directly.
The variability found in the outflow from the OR towards the inpatient clinic is not stable or predictable (Appendix D, IV). This can cause trouble in the inpatient clinic, as they have to adapt to the uneven flow.
4.2 Cross-case analysis
4.2.1 Strategic versus variability reduction stages
The strategic level is divided in corporate and functional responsibilities. First of all there is the corporate side, where the overall strategy of the hospital is determined. Found are multiple ways of integration to communicate the production plans. However, the discussion of variability does not play a major role at this point according to the managers, as one of them stated:
“I do not take capacity or logistics into consideration. Consciously. It is my role to flourish the hospital’s strategy. How more growth, the happier I am.”
This means that they do not specifically focus on one of the three stages of variability reduction. However, it can be argued that the choices they make about the strategy can, in the end, affect the amount of variability. For instance, a decision to no longer treat a group of patients from the ENT flow, can impact the flow dynamic and cause more variability. At that moment this is not considered. At the functional side, the capacities for each department are established. What is found is that the capacity managers arrange this for their own department with little interference of other capacity managers or care process managers. The interaction that takes place, is established in the service level agreements. However, variability is not an extensive subject in the arrangement of capacities at a strategic level. Respondents agree that this is something arranged at a tactical level:
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This means there is not searched for other causes or influences with regard to their own actions. The importance of variability reduction at a strategic level is not recognized, so the stages of identification, quantification, and elimination are not pursued at all. So, the awareness of variability is present, however, their opinion about the topic is set. In this way they are not able to find out what kind of impact their decisions may have.
4.2.2 Tactical versus variability reduction stages
Variability is a topic that is clearly present at the tactical level. The integration is structured by several structural meetings and by introducing weekly TPM’s, at which the planning is discussed. Each department has an eight-week planning horizon, and every week another week is attached to the planning. Making this a continuous loop of reevaluation of events. All steps in the flow benefit from this in terms of handling variability. Since the unit heads of different departments also join other TPM’s or invite other people at their TPM when needed. In this way coordination between the steps is better guaranteed. As various topics are discussed, the realization of a stable flow is something that is pursued by all. First of all, the identification stage is present. Generally, there is awareness of variability in the flow and that it is caused by their own scheduling techniques. This applies to the ENT flow, for whom it is clear that the physician planning is a determining factor. Variability is also discussed and identified at the orthopedics flow whenever a problem occurs. For them it became clear in a meeting that the physician planning at the outpatient clinic was not stable and influenced the flow toward the radiology:
“And there is a huge bottleneck. That is because the flow from the outpatient clinic is quite variable, so with them we have structural meetings.”
The next stage of quantification is as performed in both flows. If the source is clear, mainly they respond to it by looking into the issue. Sometimes identification goes hand in hand with the quantification or occurs in reverse order. For instance, when noticing a higher than normal amount of surgery blocks scheduled in a certain week, which influences the flow toward the inpatient clinic:
“That are three to six extra patients and planned on a Monday, Wednesday, and Thursday.
The ward will be filled up.”
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further exploration is done. For instance, the ENT indicated that in the TPM’s it became clear that the way physicians were planned influenced the patient volume in the sequential unit. As an individual physician can work according to other methods and therefore increase the number of requests for the radiology. Now they use data on physician level, instead of specialist level. The orthopedics encounter more problems within their entire flow. At this point, the orthopedics asked help from the capacity managers and the ICM department in order to give insights into the capacity variability and other factors that disturb the flow. However, indicated is that the overall performance of the flow process is far from optimal. Therefore, it could do no harm to take preventive matters in quantifying variability issues related to the capacity, mix of volume.
After the size of the variability is seen and known the flows have to eliminate it. The ENT can really focus on elimination since they generally know where it comes from and what the impact is. Stated is that the physicians are willing to take over working hours from colleagues, in order to fill out gaps. So, they attempt to provide a stable planning throughout the week at the outpatient clinic and try to maintain a stable outflow from the OR to the inpatient clinic. In contrast, for the orthopedics it is hard to eliminate variability. Indicated is that this is due to the overload of patients. However, the main problem is the focus on the OR, which is recognized by the unit heads:
“Their main focus is the OR, they make sure that that inflow remains stable. That means that this causes variability in the commitment at the outpatient clinic.”
When a physician is absent another physician would replace the OR time planned and give up the outpatient clinic time planned. Besides, the outpatient clinic time planned is not replaced for the absent physician as well. At this point, the issue is known and analyzed, but real adjustments are not yet executed. This makes identification and quantification of variability necessary so that minor issues can be recognized and eliminated when possible.
4.2.3 Operational versus variability reduction stages
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they just deal with it, while variability is not directly considered. Elimination can therefore be non-intentionally. Whenever problems occur the reaction is to solve it. When it is fixed properly no one will consider patient flow variability. At the moment it causes more problems, it will be discussed in the TPM. An example was indicated by the radiology department:
“That operational issue, that came forward in the TPM. As a result, we put the secretariat together and told them; the bottleneck is not the radiology, but the lack of communication is the problem.”
Due to miscommunication scans were rescheduled, what hindered the follow-up appointment. Whenever there is time to anticipate actions, it is more likely that variability is considered. So, the ENT will not give back OR time, and carefully reconsiders extra OR time as it directly influences both the flow of the OR and the outpatient clinic. Also, attention is paid to stabilizing both control and new patients, in combination with the patient mix. Besides, both flows provided the admission scheduling department with restrictions in terms of patient planning, related to patient mix and volume in order to provide some guidelines. Though, the orthopedics department will not consider variability in capacity whenever there is offered extra OR time. Indicated is that this is due to the pressure of the waiting list of the OR, and therefore they chose to reschedule their patient planning in order to use OR time whenever possible. However, whenever this leads to more variability, the more problems they will experience concerning capacity.
4.2.4 Overall connections
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variability policy. Since the departments mostly deal with variability individually, not considering variability nor the impact of the patient planning on other departments.
Hierarchical levels
Variability reduction Comments
Strategic - - Awareness about variability
Tactical Identification → Quantification → Elimination
Quantification → Identification → Elimination
- Quantification sometimes superficial - Exchanging of identification and quantification
Operational Identification → Quantification → Elimination
- The identification and quantification occur mostly at a tactical level.
- Attempts to eliminate - Now and then interference
Table 8: Summary; overall differences
Regarding the flows, it is seen that the ENT performs better than the orthopedics in terms of variability. The ENT shows variability, but actively attempts to reduce variability. The orthopedics flow, however, indicates that there are many other difficulties in the planning. What leads to less priority towards reducing variability in capacity, patient mix, or patient volume. Besides, the focus on the OR makes it hard to eliminate variability as the focus is not on the entire flow.
4.2.5 Obstacles
The relations between integration and variability are identified. However, as established variability is still common around both patient flows. Therefore, this section will discuss six factors that inhibit the effect of integration on the reduction of variability in the patient flows.
Physician planning
Variability in the physician capacity creates flow variability. Therefore, a stable physician planning is the start of creating a stable flow. However, a feeling encountered during meetings is that many physicians do not care about variability, because they experience no direct consequences from it, as a manager stated:
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Besides, it is hard to convince them that variability in capacity is really a problem. Those attitudes towards the concepts inhibit the reduction, which inhibits the identification stage. Additionally, they hold autonomy of their own agenda’s causing fluctuations in the planning due to vacations and day offs. And more difficulty is created by having consulting hours, multidisciplinary consulting hours, teaching, surgery, and emergency department. The amount of different obligation in different parts of the hospital complicates a stable planning, which interfered the elimination stage on a tactical level.
Natural variability
At some moments natural variability disturbs the attempts to stabilize the flow. As it can cause a peak in the number of patients, which are recognized by the flows:
“At the moment that there are certain weather conditions, that affects us. Flu epidemics, it affects us.”
Another striking observation is that variability reduction can be distorted by patients preferences. When they are not willing to undergo surgery in certain periods of the year, due to school or vacations. This can cause a huge valley in the patient mix and the patients available for surgery. The hospital can try to be more strict regarding individual wishes, however, they do not do that yet. These kind of influences inhibit the elimination of variability at all levels.
In addition, sometimes people confuse artificial variability and natural variability. When asking about artificial variability, topics surrounding the stabilization of the waiting list were indicated. However, stabilizing the waiting list before the outpatient clinic or OR means adjustments of schedules in order to realize that. This problem can be solved by providing more information about this topic. Because, now it creates a barrier to proper identification of variability in capacity, patient mix or volume.
Division of responsibilities
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responsible for long lead times, so it would be reasonable to discuss it. As this is not done, not even the possible origins of variability in their capacity management are found.
Meeting arrangements
Despite TPM’s and other communication possibilities, not all problems concerning variability are discussed between different parts of the chain. In addition, variability is also not discussed as long as process steps go well, which does not imply that there is no variability. First, there must be a sense of urgency before measures are taken. This can all be due to human traits such as forgetfulness, or underestimating the consequences. This disturbs the identification phase. By making it a standard topic of conversation those inhibitions can be solved.
Undercapacity
Respondents argue that another variable that disrupts the relationship is undercapacity. Indicated is that there are limited ways to stabilize the flow when the capacity is not there to back it up:
“I think you need a bit of space to be able to coordinate. Now everything is totally full. We do not want that. It causes variability.”
However, when variability is reduced a more stable flow is created. Resulting in fewer peaks, which benefits the departments with less capacity. More attention could be paid to explaining the cruciality of the reduction of variability in this situation. This mindset causes a lack of identification of real variability origins on each hierarchical level.
Organizational variables
Obstacles towards variability reduction are sometimes created due to people or procedures of the hospital organization itself. Some situations are complex, as radiology has to handle flows from all the departments, and the planning of the operation schedule has to deal with various planning restrictions. Besides, there are many dependencies, such as physicians in training, or shortage of personnel or information. This was experienced by the radiology:
“But it is hard to estimate when looking at the eight-week period, because the outpatient clinic cannot give the data to me yet. The information is just not available.”
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motivation. Or decisions are made according to other incentives that go against the maintenance of a stable flow. This can counteract when trying to reduce variability as a whole. Creating more awareness and providing more information could possibly counter those barriers. At the moment it still inhibits quantification and elimination on the tactical an operational level.
Looking hierarchically, it is seen that all the inhibitions are interrupting the reduction of artificial variability on certain levels (table 9).
Obstacles Level(s) involved Step(s) distorted
Physician planning Tactical Identification and Elimination
Natural variability Strategic, Tactical, and Operational Identification and Elimination. Division of responsibilities Strategical Identification
Meeting arrangements Tactical, Operational Identification Undercapacity Strategic, Tactical, and Operational Identification
Organizational variables Tactical, Operational Quantification and Elimination
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5. DISCUSSION
This section will discuss the different topics concerning the relation between integration on the different hierarchical levels and variability in the patient flow. First, the influence of the hierarchical levels will be discussed. Followed by a more in-depth view on main differences between the flows. Lastly, this study will discuss the factors that inhibit the relationship.
5.1 Variability within the hierarchical levels
This study takes a closer look on integration and views it from the different hierarchical levels. It became clear that the integration that takes place at the strategic level does not benefit the reduction of artificial variability in the patient flow. This applies to both the corporate as well as the functional responsibilities. Stated is that variability in capacity is no concern at the strategic level, as this should be handled at a tactical level. This is in contrast with literature, that mentions the importance of having a hospital-wide patient flow logistics strategy, in which variability is an important factor (Villa et al., 2014). Besides, their decision and policies can influence the degree of variability encountered in the flow. For instance, when deciding to no longer treat a certain patient group, what will affect the patient volume and mix for a specialism. Or by deciding to change or provide other services in their portfolio. This is supported by Butler et al. (1992), who argue that the strategic levels decision-making influences the planning and scheduling on lower hierarchical levels. Next to this, capacity management is done at a strategic level as well. And found is that they mainly look if the production fits with the capacity for their department, not considering variability. This is in line with the opinion of Roth and van Dierdonck (1995), who state that averages are sufficient for capacity planning at a strategic level and should not explicitly take variability into account. They may not know at this level how the exact planning will be. As due to a lack of information the capacity management cannot influence the way capacity will be planned. However, integral rules, policies and by discussing the impact of choices on the whole chain could help reduce variability in capacity.
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involvement of different units. Here the physician and capacity planning are central to the meetings. Which is important as stable capacity is the first step towards a stable flow. Because, one can try to stabilize the volume of patients, however, this is not possible when there are too few physicians present on that day. Besides, it provides the foundation for the operational level. As the patients are planned on the basis of the capacity schedules. So, if those schedules are not properly arranged it is hard to create regularity in the flow at an operational level. This is in line with Hans et al. (2012) who indicates that the patient planning depends on the allocation of time and resources on a tactical level.
When looking at the particular stages it is seen that identification is merged with the quantification stage. Besides, Smith et al. (2013) and Litvak and Long (2000) indicated the steps of first identification and then quantification. However, the results showed that quantification could happen before the actual identification of variability. By determining variability in the process flow, what subsequently leads to discussing the causes. This would be appropriate as well, as long as it leads to elimination of variability in order to improve the flow.
The variability found in the chains is partly due to the operational level. Variability is not much deliberated from an integral perspective, which is in contrast with the recommendations in literature where the importance is stressed (Roth and van Dierdonck, 1995). Findings imply that issues concerning the patient planning are handled in the concerning department itself. This is not per se beneficial for variability reduction as the patients planning is crucial. Since the capacity might be stable, the planning of patient volume and mix can still be highly differ through time due to poor planning. The planning may work for a single unit, however, it could affect the sequential processes. Besides, the short-term operational problems between departments were sometimes discussed on the TPM. This meeting takes place every week, so problems concerning variability can be dealt with on short notice. A shortcoming is that either the tactical planning conversation shortens the time to discuss operational planning issues or vice versa.
5.2 Differences between flows
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the ENT has not. This means on a tactical level that the orthopedics want to use all the fixed blocks of OR time, whether or not this impacts the availability of physicians in the outpatient clinic. Besides, on the operational level they are willing to accept all other time offered to plan patients in the OR. Indicated was that it was due to the pressure felt by the waiting list and that it was completely full and used every capacity available. However, flows operating near capacity, like the orthopedics, could have enormous advantages when variability is under control (McManus et al., 2003).
5.3 Obstacles within the relationship
Other findings were concerning the inhibition of the relationship between integration and reducing variability. For the identification of variability the source must be clear. However, there is a lack of understanding of the concept of artificial variability. For instance, contradictions are caused when the difference between artificial and natural is not clear. As stabilizing the waiting list is a reaction on natural variability. It causes artificial variability when the capacities are used according to the fluctuations in demand. This is also found in literature as a consequence of dysfunctional management (Litvak and Long, 2000). Besides, negative attitudes towards variability reduction and its necessity are not convenient. Those attitudes are found at the strategical level with the division of responsibility and at the tactical level with the physicians. Also, within the meeting arrangements the sense of urgency about the topic is underestimated. So, this could be better arranged in terms of creating awareness about the sources of variability and provide explanations and information about which role people can play in the reduction stages. Furthermore, there is the concept of undercapacity. This becomes mainly clear at the bottleneck, when there is limited capacity per flow. This concept is explained in literature by the theory of constraints, as the production cannot be more than the pace of the bottlenecks. What in turn leads to buffers (Gupta and Boyd, 2008). However, when there is a greater demand than there is capacity it would lead to a constant growth of the waiting list (Eriksson, et al., 2011), which is not the case. Therefore, the undercapacity experienced in some periods could be due to variability. This means, that there is a misconception about the reason for undercapacity, which does not enable them to search for the real cause.
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differences of physicians request pattern, which affect the variability in the flow. The impact may not be recognized, and will therefore not be eliminated.
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6. CONCLUSION
This research had the aim to gain a deeper understanding of the relationship between integration and variability. This led to the following research question:
“How does integration contribute to the reduction of artificial variability on different hierarchical levels?”
The hierarchical levels provide insights on the different perspectives and involvement on variability reduction in capacity. The strategic level has the responsibility for many important issues, not directly related to capacity planning and scheduling. Their decision-making can influence the way capacity planning is established. Therefore, it is essential that on this level to take into account the effects of their decisions on variability. Besides, integral rules and policies could be discussed, which help create improvements for capacity planning. The tactical level is crucial in the first step of the reduction of artificial variability, as the physician planning is created here. Awareness of the importance of variability can be shared and communicated among different units, through the arrangement of structural meetings and establishing many connections throughout the flow. The impact of inefficient scheduling on the sequential process step becomes clear, which leads to attempts to eliminate the origin of the artificial variability. The operational level builds on the tactical planning and determines the patient planning. A lack of integration at this level causes that decisions are made without considering the consequences for the flow. For the operational level it is of interest to gain a more integral perspective, to justify the efforts taken on a tactical level.
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6.1 Theoretical implications
The theoretical contribution becomes clear in the depth that is given to the concept of integration. As the span, scope, and intensity of integration were already researched, the hierarchical levels not yet. This study provides insight into the contribution of each level and explores the inhibitions encountered. The strategic level can make a difference, as long as they are aware that their decision-making can influence, and therefore also facilitate in capacity planning. Furthermore, the basis of a stable flow is good capacity planning on a tactical level. However, this is in combination with the operational choices for patient planning. Furthermore, the result showed inhibitions which can explain why the relationship is not understood well. From this the patients will suffer, as it causes variability in the flow. Therefore, literature can focus on those inhibitions in the future.
6.2 Managerial implications
Findings from this study can be helpful for managers as an overview of the integration that is present in the hospital is created. This is done per hierarchical level, which provides also insights in what kind of connections there are for each department. Additionally, the results provides clarity in how the hierarchical levels relate to variability reduction. Understanding is gained about to which extent each level contributes to variability and how they do that. Interesting is that the tactical level contributes the most to the relationship, and that improvement are needed on the strategic and operational level. Awareness of inhibitions is created, which can give insight on where to focus on when reducing variability. Found is that much can be solved by changing opinions and providing information. Furthermore, insight into the flows are provided and indicated is where improvements are possible. Besides, adopting the steps of the variability reduction methodology can help to create more structure. As a way of reducing variability is characterized by proper identification, quantification and elimination.
6.3 Limitations and further research
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8. APPENDICES
Appendix A - Interview Protocol
Interview Protocol
- The departments chosen to investigate are based on the criteria for the case selection stated in the methodology chapter.
- In order to get a whole view of the patient flow it is necessary to select a combination of interviewees that represent the whole chain and all hierarchical levels.
- Looking at the function and tasks performed, a division is made between the interviewees performing on strategic and tactical level and interviewees performing on tactical and operational level. Based on this division of the interviewees, two semi-structured questionnaires will be prepared.
- The interviewees are asked and informed by the supervisor who personally contacted them, while explaining the context of the research and the contribution they would deliver to the research. After agreement the time and date will be passed on to the interviewer.
- A simple flow chart will be made to clarify the interviewer's perspective and make sure the interviewees will understand exactly where it is about.
- Beforehand, the interview and the flow chart will be printed and the recording device will be checked.
- There will be one interviewer who does all the interviews, face-to-face.
- Additionally, the interview duration will be attempted to last one hour or less, since the fixed time planned in the agenda’s.
- At the beginning of the interview, the interviewer will ask if the interview can be recorded, and explain that the anonymity of the interviewee is guaranteed.
- The interview script will be followed during the interview, as it makes sure that definitions and explanation will be given beforehand. If further explanation is needed during the interview this will be provided. Furthermore, if answers given by the interviewee are not clear additional questions will be asked to gain better insights.
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Appendix B - Questionnaire
Interview guide (Dutch)
Strategisch en tactisch level:
Personen die worden geïnterviewd:
Medisch coördinatoren, zorgprocesmanagers, capaciteit managers
Dit interview zal ongeveer een uur duren en bestaat uit drie delen, het begint met korte introductie vragen, gevolgd door vragen over de mate van integratie van de patiëntenstroom. Het laatste deel zal ingaan op de door u genoemde integratiemaatregelen. Van te voren zal een plaatje worden getoond om te verduidelijken waar ik op in wil gaan. Daarbij zal ik voor elk deel definities geven. Verder zou ik graag toestemming willen krijgen voor gebruik van opnameapparatuur tijdens het interview. Waarbij vanzelfsprekend uw anonimiteit wordt gewaarborgd bij de verwerking van de informatie in het verslag.
- Laten zien patiëntenstroom KNO en orthopedie, het gaat dus om het proces en hoe de stappen op elkaar zijn afgestemd.
A. Introduction
1. Kunt u uw belangrijkste taken binnen uw functie omschrijven?
2. Wat is het doel van: Kies; Medisch coördinatoren, zorgproces managers, capaciteit managers?
B. Integratie
Het gaat hier om strategische en tactische integratie, waarbij het onderscheid ligt bij in de tijdsduur en perspectief. Strategisch is 2 tot 5 jaar waar het gaat om creëren van gezamenlijk doel en tactisch van 8 weken tot 1 jaar waar het gaat om management controle. Verder gaat het over een geïntegreerde patiëntenstroom, waar het belang ligt bij de afstemming tussen de verschillende onderdelen binnen deze stroom.
3. Wat zijn de lange termijn afspraken/gezamenlijke doelen binnen het ziekenhuis dat zorgt voor een afgestemde patiëntenstroom?
- Wat zijn de strategische plannen om dit te realiseren? - Op welke manier wordt dit gemanaged/gecoördineerd?
4. Hoe wordt er voor gezorgd dat iedereen dit echt nastreeft en zich ernaar gedraagt?
5. Wat zijn de gezamenlijke doelen op middellange termijn die zorgen voor een afgestemde patiëntenstroom?
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7. Hoe zorgt u dat dit alles zowel horizontaal als verticaal op elkaar wordt afgestemd? (zie plaatje, horizontaal is tussen vakgroepen en verticaal is tussen de verschillende clusters)
C. Link tussen integratie en variabiliteit
In het onderzoek kijk ik verder naar de interactie tussen integratie en variabiliteit. Het gaat hier om kunstmatige variabiliteit, die veroorzaakt wordt door het ziekenhuis zelf in de patiëntenstroom. Literatuur wijst uit dat integratie een positieve invloed heeft op variabiliteit reductie. De vraag is waar dat het nu in zit.
Voor elk van de eerder genoemde gezamenlijke doelen op lange termijn en de management van de tactisch doeleinden op middellange termijn kijk ik of daar een relatie is met het zorgen voor reductie van kunstmatige variabiliteit in de patiëntenstroom.
Strategisch
8. Wat voor invloed heeft (vul bovengenoemde doel/strategie in: ...) bij aan het achterhalen van bronnen van kunstmatige variabiliteit in de patiëntenstroom?
9. Hoe draagt (vul bovengenoemde doel/strategie in: ...) bij aan het in beeld brengen van de impact en grootte van de variabiliteit in de stroom?
- Wordt het gemeten?
10. Wat voor invloed heeft (vul bovengenoemde doel/strategie in: ...) bij de daadwerkelijke acties die worden ondernomen om variabiliteit in de patiëntenstroom te reduceren?
Tactisch
11. Wat voor rol speelt (vul bovengenoemde management techniek in: ...) bij het achterhalen van bronnen van variabiliteit in de patiëntenstroom?
12. Hoe draagt (vul bovengenoemde management techniek in: ...) bij aan het in beeld brengen van de impact en grootte van de variabiliteit in de stroom?
- Wordt het gemeten?
13. Wat voor rol speelt (vul bovengenoemde management techniek in: ...) bij het reduceren van variabiliteit in de patiëntenstroom?
Tactisch en operationeel level:
Personen die worden geinterviewd:
Unit hoofden van KNO en orthopedie van de poli en kliniek. Unit hoofden van de opnameplanning en de radiologie.
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Verder zou ik graag toestemming willen krijgen voor gebruik van opnameapparatuur tijdens het interview. Waarbij vanzelfsprekend uw anonimiteit wordt gewaarborgd bij de verwerking van de informatie in het verslag.
- Laten zien patiëntenstroom KNO en orthopedie, het gaat dus om het proces en hoe de stappen op elkaar zijn afgestemd.
A. Introduction
1. Kunt u uw belangrijkste taken binnen uw functie omschrijven?
2. Wat is het doel van uw functie unit hoofd: Kies; KNO, Orthopedie, Radiologie, Opname Planning?
B. Integratie
Het gaat hier om tactische integratie en operationele integratie, waarbij het onderscheid ligt bij in de tijdsduur en perspectief. Tactisch is van 8 weken tot 1 jaar waar het gaat om management controle door het uitwisselen van informatie. Daarnaast kijken we bij operationeel naar alle acties die binnen de 8 weken vallen, dat een gezamenlijk doel heeft voor het verbeteren van de patiëntenstroom. Verder gaat het over een geïntegreerde patiëntenstroom, waar het belang ligt bij de afstemming tussen de verschillende onderdelen binnen deze stroom.
3. Wat zijn de gezamenlijke doelen op middellange termijn die zorgen voor een afgestemde patiëntenstroom?
4. Hoe wordt de koers richting deze doelen op middellange termijn vastgehouden? - En hoe worden de capaciteiten hierop afgestemd?
5. Hoe zorgt u dat dit alles zowel horizontaal als verticaal op elkaar is afgestemd? (zie plaatje, horizontaal is tussen vakgroepen en verticaal is tussen de verschillende clusters)
6. Wat zijn de doelen op korte termijn die zorgen voor een afgestemde doorstroom van de patiënten?
7. Wat zijn bepaalde acties of methodes die worden ingevoerd binnen alle units om die doelen te realiseren?
8. Hoe zorgt u dat iedereen op de hoogte is van deze korte termijn acties?
C. Link tussen integratie en variabiliteit
In het onderzoek kijk ik verder naar de interactie tussen integratie en variabiliteit. Het gaat hier om kunstmatige variabiliteit, die veroorzaakt wordt door het ziekenhuis zelf in de patiëntenstroom. Literatuur wijst uit dat integratie een positieve invloed heeft op variabiliteit reductie. De vraag is waar dat het nu in zit.
