How lean service chain in collaboration affect the eldercare service - a comparison between China and The Netherlands

1

How lean service chain in collaboration affect the eldercare

service - a comparison between China and The Netherlands

University of Groningen

Faculty of Economics and Business

Pre-MSc Supply Chain Management

June 2020

2 ABSTRACT

The aging population is a problem that many countries are facing. Eastern countries and western countries have different ways to perform their eldercare because of the culture and healthcare systems. However, collaboration is the keyword for both countries to endeavor for having a better outcome of eldercare service performance. The collaboration efficiency can be addressed. Efficiency, which is often discussed in supply chain management, and it is also the main indicator in healthcare service performance. From SCM lean perspective, reducing waste can make the entire service chain efficient. This paper aims to show how lean knowledge applied in the healthcare provider’s collaboration affects the eldercare service performance by comparing the two countries, which are China and the Netherlands. The results reveal that a leaner service chain has a positive impact on collaboration efficiency between care providers. This paper contributes to the current literature in lean knowledge applied in the healthcare sector.

Keywords :

Healthcare collaboration Service chain

Lean

3 INTRODUCTION

4 In this paper, The Netherlands is the counterpart of China. The research aims to generate the interconnection between healthcare providers for both countries through a service chain framework and see how lean affects collaborative activities in the service chain to lead a better health service outcome.

Therefore, the research question discussed in this research paper is :

How Dutch and Chinese healthcare providers collaborate to affect health service performance via a lean service chain? - A comparison between two countries

5 LITERATURE REVIEW

In this chapter, an overview of the important theoretical concepts related to the research is discussed. These insights are combined in a conceptual framework.

Collaboration

Collaboration is one of the topics most discussed in the business world (Barratt, 2004; Bowersox et al., 2003). Collaboration is explained that involves two or more organizations setting strategies in which different complementary capabilities achieve their common aspirations and goals in a competitive environment that cannot be achieved individually (Kumar and Banerjee, 2012). It is more than coordination and cooperation (Kumar, Singh & Shankar, 2016). The relationship between collaborative firms has to be open, trusted, share risks, costs, and in the long term (Sandberg, 2007, Whipple et al., 2010). It is a driving force to achieve effective supply chain management (Horvath, 2001). Successful collaboration in the supply chain is that each chain partner receives adequate information in time (Raweewan & Ferrell, 2018). A regular meet up and follow up improves the coordination between firms and collaborative relationships (Bowersox, 2003). Technology development makes regular contact easier and promotes information and resource exchange much quicker (Singh et al., 2008). A high level of IT infrastructure development leads to higher customer service performance (Wong et al., 2015), particularly in joint decision-making and problem-solving, which are the main collaborative process (Stank et al., 2001; Spekman et al., 1997).

6 capability, which enhances the information flow for better communication (Fawcett et al., 2008, & Palanisamy, Taskin, & Verville, 2017).

There are different forms of collaboration in healthcare provision. The referral is the basic collaboration. Most collaborative relationships involved patient referral agreements (Halverson et al., 2000). The referral system is connecting all levels of the health system and ensures people receive the optimal care that is closest to the patient home (Coleman et al., 1979). Joint decision making is another form of collaboration, it relates the concept “Client-centered care” is based on the collaboration (Chewning & Sleath,1996; Van der Kraan, 2001). Older patients who have chronic diseases normally receive care from multiple healthcare providers, those who deliver the entire care service for one older patient. Care providers coordinate and optimize the treatment plan based on the patient's conditions (Elwyn, 2001; Jewell, 1994; Sainio, Lauri, & Ericksson, 2001).

Eldercare Service Performance

7 Lean Service Chain as a Mediator

The service chain can be understood as the same idea of supply chain applied in service industries such as tourism, financial service, as well as healthcare (Christopher, 1992). Compared with the supply chain, service has characteristics of intangibility, heterogeneity, inseparability, perishability, customer-supplier duality, and labor-intensive (Christopher, 1992, Gronroos, 2000). That means suppliers in the healthcare service chain are healthcare providers, while patients replace the position of customers (Meijboom et al., 2010). Healthcare providers give care to patients who receive it simultaneously. Patients are part of the service chain. Unlike supply chains, product quality can be monitored and measured, service is hard to standardize because service is provided and received by human beings. Different people have different feelings. According to the characteristics of service, the service supply chain could be shorter than the traditional supply chain. In addition, service traits lead to the service supply chain to have more challenges in terms of exchanging information and resources (Ramayah, & Omar, 2010). A framework shows in figure 1 identifies the participants in the service chain and reflects the relation between them, the solid line refers to resources, and the dotted line means information (Avery & Swafford, 2009). This helps to visualize the information and resource exchange relations between healthcare providers.

Lean is a philosophy applied in manufacturing for improving their production efficiency. The lean approach emphasizes waste reduction during the process of manufacturing. Nowadays, it has become fashionable to apply it in the service sector (Slack, Lewis, 2017). By using the waste concept from the manufacturing field, Cohen (2018) defines the wastes in the healthcare sector includes waiting time of patients, overproduction of unnecessary diagnoses and laboratory tests, and over processing of filling out multiple forms at every clinic visit. Reducing waste finally leads to an effective service chain. Successful lean implementation requires support from both the technical and mental side (Krueger et al., 2013). Adding lean on the service chain to reduce waste of collaborative activities increase collaboration efficiency, then finally achieve better health service performance.

8 Figure 1

Service Supply Chain

Source: Avery SL, Swafford PM, 2009. Social Capital Impact on Service Chains. Journal of service science. Volume 2, Number 2: 9-16

Combining all above-mentioned literature insights, the conceptual framework is presented below (Figure 2).

Figure 2

Conceptual Framework

Collaboration

Performance

9

METHODS Research Design

Qualitative research is used in this research. It helps to explore more rich and detailed information for the research topic or explains the social phenomena (Neuman, 2003 & Yin, 1981). The non-numerical data from the interview will be obtained. Based on the semi-structured interview, it is encouraging participants to speak freely about their experience. For this research question, qualitative research fit the best, because little is known about service chain, lean, the collaboration between care providers, and the effect of eldercare service performance. Studying multiple cases from the care providers' interviews enables this empirical research to examine the practical phenomenon.

Research Setting

In order to see the service chain between two countries, and how lean affects collaboration to a better eldercare service performance, four interviewees work in primary healthcare and eldercare organizations have been selected from two countries. To conduct a fair comparison, interviewees are selected in the equivalent institute. Primary healthcare providers are one Dutch general practitioner and one Chinese physician from hospital-level 2, which belongs to primary healthcare providers in China. Eldercare providers are one psychosocial assistance from Dutch eldercare home and operation manager from the Chinese community elder service center. In addition, a group of 20 students who researched the same theme will be looked at and analyzed to enrich the interview data.

Data will be collected from the above-mentioned care providers and the data pool of related topics. Prior to conducting the interview, the literature on collaboration status in both countries has been reviewed. To answer the research question, the first step is to draw the service chain for both countries. The interview result will be analyzed and summarized to show the difference in how Chinese and Dutch healthcare providers collaborate with each other for achieving higher efficiency. The detailed information of observed objects is shown in table 1.

10 Table 1

Overview of the selected healthcare organizations

Case number 1 2 3 4 Type of health organization Eldercare service center in the community

Hospital (level 2) Care home organization General practitioner Interviewee Operation Manager Physician Psychosocial assistance GP

Location China China The Netherlands The Netherlands

Data Collection

Due to the restriction and COVID 19 and geography, the interviews were all conducted by phone or skype. The interview was designed in semi-structured so that interviewees have the flexibility to speak freely about the questions (Barriball & While, 1994). A standardized interview guide was used to assure all interviewees have the same questions. Data were collected from four interviewees, who are either eldercare providers or healthcare providers. To have a fair comparison, numbers of interviewees, interviewee working organizations are equally distributed. Interviews have been recorded and transcribed for information validity and traceability. Information collected from the interview belongs to primary data. All questions are connected with the focal question. The interview includes three parts, which are a collaboration between healthcare providers, communication between healthcare providers.

11 informed with signing the participant consent form. The conversation was transcribed afterward. In that way, information can be traced and checked to avoid missing and misunderstanding information.

Data Analysis

To widen the analysis of this topic, additional interview transcripts under the same theme have been used. Transcribed interviews were analyzed with a code tree. Coding is the process of indexing or categorizing the text to identify concepts and find relations between them (Gibbs, 2007). It reduces the amounts of empirical material and makes data readily accessible, and improves the quality of qualitative research (Miles & Huberman, 1994). The composed table tree categorized the distinguished main codes out of the literature review, see table 2. This becomes the basic form of analysis to answer the research question.

Table 2

Code tree with the most important concept

Theoretical background Main code Definition

Collaboration Referral

Joint problem solving IT application

Information sharing

Healthcare providers and elder care providers exchange information and resources for better care elder patients

Service chain

Lean

Participants

Participants Interactions

How does information Indicate the numbers of participants and their relations

Reduce wastes Health Service Performance Service quality

Efficiency

12 quick patient arrangement

RESULTS

This section will discuss the findings by analyzing the collected data. Insights regarding how lean of service chains affect collaboration between healthcare providers lead to a better result of healthcare service performance by presenting the comparison between two countries.

Table 3

Defining interviewed specialists Operation manager in eldercare community service center Physician Psychosocial assistance at elder homecare General practitioner

Case 1 Case 2 Case 3 Case 4

Care provider 1 Care provider 2 Care provider 3 Care provider 4 Collaboration

13 patients are elderly in her emergency department and they either arrive with us via ambulance or GP. “GP’s are supposed to provide a referral (verwijsbrief) in which they communicate their diagnosis, and why he/she has decided that this patient requires emergency treatment” GP normally required to provide a referral to the emergency department and hospital officially. In practice, GP left handwriting paper with an ambulance car so that nurses can quickly get the patient's message. There is a partnership established between GPs and specialists from the hospital by holding regular partner courses aim to have better joint problem solving process in further collaborations, supporting data indicated. IT applications play an essential role in exchanging information, it largely increases the internal work efficiency within the organization. Most external information exchange is done by a phone call or email. The Netherlands has a system to connect GP with a physician via a system called Zorgdomein.“Also not really because the communication with hospitals goes via a system called Zorgdomein, this system has a chat function which we can use to talk to physicians. The digital platform provides the conveniences for GP and physicians to be able to talk immediately. Finding a particular physician or GP through searching on the platform becomes much easier. Case 4 stated, “We are using Siilo to talk to each other, which is supposed to be a safe app...”Siilo is an application that can be seen as a community for all GPs, they are able to exchange information on Siilo. Case 4 a system that enables information exchange between patient and healthcare professions “MedMij is defining the building blocks for what data a patient file should contain. ”

Table 4

Additional supportive data from the data pool Code Supporting data from the data pool

Referral It is always on referral from a doctor, who then refers to the rehabilitation center

Referral We almost always get them in the post. Mostly by post Referral There is the referral system called www.zorgdomein.nl

that’s used by GPs

14 In general, there is less collaboration among healthcare providers in elder care in China. Community eldercare service center is playing a role of connecting external professional caregivers to elders who live in the community. To help elders lives in the community have more knowledge about health and disease prevention, hospital and community eldercare service center made the decision together for give health education periodically in the community. Care provider 2 stated “ I went to each community for a health education presentation aiming for disease prevention.” In the hospital, a specific contact person coordinates with the community service center for the health education held in the community. Furthermore, in case 1, “Our convenience center is mainly for elders who can take care of themselves most of the time. We will deliver the patients who need 24/7 care to the eldercare center, which is in the same holding company.” The community service center has a collaborative relationship with elder home care, which is under the same group. Regarding the IT application, both cases 2 mentioned the multiple IT applications are and widely applied in healthcare providers and eldercare providers, enabling the self-service for patients. “The good news is that most hospitals in China have online services for patients, patient can reach us via our website or Wechat. ”

To sum up, collaborative activities are mainly between care providers in the Netherlands, while collaboration happens more frequently between care providers and individual patients in China. Both countries rely on information technology to collaborate closely.

Lean Service Chain in Eldercare

15 Afterward, receive the following treatment by visiting the community elder service center or going to the eldercare home.” This implies Chinese elder patients have much freedom to choose hospitals, physicians, and specialists. They made their own decisions to transfer to another hospital, visit another specialist. It actually makes the service chain much wider than the Netherlands. Patients design their own service chain, each kind of care provider can be involved in the chain. The collaboration activities are mainly between patient and care providers. It makes Chinese elder patients much more involved in the service chain.

16 Figure 3 Dutch elder care service chain

17 Waste of over processing can be reduced by developing more functions in IT applications. Patients are easily able to access their health reports, and so on. Case 2 stated, “Patients show their scans, lab reports, prescriptions, a report which is stored in the cloud to save their time for doing the same test in different hospitals.” The development of mobile applications enables more collaboration between patients and healthcare professionals, improving working efficiency, and avoiding repetitive work. Both of the countries are focusing on reducing the patient waiting time, so that elder patients can reach the correct care providers in a short time. Dutch care providers developed IT applications for care providers to be able to communicate and search for each other online. Collaborative activities become easier by the conveniences of getting in touch and following up via platform. Case 1 “We now use mobile applications to select a time slot for treatment, seeing doctor, and many other services, the functions on mobile applications is continuing developing for meeting more patient’s needs .” It becomes more flexible for elderly arrange their time, largely reduces the waiting time for the them. More importantly, it increased the quality of health service because less time exploring an “unsafe environment” considering the elderly are weaker than a young man. It will be easier for them to be sick when they are waiting at the hospital.

Health Service Performance

18 patients. In the Netherlands, supportive data shows from a Dutch care provider’s perspective, the collaboration between each healthcare in the chain increases the final efficiency.

Table 5

Additional supporting data from the data pool Code Supportive quote from the data pool

Efficiency “And in my opinion, there are a lot of organizations that can work much more efficiently in the field of care, deployment, looking at aids, looking at materials that are used, for example for wound care materials.”

19 DISCUSSION AND CONCLUSION

In this part, discussion and conclusion will be provided by analyzing and explaining the result. The implications of the studies for theory and practice will be presented. Limitations and recommendations for future research are advised.

Interpretation of Results

The service chain framework visualized the elder chain care in the two countries. The service chain represented two styles of eldercare. It influences the collaboration modes between chain participants. Due to the difference in healthcare systems, the collaboration activities differ. A significant difference in collaborative activities is that Chinese patients is more involved in the service chain, they have more autonomy to decide who and where to go when they are sick. In the Netherlands, GP as primary care professional help patient to do so. However, the results shows as long as the collaboration efficiency improved, the health service performs can be enhanced.

20 requires to keep participants on the same mind page. In many manufacturing organizations, training the participants who are involved in lean project implementations is the preparation before implementation.

Critical Reflection of Study

To generalize the full picture of the healthcare industry in both countries, it requires more samples to contribute to this research. The current samples provide us some insightfulness regarding this topic, but still limited. Therefore, the lean service chain doesn’t show a strong relationship between collaboration and eldercare service performance. Further research should find more interviewees within the eldercare section to find its relation. Moreover, healthcare service performance includes wider range such as evaluation of healthcare hardware, infrastructure, and so on. Lean techniques can be considered to improve these aspects as well. Especially under COVID-19 circumstance, visiting care providers is impossible.

Finally, the soft side such as leadership, management supported lean implementations in collaboration between care providers excluded in this paper. This could be another direction for future research.

Theoretical and Practical Implications

This research indicates that applying supply chain management knowledge in collaboration between care providers has a positive effect on certain performance, from the perspective of two countries. This research shows the positive impact among collaboration, lean, eldercare service performance. The importance of technical side of lean implementation is emphasized in this paper. It sets a base for further research to investigate lean knowledge for inter-organization collaboration in the healthcare provision. Comparing the lean in manufacturing, the amount of literature discussed lean in healthcare is much less. Therefore, further research needs accumulate more investigation regarding lean in healthcare so that to be able to quantify the effect between lean in collaboration and healthcare performance.

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25 Appendix

Interview questions used to answer the research question

Service chain Could you please describe the service chain for elder patients?

Problems and difficulties in collaboration Do you have difficulties or problems when you are working? / Which part of the service chain has difficulties from your perspective? And Why

3. How do you think the problem can be solved ?/ or the service supply chain can be improved

Collaboration Are you directly involved in homecare? How do you think you cooperate with home care services for older people?

26 providers improve the overall care for the elderly patient? How does the collaboration between health providers help patients? What’s the ideal situation for you? Are there instituted groups (contracted partnering organizations, general practitioner societies, policymakers) that work together to improve the overall care of elderly people? Information Technology What system do you use when you work?