Learning in health care: A Comparison between focused and non focused
inguinal hernia surgery
Master thesis, MscBA, specialization Supply Chain Management University of Groningen
June, 2014 TIM VAN DER VELDEN
Studentnumber: 1642987 e-mail: vandervelden.t@gmail.com
Supervisor/ university C. de Blok Co-assessor/ university
Introduction
In order to eliminate mistakes, improve patient satisfaction, reduce costs and improve clinical outcomes, hospitals have been developing new management practices and innovative
healthcare delivery systems (Shortell et al., 1993; Weaver, 1999; Schweikhart & Smith-Daniels, 1996). Hyer, Wemmerlov and Morris (2008) derive from literature (Berwick et al., 1990;
Clemmer et al., 1999; Bush, 2007; Weber, 2006) that many of these changes in health care were inspired by observations in the industrial sector. One of the practices coming from the manufacturing industry is focused factories, introduced by Skinner (1974). Hyer et al. (2008) find that there is an increasing interest in the concept of focused factories in the health care sector. They state that the fundamental idea behind focus is to reduce complexity so that a plant can concentrate on doing fewer things better. With the main goals being to reduce costs and increase patient satisfaction several hospitals are applying the concept of focused factories. Literature is divided on whether focus facilitates or restricts superior performance (McDermott & Stock, 2011). Some authors claim that focus leads to superior performance by enabling organizations to select and choose market and customer segments thereby reducing task variety and thus better enabling the organization to align its decisions with a narrower set of tasks (McDermott & Stock, 2011). On the other hand, though fewer in number, there are opponents who claim that focus promotes tunnel vision and performance is worse, partly due to missed opportunities regarding economies of scope (McDermott & Stock, 2011). Kekre and Srinivasan (1990) state that a larger market share and higher profit is obtained by organizations with a broader product line than focused organizations. McDermott and Stock (2011) claim that, thus, it is still unclear if hospitals and patients benefit from focus.
As stated earlier focus includes a reduction in task variety. Through this reduction an individual can gain repeated experience in a task, can gain knowledge about a task and learns about the relationship between the activities that make up the task and the underlying causal linkages (Bohn, 2005; Bohn & Lapre, 2011). Since healthcare has an increasing interest in focused
Furthermore I will try to integrate this into a model where focus, learning and performance outcomes come together.
Huckman and Zinner (2008) state that learning can be obtained through focus but it does not require focus. In this research I will look at this statement and compare learning of focused inguinal hernia surgery to non-focused practices. Additionally I will look at the performance of focused hospital units for inguinal hernias compared to non focused hospital units that perform inguinal hernia surgery, and look at the effects the learning effects that are achieved and how they are achieved. I aim at finding a relationship between focus and learning. This relationship has not yet been proven, but by further exploring the topic I aim to open up new insights that eventually might lead to proof or disproof of this relationship. This may lead to other opinions of focus and learning in scientific literature and can open up new opportunities to make further developments in the scientific fields of the literature on focus and learning. I do not question the statement of Huckman and Zinner (2008) that learning does not necessarily require focus, but I will make the assumption that learning effects are greater in a focused environment than in a non-focused environment, and thus that focus may not be necessary for learning but does improve learning effects. By exploring the effects of focus on learning, organizations that want to maximize learning effects might need to reconsider the way they work and the way they align their processes. By looking at the effects of focus on learning and performance of inguinal hernia surgery this research hopes to provide insights for hospitals to make the choice between focus or non focus for inguinal hernia surgery.
By answering the main research question: “How does focus influence the learning of surgeons and teams and how do the outcomes of inguinal hernia surgery influence learning compared to non-focused practices?”I strive to provide new insights on the concept of learning, where focus can be considered a factor that influences learning. By exploring the relationship between focus and learning, compared to learning in a non-focused environment, underexposed benefits of focus might come to light.
Theory
The theme of focused factories was first introduced by Wickham Skinner in 1974. He states that factories who focus on a particular market niche will outperform the conventional plant, which attempts a broader mission. Skinner (1974) claims that the equipment, procedures and
supporting systems of a focused factory can concentrate on a limited set of tasks for a particular group of customers and thus its costs and overhead are lower than that of the conventional plant. Because of repetition and concentration on one area Skinner (1974) finds that the workforce and managers become more effective and experienced in the task
compared to the conventional plant. This allows organizational management to organize the manufacturing task in the form of appropriate organizational routines (Mukherjee et al., 2000) which ensures consistency and reliability of the performance of the manufacturing task (Kelly & Amburgey, 1991). Furthermore repetition enhances learning, thus increases productivity and drives costs down (Lapre & Tsikriktsis, 2006). Despite of their advantages, Skinner (1974) finds that focused manufacturing plants were surprisingly rare. This claim is supported by several other, more recent, studies (Ketokivi & Jokinen, 2006; Vokurka & Davis, 2000). Skinner (1974) states that organizations hold on to the idea of the conventional plant due to economies of scale and lower capital investment. According to Skinner(1974) these organizations were too focused on the idea that a low-cost plant was a better plant. In other words, conventional plants were focusing too much on productivity and efficiency gains where the idea of the focused factory is not productivity improvement (Ketokivi & Salvador, 2007). Efficiency does matter in the end, but organizations should focus on efficiency in delivering what the customer wants (Ketokivi & Salvador, 2007). Because the conventional plants attempt to do too many things with one plant or one organization to lower their costs, they add products, markets, technologies, processes, quality levels and supporting services which conflict and compete with each other and compound expenses. This happened often due to several reasons according to Skinner (1974). One of the reasons is that the goals of one area of a plant weren’t congruent with other areas. Furthermore the tasks often would not have been made explicit or there were inconsistencies that just were not recognized. Besides the idea that low-cost plants are better, Huckman (2009) states that the concept of focused factories is difficult to implement. He sees that, in a number of industries, managers view the concept to narrowly and see it as an isolated tactical change in the structure of a firm’s operation rather than as a system.
technologies and volumes probably needs five plants, five organization structures, five sets of equipment, five processes and five technologies. Though it seems that this example
organization needs to build five different plants, it is often a better solution to build a plant within the plant (PWP) (Skinner, 1974). In this case five PWP’s. Each PWP has its own workforce and set of tasks. The PWP’s gain experience by focusing each element on a limited set of
objectives which constitutes its manufacturing tasks. Hyer et al. (2009) look at focus from different angles. They developed four perspectives, where an organization can reach focus. An organization might be focused on one, several or on all of these perspectives. Their resource perspective states that with focus, there are dedicated human and technical resources for processing a set of similar objects. These resources are located within a close range from each other. This is considered the spatial perspective by Hyer et al. (2009). The transformation perspective states that a focused unit performs multiple comparable process steps on a family of objects, which are considered a family based on having the same attributes (Hyer et al., 2009). From an organizational perspective, the focused plant is accountable for all its administrative tasks and its performance and improvement (Hyer et al., 2009). These four perspectives also can be used to make a distinction between focus and specialization, which otherwise might be considered interchangeable concepts. The biggest difference between the two concepts lies in the resource perspective from Hyer et al. (2009). Where both, focus and specialization, require a narrowed down set of tasks, focus needs a group of resources
dedicated to these tasks, where specialization does not need this group of dedicated resources (Hyer et al., 2009; McDermoth, 2012).
In conclusion, focused factory can be applied to reduce complexity of certain tasks or
processes. Though the concept of focus is known by many organizations, not many are adopting it correctly, partly since the concept is viewed too narrowly by managers.
Focus and performance
Ketokivi and Salvador (2007) argue that focused manufacturing strategies will particularly rise in organizations operating in a stable environment. However, even when the environment is unstable, focused manufacturing strategies can help to achieve high levels of customer satisfaction (Ketokivi & Salvador, 2007). In contradiction to Skinner (1974), Ketokivi and
This means that decisions these organizations make are limited by decisions they have made in the past and they are unable to adapt to changes in the environment. Though Ketokivi and Salvador (2007) state that focus might be a necessity when striving for operational excellence. They derive this from the argument that what a manufacturing organization can achieve is restricted by performance frontiers (Schmenner & Swink, 1998), meaning that it is often impossible for organizations to simultaneously excel in multiple things. This is supported by Hayes and Wheelwright (1984) who find that there is a negative relationship between operating margin and the number of product lines, a finding in favor of a focused strategy. Data, conducted from surveys on the managers of around 300 organizations, found by Vokurka and Davis (2000), also suggested that focused organizations have a higher performance,
relating to cost, quality, dependability and speed, relative to unfocused organizations. Supporting this is the evidence found by Bozarth and Edwards (1997) which suggested that a lack of focus in either the market requirements or manufacturing characteristics of a given organization is associated with poorer organizational performance. On the other hand there are authors who claim that focus might lead to a worse performance when compared to non-focused organizations. Some even suggest that its implication for the financial performance of the organization might be negative. For example, Suarez et al. (1996) find that a broader product mix is not associated with decreased performance in terms of either cost or quality. In addition, Kekre and Srinivisan (1990) find that organizations with broader product lines are characterized by larger market shares and higher profitability than more focused organizations. Ketokivi and Savador (2007) found several influences of focus on performance. Looking at customer satisfaction, they found that performance on this part could be high with or without focus. There was no statistical evidence that customer satisfaction would be higher when applying focus.
Focus in healthcare
Ginsburg (2000) states that the adoption of focus by general hospitals is usually based on the general concept of focus derived from the manufacturing industry. McDermott and Stock claim that the potential benefits of focus come in two main forms. First, focus can create more volume leading to economies of scale (Barro et al., 2006) and opportunities for enhanced learning (Huckman and Pisano, 2006). Secondly, the heightened attention to a particular element related to its service offerings allows a hospital to better and more consistently configure its operational elements towards the areas where it chooses to focus on (hyer et al., 2009), independent of scale. To illustrate this second benefit McDermott and Stock (2011) give an example of a two hospitals with 1000 cardiology patients each year. For the first hospital this is 10 percent of its total patients and for the second hospital this is 20 percent of its total
patients. According to Skinner (1974) the smaller hospital, where 1000 patients contribute for 20 percent of its total patients, would have greater consistency of purpose because it is emphasizing a particular field of surgery above others and thus should generally be able to configure its operational elements in a way that is more uniformly targeted towards this particular area. Based on this example McDermott and Stock (2011) claim that scale is an element of, but not the same as focus. This example illustrates that it is not enough for
hospitals to simply increase the amount of patients for a particular type of surgery to adopt the concept of focus.
Focus and performance in healthcare
Huckman and Zinner (2008) refer to a smaller set of studies that consider the role of focus outside of traditional manufacturing environments (Heskett, 1986; Johnston, 1996; Lapre & Tsikriktsis, 2006). Much of this work occurs in health care settings. A survey by McLaughlin, Yang and van Dierdonck (1997) suggests that focused surgery centers perform better than regular hospital-based surgery centers. Huckman and Zinner (2008) introduce an example to illustrate this with the Shouldice Hernia Center. Shouldice has streamlined its internal processes to concentrate on a single procedure, by performing only hernia surgery, and the set of
time for patients. Though these two explanations correlate with focus, Huckman and Zinner (2008) state that they do not require focus.
Focus, learning and performance
Whether tasks should be allocated in a varied or specialized way has been a hot topic
throughout the years (Taylor, 1911; Skinner, 1985). KC and Staats (2012) claim that focus may improve individual performance for several reasons. Through repetition of a task an individual gains knowledge about a certain task and learns about the relationships between the activities that make up the task as well as the processes’ underlying causal linkages (Bohn, 2005; Bohn & Lapré, 2011). Focus also allows for the creation of routines and systems through repetition (Mukherjee et al., 2000). In contrast to specialization where only the set of tasks are limited and repetition of the task for each employee does not necessarily occur. The difference with focus, as described earlier, are the dedicated resources that a focused unit has. When a dedicated team of employees perform the same task it might be argued that repetition of tasks might occur on a more regular basis. With specialization it does not necessarily mean that the same person performs the same task at a given day of the week, every week, for example. With a dedicated team of employees it can be assumed that they do perform the task on a given day of the week so repetition occurs on a more regular basis. Thus it might be assumed that the
knowledge about a task and the learning about relationships of the underlying processes, as described earlier (Bohn, 2005; Bohn & Lapré, 2011), happens more regularly when repetition of the task occurs on a regular basis. In addition, Adler et al. (2009) state that the increased understanding of the tasks creates an opportunity for the individual to improve individual parts of the task and redesign the entire process. Focus also has its value in the fact that it limits the distraction of workers due to changing tasks (Schultz et al., 2003; Staats & Gino, 2012). Though repetition might have a positive effect on learning, it can also create boredom (Bruursema, Kessler & Spector, 2011). Individuals that have high levels of boredom show higher rates of absenteeism (Kass et al., 2001; Melamed et al., 1995), have less job satisfaction (Melamed et al., 1995) and show less work effectiveness (Drory, 1982). Though the amount of boredom one experiences in a given situation is related to the specific individual (Culp, 2006). Research done in the field of psychology shows that when workers need to change between tasks it is
prior tasks when resources are not dedicated. Thus learning might be stimulated by limiting cognitive interference (Sarason and Pierce, 1996).
Huckman and Zinner (2008) state that a positive correlation between learning and productivity or performance is now regularly assumed. They found that this relationship exists on several levels and they refer to several authors: The level of individuals (Newell & Rosenbloom, 1981; Delaney et al., 1998), teams (Weick & Roberts, 1993; Pisano, Bohmer & Edmondson, 2001), and organizations (Argote & Epple, 1990; Adler & Clark, 1991). Huckman and Zinner (2008) also claim that the repetition of certain routines leads to benefits of learning such as lower costs and improved quality. They refer to Delaney et al. (1998) to explain the relationship on the
individual level where practice on a task often improves performance, both by reducing the number of errors and by reducing the time required to perform the task. On the level of teams Huckman and Zinner (2008) refer to Pisano et al. (2001) who find that learning also occurs through increasing experience with a task. Team learning consists of a returning cycle of action and reflection where knowledge is accumulated, stored and shared within the team (Vashdi, Bamberger & Erzez, 2013). Organizational learning is viewed as a process of seeking, selecting and adapting new routines to improve performance (Nelson & Winter, 1982; Levitt & March, 1988).
Consistently, researchers found a significant variation across surgeons and hospitals when examining surgical outcomes in healthcare (Hannan et al., 1990; Birkmeyer and Dimick, 2009). Singh and Staats (2012) provide us with the insight that higher surgery volumes increase patient outcomes. On the other hand, not all units of experience impact performance improvement equally (Mishina, 1999; Lapré & Nembhard, 2010; Argote & Miron-Spektor, 2011). Singh and Staats (2012) derive two forms of experience from literature: focal experience and task-related experience (tasks similar to, but not identical to the focal task) (Boh et al., 2007; Narayannan et al., 2009; Staats & Gino, 2012). Both focal and related experience likely positively influence performance (KC & Staats, 2012).
task might stimulate SLL.
DLL refers to change in the actions with the goal to improve performance, by taking into consideration the assumptions that were made that led to these actions in the first place (Wong et al., 2009). DLL enables an organization to detect and address the root causes of why certain performance occurs and to assist in reforming their ways of working (Argyris & Schon, 1978). The concept of double loop learning might imply that the outcomes of performing focused tasks might have an influence, through double loop learning, on the way the organization focusses its processes (Adler et al., 2009). When the outcomes do not match intended outcomes, an organization will search for the root causes of this mismatch. This might lead to change in the fundaments of the processes, or in this case a reorganization of how the tasks or processes are focused (Adler et al., 2009).
Huckman and Pisano (2006) find that the performance of individual surgeons is firm-specific in cardiac surgery. When surgeons work repeatedly with the same organizational-specific assets, such as team members (Huckman et al., 2009; Huckman & Staats., 2011), performance improves.
In summary, focus seems to have an influence on learning by allowing the repetition of tasks, which allows an individual to gain knowledge about a task with repeated experience which allows the individual to learn about the underlying processes of the tasks and improve them. Especially single loop learning seems to play a role, where a surgeon may change certain parts of the task based on the outcomes of the task. Furthermore, as introduced earlier, focus may lead to more volume which offers opportunities for learning. It can be assumed that the data gathered through the higher volumes is used to adjust the organizational process and thus has an influence on DLL. The relationships and assumptions are shown in the conceptual model below.
Performance measurement for low risk surgery
seems a good start to look at the patient outcomes as a performance indicator, defined as chronic pain complaints.
Expectations
In this thesis I will look at the influence of focus on the performance outcomes of inguinal hernia surgery, through the influence of focus on learning. I assume that focused inguinal hernia surgery units only perform inguinal hernia surgery without switching to other tasks while showing focus on the four perspectives of Hyer et al. (2009). Thus, as earlier stated, I expect that focus stimulates the learning of surgeons by limiting cognitive interferences (Sarason & Pierce, 1996). By narrowing their range of what they do, the firm affects learning, and, ultimately, results in improved organizational performance (McDermott & Stock, 2011). I expect that performing inguinal hernia surgery in a focused environment has a positive effect on the learning of inguinal hernia surgeons, and positively influences team learning and
organizational learning. By individual learning, team learning is promoted by integration and verification of the knowledge and experiences of individuals to form team’s knowledge and routines (Yang & Chen, 2005). Teams also learn through increasing experience with a task (Pisano et al., 2001). Organizational members than adopt these knowledge and routines leading to organizational learning (Crossan et al., 1999).
I expect to see less chronical pain complaints in the focused hernia surgery units, possibly leading to less reuptakes of patients after inguinal hernia surgery. These will be referred to as patient outcomes in the conceptual model. I expect that the patient outcomes alter the way tasks are performed through single loop learning. I assume that the intention of the surgeons is to have as little possible patients with, for example, chronic pain complaints. When the amount of patients with this type of complaints is too high, I expect to see surgeons altering their behavior and actions, while correcting possible errors, to assure the anticipated outcomes of lower pain complaints by patients. Furthermore I expect to see positive outcomes in the duration of the surgery per patient, meaning the surgery takes less time. Adler at al. (2009) state that increased understanding of the tasks creates an opportunity for the individual to improve individual parts of the task and redesign the entire process. Focus also allows for the creation of routines and systems through repetition (Mukherjee et al., 2000). Though surgeons probably will not redesign the entire process for inguinal hernia surgery, they might recognize possible efficiency gains to reduce surgery times. If reduction in surgery times can be reached, more patients could be treated per time unit, for example per week. Huckman and Pisano (2006) look at the influence of volume on surgical outcomes. It suggests that surgical outcomes improve as a surgeon or hospital increases its recent or cumulative volume of procedures and will be referred to as volume outcomes in the conceptual model. I expect that this
Focus focused taskPerforming
Patient outcomes
Volume outcomes
Double Loop Learning
Methods Research Design
The central question, as introduced in the introduction, in this research is:
“How does focus influence the learning of surgeons and how does it influence the outcomes of inguinal hernia surgery compared to non-focused practices?”
To answer this question I will compare focused units and non-focused units in practice with a case study supported by interviews. Voss (2009) derived three strengths of case studies derived from Bebensat et al. (1997). Relevant for this thesis is that case study lends itself to answer how questions while gaining a complete understanding of the complexity and the nature of the phenomenon or relationship studied (Voss, 2009). Yin (1994) also states that case study research is particularly suitable for answering how and why questions. Furthermore, a case study leaves room for exploratory investigations where the variables may be unknown and where the phenomenon is not well understood (Voss, 2009). McCutcheon and Meredith (1993) state that case research can build on existing theories and is an excellent method when
developing theories.
The choice to conduct interviews when doing the case study is supported by Voss (2009) who states structured interviews are often the main source of data when doing case studies, and it can be backed up by unstructured interviews. A research protocol is needed to support the reliability and validity of the case study (Yin, 1994), and has the set of questions to be used in the interviews as its core (Voss, 2009). Voss (2009) also states that a well-structured protocol is particularly important when conducting multi-case studies. In this thesis only three cases are chosen, mainly due to time constraints and accessibility, in the UMC Groningen, the St. Elisabeth hospital in Tilburg and the Elkerliek hospital in Helmond, so the protocol will mainly focus on the interviews, and the ways interviews are used to make focus and learning
To give a clear answer as to how performance differs between focused and non-focused units and how the learning effects differ, interviews in the UMC Groningen, the St. Elisabeth hospital and Elkerliek hospital were conducted. By using interviews I aimed at getting the differences and comparisons in learning clear, which could also help me explain why certain differences in performance might occur. The UMC Groningen is now doing research on the influence of the learning of surgeons on the outcomes of inguinal hernia surgery. The UMC Groningen has not adopted a focused factory strategy for inguinal hernia surgery, where the st. Elisabeth Hospital and the Elkerliek hospital have. By comparing these three hospitals I hope to find differences in learning and performance on the patient outcomes. As patient outcomes the main indicator is chronic pain complaints by patients after inguinal hernia surgery, which seems to be a problem in practice. The UMC Groningen is therefore looking if there is a link between surgeon expertise and a reduction in chronic pain complaints by patients. Mortality rate is not discussed as a performance indicator since this is not a viable indicator for low-risk surgery (Zuiderent-Jerak, Kool & Rademakers, 2012). Given the research question, first the relationship between a focused factory strategy and and learning effects on individual, team and organizational level were made clear. Then I needed to find the relationship between learning and the chosen performance indicators. By finding out how learning takes place in the organizations I aimed to discover the occurrence of single and double loop learning and the influence focus might have on these types of learning or other learning effects. With the results from the interviews and data derived from practice I could compare the found relational influences to these same relations in non-focused practices for inguinal hernia surgery.
To make learning operational I looked at the dimensions of the learning organization
questionnaire (DLOQ) as used by Getha-Taylor (2008). I did not copy this list but rather used it as inspiration to make open questions for the conducted interviews. The DLOQ measurements were translated to measurements which were more appropriate for the UMCG, the St.
Elisabeth hospital and the Elkerliek Hospital. For each level of learning, eg. Individual, team and organizational, I used one dimension of the DLOQ model as an inspiration source. For individual learning I used the first dimension to find out if they help each other learning. For team learning I used the fourth dimension to find out if evaluation takes place. For organizational learning I used the first dimension to find out if data is collected and analyzed within the organization and how learning effects on this aspect occur. The model can be found in appendix A.
Data Collection
Primary data in this thesis mostly came from the data derived from semi-structured interviews. The choice for semi-structured interviews was mainly done to leave room for questions that came up during the conversation. Some issues might get more elaborated on in-depth in this way, by allowing the interviewer to ask questions based on what the interviewee answers. This provided better quality data due to a more complete overview of the issues addressed. Data coming from these interviews was mostly aimed at mapping the differences between focus and non-focus on an organizational level for inguinal hernia surgery and to find out how learning occurs and where the learning effects came from. The aim was to find out if learning effects occurred influenced by the organization of the processes. By looking at these differences between the UMC Groningen, the st. Elisabeth Hospital and the Elkerliek hospital, I aimed to find explanations for differences in learning and performance of inguinal hernia surgery, related to volume and patient outcomes. The secondary data was gathered from existing literature found in the electronic library of the university.
Since the limited personal contacts I have in the field of health care the UMC Groningen and st. Elisabeth Hospital seemed the most realistic options to gain additional information for my research, since there are existing contacts in these hospitals which made the barrier to entry lower. Several other options were tried and thankfully the Elkerliek hospital was able to participate in the research. It must be noted that the Elkerliek hospital and the St. Elizabeth were focused inguinal hernia surgery centers within the hospitals. These are referred to as expert clinics in the rest of this thesis. The interviewees from the St. Elizabeth hospital will be referred to as interviewee A and B. Interviewee A is a surgeon and interviewee B is an
anesthetic. I interviewed one person from the Elkerliek hospital. He is a surgeon and will be referred to as interviewee C. The UMC Groningen is an academic hospital which lays the emphasis on higher complex surgery but also offers inguinal hernia surgery. They do not have an expert clinic for inguinal hernia surgery. I interviewed one surgeon from this hospital. He will be referred to as interviewee D.
The interviews covered several subjects. Questions about the performance indicators I chose were compared with questions about performance indicators they find important. These did match, especially on the amount of patients with chronic pain complaints. Indicators such as cost per patient also came to light, but I did not find them important enough for this research to include them.
how focus is applied and how the individual thinks that setting might affect his or her learning, the learning of the team and, potentially, the search for, or development of, new methods and techniques. For this part I partly relied on information given to me by the interviewee to base any further questions on.
The interviews with interviewee A, B and C were conducted together with a fellow student who was also doing his thesis. The interview with interviewee D was conducted by myself. I used the combined interview questions we used to interview interviewee A, B and C, but I left out the questions about the ZBC in this last interview. The list of questions can be found in appendix B.
Data Analysis and measurement
To analyze the data collected from interviews I used codes. I did the coding in Microsoft Word. I figured I needed to cover the aspects of focus, learning and performance with my codes. To break down the level of focus as discussed by Hyer et al. (2009) I used the following codes: FF: Resource perspective
FF: Transformation perspective FF: Spatial perspective
FF: Organization perspective
Pieces of text from the interviews were coded with one of the above codes if they said
something about focus on one of the four perspectives. There was also a version of these four codes when the interviewee had said something that implied that there was no focus on one of these four perspectives, these codes were the same as the above but the word “negative” was added in capitals.
To cover the subject of learning and to find out on which level learning effects occurred I used the following codes:
Individual learning Team learning
Organizational learning
These codes were used in the same way as the codes for focus. For these codes I also made a “negative” version for instances where learning effects might be contradicted by the
interviewee. This did not happen often however so I barely coded pieces of the interview with the negative versions of the codes for learning.
Patient outcomes Volume outcomes
When something was said about, for example chronical pain complaints, that piece of text got the code “patient outcomes”. There were other patient outcomes that came forward in the interviews though, they got the code “other non-medical patient outcomes”. Though these pieces of text mostly were not used in this thesis, the extra code did help to keep things organized and keep a good overview of the information.
When I coded the interviews, sometimes certain relationships, or indications for relationships occurred. When this happened I attached several codes to one piece of text. When analyzing the results this would give me a good indication that the specific piece of text could be used when giving argumentation why certain relationships did, or did not, exist.
After coding I put everything in tables to give myself a good overview of all the information. When several interviewees gave the same answer, but in different words, I used the answer of one of the interviewees to cover the information for all the interviewees if no important information would be missed this way. After putting all the important information in tables using quotes, I did a within case analysis of the expert clinics and the general hospital. I
determined their level of focus on the different perspectives, after which I tried to relate focus, learning and performance based on the quotes given. I kept track of which quote belonged to which interviewee after looking back at the coded interviews again to make sure. If several interviewees said the same I put this in the text to support the particular quote better. The results from this within case analysis were then compared to each other in a cross case analysis.
Internal validity
When trying to prove a causal relationship, where factor x leads to factor y, internal validity is used (Yin, 2003). In this research it is important to consider the fact that learning can come from several factors. I need to make sure that, when I look at the relationship between focus and learning, I draw the right conclusions. It might be for example, that learning is improving in a focused factory setting but that there are other causes that have a direct influence on
Construct validity
This type of validity is concerned with getting the correct operational measures for the concept being studied (Yin, 2003). Things that can threaten the construct validity are respondent bias and incomplete information. To reduce respondent bias I will try to ask open questions, partly based on literature, and let the respondents form their answers on themselves without interrupting or steering in a certain direction. Only when respondents move away from the topic being discussed I can intervene and get them on the right track considering the topic. To make sure I get all the information I need I will double check the answers and let the
respondents double check their answers a certain time after the interview. If they miss something in the information they gave me they can add additional information leading to a more complete answer.
Results
Patient process expert clinics and general hospital
All interviewees were asked to describe the process the patient goes through from start to end. In the expert clinics the patient calls a central telephone number of the expert clinic to make an appointment. Interviewee A and B claimed that the patient gets an appointment within one week to see an inguinal hernia surgeon. Then the patient sees the anesthetic on the same day, the form of narcosis is decided with the patient, and he makes an appointment for the date of surgery with the patient. Interviewee A and B say that the patient is operated within two weeks while interviewee C has a time span of three weeks. All say that, eventually, the exact date for surgery depends on what the patient wants. If the patient wants to have surgery in four weeks for example, this can be scheduled if there is room on that specific date. When the patient comes in for surgery he or she needs to undress and is placed in a bed. A nurse will bring them to the operating room where they get the agreed on form of narcosis. After surgery they wake up at recovery after which the patients are brought to their normal room. They stay in the hospital until they can leave the hospital on that same day. Thus, in general this process looks the same according to interviewee A, B and C.
In the general hospital the general practitioner sends a letter to the hospital with the patient
information and to make an appointment for inguinal hernia surgery. The patient information is scanned in the hospital and based on this information it is decided on which department the patient will be operated. If the patient has no severe medical history or any big risks this will be daycare. Often within three to four weeks, with a maximum of two months, the patient will go to the hospital to meet the surgeon and to get the diagnosis from the surgeon. Than the patient is placed on a waiting list. It may take up to two months before the patient can have surgery. The hospital does not reserve beds for this type of surgery because the patient leaves the hospital on the same day. One of the available surgeons or assistants will perform the surgery. The patient is moved from the daycare department to the
in the recovery room and afterwards the patient is brought back to daycare. There the surgeon decides when the patient may leave the hospital. This is often on the same day.
When comparing the expert clinics with the general hospital the patient process, on the day the patient has surgery, looks generally the same. Though differences are seen in the period before the day of surgery. Where the expert clinics have short waiting times and seemingly high efficiency, the general hospital has very long waiting times and seems to be more inefficient.
Both of the expert clinics I visited were part of a normal hospital. This does not mean they were dependent on the hospital. They both have a dedicated team of surgeons and nurses with dedicated operating rooms and beds. The expert clinics perform inguinal hernia surgery a few days per week. On those days the team only performs inguinal hernia surgery and only takes care of inguinal hernia patients. The rooms used for these patients are dedicated to inguinal hernia patients on these days. They seem to operate according to the plant-within-a-plant concept.
The general hospital I visited is an academic hospital. Besides the healthcare function it has an educational function for medicine students. The hospital focusses on the high complex surgery so inguinal hernia surgery is not one of their main points of attention. Though they do perform around one hundred inguinal hernia surgeries per year. They have a daycare center for all the low complex surgery, and they perform low complex surgery once a week. This does not mean that inguinal hernia surgery is performed every week. The general hospital has a couple of surgeons that perform inguinal hernia surgery and they do not have a dedicated team for this type of surgery.
Expert clinics Focus
When looking at the resource perspective, the interview outcomes show several results. First of all, it seems that all of the expert clinics for inguinal hernia surgery have dedicated resources for treating inguinal hernia patients. This is supported by interviewee A & B: “We work with a team of dedicated inguinal hernia surgeons and anesthetists and patients get treated by the same dedicated team, only the anesthetist may differ on occasion”. While interviewee C answered: “We use the same operating rooms, shortstay rooms, recovery rooms and beds on the days we perform inguinal hernia surgery and only for these type of patients”.
Often the answers show that there are only a few surgeons that will perform inguinal hernia surgery, not occasionaly will it be the same surgeon that also does the intake with the patient. This is supported by interviewee A and B: “The surgeon who does the first meeting with the patient is also the surgeon to perform surgery on that patient”.
Furthermore the clinics make use of dedicated beds where only inguinal hernia patients will be placed. It can be seen that no other types of patients will be placed in these rooms. This can be concluded from the same answer interviewee A, B and C gave: “There are dedicated nursery rooms with beds, only for inguinal hernia patients”.
It can also be seen that the expert clinics do not have a good way to deal with complications during or after surgery. When there are patients that also have other severe problems besides the inguinal hernia or when complications occur, the expert clinics need to make use of other parts of the hospital to provide these patients with the specific care they need. All expert clinics seem to have this problem since interviewee A, B and C gave the same answer: “When post-surgery complications occur, patients need to be treated in other parts of the hospital”. Though this is a negative indicator for the level of focus considering the resource perspective, this occurs on high exception.
For the transformation perspective it can be seen that the expert clinics have a strict protocol for the low risk patient category. They treat these patients, who all have the same attributes, in the same way, according to a strict protocol. To support this claim I can quote interviewee A: “Every patient gets treated according to the same, strict protocol”; and interviewee B: “The whole process is standardized in the same way for each patient”. The whole process seems to be standardized for each patient to keep efficiency on a high level. Furthermore interviewee C answered in the same way: “Each patient goes through the same process steps, this helps us to compare patients reliably when doing scientific research”.
The only times the expert clinics deviate from the protocol is when patients fall in the high risk category (ASA 3 & 4) or when patients have certain other demands, for example regarding the method for narcosis or surgery times and dates. To make sure in which category the patients fall they do have protocols supported by quotes of respectively interviewee A and C: “Only high risk patients get treated differently or are not operated at all”; “We have a checklist, patients need to be healthy, below 65 years old, no other diseases, no past surgery”.
Regarding the spatial perspective, all expert clinics are focused. Every part of the organization that is needed to guide the patient through the process is within short distance from each other. This claim is supported by quotes of interviewee A, B and C:
Interviewee A: “We have all inguinal hernia patients grouped together”
Interviewee C: “You can not have this type of organization on a too big location, everything needs to be in short distance from each other to maintain short (communication) lines” The last aspect of focus is the level of focus regarding the organizational perspective. Though the expert clinics show high levels of focus in the three other perspectives, there does not seem to be a high level of focus when looking at the organizational perspective. As indicated by interviewee A, B and C: “The hospital itself does the negotiations with the health insurance companies”, price negotiations with health insurance companies, administrative functions and budgets, are all done by the hospital itself. This is also supported by another quote by
interviewee C: “Activities regarding administration and budget is done by de hospital itself, we only provide necessary data”. The only thing, regarding the organizational perspective, the expert clinics handle themselves is guarding the quality and taking responsibility for the quality. Quality check-ups by external companies are therefore also handled by the expert clinics
themselves. This is supported by interviewee B: “We guard our own quality and when quality inspections take place by external organizations we handle this independent of the hospital”.
Focus and learning
On the level of individual learning a thing that comes forward the most is that the expert clinics provide training or workshops for other surgeons to learn their techniques. This is mostly supported by interviewee A and C: “Our goals contain innovation, development, training and scientific research”; “We give workshops to other surgeons who want to learn our techniques”. Because of the volume of patients they perform surgery on they claim to be faster but also have more skills than other surgeons. The interviewees also claim to recognize abnormalities faster and that they have the knowledge and skills to provide a quick and accurate solution for these problems. This is supported by a quote from interviewee A and B: “We recognize problems with surgery very fast and we have the skills and knowledge to find a solution”. Both interviewees say that they can find solutions better individually but learning effects can also be seen on the team level. Interviewee A and B say: “Every mistake or failure gets evaluated with the team, we draw our conclusions and overcome these problems together”. While interviewee C supports this quote with: “We evaluate our whole process on a continuous basis”; and “We use the plan, do, check, act cycle to continuously improve ourselves”. The context in which these answers were given by the interviewees was about the resource perspective and transformation
resources, and the efficient way the process is organized with for example dedicated operating rooms and dedicated recovery rooms. Learning seems to take place on team and organizational level with the development of new techniques following from scientific research. Support is given by interviewee A, B and C with the following claim: “We do scientific research to develop new surgery techniques which have less complications”; and interviewee C: “Because of the way we focused our patient care, we are able to answer important scientific questions quicker”. The interviewees seem to think that, because of the way they organize their inguinal hernia surgery, with a dedicated team of surgeons and nurses and dedicated rooms for their patients, while being able to treat each patient in the same way, they are able to develop new methods and improve the way they are organized through scientific research. More importantly, they seem to think that they are able to get outcomes of the research quicker than if they were not organized in this way. So they learn more quickly on the team level because they are able to share knowledge faster and organizational learning seems to be stimulated, meaning they seek and adapt new routines or methods to improve their performance, in this case mostly through scientific research.
Focus, learning and performance
Firstly I will relate focus to the performance outcomes. There seems to be a consensus between interviewee A, B and C that the way they have organized there organizations leads to safe and good healthcare for the patient. This can be showed through a quote of interviewee A: “By focusing our healthcare like this patient quality and safety improves”; and interviewee C: “Because we have shorter surgery times than other surgeons it is often expected that we do not deliver quality for the patient. This is not true, patient quality is still very good”. The focus interviewee A means is on the level of the resource perspective and the transformation perspective, so with dedicated resources and the same treatment for each patient.
performing surgery on high volumes of patients we have more expertise and have perfected our operating skills”; and interviewee C: “We gain more experience because we perform surgery on large numbers of patients”. The number of patients they treat varies between the two expert centers and can be shown with quotes from interviewee A and C respectively: “I perform more than 200 inguinal hernia surgeries per year, we do 900 in total”; and “We
perform around 700 inguinal hernia surgeries per year, around 100 on my account”. The above might imply that higher amounts of patients treated lead to better knowledge of the surgery and its methods. Because the amount of patients also give valuable data about the patient outcomes, patients can be compared and methods are adjusted accordingly. Thus these
outcomes, recognized due to the amount of patients treated, might lead to single loop learning, in the way that the surgeons can adjust their methods to improve patient outcomes.
One quote from interviewee C might suggest that double loop learning is involved as well: “Because of the high volumes of patients we can use patient questionnaires to recognize problems in our organization or methods and improve them based on the results”. Because of the high volume of patients a big data pool can be used to compare patients and their surgery outcomes. Based on abnormalities in these outcomes or unwanted outcomes interviewee C suggests they might recognize problems in their organization as well. Based on the outcomes they can adjust the way they organized the expert clinic if they can improve the outcomes that way.
The patient outcomes, such as chronic pain complaints also seem to lead to single loop
learning. Interviewee A supports this: “15% of patients had chronic pain complaints after a year. By developing a new technique we managed to bring this down to 3.5%, and wound infections and patients needing a reuptake is now below 2%”. They developed a new technique through scientific research. They started this research because they considered the level of chronic pain complaints to be too high. The following statement by interviewee A seems to support the claim that patient outcomes might stimulate single loop learning as well: “Because of the problem of chronic pain complaints we re-evaluate our surgery techniques and try to adjust it to overcome this problem, we have had great success with this”. The way they organized their expert center might also stimulate single loop learning as indicated by interviewee B: “Because of our organization of the process we could develop new techniques that have reduced
level.
General Hospital Focus
Regarding the resource perspective the general hospital does seem to have a few surgeons that perform the low complex surgery but not a dedicated team of surgeons as shown by
interviewee D: “We do have a few surgeons that perform the low complex surgeries, though it is not clear beforehand which surgeon does which type of surgery specifically, this rotates”. Sometimes trained assistants perform the surgery: “There is no dedicated team of surgeons for inguinal hernia surgery, sometimes even an assistant might treat the patient”. Thus there is no dedicated team of surgeons or nurses that treat the patient. This implies that the level of focus regarding the resource perspective is low in the general hospital. When patients have
complaints post surgery, they do see the surgeon that performed surgery on them, the first time they visit the hospital again as indicated by interviewee D: “When complications occur and patients revisit our hospital, they will see the same surgeon who performed surgery on them”. Though there is no dedicated team of surgeons the general hospital does make sure they see the same surgeon who treated them when they have complaints, which implies a small form of focus. Besides that they also have one day of the week scheduled for low complex surgery. This might not necessarily mean that inguinal hernia surgery is performed. They do also not have dedicated operating rooms, recovery rooms or beds for inguinal hernia patients. This is supported by the following quotes from interviewee D: “Every week we have one day for low complex surgery, but not necessarily inguinal hernia’s. We do not have dedicated operating rooms or recovery rooms for each type of patient”; and “We do not reserve beds especially for inguinal hernia patients”. Thus, this all implies that the level of focus regarding the resource perspective is low.
when low complex surgery is performed, every space that is needed is located near one another to improve efficiency making the level of focus regarding the spatial perspective fairly high as well which is supported by interviewee D: “Daycare is at a few meters from the
operating room and the recovery room, this is one center”.
Concerning the organizational perspective the same results show as with the expert clinics. The surgeons are responsible, and guard, the quality of the surgery. But administrative functions, budgets and negotiations with health insurance companies is done by the hospital itself as indicated by interviewee D: “We guard our own quality but the hospital takes care of the administrative functions and budget. They also do negotiations with the health insurance companies”.
Focus and learning
On the level of individual learning the hospital functions as an educational place for learning surgeons. This is supported by interviewee D: “We teach this type of surgery to our assistants, this is the ideal operation to learn surgery”. This form of learning does not seem to occur from the way the general hospital organized its processes but might occur because this hospital is an academic hospital and a learning place for students. Inguinal hernia surgery is considered to be an ideal type of surgery to learn, though due to the low volumes there is not enough place for every assistant to be able to learn inguinal hernia surgery. Interviewee D supports this with the following quote: “Because of the low volume of inguinal hernia patients we treat, not every assistant might be able to learn using this type of surgery”.
On a team and organizational learning level the hospital performs scientific research to further enhance methods and techniques as indicated by interviewee D: “We try to develop on the part of chronic pain complaints and try to find new solutions to this problem. We developed a step by step protocol for this type of patient, this is getting published in a scientific journal”. Though they learn through scientific research and want to develop new protocols for treating patients with chronic pain complaints, they do not have accurate numbers of patients with these complaints in their hospital as indicated by interviewee D: “We do not have accurate numbers of percentages of patients with chronic pain complaints or recurring problems”. This might imply that they are involved in developing new methods, but they do not seem to have the intention to apply it for their own inguinal hernia surgery methods, since they do not seem to be interested to look up important data regarding chronic pain complaints in their own
not known. The interviewee proposes an annual checkup of the accurate numbers, but thus far this has not happened.
Furthermore, they do not seem to develop new methods and techniques themselves but rather they use developed techniques, developed in high volume centres such as expert clinics, and compare them to existing techniques: “We make use of techniques developed by others. Another surgeon developed a new technique in a high volume centre, we are now publishing that technique in a scientific journal and we are comparing it to the other available
techniques”. This is the first indication interviewee D gave that developing knowledge happens more in expert clinics than in the general hospital. Rather, the general hospital uses the
knowledge gained by this expert clinic to further study the new method or technique. This might imply that the way things are organized might influence the way and rate of learning. I will come back to this in the following section.
Focus, learning and performance
Because of low volumes the hospital has less expertise in inguinal hernia surgery and interviewee D expects patient outcomes, such as chronic pain after surgery, to be better at expert clinics: “Because of low volumes we have less expertise. If I had an inguinal hernia I would get surgery at an expert clinic, though I still think we deliver good quality”. Thus, interviewee D seems to explain their low expertise mainly due to the low volume of patients they treat. This does not however, show a relationship between focus and learning, it mainly implies that single loop learning takes place due to higher volumes of patients and repetition of the task: “Because of higher volumes, I think surgeons in expert clinics see more rarities and thus know better how to deal with them than us”. Further explained with the following quote: “I think that, purely for the development of inguinal hernia surgery, expert clinics can
contribute greatly because they do it on a daily basis and have larger databases than us”. As shown earlier the hospital does not keep track of their databases regarding inguinal hernia patients, so interviewee D thinks that the development of new methods is affected by the size of these databases.
the newest techniques”. This implies that they do not develop new techniques but also do not have the capability to keep themselves informed about new techniques and share knowledge where needed. Interviewee D thinks this is the result of the organizational differences between the hospital and expert clinics: “I think that, purely for the development of inguinal hernia surgery, expert clinics can contribute greatly because they do it on a daily basis and have larger databases than us”. The expert clinics perform inguinal hernia surgery every day, or on the days the surgery is planned, because of the way they are organized. Interviewee D thinks that, because of this organization of the process, expert clinics see more patients and can provide a better contribution to the development of new techniques. This thus implies that interviewee D thinks that, because of the way the hospital has organized its processes, they have lower
volumes and less single loop learning effects, meaning they do not develop new techniques. The interviewee also thinks that the surgery time is longer compared to expert clinics due to these low volume of patients and he thinks the expert clinics might be able to better treat patients with certain rarities which might occur during inguinal hernia surgery according to interviewee D: “Because of higher volumes, I think surgeons in expert clinics see more rarities and thus know better how to deal with them than us”; and “Because we do not focus on inguinal hernia surgery the waiting times are long, 2 months minimum”. Besides the patient outcomes regarding chronical pain complaints, the waiting times for the patient also increase according to interviewee D, due to the lack of focus in the hospital. The hospital does not show any learning effects because of this outcome. They simply do not care if the waiting times are longer and do not show any intention to change their process.
Comparing the expert clinics to the general hospital
Expert clinics General Hospital
Dedicated team, rooms and material Hardly any dedicated resources Same protocol for each patient Same protocol for each patient Dedicated rooms near each other Needed rooms near each other Continuous evaluation of methods and
process
Evaluation is possible but does not take place on a regular basis
Single loop learning based on outcomes and possibly influenced by the organization of processes
Hardly any development of methods and techniques
High volumes of patients Low volumes of patients
Short surgery times Longer surgery times
When comparing the expert clinics to the general hospital on the level of focus there is a big difference on the resource perspective. Where the expert clinics have dedicated teams, rooms and materials, the general hospital does not have this for inguinal hernia surgery. Regarding the transformation, spatial and organizational perspective they do show similarities where patients follow the same protocol and rooms needed for the patient are located near each other. Learning effects seem to occur mostly in the expert clinics. The interviewees of the expert clinics and the interviewee of the general hospital all seem to agree that the higher volumes of patients, that expert clinics treat, lead to more data and lead to more learning. The
interviewees show that the learning effects are single loop learning, where methods are
evaluated based on outcomes and new methods or techniques are searched for, often through scientific research. This does not seem to occur in the general hospital, where they only
compare developed methods, developed in an expert clinic, to the current methods. Though interviewee D thinks that these learning effects that are seen in the expert clinics are mostly stimulated by the higher volume of patients, the interviewees of the expert clinics also show this single loop learning effect based on patient outcomes. They evaluate patient outcomes, often chronic pain complaints, and search for new methods and techniques through scientific research to influence the patient outcomes in a positive way. The interviewees of the expert clinics also seem to agree that these learning effects occur because of the way they have organized their processes. They say, because they work with a dedicated team, it is easier to search for new methods and they claim to find answers to their scientific questions quicker because of their organization. These effects are not found in the general hospital. Since the focus of the expert clinics differs from the general hospital mostly on the resource perspective, it might imply that the level of focus on the resource level is the part that might have an
Discussion
Firstly I will discuss the level of focus seen in the expert clinics and the general hospital. As described by Hyer et al.’s (2009) resource perspective, there need to be dedicated human and technical resources for processing a set of similar objects. This seems to be the strongest point of the expert clinics. Both expert clinics have a team of surgeons and nurses dedicated fully to inguinal hernia patients. The general hospital does not show focus on this level. They do not have a dedicated team treating inguinal hernia patients, but the team seems to rotate depending on who is available. This difference can be explained by the choice the general hospital has made to have more high complex surgery, rather than low complex surgery. This is also the reason that they do not treat as much inguinal hernia patients as the expert clinics. Since a general hospital needs to fulfill needs of all kinds of patients and needs to be able to treat all these patients, focus on all types of surgery is not possible (Capcun, Messner & Rissbacher, 2012). Though the general hospital needs to deliver a broad range of services it is often seen that they choose to specialize in just a few services (Capcun et al., 2012), in this case the high complex surgery. Because the general hospital does not lay the emphasis on low complex surgery they choose to not dedicate resources to this type of surgery.
(2009). Furthermore there are dedicated operating rooms only used for inguinal hernia patients on the days that inguinal hernia surgery is performed. Besides that the recovery rooms are located nearby, in line with the spatial perspective of Hyer et al. (2009), where only inguinal hernia patients are placed. Based on these first three perspectives of Hyer et al. (2009) the expert clinics seem to be highly focused. Though they stay behind on the organizational perspective (Hyer et al., 2009), where their administrative functions and budget is still regulated by the hospital itself. For the spatial and transformation perspective the general hospital shows signs of focus. Though the operating rooms and recovery rooms are not
dedicated to inguinal hernia surgery specifically, they do make sure that these locations are not far apart from each other to keep efficiency high. Furthermore the low-risk patients follow the same trajectory from the moment they enter the hospital until they leave the hospital.
When comparing the learning effects of the expert clinics and the general hospital we see that both actively participate in scientific research on the organizational learning level. Furthermore they both teach individuals the techniques of inguinal hernia surgery. In the hospital this is mostly for educational purposes with students, where the expert clinics show their techniques and methods to already educated professionals. Furthermore the expert clinics both seem to put an emphasis on evaluating outcomes and developing and learning new methods or techniques. This development of techniques is also stimulated by the volume of patients the expert clinics treat. The interviewees of the hospital and the expert clinics seem to agree that the higher volume of patients, and thus more repetition of the task, stimulates this single loop learning effect. This repetition stimulates the knowledge of the task and the individuals and teams learn about the relationship between the activities that make up the task (Bohn, 2005; Bohn & Lapre, 2011). This increased understanding of the task allows for improvement of individual parts of the task or redesign of the whole task (Adler et al., 2009). This can explain why the expert clinics are developing their methods and techniques and the general hospital is not. Besides this, the patient outcomes also seem to have an influence on learning. First of all, the chronical pain complaints after surgery seem to be lower in the expert clinics when
intended outcomes. Because the hospital does not seem to evaluate the outcomes, they do not notice if intended outcomes differ from actual outcomes, and thus will not take action
accordingly.
In conclusion I can say that single loop learning takes place in the expert clinics but barely, or not at all, in the general hospital for inguinal hernia surgery. Another reason why this might occur is the level of focus the expert centers have which the general hospital is lacking for inguinal hernia surgery. Though this relationship only seems to occur on the level of the resource perspective. The interviewees of the expert centers all claim that they evaluate outcomes more often because of the way their processes are organized for example. Besides that they claim to find answers to scientific questions more quickly and thus are able to develop new methods and techniques quicker, due to the organization of their processes. It seems, that because they have dedicated teams, the single loop learning is stimulated or at least enhanced. When surgeons work repeatedly with the same resources, such as team members,
performance improves (Huckman et al., 2009; Huckman & Staats, 2011). The link between this improvement of performance and working with dedicated resources is arguably a learning effect. In line with the answers of the interviewees who say they can share and evaluate outcomes better and quicker because of the organization of the process, the link is arguably single loop learning. Thus, because the expert clinics work with dedicated human resources, single loop learning is enhanced and performance outcomes are better. Besides that the expert clinics have scheduled days where they only perform inguinal hernia surgery and the amount of learning compared to the general hospital does seem to be in line with the statement of
Sarason and Pierce (1996) who claim that learning might be stimulated by limiting cognitive interference.
Conclusion
Several papers concluded that focus leads to better performance outcomes. There are authors who beg to differ but this seems to be the general consensus. Though the relationship of focus and performance has been widely researched, the influence of focus on learning and learning in general in a focused organization has not been addressed that often. In this thesis I looked at the concept of learning in a focused organization and the role focus seems to have in this learning process. First, let me repeat the main research question:
team level, since information sharing, and seeking new knowledge, takes place more often and with quicker results. Having dedicated resources seems to stimulate the amount of team learning and single loop learning that takes place and seems to enhance the pace in which new methods and techniques are developed. Because there is a dedicated team, members of the team are able to gain and share knowledge faster and in a more efficient way compared to non-focused practice. Being able to share this knowledge throughout the team more efficiently, allows the team to find answers to scientific questions quicker which allows them to develop and implement new methods or techniques quicker. Compared to non-focused practice this type of learning happened a lot more, and the results suggest that the way the expert clinics organized their processes was of influence on this learning process. Also the volume of patients seem to stimulate single loop learning. Because of the higher volume of patients that focused clinics treat, they have more experience and patient data, which leads to development of new methods or redesign of current methods. This was not seen in the non-focused general
hospital, where they treat lower volumes of patients. In this case of single loop learning, having dedicated resources also seems to stimulate the amount of learning and the pace of learning. Thus, focus does seem to have a positive relationship with learning. Mainly learning on team level but there are also indications that focus influences the amount and pace of single loop learning. Though not all perspectives of Hyer et al. (2009) seem to have an influence. The perspective that does seem to play a role is the resource perspective. Since on this perspective of focus the biggest differences were seen when comparing the focused and non-focused practices. The influence of this perspective on learning mainly lies in the fact that the focused practices had dedicated teams where the non-focused practice did not. Where the focused practices were continuously trying to improve themselves and their operating methods, the non-focused practice did not put much effort in this.
Limitations and implications
Though the time available for this master thesis was almost six months, several problems occurred due to time constraints. To gather the results as much interviewees and cases as possible were appreciated. This, to improve reliability of the thesis and to increase validity. Though the results seem promising there are a few sidenotes. For the data gathering there were three cases used. Namely, two expert clinics and one general hospital. This was due to the fact that getting appointments was more difficult than expected and the time needed to
