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Improving service quality: the aid of supply
chain integration in focused factories
I would like to thank all interviewees for taking their time and provide me and my fellow researchers with useful data to complete this research. I would also like to thank my supervisor Dr. ing. J. Drupsteen for providing me with feedback and guidance throughout the thesis project. My co assessor Dr. C. de Blok for her feedback during this project. And not forget my fellow researchers on this topic with whom many discussions were held in order to improve our thesis’s ; T. Reehuis, B. de Jong, M. Hoekstra, J. Rottine and Y. li.
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Inhoud
1. Introduction ... 5
2. Theoretical Background ... 7
2.1 Focused healthcare organizations ... 7
2.2 Supply chain integration ... 10
2.3 Service Quality in health care... 12
2.4 Conceptual framework ... 14 3. Methodology ... 15 3.1 Case selection ... 15 3.2 Data collection ... 16 3.3 Measuring service ... 17 3.4 Data analysis ... 17 4. Results ... 18
4.1 Within case analysis ... 19
4.2 Cross case analysis ... 23
4.2.1 Effective ... 23 4.2.2 Efficiency ... 24 4.2.3 Accessible ... 25 4.2.4 Acceptable/patient centered ... 26 4.2.5 Equitable ... 27 4.2.6 Safe ... 27 5. Discussion ... 29 6. Conclusion ... 31 7. References ... 32 8. Appendix ... 34 Appendix A ... 34
Appendix B tables WHO dimensions ... 35
Table A1 - effective ... 35
Table B2 - efficient ... 37
Table B3- Accessible ... 40
Table B4 - Acceptable/patient centered ... 41
4 Abstract
In recent years, due to increased competition, healthcare organizations moved, and are still moving, towards a more focused approach. At the same time in these organizations supply chain integration is emerging as a way to enhance performance. These trends oppose each other in the essence of the first being more specialized focusing on a chosen expertise, whereas supply chain integration aims at collaboration with partners in the chain. The dynamics between these
5 1. Introduction
In recent years healthcare institutions moved , and are still moving, towards a more focused approach to handle increased competition and the requirement to handle patients in a more efficient way (Vries & Huijsman, 2011). This leads healthcare organizations to dedicate their attention on their chosen specialism. However, opposing to this focused approach is the need for more integration of processes, where cooperation between chain partners is required to
collaboratively manage intra- and inter-organizational processes (Flynn, Huo, & Zhao, 2010). Wan et al. ( 2002) concluded that healthcare organizations, successfully using integration, achieved higher performance. This need for integration is emphasized by De Vries & Huijsman (2011) ,they mention that “the implementation of integrated care programs are frequently addressed as being critical strategies to decrease resource utilization and improve health care quality”. This results in hospitals moving towards a more focused approach, but at the same time the need for supply chain integration becomes more apparent. Where focus is aimed on internal optimization, supply chain integration is focused on external goals.
The contributions from a focused approach result in better outcomes in operational and financial sphere (Hyer et al., 2009; KC & Terwiesch, 2011). The focused factory approach is aimed at improving performance by concentrating the available resources on a specific task instead of attempting to address all demands from internal and external sources (Pesch, 1996). In the healthcare the focused approach manifests itself through concentrating on specific treatments or diseases opposed to a full treatment spectrum. However, there is a downside: specialization leads to differentiation and fragmentation, which may require organizational arrangements for the coordination and integration of different but complementary tasks (Peltokorpi, Torkki, & Lillrank, 2011). The idea of integration is that distinct and interdependent organizational components should constitute a unified whole (Barki & Pinsonneault, 2005). In the
manufacturing industry different degrees of supply chain integration have shown operational improvements (Frohlich & Westbrook, 2001). The operational improvements that can be gained from supply chain integration in manufacturing industries are also found within the healthcare setting (Wan et al., 2002).
The concepts of focused factory and supply chain integration and their impact on performance are well found in literature (Frohlich & Westbrook, 2001; Hyer et al., 2009; Wan et al., 2002). However, little is known about the dynamics between the focused factory approach and supply chain integration and their combined influence on service quality. Nowadays, monitoring service quality is more critical than it used to be within the healthcare setting (Yasin & Gomes, 2010). Therefore this research will take a closer look at the benefits focused healthcare organizations can achieve through applying supply chain integration tactics, opening the research within the
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Service quality is ordinarily a reflection of values and goals current in the medical care system and the society of which it is a part (Donabedian, 2005). Improving service quality in the healthcare sector can have influence on quality of life.
In order to investigate the relationship between focused factories and supply chain integration and their combined impact on service quality, this aim is translated into the following research
question:
“How can focused healthcare organizations use supply chain integration to improve service
quality?”
The research focus will be on a supply chain wide perspective where different healthcare units will be investigated to obtain an overview in different integrated practices and see whether this improves service quality. In order to gain sufficient and reliable data a multi-case study among focused healthcare units throughout the Netherlands will be conducted. These focused factories will be selected based on differentiating types and configurations of focus. Based on the results of the case study combined with available literature, conclusions will be drawn.
7 2. Theoretical Background
In this section the research question “How can focused healthcare organizations use supply chain
integration to improve service quality?” will be fragmented in pieces starting with an explanation
of the concept of focused healthcare organizations. Relevant literature for focused healthcare organizations, supply chain integration and service quality will be discussed. The focus in this research is to look at the impact supply chain integration has on focused factories in order to improve service quality. As not much has been discussed on the topic supply chain integration within focused healthcare units, some literature which has its foundation in other fields will be presented to create a more elaborate overview.
2.1 Focused healthcare organizations
In general a focus factory builds on three basic concepts: 1) reducing costs, 2) a factory cannot perform well on every yardstick, and 3) simplicity and repetition breed competence (Skinner, 1974). These basic concepts result in an organization that limits its activities to a few products, technologies, volumes or customers. Through the concentration of all its equipment, procedures and supporting systems on a specific product mix and selected customer group a focused factory is able to outperform its less focused competitors. as a result of their focus organizations lead to higher product quality, reduction in lead time, inventory and costs (Hyer et al., 2009).
Within the manufacturing industry the focused factory approach has proven to improve
performance and quality through the use of these basic concepts. These basic concepts can also be translated to the healthcare setting, McDermott et al. (2011) discuss these basic concepts in a similar way noting that the use of focus offers two main benefits for healthcare organizations. The first being that higher levels of focus achieved by a greater proportion in a particular specialty can create greater volumes in that area, which leads to economies of scale and opportunities for enhanced learning (these compare to points 1 and 3 from Skinner (1974)). Secondly the heightened attention to a particular service also enables a hospital to configure its operational elements to support the chosen specialty (point 2 of Skinner (1974)).
Although focused factories are becoming more apparent within the healthcare sector (Vries & Huijsman, 2011), general hospitals are not able to use focus in the traditional way as this would result in treating a limited amount of patients and thereby losing the total care providence (McDermott et al., 2011). To avoid this negative result, focus manifests itself in different ways within the healthcare sector. Although general hospitals cannot lose their total care providence, other focused factories can. This resulted in specialty centers and ambulatory surgery centers. These manifestations will be explained after distinguishing types of focus.
The healthcare sector started with a small focus approach with the introduction of service lines where hospitals moved from a doctor view towards a service line (Hyer et al., 2009) that
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however, did not result in the desired performance impact (Byrne et al., 2004). As time
progressed other types of focused healthcare organizations emerged in the healthcare industry. Bredenhoff et al (2010) introduced the following three different types of focus in which focused healthcare organizations can be divided:
The first domain is the product focused approach. Organizations within this domain achieve a high degree of focus through limiting the treatments to a chosen specialty and select their patients based on their specialty. This product domain is closely linked to the specialty hospitals by Chukmaitov et al. (2008).
The second domain is the process focused approach. Organizations that fall within this domain are low-complex elective surgery centers (Bredenhoff, van Lent, & van Harten, 2010) aimed at achieving efficiency through standardization and adjusting layout in order to minimize delays. They tend to focus on processes, hereby opposing the product domain that aims at treatments. The third domain is a combination of product and process as organizations cannot always be categorized as one or the other, the third domain is called the procedure based approach. This approach adopts working methods of both product and process to achieve efficiency within a specific type of treatment. Hereby solely focusing on a specific treatment and patient group. These types allow classification of healthcare organizations over the different existing domains depending on their focus. Within the healthcare sector three different configurations of focused factory are depicted. The first type being focused hospital units (FHU). FHU can be seen as cells within a larger hospital (Hyer et al., 2009). These cells focus on specific treatments and hereby are able to optimize their procedures with specialized physicians. The second type are specialty hospitals (Chukmaitov, Menachemi, Brown, Saunders, & Brooks, 2008). As mentioned specialty hospitals fall under the product focused approach. Specialty hospitals focus on a certain type of treatment in which they excel. Within specialty hospitals the basic concepts of Skinner especially become apparent (not all yard sticks). Through the specialization on specific treatments they are able to reduce costs and reduce errors (Kumar, 2013). The third type are ambulatory surgery centers (ASC) (Carey, Burgess, & Young, 2011). ASC are focused on a limited number of treatments, closely related to FHU. ASC however are not connected with a hospital and therefor are freestanding organizations that do not rely on other departments. Besides, ASCs do not offer overnight stays which also distinguishes them from specialty centers and FHUs. At first sight ASCs and specialty centers seem the same as they both focus on a specific patient group instead of a full service. The difference however, is that ASCs can offer multiple specialties whereas specialty centers are specialized in a single specialty e.g. eye-care, dermatology.
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(Wemmerlov & Johnson, 1997). Based on the improvements which the focused approach shows, within the manufacturing industry in terms of performance and quality, the link towards service quality in the healthcare setting can be investigated.
The downside of focus is that specialization leads to differentiation and fragmentation, which may require organizational arrangements for the coordination and integration of different but complementary tasks (Peltokorpi et al., 2011). This integration should not be limited to internal aspects, but can be extended towards external chain partners. Therefor the effects of supply chain integration will be discussed in the next section in order to see whether this can improve focused factories.
10 2.2 Supply chain integration
The general concept of integration is the extent to which distinct and interdependent
organizational components constitute a unified whole (Barki & Pinsonneault, 2005). Several studies show that through the use of supply chain integration performance outcomes are
improved (Frohlich & Westbrook, 2001; Wan et al., 2002). Although the benefits of supply chain integration are well known, the definitions of supply chain integration vary and no clear
definition is available (Mendes Primo, 2010). In order to establish a clear definition within this research, the following definition will be acknowledged; “the degree to which a manufacturer strategically collaborates with its supply chain partners and collaboratively manages intra- and inter-organization processes” (Flynn et al., 2010). This definition is chosen as it specifies three dimensions in the chain; customer, supplier and internal. Where customer and supplier
integration are seen as the external integration (Flynn et al., 2010). The internal integration is the extent of collaboration between departments to fulfill the customers’ requirements. The objective of an integrated supply chain strategy is to synchronize the requirements of the final customer with the flow of materials and information along the supply chain in order to reach a balance between high customer service and cost (Vickery, Jayaram, Droge, & Calantone, 2003). As mentioned above Flynn specifies three dimensions of supply chain integration. Customer integration involves core competencies derived from coordination with critical customers (Flynn et al., 2010). In service industries customers have a central role, and without customers there is no service provision (Meijboom, Schmidt‐Bakx, & Westert, 2011). To include customers in the process of service delivery might therefore be a wise choice in order to improve quality. In the healthcare section a customer (patient) is a singular person instead of an organization, therefore it might seem unnecessary to include them in the supply chain. The patient however is a crucial factor in the healthcare and should therefore be incorporated. Supplier integration has a focus on core competencies related to coordination with critical suppliers. Internal integration is the degree to which manufacturers structure its own organizational strategies, practices and processes in order to fulfill its customers’ requirements (Flynn et al., 2010). As this research aims at the aid supply chain integration can have for focused factories to improve their service quality, the focus will be on how customers, suppliers but also inter-healthcare organizations relations can be used in order to improve the service quality.
Although the supply chain integration construct is a relatively new area of research, there is an extensive body of research on unidimensional supply chain relationships (Flynn et al., 2010). The literature shows that supply chain integration is linked to many improvements for organizations (Frohlich & Westbrook, 2001; Meijboom et al., 2011; Vickery et al., 2003; Wan et al., 2002). These improvements include customer-service, -satisfaction, performance quality, supplier quality, lead time, worker productivity and product quality all obtained through closer relationships with customers and suppliers of an organization.
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different stages of supply chain integration (figure 1). It presents an overview of the
developments manufacturing companies have concentrated on during the last decades. Many organizations are currently in phase 1. These developments shown in figure 1 are to a certain extent also applicable to the healthcare sector (Vries & Huijsman, 2011) as, from an operations perspective, the focus in the healthcare sector originally also was on optimizing individual processes. The focus on optimizing individual processes has shifted towards a more integrated approach in the manufacturing industry, and these trends are also seen in the healthcare sector as the need for integrated care chains is becoming more apparent and supply chain practices are being used to a bigger extent (Vries & Huijsman, 2011). The figure can be used to assess the phase healthcare organizations are currently in and on which aspects they can improve to achieve a higher integration level. Through the categorization of focused healthcare organizations and their supply chain integration practices the beneficial practices can be discovered in terms of improving the service quality. Allowing to see how focused factories can apply different integration practices.
Figure 1
12 2.3 Service Quality in health care
In the previous paragraphs the promising improvements of the focused approach and supply chain integration were discussed. This section will discuss the potential benefits focus and integration can have on service quality. In order to assess the impact focus and integration can have on service quality the dimensions introduced by Donabedian (2005) will be used. In the Donabedian’s model of quality improvement, quality can be achieved by means of a structure-process-outcome relationship in which the quality system –the structure– is thought of as improving the organizational processes that in their turn should positively influence quality of care –the outcome (Schoten, Groenewegen, & Wagner, 2015). In order to show the relevance of the model in relation to this research this paragraph will contain 3 headings concerning the dimensions introduced by Donabedian; Structure, process and outcome.
Donabedian treated all three dimensions as equally important and emphasized that they are complementary and should be used collectively to monitor healthcare quality (Qu, Shewchuk, Chen, & Richards, 2010).
Structure
The structure dimension concerns the organization of the care and the characteristics of the organization. Therefore, structure includes the physical environment of the organization and the type of employees/specialists that are present. Characteristic of the organization is how an organization is managed towards achieving goals and performance.
In this research the structure dimension as introduced by Donabedian will be seen as the configuration of healthcare organizations. This implies that the structure is FHU, ASC or specialty center. The configuration of healthcare organizations determine the number of specialists and goals of the organization, the differences between these configurations thereby result in different organizational structures. Besides, the type of focus also determines the structure. A product focused organization limits their patient group towards a certain treatment and excels in this treatment.
Focusing on structure could result in a reduced complication rate (Kumar, 2013). Specialty hospitals achieve a lower complication rate due to high volumes in order to improve learning, which ultimately achieves significant quality and efficiency improvements (Kumar, 2013).
Process
Donabedian defines process as the nature of providing and receiving care. This contains both providers and recipients, but their input differentiate. Providers should diagnose, recommend and implement treatments whereas patients should seek and stick to the care. Process can be further defined as all technical processes, how care is delivered and in which way care is delivered. Judgements in this area are based on coordination and continuity of care, acceptability of care to the recipient, technical competence in the performance of diagnostic and therapeutic procedures (Donabedian, 2005).
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The type of focus also plays a role in the process dimension. An organization that is process focused aligns its technical processes and lay-out in order to achieve an efficient and effective result of diagnoses or treatments (Bredenhoff et al., 2010).
Outcome
This dimension is never questioned as an important measure of service quality. Although the outcome dimension is seldom questioned, the criteria of the outcome should be adapted to fit the organization. Measuring outcome in terms of mortality for example does not fit an eye-care organization as this would be seldom the case. Outcome contains all effects of healthcare on the patients status, behavior, knowledge and satisfaction with the treatment. Although the outcome is an important dimension, the quality of care is a remarkably difficult dimension to define
(Donabedian, 2005).
The outcome dimension can be considered the service quality dimension of an organization. In order to measure the outcome, six dimensions that are introduced by the world healthcare organization (table 1).
Dimension Definition
Effective Delivering health care that is adherent to an
evidence base and results in improved health outcomes for individuals and communities, based on need
Efficient Delivering health care in a manner which
maximizes resource use and avoids waste
Accessible Delivering health care that is timely,
geographically reasonable, and provided in a setting where skills and resources are
appropriate to medical need
Acceptable/patient-centered Delivering health care which takes into account the preferences and aspirations of individual service users and the cultures of their
communities
Equitable Delivering health care which does not vary in
quality because of personal characteristics such as gender, race, ethnicity, geographical
location, or socioeconomic status
Safe Delivering healthcare which minimizes risks
and harm to service users Table 1 – dimensions of healthcare quality (World Health Organization, 2006)
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outcome (Legido-Quigly, 2008). Whereas efficiency in contrast is aimed at how objectives are achieved by minimizing the required resources. Access to care is an important dimension of outcome to measure who is able to receive the intended health services, moreover is the required treatment available at the required time. Equitable is to what extent the treatment is considered in fairness, is the attention divided fairly and adjusted. The safety dimension is concerned with the hygiene and safety procedures that are performed in order to provide a safe healthcare
environment.
2.4 Conceptual framework
The aim of this research is to see how focused healthcare organizations can use supply chain integration to improve their service quality. In figure 2 the conceptual framework is shown. It shows the relationship between focused factories and service quality with the possible influence of supply chain integration.
15 3. Methodology
The aim of this research is to discover the effects of supply chain integration on focused factories and the combined influence on service quality delivered by a healthcare organization. This field of research is new in the disciplines of healthcare as the dynamics between supply chain
integration and focused factories has not yet been researched so far. Due to the lack of literature case study is conducted as this can be used as an exploration method (Voss, Tsikriktsis, & Frohlich, 2002). Besides, the lack of available literature on the dynamics between focused factories and supply chain integration require that the data that will be used is mainly qualitative of nature. The qualitative data will be gathered through the use of interviews that will be
conducted in different focused factories within the Dutch healthcare setting, where the focused factories will be the unit of analysis. As a result of the multiple cases that are going to be used, the evidence gathered will be more reliable opposed to investigation in only a single organization. Besides, through the use of multiple case studies observer bias will be reduced and
generalizability of the research will improve, although care is needed due to the limit number of cases (Voss et al., 2002).
3.1 Case selection
To collect sufficient and reliable data the grid as shown in table 2 is used. The grid is divided in degree of focus and type of focus. In order to collect enough data the grid was divided over six students whom collected data in different focus configurations. The grid is chosen due to the allowance of comparison between different types and configurations of focus within the Dutch healthcare system. Based on the type and configuration of healthcare organizations I expect to find different results. Specialty hospitals for example are expected to have a higher efficiency ratio and have a higher service quality. This ought to be the case as they are able to configure their treatments towards one specialty. Hospitals on the other hand are expected to perform lower on service quality as they are part of a bigger organization that limits their way of working. In order to answer the research question the service quality for the chosen centers was assessed through a questionnaire and the influence of supply chain integration on the service quality will be evaluated. Based on the criteria 98 cases were approached which resulted in 10 cases that fit the criteria and participated. These 10 cases are divided on different specialties and different configurations. Eventually one case was scrapped from the analysis as this specific case did not fill out the questionnaire part on service quality which is a selection criteria for this research.
Table 2
Degree of focus/Type of focus
Product focus Product-process focus Process focus
ASC Case 6 9 3 Case 8
Specialty Case 2 4
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The 9 cases are placed within the grid based on their configurations. However, the type of focus turned out to be less straight forward then suggested. Therefore, the placement is done through collaboration and discussions with fellow researchers based on the gathered data. This eventually resulted in a better placement. To determine the product, process or product-process focus some questions out of the Bredenhoff (2010) questionnaire were inserted in the protocol. Due to the adaptation of questions there were some difficulties in determining the type of focus as all cases were product-process according to Bredenhoff (2010). Therefore a small mathematical method is used in order to determine the type; product score/process score = ratio. This ratio should be below 85% in order to be process focused, 85-115% to be product-process focused and above 115% is product focused. These boundaries were set based on half the max deviation from 100%. This resulted in an assignment for each case over the 3 types (as seen in table 2).
3.2 Data collection
This study is built on three data types : Interviews, questionnaires and personal observations. The interview and questionnaire were protocolled (see appendix C) in collaboration with fellow researchers within the same study in order to provide a well-structured protocol. Eventually the protocol consisted of 34 open questions with 5 sub-questions and 36 Likert-scale questions in the questionnaire. The goal of the interviews was to understand the background of the focused factory and receive information about the configuration and supply chain integration resulting in the service quality that is offered. In order to receive a total overview different fields of expertise were interviewed from specialists to a CFO. This resulted in different perspectives in order to receive enough reliable and useful data. Interviews were conducted at location of choice by the interviewee and were recorded if allowed. All data that is gathered is shared with the fellow researchers.
17 3.3 Measuring service
The literature on benchmarking as it relates to performance measurement, such as service quality, in service organizations has multiple difficulties (Vagnoni & Maran, 2008). For this research I have chosen to assess the service quality based on the WHO definitions, previously shown in the theoretical background, by using the questionnaire. The protocol also contains several open questions concerning the service quality on which the interviewee could elaborate. Besides this protocolled investigation personal observations were made to see how we as researchers were treated but also how patients were received. Based on the results that are obtained through the open questions a service indication can be made. This service indication is checked taken the questionnaire in consideration. Although as the questionnaire is filled in by the interviewee themselves, the opinion of the researchers is considered to be key information and results will mainly be derived from qualitative data. By using the protocol and the standard approach of obtaining observation results are not influenced by interviewers through different approaches. The downside of this, necessary, measurement technique is that organizations were allowed to grade themselves on the provided service quality which could result in less reliable data. In order to obtain the most reliable results the notion that all results are kept private was explicitly
mentioned. To reduce the possible incorrect answers the qualitative results of the interview are considered more reliable and are therefore the leading results.
3.4 Data analysis
After collecting the data, making a detailed case description and coding the data the proposed steps by Eisenhardt (1989), namely within case and cross case analysis, will be followed. As a starting point the obtained data is presented by use of an array to systematically present the information. The array contains the six WHO dimensions on quality, practices that are conducted within the organization are provided and were assessed on their dimension. This effectiveness is determined by the researcher, but all information is obtained from qualitative data and validated through quotes from the interviewee.
Starting with a within case analysis, familiarity between the cases emerges and the unique patterns of the cases became clear. This resulted in an overview of the provided service quality and how they make use of integration within their type of focus. Afterwards cross case analysis was conducted. This cross case analysis is divided in two sections. Firstly the type of focus will be discussed and secondly the configuration of focus. From the cross case analysis I expect to find the different impacts supply chain integration can have on service quality for their respective focus type. This results in an overview of which methods of supply chain integration are useful to improve service quality.
18 4. Results
This section will exist of a within and cross case analysis. Table 3 provides a short overview of the descriptive of the cases. The type of focus, as discussed in the method, is determined through the questionnaire adopted from Bredenhoff. All cases are described based on their service quality and how the configuration and type of focus influence this. In the appendix B there is a set of practices for all cases based on the WHO dimensions and integrative practices. Besides that the questionnaire score based on the WHO dimensions is also showed in the appendix C.
Treatment specialism Configuration Patients annualy Specialists in FTE
1 Eyes Product process
FHU
35000 11
2 Sleep diagnosis Process specialty 3000 2
3 Eyes ASC 31000 5
4 Obesitas Process specialty 7000 25
5 Eyes FHU 700 4
6 Eyes ASC 7500 6
7 Obesitas Product FHU 690 3
8 Diagnostics ASC n/a 40
9 Asthma ASC 250 1
Table 3 – description of cases
Table 4 shows an overview of the number of practices that are conducted within each case for all six dimensions of the WHO. The number indicates the amount of practices that are conducted within in an organization concerning the specific WHO dimension. The first number gives the total amount (positive and negative) and the number between brackets is the total negative practices. The numbers are derived from the tables in the appendix (B1-B6).
Effective Efficient Accessible
Internal External Internal External Internal External
Case 1 5 (2) 1 4 (2) 1 3 (1) - Case 2 1 4 (1) 1 3 (2) 2 1 Case 3 5 1 6 (1) 1 4 (1) 1 Case 4 2 4 (1) 4 1 4 (1) 1 (1) Case 5 1 (1) 3 (1) 3 (1) 2 (2) 3 (1) 1 Case 6 2 2 (1) 2 (1) 2 (1) 3 1 Case 7 3 (1) 3 (2) 3 (1) 3 (3) 2 (1) - Case 8 2 5 (1) 3 1 2 1 Case 9 1 2 (1) 2 1 2 -
Acceptable Equitable Safe
Internal External Internal External Internal External
Case 1 3 (1) - 2 - 2 -
Case 2 1 2 1 1 1
Case 3 5 2 3 - 4 2
19 Case 5 1 - 3 1 1 - Case 6 2 (1) - 2 - 2 (1) - Case 7 3 1 2 - 3 - Case 8 2 1 2 - 2 - Case 9 3 1 1 - 2 -
Table 4 – overview number of practices on WHO dimensions for each case
4.1 Within case analysis
Case 1 – FHU 1
FHU 1 is part of a large academic medical center and is product-process focused. The department is focused on eye-care and is therefore product focused. However, the specialists are process focused to a greater extent as they have sub-specialism in specific treatments and perform these treatments more efficiently. Table B in the Appendix shows that there are 6 integrative practices of which most are internally focused. Due to the specific treatment offered by FHU 1 equipment is not shared as it is not applicable for other departments.
FHU 1 is obligated to treat all potential patient groups as it is part of an academic center which is the final option for treatments in the Dutch healthcare system. Therefore all patients that require care are accepted and treated within the hospital, if capacity allows it. A downside of being a large hospital is that the organization grew the way it has and it’s difficult to adjust due to developments over time. This results in inconvenience for patients as they move from room to room to receive their treatment. In order to digitalize the planning and storage of information some general IT systems are in place. These IT systems (EPIC) make the information and planning accessible to all specialists within the hospital, but entering the information in EPIC takes valuable time. However, planning is not shared with the hospital and is done within the department. This allows the FHU to plan their own patients, which often do not require attention from other departments. This way, patients receive personal attention and the procedure is explained by specialists that will perform the treatment, this gives patients a feeling of trust and safety. Once the treatment is finished however, they receive a checklist and only if complications occur they are allowed to come back.
Case 2 – Specialty center 1
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treatment is performed the center stays in contact with their patients through a sophisticated E-health program in order to track their progress and allow patients to give feedback. The progress of patients can be traced by all employees, ensuring that a good service is provided for the patient.
Case 3 – ASC 1
Ambulatory surgery center 1 is a product focused eye center which performs treatments for all patients with eye conditions. All employees are fully dedicated to the organization and specialists have their own preferences resulting in sub-specialism. This sub-specialism allows them to perform certain treatments with more efficiency. The center was set up in order to provide
treatments with the highest quality in the most efficient way. This can be observed throughout the organization, as all aspects are patient focused and created in an efficient and effective way. Specialists walk from treatment room to treatment room and are only present when their attention is required, letting assistant staff perform the preparation and provide the information to patients after treatments. The center also developed a special CRM system to allow all information
regarding patients to be stored immediately, including diagnostics equipment. This system allows referrers to easily provide the patients information by showing a good integrative process.
Besides, patients’ needs and demands are taken into account by organizing meetings with patients allowing them to explain their expectations. In addition, when patients leave the facility they can press a button to express their feeling. This feedback is used to determine periods in which the service was inadequate and which employees were responsible.
The focus the organization has on the patient is continuously improved and all available options concerning extra integration are examined. This results, for example, in collaborations with mobile companies to discuss the implementation of RFID chips in order to trace all singular items that are used. Providing extra safety for the patient, and allowing the organization to
automatically reorder inventory. Case 4 – Specialty center 2
Specialty center 2 is a process focused center specialized in treating morbid obese patients across the Netherlands, allowing all patients that fit the selection criteria. The specialty center has
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they are traced for 5 more years with intermediate checkups and controls. The patients are allowed to indicate preferences for a specific location which is often acknowledged, if they are willing to wait.
Case 5 – FHU 2
FHU 2 is an eye clinic which is part of the holding of a larger academic medical center. The eye clinic is product- process focused. Although they are part of the hospital and share their
equipment and facilities there is a dissimilar culture which stimulates a more comforting
environment for the patients. Being part of the holding means that the IT systems are integrated and orders are performed by the hospital. Planning is done within the FHU where no interaction with the hospital is required. Downside of the FHU configuration is that there are several IT systems required at the same time to provide patient information.
The service starts when patients enter the facility as they are welcomed and offered something to drink to improve waiting time experience. Once the patient is ready for treatment they are
informed by a specialist and proceed to the treatment. In order to provide an efficient treatment the lay-out of the FHU is adapted. This allows specialists to work in an effective and safe
surrounding. The lay-out allows the FHU to perform more treatments on a day without creating a hectic environment.
Case 6 – ASC 2
ASC 2 is specialized in eye treatments and is product focused. There are some integrative
practices within the center, mainly about information flow. This information flow is done through “zorgmail” but is experienced as ineffective as information needs to be re-entered in their own EPD. Specialists within the center are sub-specialized in their preferred treatments, but also work for other hospitals. Noticeable was that the quality of treatments varies within this center due to varying expertise of doctors.
Patients are first triaged when they arrive at the center in order to indicate what specific treatment is required. If this treatment can be provided by the center they will be accepted and the whole treatment from A-Z is performed. On average the center sees a patient 1,8 times. Meaning that after a consult the patient often has to come back for the treatment. Once the treatment is accomplished the organization tries to dismiss the patient.
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Case 7 – FHU 3
FHU 3 is a product focused unit specialized in treating obesity patients. Their integrative practices mainly concern information flow. Specialists are not dedicated to the unit which
sometimes results in priorities being set that are non-favorable. Besides, all logistics and planning are intertwined with the collaborating hospital which requires the unit to work with the systems of the hospital and not being able to plan on their own. Patients are referred by their general practitioner and enter the program that is offered by the unit if they pass the preselection phase. After information is processed the patients enter a process in which they are treated by varying specialists on different fields. Meetings are held with all these specialists in order to personalize the treatment for patients step by step, requiring an adequate internal integration. Patients are able to communicate their habits and lifestyle and this will be taken into account by the specialists. After an initial strict startup phase the patients are tracked for five more years before they are referred back to their GP. Currently the unit is considering options to allow patients to get back to their GP earlier and to use an E-health system to track the patients.
Case 8 – ASC 3
ASC 3 is a product process focused center performing diagnostics, dermatology and pain treatments. Several systems are used and shared with external parties in order to provide an adequate information flow. Collaborating hospitals receive the outcome of the diagnostics from the center after they are performed. EPD is used to store all information from referrals to their own data. Besides, ASC 3 shows their waiting times on the website for all to see. Specialists working at the center all have sub-specialisms and based on the sub-specialism of the doctors the patients are assigned to their personal specialists for the entire process they will follow. This allows them to receive personal contact and attention. Simple treatments are strictly protocolled in order to ensure safety and effectiveness of the treatment.
This protocol for treatments is obtained through their product process approach. The integration with external and internal parties through IT systems allows employees to quickly share and obtain patient information resulting in a smooth service provision.
Case 9 – ASC 4
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patients receive personal attention: there is just 1 specialist that performs the diagnosis. After the patient is diagnosed the center calls their patients personally in order to receive feedback and send out small surveys. In order to grow they take the patients feedback seriously.
4.2 Cross case analysis
The structure of this section is based on the six WHO dimensions as shown in Table 1. Each dimension will be cross analyzed with the available cases through firstly looking at the type of focus and secondly the configuration of focus. All tables showing practices are represented in the Appendix (B1-B6).
4.2.1 Effective Type of focus
Each type of focus is concerned with improving effectiveness of their organization. Process focused organizations (cases 2 and 4) are using cross functional teams in order to provide their patients the best possible treatment. Consults are part of their service provision resulting in a high degree of information sharing (both 3 practices). The combination of cross functional teams and information sharing practices result in an effective treatment that obtains the desired results, as confirmed by the survey.
Opposite to the process focused organizations are the product focused organizations ( cases 3,6,7,9). These organizations have a high amount of information sharing practices ( 3+), only case 3 uses dedicated employees. Two cases go to conventions that provide specific information for their product group.
The combination, product-process focused organizations, (Case 1,5,8) shows results that are a combination of the previously discussed types. Information sharing is perceived as an important part to improve effectiveness. However, also medical conventions are visited to obtain specified knowledge on their product.
The differences in terms of effectiveness across different types is not really noticeable. The main difference seems to be that product focused organizations more often go to medical conventions to obtain knowledge. This was not seen in the process focused organizations. Instead, process focused organizations rely more on cross functional teams.
Configuration of focus
The FHUs ( case 1,5,7) are all part of the EPD system that is used by the hospital they are connected with. Often this is considered both effective and ineffective. Data is accessible at all times, but has to be entered manually which gives room for small errors. These errors can occur due to mistakes that are made by the referrer and by the specialist that manually updates the EPD. Employees are often dedicated to the organization.
ASC (case 3,6,8,9) highly rely on their IT systems to provide effective treatments. Specialists in case 3 and 9 are dedicated and equipment is not shared resulting in higher quality of the
treatment.
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the treatment and the centers update their treatment according to feedback.
Although all configurations use IT systems, the intended goal seems to differ between configurations. Specialty centers are highly concerned with their patients and measure the effectiveness through an intensive after care program. Whereas, other hospitals are less concerned with the after care and use IT more as a supporting facility to improve their
effectiveness. With the exception of case 3 that falls under ASC (due to lack of overnight stay), but developed their own CRM system in order to provide the best possible care to their patients in a most effective way.
4.2.2 Efficiency Type of focus
All employees in the process focused organizations are allowed to monitor the progress of patients, allowing earlier interventions. The organizations are aimed at continuously improving and innovating the treatment they provide in order to increase efficiency. Through highly specialized knowledge they perform treatments more efficient.
Product focused organizations are specialized in certain products and optimize their treatments through protocols for less complex operations. Sub specialism occurs in order to allow for a learning curve among specialists in order to provide a more efficient treatment.
These product process focused organizations do not have common ground and vary in various aspects. Where case 5 has a direct implementation of referrals case 1 has specialists losing time due to manually entering data. Common ground of these cases is that a specific doctor is assigned and is responsible for the patient. All information is known by this specific doctor and no extra information flows are required.
The interviews did not lead to big differences in approach to efficiency regarding different types of focus. Sub specialism is a common way of improving efficiency. This allows specialists to perform their preferred treatment more often and thereby increasing efficiency. Across the cases IT systems play a role in the efficiency dimension as in some cases the information has to be manually entered, losing precious time of specialists.
Type of configuration
2 Out of the 3 FHU’s have a shared planning system with the collaborating hospital. This is seen as an inefficient practice as they are working on their own planning system. The integration with the hospitals system is therefore not seen as a productive integrative practice. In FHU 1 and 2, both offering eye-care, the facility lay-out is of influence on the efficiency. FHU 1 has “grown” this way and this resulted in an inefficient routing, whereas FHU 2 designed their lay-out to maximize resource utility.
All ASC make use of IT systems to manage information and patient flows. ASC 1 created a system that automatically stores diagnostic data in the CRM system. The other ASCs described this as an ideal situation that is not yet achieved. Besides, in order to achieve efficiency for low complex treatments protocols exist in order to improve throughput time of patients.
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agreements with their external parties, where center 2 has all expertise internally.
Across all cases there are multiple ways to achieve efficiency. Outsourcing some expertise knowledge through service agreements is optional as this allows the organization to focus on their specialism. Optimizing lay-out or process through protocols allows specialists to minimize time loss and improve resource usage.
4.2.3 Accessible Type of focus
Process focused organizations have the skills that are appropriate to the medical need, both are specialized in their treatment. Case 2 and case 4 are both highly accessible, case 2 treats patients at their own home within a few days. Case 4 has several locations spread across the Netherlands in order to allow all patients to find a nearby location. A difference between the 2 organizations is that the waiting time varies. Although this can result in longer waiting times, the patient group of case 4 has a lower urgency and often does not mind the longer waiting time.
Results show that on average, the product focused organizations have a higher waiting time. Although this is not always the fault of the organizations due to insurance company regulations. The service offering is built around a certain product and the required skills are available. In conclusion; Product process organizations have a lower waiting time and see their patients sooner. Case 8 even has an indication of the waiting time for certain treatments accessible for all customers. Case 5 accepts all patients, except for the complex cases. For case 1 this is the opposite as they are the final stage regarding available treatments
Type of configuration
FHU show a large variance in waiting time for patients, varying from 6 weeks to at most half a year. This variance is the result of the different treatments that are provided and the amount of people that require this service. A disadvantage that all FHU have is that they are stationed at 1 location. However , the treatment they provide is of high quality and skills are available which enables them to treat high complex situations. The fact that a hospital is nearby means that the American Society of Anesthesiologists classification can be higher due to the presence of Intensive Care (IC).
ASC differ in size and number of locations and this results in varying waiting times. Although the larger ASC is accessible the quality of care is lower and there are more variations in the
effectiveness of the treatment. This indicates that the skills are not always present. The ASC do have their personal equipment that is not shared with external parties.
Specialty centers attempt to innovate the process and deliver a highly accessible service through low waiting times and high expertise. Center 2 does maintain a strict entry screening and only patients that pass this screening are accepted.
26 4.2.4 Acceptable/patient centered
Type of focus
Personal attention is considered important in both process focused organizations. From acceptance of the patient to aftercare needs and demands are taken into account. E-health programs are used to follow progress for a longer period in both cases. Personal attention is provided by case 4 if patients are not progressing as they should. Case 2 provides at home analysis, reducing the inefficiency for patients to a minimum.
The product focused organizations don’t explicitly work on personal attention besides consults. The environment is a factor that is of significant influence for the experience of the patient. If the ambiance is unwelcoming the patient will be less comfortable. Case 8 is working on service development through creating applications for the next generation to improve their service experience.
From the 4 cases that are product process focused, only 1 is not putting in extra effort for
patients. Case 6 tries to dismiss patients after the treatment and does not follow up on feedback or experience. The other cases all developed their service provision around the patient, scoring high on personal attention and aftercare. case 3 goes further and has meetings with their patient groups in which they are allowed to voice their expectations.
Overall patients’ needs and demands are taken into account relatively adequate, the product focused organizations are less focused on patients and do not score high on personal attention and preferences.
Type of configuration
FHU differ in their contact with patients. It depends on the type of service that is delivered and the attention that is required. Eye hospitals aim at providing an effective and efficient treatment which is part of their service, where FHU 3 has a more intensive contact with their patients including aftercare and developing extra services to improve the patient experience.
3 out of the 4 ASC provide extra services on personal attention to make them feel comfortable, including aftercare aspects. The ASC that is not providing personal attention is part of a multiple organization group and might therefore be less focused on singular patients and personal
attention.
27 4.2.5 Equitable
Type of focus
Both process focused organizations do not discriminate their patients on ethnicity or other aspects. Case 4, however does have an entry requirement which patients need to fit.
Product focused organizations neither have a distinction in the patients they accept. Quality will be constant and acceptance is high.
Product process focused organizations are also high on acceptance and do not differentiate in quality.
There is no difference between the different types of focus in terms of equitable, some organizations have some selection criteria but this is only based on the treatment they are offering. The Dutch healthcare organization is designed to be equitable and there are strict rules healthcare organizations need to adhere to (see 4.2.6).
Type of configuration
The same as for type of focus is valid for configurations. There are no differences between patient acceptance and overall quality of care. All configurations accept patients which they are allowed to accept and the ones that cannot be treated within their organization are sent to another healthcare organization which is allowed and capable. There is no difference made between patients other than on medical criteria.
4.2.6 Safe Type of focus
Both process focused organizations have strict protocols for safety and hygiene which are regularly updated. Case 4 goes beyond the standard safety rules and only uses operation rooms that fit strict rules regarding safety, for example cameras.
The product focused organizations tend to show different results regarding safety protocols. In 2 out of 4 there is a strict policy regarding safety and there is an open culture with multiple audits. ASC 2 does have a protocol, but there is no control by employees. Only if a manager takes notes there will be consequences.
Combination of the two shows varying results scoring on safety environment to just protocols. There does not seem to be a trend among different types of focus as all organizations vary on their safety rules and the environment on hygiene and safety. They do however all have protocols and if they were not considered safe they would lose their license to operate.
Type of configuration
Among all FHU there are strict safety protocols which need to be adhered to. FHU 3 goes further by organizing personal trainings and creating an open environment on safety.
ASCs also need to adhere to protocols and audits. ASC 1 only uses their own equipment in order to guarantee the safety and hygiene of their materials. In order to stand out ASC 3 created a safety environment where they are progressively trying to improve safety.
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checklist of items that they require from the hospitals.
Same as among type of focus there are no observable differences that are specific for certain configurations. FHU tend to have a less strict environment which might be caused by the
environment. ASCs and specialty centers are not part of a hospital which results in a higher safety control from insurance companies.
Factors that are often mentioned by interviewees (in appendix B1-B6) are represented in figure 3.
29 5. Discussion
Overall, the distinction made by Bredenhoff (2010) were applicable to the selected cases. However the categorization in process-, product- and product-process focus was not as straight forward as was suggested. Focused factories are seldom only product or process focused based on the results of the interviews and questionnaire. Noticeable is that while on the outside a focused factory might seem product focused, the internal operations are more aimed at optimizing the process. This is manifested in sub-specialism of specialists where they have a preference for certain treatments. By sub-specializing the process of certain treatments has become more efficient through repetition and experience, which is also recognized as one of the basic concepts of focus by McDermott et al (2011). This sub-specialization mainly occurs within hospitals units as they are required to treat all patients ranging from low complex to high complex operations whereas specialty centers and ASCs have a limited range of operations.
The cross case analysis shows minor differences between the different types and configuration of focus. Theory suggested that specialty hospitals and ASCs would limit their patients to a certain treatment in order to provide a high quality of care. In some cases this turned out to be true as they refer higher complex patients to hospitals. However, some of the specialty and ASCs were able to treat all patients and only if there are extreme circumstances the patients were referred. Common ground for efficiency and effectiveness were found across cases. Collaboration with external parties was found to be crucial to achieve effective and efficient healthcare. IT systems play a role in this collaboration through allowing communication and shared planning. Noticeable is that in order to be more efficient automatic synchronization of information is crucial.
Organizations that did not manage to have this had to manually enter data costing valuable time of specialists and allow room for errors. Achieving automatic synchronization would improve resource utilization and avoid wasted time on unnecessary tasks. Furthermore the lay out should be considered in order to improve effectiveness and efficiency. In the theory section it is
discussed that specialty hospitals achieve a lower complication rate and thereby a higher
effectiveness through learning curves obtained by repetitive treatments. The results confirm this as the employees in specialty centers are highly specialized and are highly skilled. Although this was not singularly found in specialty centers; ASC and FHU make use of sub-specialism
allowing specialists to profit from a learning curve in their preferred treatments and thereby achieving similar results as specialty centers.
In manufacturing a shift from individual processes towards a more integrated approach, in healthcare the same shift is noticeable. All cases were connected with external parties. Some had established partnerships and collaborations with supply chain partners in order to improve their own service. These collaborations increased the effectiveness, efficiency, equitability, and acceptable dimensions of service quality.
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Therefore these dimensions were always taken care of in the cases. Some cases took it further and were providing extra attention to safety and hygiene by implementing extra protocols and
31 6. Conclusion
This study explored how focused factories can use supply chain integration to improve their service quality. This was researched through a case study among cases that differ in type and configuration of focus. All research has been done in the Dutch healthcare system.
To approach this research a combination of Donabedian’s model with the theoretically discussed focus, integration and service quality is used. This allows the researcher to see the focus of organizations as a structure, the integration as process and eventually the service quality as the outcome.
Results show that the service quality is not dependent on the configuration or type of focus but rather the practices that are conducted within the organizations. The quality of care in the Dutch healthcare system is of high standards and does not differ significantly among different
organizations. The practices that influence the service quality can be internal and external. Aligning specialists and having multi-disciplinary meetings are shown to be effective in improving the service quality. Strong collaborations with chain partners, including service agreements with external parties, provide the ability for organizations to arrange the alignment among specialists and consistency in their care. Besides these influences there are complementary services that influence the service quality. For example the environment that is created by the organizations has an influence on the patients and results in a higher perceived service quality. These combined contributions add to the existing theory.
The managerial contributions of this paper lie in the practical advice to include patients and create strong collaborations with external parties, but also internal improvements can be reached based on the results of the study. Developing or adjusting IT systems in order to allow automatic referral synchronization leads to a higher resource utilization which results in a higher efficiency and thereby an increasing service quality. Organizing meetings with other specialists within the same field and other fields provides an increasing skill for specialists and a better collaboration with the external specialists, resulting in an increased effectiveness. In order to stand out and increase service quality for patients, the patients need to be considered as part of the organization. Organizing meetings and allowing patients to provide feedback results in a welcoming
environment that makes patients feel at ease.
The study has some limitations. First of all the limited time in which the research had to be conducted was a limiting factor. In order to collect sufficient data on service quality there were some Likert-scale questions in the questionnaire. Downside of the questionnaire was the allowance of self-assessment which gives room for organizations to unfairly praise themselves. Besides, the research is set among different specialties which might have different approaches to care resulting in some disparities amongst the results. In future research the service providence could be kept constant in order to allow for more specific comparisons. Where this research is focused on the six WHO dimensions, one could look into different dimensions in follow up research to broaden the service quality aspects.
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Appendix B tables WHO dimensions Table A1 - effective
Practice Type Type of integration
Effectiveness
Ho
sp
ital 1
EPIC is used to store patients information throughout the hospital
Information sharing
Internal (hospital)
Effective “Epic allows us to quickly reach information about patients”
New patient information is send through fax
Information sharing External ( Other specialists/ GP)
Effective “We receive the information from GP through fax, which can easily be stored” Diagnostic equipment
information not centrally stored
Data storage Internal Ineffective “ There is no central location on which diagnostic information is stored and thus we occasionally make multiple checks” Equipment is not shared
with other departments within the hospital
Facilitating goods
Internal Effective “Our equipment is specific for eye’s and can’t be used elsewhere therefor it is always available”
Planning is performed within the FHU.
Planning Internal Effective “EPIC does not show planning. We plan our patients in our own system and only when required contact other departments” Patient is send through the
department to reach all equipment
Patient flow Internal Ineffective “Patients keep moving from room to room across the reception to reach all
equipment which looks messy”
Sp ec ialty ce n ter 1
Patient is visited at home for analysis
Patient flow External Effective “Patients feel more at easy within a safe environment and this improves the results”
Patient is referred by a GP through “zorgdomein”
Information and patient flow
External Effective “we can select our patients with “zorgdomein” after which our nurses can contact them in one day”
There are multiple IT systems for patients
Information flow
External Ineffective “Unfavorable is another party, “zorgmail”, which integrates the mail correspondence with the 2nd line GP”
Planning team that is in contact with external parties
Information and patient flow
External Effective “ all of the planning team are able to monitor the total system to make sure patients are referred to dentists psychologist or others”
Sophisticated E-health program to stay in touch with patients
After care Internal Effective “through the E-health program we stay in touch for at least 1 year”
ASC
1 Personally developed customer relation
management (CRM) system Information flow + data storage Internal and external
