Resource allocation in a multi-channel healthcare setting

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Resource allocation in a multi-channel healthcare setting

Master thesis, MSc Supply Chain Management University of Groningen, Faculty of Economics and Business

26.01.2015 P.H.J.M. Verspeek Student number: 1693123 Email: p.h.j.m.verspeek@student.rug.nl Supervisor/university: Dr. H. Broekhuis Co-assessor/university: Dr. M.J. Land Supervisor/field of study:

Drs. A. Van der Heide UMCG Centrum voor Revalidatie

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Acknowledgements

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Abstract

The allocation of resources in a multichannel design is one of the most complex decisions a service provider has to deal with. Its application and research in the healthcare industry is minimal, therefore this paper sets out to answer the question ‘How to allocate shared resources to a

multichannel design to ensure high quality standards in a healthcare setting?’ Theory states that the

multichannel design is dependent on customer characteristics and supplier strategic objectives, and that the actual design is influenced by the allocation of resources to different channels. Data was gathered through an in-depth case study at a hospital setting and interviews were conducted with the users of the multichannel design. The results have shown that, together, the service provider and customer determine how and when to allocate resources to channels and that for each customer the multichannel design is adapted, within the framework set by the supplier strategic objectives.

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1. Introduction

Upcoming trends in the healthcare industry, such as eHealth (electronic Health) and mHealth (mobile Health) create new opportunities for the treatment of patients. Due to progress in technology it becomes possible to provide remote care and increase efficiency, whilst still maintaining high quality standards. The number of service delivery channels has increased enormously over the past years and the issue arises which channels to use and how to allocate resources accordingly (Broekhuis & van Offenbeek, 2011; Kumar, 2010). This research focuses on one of the most important and perhaps most complex decisions related to a multichannel strategy; how should organizations allocate their resources across channels in such a way that they are used efficient and effectively?

An increase in service delivery channels provides customers with a vast array of possibilities to engage with the service provider (Kumar, 2010; Madaleno, Wilson, & Palmer, 2007). To cope with demand using a multichannel (MC) approach, the service provider can use different channels to provide the required service to customers, wherever and whenever the customer wants (Cassab & Maclachlan, 2009; Sunikka & Bragge, 2009). However, the unpredictability and variety in demand complicates suppliers decisions on which channels to employ and/or how to allocate limited resources to the different channels (Coelho & Easingwood, 2005). Hence, resource allocation is critical, where sharing resources between different channels enables to increase the range of channels through which to provide the service (Coelho & Easingwood, 2008; Neslin et al., 2006; van Donk & van der Vaart, 2005). By sharing resources among different channels, the service provider enables channels to complement each other in providing a service and resources can be used more effectively (van Donk & van der Vaart, 2005).

A multichannel approach in service industries has received some degree of research (see for example Montoya-Weiss, Voss, & Grewal, 2003; Neslin et al., 2006; Sousa & Voss, 2006; Sunikka & Bragge, 2009). In particular, the benefits of a multichannel approach and the allocation of resources have been researched for the marketing industry (Chen, Kou, & Shang, 2013; Rosenbloom, 2007) and financial services (Sunikka & Bragge, 2009; Xue, Hitt, & Harker, 2007). We support the findings of previously mentioned researchers and extend the knowledge to the scarcely researched healthcare industry. We focus on resource allocation, where we aim to create guidelines for efficient use of resources to create patient independence, while maintaining high quality of care. We set out to investigate how resource allocations in an MC design can best be approached in a service setting, where we focus on the use and allocation of human resources, i.e. the time that is made available to patients through different communication channels such as email, telephone, face-to-face at the patient’s home, face-to-face at the service provider’s location, and virtual face-to-face communication. The allocation of resources to multiple channels is a complex decision as it requires the allocation of same resources to multiple channels under conditions of uncertainty in demand and the customer’s channel choice. Customers with a large variety of needs and wishes can make different channel choices to contact their suppliers and receive their supplies. These channel choices might even vary depending on the type, timing and urgency of the question. A service provider’s strategy can determine which channels best fit demand and allocate its resources accordingly, however, this might affect the quality and speed of service delivery. Therefore, allocation of the same resources to an MC design requires management insights to how (the use of) different channels affects the quality of the service provision (De Keyser & Lariviere, 2014).

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7 remote healthcare provision. Effective implies that the overall MC design enables an increase in quality of care and patient independence. To do so, this research reports the data of an in-depth single case study and we describe what strategies the service provider uses and what the customer characteristics are. From this, we determine what channel functions should be and describe resource allocation policies accordingly. This research aims to answer the question:

‘How to allocate shared resources to a multichannel design to ensure high quality standards in a

healthcare setting?’

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2. Literature Review

To determine how to allocate resources in an MC design we need to understand what such a design entails; what are channels, what does the use of multiple channels mean, and what influences the development of such a design. In addition, to understand how resource allocation decisions are made we need to understand on what decisions channel choices are based, by which factors these decisions are influenced, and which resources are available. These insights should help service providers determine which channels to use and where to allocate their resources accordingly, and are described next (Sousa, Amorim, & Rabinovich, 2008).

2.1. Multichannel Design

2.1.1. Channels

A multichannel approach entails delivering a service through two or more channels, where channels are the contact points with customers, are used as a medium to deliver services, and through which customer and supplier can interact (Shankar & Carpenter, 2013:135; Sousa and Voss, 2006). Using various communication and delivery channels contributes to a specific context design where more frequent interaction is possible, whilst self-management is extended and services can be personalized (Simons & Bouwman, 2006). Distinction is made between virtual and physical channels. Virtual channels can contribute to convenience, efficiency, information availability and accessibility, and physical channels provide a more rich and complex customer interaction and bring a certain level of security (Sousa et al., 2008; Xue et al., 2007). In virtual channels, customers often have larger and more important roles and make use of self-service technology. Customers often interact with “technology interfaces, independent of direct service employee involvement” (Sousa & Voss, 2006, p. 357). To determine which channels to use, we describe MC design characteristics.

2.1.2. Design characteristics

Deciding which channel(s) to use is an important choice as channel functions can vary, channels have different capabilities, and, from a providers perspective, different channels can require different investments (Simons & Bouwman, 2006; Sousa et al., 2008). Channel functions are defined as information search, transactions, or post-activity services, and the effectiveness of a channel is determined by the willingness and capability of customers to use it (Verhoef, 2013; Neslin et al., 2006). From this, the supplier needs to determine whether channels should be added and/or whether existing channels should be deleted (Verhoef, 2013; Sousa et al., 2008). To determine which is appropriate it is important to understand customer characteristics (section 2.2), resolve conflicts among channels, and create channel synergies (Chen et al., 2013; Simons & Bouwman, 2006). Table 2.1 describes the factors that influence channel choice.

Factors Definition

Channel type The medium through which services can be provided Channel function The purpose of a channel

Channel conflict When different channels have the same function such that they compete instead of complement each other

Channel combination The possibility to combine and switch between channels Channel redundancy The possibility to use a channel for different functions

Channel synergy The customer receives the same service, independent of channel choice

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9 Vinhas and Anderson (2005) argue that channels will compete with one another if they have a similar function, contact the same customer, or customers set them in competition with each other (Verhoef, 2013; Vinhas and Anderson, 2005). Organizations consequentially might reduce the amount of channels used to prevent conflict from happening (Vinhas & Anderson, 2005). However, research has also shown that channel combination and channel redundancy is possible, where channel switching (physical to virtual, virtual to physical, and virtual to virtual) and the use of different channels in different process steps, can enhance organizational and customer benefits (Verhoef, 2013; Pauwels & Neslin, 2011). In an MC approach it is important to consider that the range of channels provides the same added value to the customer and that channel combination and redundancy can reduce “the costs of intertype conflicts” (Vinhas & Anderson, 2005, p. 513).

In channel choice, the service supplier should consider how back office resources can ensure content and process consistency (Verhoef, 2013; Sousa and Voss, 2013). Content consistency requires front offices to receive coordinated support from the back office(s), so that outgoing and incoming information is consistent (Sousa & Voss, 2006). Process consistency can be ensured when a uniform design and operation is established of front office channels (Sousa & Voss, 2006). Through channel synergy a uniform design can be established and channels become interchangeable (channel combination) (Chiu, Hsieh, Roan, Tseng, & Hsieh, 2011; Rosenbloom, 2007; Simons & Bouwman, 2006). Synergy requires the reuse of resources for different channels, where close coordination and sharing of information becomes imminent, supporting the need for back office coordination. In turn, synergy induces customer trust and strengthens the relationship with the service provider (Simons & Bouwman, 2006).

Eventually, decisions concerning channels influence the MC design and relate to the allocation of resources. However, to develop an effective MC design, the service provider should also understand its strategic objectives and customers’ characteristics, and their influence on the design characteristics (Hughes, 2006; Xue et al., 2007; Verhoef, 2013).

2.2. Influence of Strategic Objectives on the Multichannel Design

Organizations’ strategic objectives can influence the MC design as they influence what and how many channels to use, what the channel functions should be, and how resources should be allocated to support the channel choice(s). For example, a cost leadership strategy tends to allocate resources such that efficiency is a primary goal (Verhoef, 2013). However, a customer relations strategy puts more emphasis on ensuring customer intimacy and customer satisfaction (Verhoef, 2013). Depending on its strategy, the wider the range of customers the organization sets out to reach, the more channels it is likely to use, and different resource allocation decisions need to be made.

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10 effectiveness, where the range and number of customers reached is prime, and; (3) customer relations, where the goal is to create customer intimacy and satisfaction (Verhoef, 2013).

Besides the strategic objectives, customer characteristics also influence an MC design and the allocation of resources to different channels. For instance, customer preferences regarding channel choice might influence the MC approach. Also, the volume and variation of customer demand in the separate channels affect the allocation of resources. Therefore we describe these characteristics in a separate section.

2.3. Customer Characteristics

In service operations, the customer is both a consumer as a co-producer, where the customers’ productivity and efficiency influence the service outcome, especially when using self-service technology (Xue et al., 2007). Customer characteristics influence an MC design as they help create a customer-centric approach and can lead to an improved customer-organization relationship (Cassab & Maclachlan, 2009; Coelho & Easingwood, 2008; Simons & Bouwman, 2006). First customer requirements are described and their influence on the MC design, and thereafter we discuss the characteristics of customer demand.

2.3.1. Customer requirements

Understanding customers’ requirements is crucial to ensure a common view of customers is implemented in the MC design (Verhoef, 2013; Sousa & Voss, 2006). Cassab & Maclachlan (2009) discovered that problem handling, record accuracy, usability and scalability are important requirements for an MC service, and Madaleno, Wilson, and Palmer (2007) found that channel choice and cross-channel consistency are determinants for customer satisfaction. Consistently, Stone, Hobbs, and Khaleeli (2002) found that the customer’s ability to have a choice of channels and to switch between channels influences customer satisfaction. Table 2.2 defines these customer requirements.

Customer requirements (to fulfil customers’ needs and wishes)

Definition

Problem handling The degree to which a problem is solved

Record Accuracy The degree to which customer information is used in different channels to provide a personalized and consistent customer service

Usability Ease of channel use

Scalability Ease to switch between channels Channel choice The variety of choice in channels Cross-channel

consistency

Whether the customer receives the same service through different channels (content- and process consistency)

Table 2.2. Customer requirements of multichannel design.

In addition, the capabilities a customer has to use channels influences their requirements, such as the degree of mobility, the geographical location of customer and service provider, and willingness to use a channel (Sousa et al., 2008). The possibility exists that some customers cannot use certain channels due to their age, lack of knowledge, skill, or tenure (Xue et al., 2007). The customers’ capabilities are determinants of success in an MC design and should carefully be considered.

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2.3.2. Customer demand

The research of Boyer, Hallowel, and Roth (2002) and Xue et al. (2007) found that customer demand varies, as when customers find a service activity complex and important they tend to use channels that can provide personal contact, but a more routine and standardized service requires less physical interaction and self-service channels are sufficient (Boyer, Hallowell, & Roth, 2002; Xue et al., 2007). The degree to which customer demand varies influences the allocation of resources, and to determine how customer demand is composed we distinguish between demand volume, variety, and visibility (Slack, Chambers, & Johnston, 2010; Coelho and Easingwood, 2005).

The volume dimension differentiates between high and low demand. High demand would implicate the possibility to systemize the service, where each step of the process is predetermined and customers require low personalization and focus more on receiving the actual service (Slack et al., 2010). Using channels that provide a quick service, which the customer can receive at any moment in time and with a low waiting time, seems applicable. High usability and quick problem handling are important, and the need for physical interaction is low. On the other hand, low demand would mean less standardization and more customization, where there is more appreciation for receiving a personalized service (Slack et al., 2010). Low demand would require using channels that can incorporate individual customer wishes, where record accuracy, problem handling and cross-channel consistency are desired, and physical interaction is a determinant for customer satisfaction.

Demand variety refers to whether different customers require a different service. High variety

implicates that the service should be customized, procedures are flexible but more complex, and output is delivered at a relatively higher price (Slack et al., 2010). The MC design should ensure that the customer is served effectively, that the problem is solved, and that a follow up service provision would use past knowledge to provide a newly customized service (record accuracy). Low variety is more standardized and can be provided at a lower cost (Slack et al., 2010) Therefore, the MC design should enable to provide quick problem handling and high usability, where the customer makes use of self-service channels.

The visibility dimension refers to what degree an organization’s value adding procedures are exposed to the customer (Slack et al., 2010). In high-visibility operations the customer’s know-how of the value-adding activities is large, they therefore have a low tolerance for waiting, and customer perception is important (Slack et al., 2010). Front office activities create visibility and should therefore be considered in an MC design, however whether front-office activities require physical and personal contact or self-service technology depends on volume and variety in demand and customer requirements. Contrary, customers of low-visibility operations have less know-how and thus value adding activities can take longer and be more standardized, where back-office activities are necessary to support process consistency and facilitate service provision (Boyer et al., 2002). In such a design, the channels are more likely to incorporate self-service technology and there is low physical contact. An MC design with both high- and low-visibility processes also exists, where front-office activities are visible and back-front-office activities are not (Slack et al., 2010).

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2.4. Allocation of Resources

The type of resources available to an MC design in a service setting are physical and human resources, which are shared among channels. Physical resources are the attributes in an organization that are available to the service provider, such as diagnostic and therapeutic resources, meeting and waiting rooms, and the building in which the service is provided. Physical resources aid in making the provision of the service possible and can be categorized as supporting facilities and facilitating goods, respectively described as “the physical resources that must be in place before a service can be offered” and “the material purchased or consumed by the buyer” (Fitzsimmons, Fitzsimmons, and Bordoloi, 2013, p.18-19). Human resources are the providers of services in an organization, such as the medical physician and a physiotherapist, who use various channels through which they can provide the service.

In an MC approach, physical and human resources are combined to provide a service that fits demand and supply requirements. For instance, a room needs to be available (the physical resource), but also human resources to provide the service, and, where virtual services are provided like a chat function or email communication, a computer and an internet connection need to be available next to the human resources. However, because the same resources are used in the different channels, they are termed ‘shared resources’, which have a limited capacity (van Donk & van der Vaart, 2005). Shared resources are categorized as ‘time-shared resources’ and ‘other shared resources’ (Vissers, Bertrand, & De Vries, 2001). Time-shared resources are allocated to specific periods, where one can indicate a preferred time slot and the allocation hinges on the total of allocations required (Vissers et al., 2001). Other shared resources do not require allocation activities as they are available for all customers (Vissers et al., 2001). The application of shared resources is most commonly done in the process industry and Van Donk & van der Vaart (2005) define them as “a common-capacity source in two or more supply chains or networks” and “resources that are used by a supplier in the network for more than one buyer” (2005, p. 98). We aim to apply these descriptions to a service operations setting, where the service provider shares human resources between different channels and where specific customers make use of the channels. Thus;

Shared resources are the human resources deployed in more than one channel (both physical and virtual) to serve a specific target group.

The allocation of shared resources is one of the most complex and difficult decisions in a multichannel design. It requires decisions concerning the allocation of same resources among the different channels, the availability of channels, such as when can customers make use of the channels (24hours a day or is this restricted to certain time slots), and when should all channels be available simultaneously? Three steps are identified in allocating resources to multiple channels: (i) when should resources be available in which channel, i.e., channel availability (ii) how should the available resources in each channel be divided in time slots that can be assigned to an individual or groups of patients, i.e., slot policy, and (iii) how and when should resources be allocated to customers; i.e. slot allocation strategy.

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13 leading, the goal is to treat as many patients as possible, so more telephone consultations are held. The third decision is to divide patients to the available time slots and allocate himself accordingly. In our example, deciding when to make resources available in channels depends on customer demand. For instance, if the variation in demand is high, the GP ensures that he can consult patients using every channel each working day. He takes into account that some customer complaints might require a specific channel, that some customers have less options to travel, and that the amount of patients that require a consultation varies. Deciding how often to use each channel also depends on the supplier’s (GP’s) strategy, such as a more cost-leadership or customer intimacy strategy. Once these decisions are made, the GP can allocate himself (human resource) to the different channels.

2.5. Conceptual Model

Figure 2.1 shows the conceptual model, where the arrows represent relations between the variables and the directions show which variables are influenced by others.

From the literature review we assume that customer characteristics and the supplier strategic objectives influence the design of an MC approach. Also, based on literature, we assume that resource allocation decisions depend on the MC design and the design characteristics. However, it is important to understand that the allocation of resources is a gradual and dynamic process which continuously adapts to customer wishes and demands, and is not solely dependent on the MC design. The successful allocation of resources depends on the capability of the MC design to achieve supplier strategic objectives and to provide high quality standards (effectiveness) and, therefore, the arrow between the variables ‘Multichannel design’ and ‘Allocation of resources’ in figure 2.1 points in both directions. The performance measures determine whether the resource allocation is effective and efficient, and are determined by the supplier strategic objectives.

Allocation of Resources Customer Characteristics Multichannel Design Supplier Strategic Objectives Performance Measures

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3. Methodology

To be able to answer the research question, we set out to determine whether and how customer characteristics and supplier strategic objectives influence the MC design and, in turn, the allocation of resources. In addition, we aimed to establish MC policies such that healthcare providers can determine how the allocation of resources to different channels might affect both quality and efficiency, and to provide directions on how the allocation of the same resources to multiple channels can be aligned with their strategic objectives. Also, we aimed to investigate the correctness of the conceptual model presented in section 2.4. In section 3.1 we present the research setting, followed by an elaboration on the data needed for this research in section 3.2. Section 3.3 follows with how the data was collected and section 3.4 explains how the data was analysed.

3.1. Setting

The setting of this research was the Centre for Rehabilitation in Haren, the Netherlands (CfR), which is part of the University Medical Centre Groningen (UMCG). Here, patients who suffer from non-congenital brain damage are treated. Such damage is acquired “as a result of a physical disorder or a trauma to the head that impairs brain function (…) thereby disrupting normal emotional, sensory and cognitive behaviors.” (All about Traumatic Brain Injury, 2009). The patients who suffer from a non-congenital brain disorder tend to go through three phases, presented in figure 3.1 ((1), (2), and (3)).

Figure 3.1. Phases of patient rehabilitation with a non-congenital brain disorder

In the acute phase (1), the brain damage occurs and the patient is taken to the hospital for initial treatment. In the rehabilitation phase (2), the patient goes from the hospital to the rehabilitation centre to learn to cope with the consequences of the brain damage. Additionally, patients functionally recover and receive support in finding solutions such that they can participate in society again. In the reintegration and chronic phase (3), the patient returns home and reintegrates in the home environment. An additional ‘route’ is that the patient does not go to a rehabilitation centre (phase 2), but goes home immediately after the acute phase. In many cases, the patients still cope with the (minor) consequences of the brain damage, which can cause serious problems in the reintegration and chronic phase.

Once patients have received treatment at the rehabilitation centre they are ready to return home. However, internal research at the CfR has identified that the transition from the rehabilitation centre to home (rehabilitation- to reintegration and chronic phase, figure 3.1 (a)) is difficult for patients as they tend to struggle with adapting to the home environment, due to the consequences of the brain damage (Nanninga, 2007). In order to enable patients to more gradually adapt to their home environment, the CfR has adopted an approach with multichannel characteristics to support patients in this transition, called the Rehab-4-Life program.

In this program, a ‘coach’ is appointed to the patient, who is a professional in the multidisciplinary team of the neuro-rehabilitation department of the CfR and supports the patient. There are six coaches available who, besides being a coach, have an additional profession as either a physiotherapist, nurse, or social worker. The Rehab-4-Life program provides combined remote and at home coaching. Initially the patient is visited at home and, gradually, support is provided remotely.

(1) Acute phase

(2) Rehabilitation phase

(3) Reintegration and chronic phase Patient goes home

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15 The home visits are important as they enable the coach to see the patient’s home environment and they get to know the people that are important to the patient. Additionally, during the home visits the coach introduces remote coaching, which is enabled by the use of a tablet.

Our research focused on the transition from phase 2 to 3 and the use of the Rehab-4-Life program (figure 3.1: (a)), where medical services are provided through a multichannel approach to a well-defined patient group.

3.2. Single Case Study

The data used for this research was gathered from interviews conducted with 12 patients, 6 coaches, and one former coach. Also, the Head of Finance and Planning, the Head of Planning and Logistics, and both program managers of the Rehab-4-Life program were interviewed. Furthermore, quantitative data on resource allocations was made available by the CfR, as were other documents such as annual reports and mission statements.

From the interviews we gained insights in the customer characteristics and the relation with the MC design. To determine customer requirements, we gathered information on how to fulfil the patient’s and coach’s needs and wants. We interviewed both, as both are users of the MC design and we wanted to capture their requirements separately. Customer demand variability consists of patient demand and is based on patient and coach interviews and on quantitative data on the allocation of resources.

In turn, we needed to determine what the supplier strategic objectives are and what the relation between the supplier strategic objectives and the MC design is. Also, we aimed to determine what the design characteristics are and how the MC design operates, for which we use the same interviews with patients and coaches. To establish how resources were allocated we used the interviews with patients and coaches and investigated available quantitative data on the resource allocation to channels and patients, over a certain period of time.

Even though the implemented MC approach is based on conjecture and limited research, the coaches and patients have gained some experience over the past years with the approach and have improved it accordingly. This was beneficial for our research as a more thought through and tested MC approach can provided us with knowledgeable insights on the important choices and underlying reasons for a specific MC design and the allocation issue. We used a single case study which gives us the opportunity to gather in-depth knowledge on how a multichannel design should be designed in a healthcare setting (Karlsson, 2009, Yin, 2009).

3.3. Data Collection

To define supplier strategy and customer demand characteristics, we used ready available data at the CfR. This data was obtained from sources such as previous conducted research, mission statements, and annual review reports. In addition, we used the interviews conducted with coaches, the Head of Planning and Logistics, the Head of Finance and Planning, and the program managers of the Rehab-4-Life program.

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16 involved in the MC approach from the beginning and patients who are almost finished with their rehabilitation or have already finished. Their insights and experience using the MC design is most valuable as they have participated in the current design from the start. Therefore, compared to patients who are in earlier stages of rehabilitation, they were able to provide us with the most usable information. Also, as they are far in the process of rehabilitation, they are better able to participate in interviews.

The coaches were interviewed individually. However, due to the nature of the brain damage suffered, a patient can need support in understanding and answering questions. Therefore, if support was needed, the patient was accompanied by a relative or other close person and not the coach. If the coach were to be present the subjectivity of the patient could not have been guaranteed. In addition, some patients’ concentration span was limited due to the nature of the brain damage. Therefore, the interviews were conducted individually, besides the possible support from family or close relative, to ensure minimal distractions and to give patients the ability to speak freely. Also, it was made clear that the answers will remain anonymous. The interviews were recorded so that any opportunity for biased interpretations of data was overcome and to minimize subjectivity and “cognitive distortion of the data” (Mariotto, Zanni, & De Moraes, 2014, p. 360; Yin, 2009).

The interviews consisted of semi-structured questions and after each question the opportunity was provided to elaborate or provide suggestions. This was done to ensure a controlled interview, where the interviewee was guided towards describing his or her optimal multichannel design. Giving the opportunity to elaborate on questions provided us with insights in customer requirements, but did not limit the answers to boundaries set by the interviewer. We used a funnel model to gain specific data, where initial questions were relatively broad, after which more detailed questions triggered what customer characteristics were (Karlsson, 2009).

In addition, the interviews with the Head of Planning and Logistics, the Head of Finance and Planning, and the program managers of the Rehab-4-Life program were used to determine what resources were available, how scheduling was addressed, and how financial measures influenced the allocation of resources.

3.4. Data Analysis

To organize and analyse data we used data reduction, data display, and conclusion drawing (Miles & Huberman, 1994). In data reduction we selected and simplified data from interviews using coding. Once the data was coded, it was displayed in a spreadsheet to create an overview of the data gathered. Additionally, the quantitative data was displayed in a separate spreadsheet to be able to determine how and when resources were allocated to patients and channels. By displaying the data, we were able to create a clear overview and we could set out to establish patterns and determine what the relations were between the variables. From these relations and patterns we described policies on resource allocation strategies.

Conducting interviews often results in data overload, therefore using coding as an analysis method helps ensure the imbedded meaningful data is retrieved, while keeping relations intact (Miles & Huberman, 1994). The codes described are provisional codes and are used as a ‘start list’. These are the variables identified in literature, and as data analysis continued the codes were revised.

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4. Results

This section describes MC design of the Rehab-4-Life program at the Centre for Rehabilitation, how the resources are allocated, and how performance is measured. At the end of this section we analyse our findings and discuss the relations between the variables.

4.1. Multichannel Design Characteristics

The Centre for Rehabilitation uses six channel types: a face-to-face channel at the rehabilitation centre, a face-to-face channel at the patient’s home, a virtual face-to-face channel (via a portable tablet), telephone, email, and a chat function. The interviews show that multiple channels can be used for the same function and that a single channel can have multiple functions (channel redundancy) (appendix 1). However, all coaches state that the channels do not compete, but rather complement each other (channel conflict). Coaches also mention that channels are used interchangeably and that channel combination, ‘the possibility to combine and switch between channels’, is present during an appointment with the patient. In addition, because the channels can be used interchangeably the MC design “makes it possible for me to deliver a complete service, fitting

to individual patient needs” (coach 7). If the patient does not want to use a certain channel “I will switch to a channel that fits the patient’s needs and wishes”, “as long as the patient receives the service he/she needs” (coach 4). Reasons for patients not wanting to use a certain channel are

explained in section 4.3.2: demand variety. In appendix 1 the different channel functions are presented.

The interviews with the coaches also show that the MC design lacks a certain level of channel availability, due to the absence of staff (staffing issue). “Due to my job next to being a coach I am not

always available via phone or email, so the patient cannot always reach me” (coach 5) and “because the CfR uses flexible working spaces, coaches can sit in a different office each day” (coach 6). Though

coaches are still available, this decreases the channels through which they are available. Similarly, the malfunctioning of channels also decreases availability. Coaches mention that “it is easy to switch

between channels, but the malfunctioning of the virtual face-to-face channel can disrupt the coaching” (coach 1) and that “it is possible to switch between channels, but only if we have all channels available in the same room. This is not always the case” (coach 5).

The ability to deliver the same service independent of channel choice is also described as a design characteristic; channel synergy. Coaches state that the face-to-face channel has a distinct function, because it allows the coach to get to know the patient in his/her own environment. It can therefore not be replaced by, for example, the virtual face-to-face channel. Also, “certain channels do not

classify as a tool to coach the patient (such as email)” (coach 2). The ability to deliver the same

service is dependent on information availability and accessibility, where coaches and patients make a distinction between channels through which they are able to see each other and channels where they are not. The face-to-face- and virtual face-to-face channel provide patient and coach with the ability to read into non-verbal communication, where other channels, such as email, telephone, and chat, do not. Coaches’ answers to the question ‘What determines which channel you use for a patient?’ were “the face-to-face channel at the patient’s home is extremely valuable, as it shows how

the patient functions at home” (coach 6), “the virtual face-to-face channel is of added value as I can see the patient and non-verbal communication is very important to communicate with the patient”

(coach 7), and “non-verbal communication is a pro of using the virtual face-to-face channel” (coach 1). Correspondingly, patients’ answers to ‘When do you use the face-to-face channel?’ and ‘When do you use the virtual face-to-face channel?’ were “face-to-face contact at my home has my preference

as it provides a better ability to communicate and to discuss what I am struggling with” (patient 1),

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my surroundings” (patient 10), and “a pro of the virtual face-to-face channel is that non-verbal communication helps the coach and me to communicate” (patient 8).

The results also show that channels such as email, telephone, and chat are used for other information exchange purposes than the face-to-face- and virtual face-to-face channels. Coaches and patients characterized these channels as a medium for asking and answering practical questions, for asking and answering questions in between coaching sessions, to change appointments, and for the patient to ask if the coach can contact them. Also, email and chat provide the patient with the ability to reach the coach if other channels, such as the telephone or the virtual face-to-face channel, do not. Table 4.1 provides an overview of the design characteristics in the MC design.

Design characteristics MC design at the CfR

Channel type The channel types are a face-to-face channel at the rehabilitation centre, a face-to-face channel at the patient’s home, a virtual face-to-face channel (via a portable tablet), telephone, email, and a chat function. Channel function The functions vary per channel, but there is overlap and channels can be

used for similar functions (channel redundancy), see appendix 1.

Channel conflict Channels complement each other and provide the coach with the ability to provide a ‘complete’ service to the patient.

Channel combination The MC design allows for coaches and patients to combine and switch between channels during an appointment.

Channel redundancy Multiple channels can be used for the same function and a single channel can have multiple functions.

Channel synergy The ability to deliver the same service is dependent on information availability and accessibility, where coaches and patients make a distinction between channels through which they are able to see each other and channels where they are not.

Table 4.1. MC design characteristics

4.2. Influence of Strategic Objectives on the Multichannel Design

The CfR´s mission is to enable people with disabilities to be able to independently function in society. The vision is to meet, and possibly surpass, the expectations of those customers and the organization believes that both its professionals and the patients are together responsible for a successful treatment. The strategic objectives are to make rehabilitation care more accessible by decreasing the physical distance between care providers and patients, to make care more accessible by ensuring the patient has more control over his/her treatment, and to ensure that rehabilitation care is of high quality (UMCG Centrum voor Revalidatie Strategisch Beleidsplan 2015-2016). Appendix 2 provides a more elaborate presentation of the strategic objectives.

Together, the objectives provide a framework for the CfR’s operations, such as the Rehab-4-Life program, i.e. the MC design. Rehab-4-Life’s overall goal is to organize rehabilitation care more efficiently and smarter in the patient’s home setting. The program has been designed to enable that the general objectives of the CfR can be reached, by:

1. Enabling patients to achieve a smooth and natural transition from the rehabilitation centre to the home situation, where one central figure, the coach, supports them;

2. Ensuring efficient coaching to patients with a non-congenital brain disorder, who have to cope with an array of problems;

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20 4. Making the patient more self-managing by decreasing the face-to-face contact at home. The use of multiple channels, with a focus on virtual face-to-face contact, is meant to aid this process.

The objectives of the Rehab-4-Life program are presented in appendix 3.

The objective of the coaches is to support the patient in the transition from clinic to home. In the past patients have had problems integrating what was learnt at the clinic to their home environment (Eindverslag UMCG Cie Healthy Ageing Pilots (v/h cie doelmatigheidsonderzoek), 2014). Coaches have indicated that “the goal of the coach is to support the patient in the transition from clinic to

home. The channels are a mean to achieve this and which channel I use is irrelevant, as long as the goal is reached” (coach 6).

4.3. Customer characteristics

In section 2.2.1 we have described a range of requirements an MC design should have in order to fulfil specific customers’ needs and wishes, and how diversity in customer demand can influence the MC design and the allocation of resources. The interviews with patients and coaches provide insight on the range of capabilities the MC design should have to fulfil their needs and preferences; presented in section 4.3.1. Section 4.3.2 presents the characteristics of customer demand.

4.3.1. Customer requirements

Table 4.2 provides an overview of the customer requirements regarding the MC design at the CfR. Per customer requirement we provide examples of what results were retrieved from the interviews, which are elaborated following table 4.2.

Customer requirements (to fulfil customers’ needs and wishes)

Patients Coaches

Problem handling The MC design allows the patients to indicate what their struggles are and to receive solutions to these struggles.

The MC design enables the coach to provide a ‘complete’ service, where all patient problems can be solved. Record accuracy Patients require a personalized

service, due to the varying consequences of the brain damage. The results show that the coach is always up-to-date and the patient receives a consistent and personalized service.

Coaches often consult with other professionals about the patient’s issues and are therefore able to provide a consistent and personalized service.

Usability The ease to use a channel varies

per patient, due to the consequences of the brain damage. Therefore, each patient has a different preference to use a channel.

For the coaches it is easy to use all channels.

Scalability It is easy to switch between channels and switching does not bring up any additional issues.

It is easy to switch between channels.

Channel choice Patients indicate that the variety of channels is sufficient, but that the use of text messaging with

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21 the coach would be of added

value. Also, all patients state that fewer channels would not be an option.

channels and themselves, the variety of channels could be increased. Also, all coaches agree that fewer channels would not be an option. Cross-channel consistency The ability to receive the same

service through different channels varies per patient.

Coaches state that they are not able to provide the same service via different channels. Table 4.2. Customer requirements at the CfR

Problem handling: Patients indicate that they are able to receive a complete service using the MC

design, i.e. a service that enables them to solve the issues they are struggling with. All patients answered ‘Yes’ to the questions ‘Can you always indicate what you are struggling with using the MC design?’, ‘Can you always receive an answer to the issues you are struggling with using the MC design?’, and ‘Can the coach always provide a solution to your issues?’ “Even though the coach

sometimes had to consult with other professionals concerning my questions or struggles, she was always able to answer my questions” (patient 1). Similarly, coaches state that the MC design enables

them to provide a complete service as the channels ensure they can coach the patient at home and remotely and, as the channels complement each other, they enable the coach to provide a complete service to the patient. Completeness is measured with the capability of the coach to provide solutions to the patient’s problems.

The interviews also show that the capability of channels to enable the patient and coach to solve problems varies per patient. Patients mention that “face-to-face contact at my home has my

preference as it provides a better ability to communicate and to discuss what I am struggling with than the other channels” (patient 1) and that the virtual face-to-face channel allows them to solve

issues they are struggling with, more than the other channels.

Record accuracy: All patients state that the coach is always up-to-date on what he/she is struggling

with and that they can receive a consistent and personalized service. “I liked the fact that my coach

was always up-to-date on what my issues were. It showed that the coach and other professionals communicated well” (patient 1). In addition, coaches state that customer information and questions

can be received and provided through different channels and enable the coach to provide a personalized service.

Usability: The ease to use channels varies. Coaches state that patients can struggle with the use of

certain channels, due to their (lack of) capabilities. Coinciding, patients mention specific examples: “email is difficult to use as I cannot remember what I wrote due to the consequences of my brain

damage. I therefore have to re-read every sentence several times” (patient 8), “the virtual face-to-face channel is not easy to use for me, as the image of myself and the coach distracts me” (patient 2),

and “I cannot make myself clear via email due to the consequences of my brain damage” (patient 4). The interviews indicate that the ease of use varies per patient, per channel.

Scalability: Scalability describes the ease for patients and coaches to switch between channels. In the

interviews, both patients and coaches mention that this is easy and that it does not bring up any issues; “We have had to switch to the telephone due to bad internet connection for the virtual

face-to-face channel, but this was not a problem at all” (patient 3).

Channel choice: According to the coaches the variety of choice in channels is sufficient to provide a

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22 fewer channels is not an option. Also, the interviews conducted show that additional channels could improve the usability of the MC design. Coaches mention that “the current design is good, but not

complete. I believe a chat function would improve the design” (coach 4), and that “the possibility for patients to upload a video would be a nice addition to the available channels. I currently use the email channel for this” (coach 5). To cope with channel unavailability, a coach mentioned that “it would be nice to always have a second option to contact the patient if the virtual face-to-face channel does not work, such as a mobile phone” (coach 7).

11 out of 12 patients interviewed mention that the variety of channels is sufficient and that more channels would confuse them. A single patient mentioned that “the variety in channel choice is

insufficient. I would like to be able to use text messaging, which allows me to ask a question whenever I have one” (patient 2). Also, the same patient mentioned that “it is easier to use text messaging than to use the current channels as it requires fewer actions”.

Cross-channel consistency: similarly to channel synergy (section 4.1.2), coaches state that it is not

possible to provide the same service through each channel. On the other hand, patient interviews show different results: 4 out of 12 patients state that the service they receive is similar in each channel, where 8 patients state that the service varies per channel. They state that they are able to receive a better fitting service via a specific channel: “the virtual face-to-face channel works best for

me, it is more personal” (patient 11) and “via email it is difficult to explain myself, I prefer to use the virtual face-to-face channel. But the telephone also works well” (patient 4). Note that each patient

has a different channel that enables them to receive a better fitting service.

4.3.2. Customer demand

Customer demand consists of the patient demand and includes demand volume, demand variety, and demand visibility. Coaches are excluded from the demand variable as they are the service suppliers. From January 1st_{till December 5}th_{2014 the demand volume in the MC design consisted of}

86 patients, which could be concluded from the 2014 planning schedule. Appendix 4 shows the amount of patients to whom resources have been allocated, presented on the x-axis.

In section 2.2.2 demand variety is defined as ‘whether different customers require a different service’. The interviews have shown that demand varies per patient due to their willingness and capabilities to use channels, and the malfunctioning of channels. Coaches and patients have specified that reasons for patients not wanting to use a certain channel can be; (a) not being able to work with the channel as a result of the brain damage, (b) the channel can be a breach of their privacy, or (c) frustration with the channel because of malfunctions. Appendix 4 presents the channel use per patient, indicating that in the period January 1st_{to December 5}th_{2014 the channel use varied per}

patient.

Demand visibility is described as ‘to what degree an organization’s value adding procedures are exposed to the customer’ (section 2.2.2). High exposure suggests that customers’ have a low tolerance for waiting on the service, whereas low exposure suggests that tolerance is high. Four patients indicated that they are willing to wait for the coach to make time for them, that they want to adapt to the coaches availability, and that they understand that the coach is busy due to their other professional activities besides being a coach. In addition, patients said that the coach always replies to questions within 24 to 48 hours and that the coach almost always has time available for them. If not, then the coach makes time available as soon as possible.

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23 (section 2.2.2). On the other hand, low exposure suggests that customers have less know-how and therefore require more standardized services. When coaches were asked ‘Can you indicate what determines which channel you use?’ they said: “which best fits the treatment and the patient” (coach 5), “it depends on what the patient wants” (coach 2 and 7), and “I make a plan, however it has to fit

to the patient’s wishes and capabilities. The patient has to agree with which channel(s) we will use and has to have faith that the channels can resolve the issues. If not, then we will use different channels” (coach 1). The results show that the individual patient’s perspective is important in the

allocation of time to channels and that the allocation is customized to the individual patients wishes, in consult with the coach’s preferences. Therefore, as the coach and patient together determine when resources are allocated, the level of visibility is high.

4.4. Allocation of Resources

The CfR uses time-shared resources, which are the coaches and who are only available in certain time slots. In section 2.3 we described three steps in allocating resources to multiple channels: (i) when should resources be available in which channel, i.e., channel availability (ii) how should the available resources in each channel be divided in time slots that can be assigned to individual or groups of patients, i.e., slot policy, and (iii) how and when should resources be allocated to customers; i.e. slot allocation strategy. First, we present what variables influence channel availability (section 4.4.1). Then, in section 4.4.2, we show when resources should be available in time slots, and in section 4.4.3 we present how and when resources are allocated to patients.

4.4.1. Channel availability

Channel availability describes when resources should be made available to a channel. An important specification for resource allocation is to ensure that the patient’s individual capabilities are considered. When asked ‘When do you decide to use a certain channel?’ coaches state that, together with the patient, they determine which channel to use and that the channel is linked to the patient. Table 4.3 presents all variables that influence channel availability, derived from the interviews. Besides the fact that the patient needs to be capable to use a channel, there is no particular order in which the variables are used to select when to make resources available to channels.

Channel availability variables Description

Patient capabilities Whether the patient is capable of using a channel (due to the consequences of the brain damage) Goal of communication / information

availability and accessibility

Whether the channel enables the coach and patient to exchange the needed information (Mal)functioning of channels Whether a channel works properly

Location of the coach Whether the location of the coach enables them to use the channel

Coach availability / job of coach besides being coach

Whether the coach has the time to and is able to use a channel

Patient phase in the process of coaching Whether the coach and patient have built enough trust and whether the coach has enough

knowledge of the patient’s environment Patient preferences Whether the patient wants to use the channel

Coach preferences Whether the coach wants to use the channel

Scheduled appointments / slot policy Whether the coach is available

Channel function Whether the channel enables the coach and

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24 Table 4.3. Channel availability variables

In which phase of the process of coaching the patient is affects channel availability, as initially the coach visits the patient at home (face-to-face channel at patient’s home) to understand the environment in which the patient tries to reintegrate and participate. Only when the coach understands this and has built enough trust with the patient (through the face-to-face channel at the patient’s home) can they switch to the use of other channels, such as the virtual face-to-face channel.

The coach’s preference influences the channel availability as, according to the coaches, not all channels are suitable to provide the patient with the needed support (also due to information availability and accessibility). Which channels are and are not suitable depends on each individual coach. One coach stated that “if the virtual face-to-face channel does not work I will make a new

appointment. The telephone or email does not suffice for me to coach the patient” (coach 6), where

another mentioned that “I will never use email as a coaching tool. The only other option, besides the

face-to-face- and virtual face-to-face, is telephone” (coach 7). Also, coaches mentioned that they will

steer towards the use of the virtual face-to-face channel as much as possible, as this is most time efficient. “Initially I try to use the tablet as much as possible, however, some patients cannot or do not

want to use it. Even though this rarely happens it is not an issue, because then I will switch to another channel” (coach 4) and “In principle, I use the virtual face-to-face channel” (coach 2, 5, and 7).

In addition, an interview with the Head of Finance and Control indicated that the allocation of resources to channels is not influenced by financial aspects. This is supported by the coaches, who all answered the question ‘Do financial aspect influence the allocation of resources?’ with ‘No’, and that when it is necessary to use a certain channel and it benefits the quality of care and the patient, then time will be allocated to that channel.

4.4.2. Slot policy

Together with the head of the department of neurological rehabilitation, the coaches and program managers of the Rehab-4-Life program have determined that the coaches should be available eight hours a week (Interview Program Manager, 2014). Most coaches (5 out of 6) are available in two time slots of four hours a week and one coach arranges the appointments to be made when this best suits her and the patient. The days in which the time slots are planned vary per coach. The Head of Planning and Logistics stated that the use of the time slots allows for an easy and efficient scheduling in the agenda of the coaches as they have another profession besides being a coach. If the patient cannot make time available in the planned time slots, the coach will arrange for an appointment to be made at another time. One coach sticks to the time slots and makes appointments in upcoming slots, others will make time available at other times, regardless of the time slots. “If it so happens

that the patient is not able to make an appointment in the available time slots, or the patient has an urgent question in between appointments, then I also make appointments on other days” (coach 1),

“I will organize my work around the appointment made with the patient, if that is necessary” (coach 6), and “I am willing to make an appointment in my spare time with the patient, if that is necessary” (coach 5).

Coaches and program mangers state that the amount of time reserved per channel is between 30 and 60 minutes for the virtual face-to-face channel and telephone, 120 minutes for the face-to-face channel, and that no specific time is reserved for emails. An important note is that “the time reserved

is based on experience” (program manager) and that future time reservations may vary. Currently, if

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4.4.3. Slot allocation strategy

The slot allocation strategy is concerned with when and how to allocate resources to patients. When asked ‘How do you allocate time to patients?’ a coach stated: “It depends on the time that is needed

and how many questions the patients has. At a certain point you understand the patient’s struggles and can make an estimation of how much time to allocate” (coach 1). Similarly, coaches said that the

patient and coach together determine the amount of time needed, based on earlier conversations and knowledge on the duration of past conversations. Within the time slots, patients and coaches make appointments, or coaches allocate time when this best fits the patient and coaches schedule (section 4.4.2).

A new appointment is made after each appointment has finished, or when the patient or coach requires contact in between appointments. Sometimes coaches are available on demand, but this is almost never the case due to the coaches’ jobs besides being a coach and due to the lack of available channels at different locations (section 4.1.1). A coach mentioned that “I explain to the patients that I

am only available at fixed time slots, even though there is some level of flexibility. They do not always remember this and can try to contact me at other times” (coach 4). Depending via which channel the

coach and patient have contact, the coach can have the ability to reply more often: “I will email or

telephone patients to answer their questions whenever I have the time, independent of the slots available” (coach 5). The desire for on demand services is high for patients, where one mentioned: “I would prefer to make an appointment with the coach when this best suits me, not in the available time slots. Sometimes I had no issues or questions to discuss before an appointment and felt that there was no need for it. At other moments I did have a question, but did not have an appointment and forgot the question when I did” (patient 2). Coaches and the Head of Planning and Logistics have

identified this desire. The Head of Planning and Logistics stated that “momentarily it is not possible

for the patient to reserve a time slot in the coaches’ agendas. We wish there would be as it would increase the independence of patients, and we are working to achieve this. Logistically it is possible, but we need to closely coordinate with coaches and program managers how to organize the allocation of time to patients besides the coaches other job.” Coaches also mention that “in using the MC design, I do not think the coach should always be available to the patient. Off course the coach can be flexible in answering questions, but it should not be expected of the coach to be available 24/7” (coach 4).

In addition, when to allocate resources to patients is dependent of which phase the patient is in. The phase refers to the process of being coached. Overall, a first appointment is made via telephone and the initial appointment takes place at the patient’s home. Coaches have however stated that some initial appointments can take place at the rehabilitation centre, or that the face-to-face channel is not needed at all, due to the fact that some patients are capable enough to be coached via other channels. The patients to whom this applied have supported this statement and mentioned that they did not need an appointment with the coach at home, because they rehabilitated well enough on their own. However, they did want to be coached via other channels, which has helped them a lot. After the initial appointment, an assessment is made by the coach whether another appointment is needed via the face-to-face channel, or whether they can switch to another channel.

4.5. Performance Measures

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26 the initial assessment has taken place, the coach and patient are able to use more time efficient channels, such as the virtual face-to-face channel or the telephone, while maintaining high quality standards. The program managers have indicated that this complex allocation of resources allows the MC design to be both efficient and effective, where efficiency is measured by the amount of time a coach spends per patient and effectiveness is measured by the quality of care and the satisfaction of patients.

Appendix 5 shows to which channels resources have been allocated for the period 02.07.2012 to 27.11.2014. The data indicates that the virtual face-to-face channel is used most frequent and interviews with patients and coaches provided the insight that the virtual face-to-face channel enables them to use non-verbal communication, provide a high quality service, and that it is time efficient. However, appendix 5 also shows that other channels are still used, though less frequent. As stated in the previous paragraph, the complex use and combination of channels enables the coaches to provide an efficient and effective service.

As some of the available data on the allocation of resources was imprecisely labelled, appendix 5 is used as an estimation to indicate how resources were allocated and whether the allocation of resources met the performance measures. Therefore, the actual allocation of resources is measured next to the planned allocation of resources, presented in appendix 6. Both appendices show that the virtual face-to-face channel is used most frequent, however that a significant amount of time is spent on other channels.

Additionally, one of the program managers has stated that the Rehab-4-Life program can become more efficient. However, this requires changes in an earlier stage of the process. If the coach were to be introduced and ‘linked’ to the patient at an earlier stage, he/she can become the central figure in all phases (figure 3.1), which allows for an increase in efficiency and effectivity. “This will have a

direct impact on the allocation of resources”, and thus on the measure of the MC design’s

performance (program manager).

4.6. Analysis and discussion

At the CfR, the MC design is a facilitating system that enables coaches to allocate time to patients in order to provide each patient with a high quality, customized, and efficient service. The supplier strategic objectives set a framework for the MC design and, in turn, the design enables the coaches to ensure patient satisfaction, i.e. a high quality and customized service. In addition, the use and combination of multiple channels enables coaches to efficiently allocate resources. Thus, findings show that the supplier strategic objectives influence the MC design and its performance.

The findings also point out that in deciding when and how to allocate resource, the patient’s capabilities and willingness to use certain channels is leading (section 4.1). In section 4.2 we presented a quote that supports this result: “the goal of the coach is to support the patient in the

transition from clinic to home. The channels are a mean to achieve this and which channel I use is irrelevant, as long as the goal is reached” (coach 6). Similarly, if the patient is unable to make an

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Resource allocation in a multi-channel healthcare setting