IMPACT OF FOCUS ON OPERATIONAL DESIGN AND PERFORMANCE

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IMPACT OF FOCUS ON OPERATIONAL

DESIGN AND PERFORMANCE

A CASE STUDY OF INGUINAL HERNIA HEALTHCARE ORGANIZATIONS IN

THE NETHERLANDS

Master thesis, Msc Business Administration, specialization Operations and Supply Chains

University of Groningen, Faculty of Economics and Business

June 23, 2014

Jorrit de Ree

Student number: 1476890

E-mail:

jorritderee@hotmail.com

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Abstract

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1.Introduction

Since healthcare is exposed to market forces nowadays, Herzlinger (1997) believes that traditional healthcare organizations will be turned into so-called ‘focused factories’. However, what this implies for the design and performance of operations within a healthcare organization differs widely. A focused factory concept means that the organizational business performance has to be supported by the manufacturing task, which in turn has to be focused upon a limit set of operations or activities (Schroeder & Pesch, 1996). Consequently, because of routine and standardization within the focus factory, this should lead to small organizational units within a larger organization that perform fewer activities better. In other words, independency of organizational units increases, while complexity within the larger organization decreases. A focused factory concept can be applied in healthcare. A shift is noticed of healthcare delivery by inpatient facilities towards free-standing (independent) and specialized (less complexity) outpatient facilities. According to Shortell, (1994) this shift will involve a fundamental restructuring of how health care professionals relate (e.g. greater use of interdisciplinary health care teams) and of how professional work is accomplished (e.g., greater use of electronic databases and treatment protocols).

A distinction can be made between two types of focused healthcare organizations. First, Hyer et al. (2009) examined a hospital which makes use of a specific focused hospital unit (FHU) for high-risk trauma injured patients. A FHU is a unit within a hospital which is focused and thereby specialized in certain treatments. Since this focused unit is part of a larger hospital, only divisional focus is present. This means a FHU can be qualified as a so-called plant within a plant (Huckman and Zinner, 2008). Patients with the same medical issues are grouped together within the hospital. In the trauma center case, creating a FHU resulted in a higher performance. Namely, a moderate improvement in length of stay, and a large improvement in net operating margins which stemmed from increased reimbursements (Hyer et al., 2009).

Another type of focus-driven healthcare organizations are private healthcare facilities, also known as Ambulatory Surgery Centers (ASCs), which are specialized in types of treatments and provide healthcare for insured persons. Since firm focus is present, this type of healthcare organization can be qualified as a focus factory (Huckman and Zinner, 2008). Besides, where FHUs are financed by public sector budgets, ASCs are financed by banks or private investors (NZa, April 2012). The Medicare Payment Advisory Commission (2013) defined them as: “distinct entities that primarily provide outpatient surgical procedures to patients who do not require an overnight stay after the procedure. Most ASCs are freestanding facilities rather than a part of a larger facility, such as a hospital.

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“Focusing on a narrow range of conditions permits nurses and physicians to more easily apply their expertise and experience, makes it easier to coordinate activities and communicate relevant information, and deal with problems and conflict situations”. This is in line with the two abovementioned aspects of focus, namely, lower complexity and higher independency. Furthermore, McDermott & Stock (2011) found that such focus in healthcare is associated with lower costs.

However, literature consists of mixed conclusions regarding the design and performance of focused operations. Evaluation is difficult since there are many different types of diseases and resulting treatments (Bredenhoff et al., 2010). Focus might be better suited for certain types of treatment with certain complexity. Research has been done when it comes to high complex treatments (Hyer et al., 2009). However, focused operations and resulting operational performances in healthcare organizations for simpler treatments has been studied less. In comparison to high complex treatments, simpler treatments are less complex, which might lead to a better fit for a focus concept. In order to find out if focus works in this situation as well, this study concentrates on low complex treatments (i.e. inguinal hernia treatments).

Within low-complex treatments, different types of focus-driven healthcare organizations exist. As described above, a distinction can be made between divisional focus and focus on a firm level leading to a difference between FHUs and ASCs. In other words, both organization types differ from each other in degree of dependencies they have with surrounding organizational units. ASCs are free-standing facilities, while FHUs are part of a larger hospital. Both entities focus on the same operational focus strategy, however, they differ in organizational context. In order to find out if that organizational factor might affect influence of focus on operational performance, this study concentrates (within low complex treatments) on both types of healthcare organizations. This leads to the following research question:

What does focus imply for the design and performance of operations regarding an inguinal

hernia Focused Hospital Unit in comparison to an inguinal hernia Ambulatory Surgery

Center?

The following sub-questions need to be answered:

- What are the similarities and differences between focused operations in a high complex healthcare situation and a low complex healthcare situation?

- What are the similarities and differences between focused operations at FHUs and ASCs regarding low-risk treatments?

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The remainder of this Master thesis is structured as follows. The next chapter will outline the theoretical framework. Chapter 3 will describe the utilized methodology, including research design, sample selection and case protocol, data collection and data reduction, and a general description of the cases. Chapter four will list the results. Chapter 5 provides the discussion, while chapter 6 presents the conclusions and limitations.

2. Theoretical framework

2.1 Focused factories in manufacturing

Focused manufacturing was already introduced in the Nineteen Seventies. Instead of struggling with issues of how to improve labor productivity in order to compete with foreign countries that offered cheaper labor, Skinner (1974) suggested to shift the attention towards finding a way to compete by the efficiency of the entire factory. He introduced the term ‘focused factory’, which is based on the concept that simplicity, repetition, experience, and homogeneity of tasks breed competence (Skinner, 1974, p. 115). By focusing on certain processes, complexity will be reduced. According to Pesch & Schroeder (1996) an organization can be recognized as highly focused when they focus on one or two competitive priorities in the plant (cost, quality, delivery, and flexibility), which agree with the competitive priority in the firm’s business strategy. This view is more outcome focus oriented. Furthermore, decision-making in the plant must be internally consistent, and product lines must have compatible volumes in terms of manufacturing lot size. Finally, manufacturing requirements must be similar among products, which results in independency among products. The occurrence of independent organizational units is then a logical result.

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Table 1. Six dimensions to consider when creating a focused plant (Adapted from Hyer and Wemmerlov, 2002, p.28)

For example, when choosing for a focus upon markets, send all products intended for Europe to a focused factory while sending all products for Asia to another focused factory. In case of creating a focused factory based upon order winners, one might produce all standardized products in one focused factory, and customized products in another factory.

Conducting a focused factory policy means defining an explicit manufacturing task which will

guide operations (plant decisions) which in their turn are consistent across (independent) departments in terms of supporting the manufacturing task and therefore the business performance (Schroeder & Pesch, 1996). Operation managers are responsible for the manufacturing task, which leads to segmenting their operations resources. Slack and Lewis (2011) describe this process as splitting up tasks of managing a whole range of resources in order to simplify them and thereby manage them more (less complexity). They elaborated on the Hyer and Wemmerlov (2002) dimensions by outlining a distinction between operations segmentation based on resource criteria on the one hand, and operations segmentations based on market criteria on the other hand effectively (Slack & Lewis, 2011, p. 73). This is shown in figure 1.

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For example, when operations are segmented by variety, high-variety products (which require often more activities) are made in one focused factory, while low-variety products are produced in another focused factory. In case of a process segmentation, focus lies upon the particular technology for the operation, which should lead to extending its knowledge and expertise regarding the specific operation. Hill (2008) concluded that a number of different segmentations could be used within one organization in order to organize operations. For example, process focus is suitable when a resource is constrained either by the level of capacity available or the investment cost required to duplicate it (resource-based focus), while a market-based focus is appropriate for other operations to create units with a single, coherent strategic task enabling them to better support their markets (Hill, 2008, p. 651). According to Skinner (1974, p. 119), the entire manufacturing system of a focused factory has to be focused on a limited task (process focus) precisely defined by the company’s competitive strategy (outcome focus) and the realities of its technologies and economics. As a result of tasks based upon simplicity, repetition and experience, the organization will receive synergistic effects instead of internal power struggles between factory departments. Research showed that in make-to-order industries, focus is beneficial in comparison to pooling when dealing with large set-up times (Van der Vaart & Wijngaard, 2007), while others experienced lower raw-material inventories after adopting a process-focused JIT system (Shafer & Oswald, 1996). Moreover, Huckman and Zinner (2008) showed that a focused factory strategy positively effects operational performance measured in terms of both output and productivity.

2.2 Focused factories in healthcare organizations

2.2.1 General information

The abovementioned definition of focused factories applies to manufacturing firms. However, it can be converted into a definition which is more applicable in an environment of service organizations, for example healthcare organizations. McLaughlin (1995, p. 1185) described focus in professional service organizations as the differentiation and selection of market segments, and the adjustment of the

process and infrastructure parameters of the service delivery system to meet the needs of those specific

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competitive strategy? McLaughlin (1995) stated that, in this case, the service delivery task (the service operations) is analogous to the manufacturing task of Skinner (1974).

Especially in the healthcare environment, focused factories are food for thought. Shortell (1994) stated that because of a large part of healthcare services will be conducted in non-hospital settings, hospitals in the future will turn into pure intensive care units. In contrast, Schneider (2008) argues that hospitals should be able to organize focused treatment centers instead of keeping the traditional hospital concept. On the one hand, nowadays, healthcare services of general hospitals are not only consisting of intensive care services. On the other hand, however, various healthcare services shifted already from inpatient to outpatient facilities. This change was amplified by new technologies that made possible all sorts of medical improvements (e.g., anesthesia, pain management) which makes it easier to perform surgeries without being surrounded by hospitals with all its capabilities (Hackbarth et al., 2006).

2.2.2 Different types of focus organizations

Huckman and Zinner (2008) presented a model in order to create categories of focus organizations. If there is focus present on a firm-level, then the organization is called a dedicated research center or focus factory. In case of units which are focused on a divisional level, these units can be referred as Skinner’s (1974) plant-within-a-plant. This is shows in figure 2.

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One example of an healthcare organization with focus on a firm-level is an Ambulatory Surgery Center (ASC). They can be defined as: “distinct entities that primarily provide outpatient surgical procedures to patients who do not require an overnight stay after the procedure”. An ASC should start with a selection of the target market (outcome focus), before they will design the processes of the service delivery system (process focus). Most ASCs are freestanding , independent facilities rather than a part of a larger facility, such as a hospital. Number of ASCs in the USA grew by 17 percent between 2006 and 2011(4.567 facilities in 2006, 5.344 facilities in 2011, [MedPAC], 2013). In the Netherlands the number of active ASCs, increased from 37 in 2005 to 288 in 2012 (Boer & Croon, 2011; NZa, December, 2013). Furthermore, in the same period, the ASC sector has shown a turnover growth trend of €0,04 billion in 2005 to €0,17 billion in 2008. In 2009, it even surpassed all expectations because at the end of the year a turnover of €0,33 billion was noted (Boer & Croon, 2011). In the USA, about one-quarter of ASCs in 2008 were jointly owned by physicians and hospitals” (Medicare Payment Advisory Commission [MedPAC], 2013).

Second, some hospitals are also shifting towards a focused factory concept (e.g. heart hospitals, trauma center). Specialty hospitals are a result of the focus on supply of a limited set of healthcare services (Herzlinger, 1997, Chukmaitov et al., 2008). One of the first successful facilities was a specialty hospital (Shouldice hospital) which focused on hernia surgeries (Heskett, 2003).

According to Davidow & Uttal (1989), great service providers have to follow three steps. First, the market has to be segmented to create core services in order to meet the needs of the customer (i.e. outcome focus). Therefore, secondly, the use of formal research programs as well as paying close attention to what customers say are perfect ways to find out what customers in a certain segment really want. Third, (process) focus should lead to a delivering system which lead to the delivering of more services than promised.

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general hospital treatments often suffer from the fact that a number of doctors provide a variety of services and yet rarely talk to one another. Therefore, she concludes, care becomes fragmented, uncoordinated, and inefficient. From the patient perspective, Herzlinger finalizes her plea by asking the following question: “Would you rather be treated by a team of people who are totally committed to

the problem, or by an everything-for-anybody kind of institution?” (Shactman, 2005).

Consequently, some general hospitals are also trying to adopt a focused factory concept. For example, Hyer and Wemmerlov (2009) investigated a general hospital that created a (successful) focused hospital unit (FHU) in order to become profitable again. They describe a FHU as a unit which can be compared to the ‘plant-within-a-plant’ concept of Skinner (1974) (Huckman and Zinner, 2008). In other words, a trauma unit was separated (in context of operations) from the larger hospital, to lay complete focus upon the trauma treatments, in order to be liberated from the above summed up complexion disadvantages by Herzlinger (2005) in general hospitals with mixed treatments.

Both ASCs and HFUs begin their existence by adopting a focus strategy (selecting markets and adjusting their processes to this markets) in order to lower complexity in their organization. However, the difference between both healthcare organizations can be expressed in the level of independencies they have with surrounding organizational healthcare units.

2.3 (Dis)advantages of FHUs versus ASCs

According to Chukmaitov et al.(2008), there are three reasons why ASCs would perform better in comparison to a focused center within a hospital. First, as already mentioned earlier by Casalino et al. (2003), ASC owners are often physicians which are in a position of referring relatively healthier people to their facilities. However, this is a specific matter for the United States. Second, despite the focus within a FHU, ASCs are the extreme version of specialization, which may increase the procedural volume. Consequently this may lead to improved patient outcomes. Third, ASCs might have the favor of advanced technologies within their facilities, which improves the effective processes, coordination and communication between members, and focus towards a patient-centered organization (Casalino et al., 2003; Shortell, 1994). Consequently, above mentioned advantages of ASCs lead to other benefits. Namely, ASCs can offer more convenient locations, shorter waiting times, and easier scheduling (Medicare Payment Advisory Commission, 2013).

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McDermott & Stock (2011) found a positive relation as well between focus and lower costs regarding ASCs and FHUs. Namely, payment rates are (still) lower with ASCs because of the higher levels of specialization. In the Netherlands, research showed that ASCs ask lower payment rates (between 10%-15%) because the logistic process is easier to schedule as well as lower overhead costs within the organization (NZa, April 2012). On the contrary, FHU have the advantage of staying in close connection with the hospital itself. Quality of care can be improved because of the fact that FHU have access to financial and organizational resources (Chukmaitov et al., 2008). Moreover, when there are complications during a surgery, all resources are there in order to prevent deadly incidents. Table 2. outlines advantages of both types of healthcare organizations.

Advantages Ambulatory Surgery Center Advantages Focused Hospital Unit

- Referrals of healthier patients by physicians (US) - Higher volumes because of extreme specialization - Advanced technologies

- Shorter waiting times

- Higher service rates (location/ friendly personnel) - Lower payment rates (10%-15%)

- Closer connection with hospital - Access to (larger) financial and organizational resources

Table 2. Advantages Ambulatory Surgery Centers versus Focused hospital units

2.4 Design of focused operations in healthcare organizations

2.4.1 Framework to link design and operations to performance

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Table 3. Four perspectives that link the design and operations to performance (Adapted from Hyer and Wemmerlov, 2002)

First, as consistent with Hyer et al. (2009), my research questions also rest on the concept of focused-work-processes and how focus is applied to a healthcare setting. Therefore, this framework will be used in order to recapitulate their findings at the Trauma Unit and comparing it to a low complex care situation.

2.4.2 The resource perspective

The resource perspective implies that a FHU is a group of human and technical resources dedicated to the processing of a set of similar patients. In the trauma unit case, according to Hyer et al. (2009), that set is an aggregated patient population consisting of injured adults, specifically those admitted by the hospital’s “trauma service”. In this case, where high complex care is conducted, the purpose was to have resources be dedicated to delivering care to the trauma unit population. Resources like beds, equipment, and other technical resources were located inside the trauma unit. However, some complicated surgeries had to be conducted outside the unit, as well as running CT scans. While physicians and other professionals are dedicated to and only assigned to the Trauma Unit, it might occur that they had to perform (emergency) surgeries outside the trauma unit. Moreover, some patients required additional treatment from a specialist outside the Trauma Unit (e.g. orthopedic surgeon ). The result of the creation of the Trauma unit, and thereby the aggregation of patients, personnel, and equipment, also benefit to the extent that bedside surgeries became more efficient (Hyer et al., 2009, p. 208).

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facilities. Namely, resources have to be dedicated to the processing of a set of similar patients. Grouping of a set of similar patients might even be higher in a low complex care situation.

2.4.3 The spatial perspective

The spatial perspective implies that an FHU is a group of resources located in close proximity within clear physical boundaries. According to Hyer et al. (2009), the Trauma Unit is located in a separate wing of the hospital. The open bay environment and cross-training make it possible for nurses to easily assist one another. In this case, where high complex care is conducted, coordination improved because of the co-location where physicians review each patient’s status and recent progress in order to determine a plan, while nurses are then responsible for executing much of that (daily) plan. In this case physicians are not moving around the hospital to visit their patients, instead “facetime” between doctor and patient is enhanced because they are present on the floor and therefore available their entire shifts (Hyer et al., 2009, p.208).

When looking at low complex care, and taking the control of its space and boundaries into account, outcomes might differ. FHUs as well as ASCs should have the required rooms (e.g. waiting rooms, meeting rooms, operating rooms) and equipment in close proximity with each other to benefit from a focus concept. Because the group of similar patients might be even narrower (in comparison to the Trauma Unit) it should be easier to control its space and boundaries. Moreover, ASCs are far more independent which results in even better retaining clear boundaries.

2.4.4 The Transformation perspective

The transformation perspective implies that an FHU is designed to perform multiple and consecutive care steps on a population of patients who share similar care needs. In the trauma unit case, according to Hyer et al. (2009), the majority of the patients follow shared, although not identical, care processes. Trauma patients are treated on location, if possible from admission to discharge. In this case, where high complex care is conducted, patients followed the multiple care steps while trauma unit staff members witness and understand the complete end-to-end flow. Furthermore, trauma physicians select the appropriate protocols based on the nature of the patient’s injuries. Despite the fact that protocols are patient-specific, most of the protocols are applicable to virtually all patients (Hyer et al., 2009, p.209).

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The organizational perspective implies that an FHU is an administrative unit within a larger organization, is allocated resources, used as a planning and control point, and held accountable for performance and improvement. According to Hyer et al. (2009), the Trauma Unit is the dominant part of a larger hospital unit, which also encompasses the hospital’s burn unit, the neurosciences unit, and the Life Flight operation. In this case, where high complex care is conducted, Hyer et al. describe the Trauma Unit as; “a permanent group of physicians and nurses who are part of an identified organizational unit and collaborate routinely in providing care has contributed to the development of a self-proclaimed “can do” and “work as a team” culture. Moreover, those who work in the Trauma Unit are continually trying to improve processes and outcomes. The physicians hold an annual retreat that focuses on the developing new protocols and updating existing ones. Nurses feedback plays a key role in refining the protocols – particularly with respect of the clarity of the instructions” (Hyer et al., 2009). The Trauma Unit expanded their task with a number of activities (e.g. pain management, minor surgeries, certain lab tests, various therapies, case management, security, etc.) which previously were performed by other departments. As stated before, there is not a complete independency since it might occur that physicians had to perform (emergency) surgeries outside the trauma unit. Moreover, in times of overflow, patients are redirected towards other parts of the hospital in case of a stable condition (Hyer et al., 2009, p.209).

When looking at low complex care, and taking the organizational perspective into account, a FHU is also in low complex health care part of a larger hospital, which is adjacent to the description of the Trauma unit. However, a FHU which conducts low complex treatments might be further specialized, which might lead to a smaller organization unit in comparison to the Trauma Unit. In contrast, an ASC should be an entire distinct organizational unit. This results in higher independency regarding an ASC.

2.5 Schematic overview

Hyer et al. (2009) their research was concentrated on a complex treatment FHU. Adopting a focus factory strategy properly, results in lower complexity within the healthcare organization while independency of the organizational unit(s) increase(s). In order to find out if a focus factory concept works in a low-complex healthcare situation as well, this study concentrates on low complex treatments. Moreover, low-complex FHUs will be compared with low-complex ASCs since the level of independencies between both healthcare organizations differ.

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complex treatments. First, they used mortality rates since they mention that it was a critical metric that motivated the establishment of the Trauma unit. However, for low-risk treatments research, mortality rates as a performance indicator on operational level are often not suitable. Namely, mortality rates are not very relevant since low-risk treatments have an extremely high survival rate (Glaneville et al., 2010; Wittenberg et al., 2005). Second, Hyer et al. (2009) used length of stay as an operational performance indicator. However, this is not a relevant performance indicator for low complex treatments either. Namely, low-risk treatments are often performed in a day, whereby the patient will be send home afterwards. Because both performance indicators used in a complex treatment situation, this study will add knowledge by outlining which performance indicators fit best in case of low-complex healthcare organizations.

A schematic overview is presented (figure 3) to guide this research. Using the four perspectives from Hyer et al. (2009) this study will investigate what a focused factory strategy implies for the design of operations and what this means for the operational performance indicators by collection and analyzing data from FHUs and ASCs.

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3. Methodology

3.1 Research design

The main purpose of this research is to gain insight in the concept of ‘focus’ and what this concept implies for the design and performance of operations in a low complex healthcare situation. Focus can be characterized by two constructs, complexity and independency, which means research has to be conducted at healthcare organizations where complexity and independency might differ. In order to answer the research question, the case-study approach will be used at focused hospital units (FHUs) as well as Ambulatory Surgery Centers (ASCs). Eisenhardt (1989, p.534) defines case-studies as a research strategy which focuses on understanding the dynamics present within single settings. Moreover, according to Blumberg et al. (2008), such studies place more emphasis on a full contextual analysis of fewer events or conditions and their interrelations. An emphasis on detail provides valuable insights in a given situation. In the process of qualitative data-collection, interview conversations will be used because it has the advantage of giving additional clarification. Another advantage is the use of probing; which is the stimulation towards answers. Since this research needs answers regarding ‘how’, and ‘what’ does focus imply to operational design and performance, this research is suited for a case study research (Yin, 2009).

The following section will give an outline of healthcare organizations in The Netherlands. Namely, Dutch FHUs together with Dutch ASCs will be investigated which perform low-complex inguinal hernia healthcare. Therefore, it is important to understand the specific situation in which both healthcare organizations find themselves in order to have an appropriate interpretation of the results. Subsequently, the method of data gathering will be outlined. Finally, followed by the case description. This chapter concludes with the method of data analysis.

3.2 Inguinal hernia healthcare in The Netherlands

The government requires hospitals and Ambulatory Surgery Centers to provide information about the quality of their care. The healthcare insurance companies use this information for their healthcare purchasing. The number of healthcare providers can be divided into the following categories: general hospitals, specialty hospitals, academic hospitals, and Ambulatory Surgery Centers. This is shown in table 4.

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Type of Healthcare provider 2009 2010 2011 2012 2013

General hospital 85 84 84 82 82

Specialty hospital 2 2 2 2 2

Academic hospital 8 8 8 8 8

Total hospitals 95 94 94 92 92

Ambulatory Surgery Centers 220 241 258 288 268*

Table 4. Number of health care providers in The Netherlands in 2009-2013 (Adapted from NZa, dec.2013) * Number of ASCs already contracted till October 2013

This research will concentrate on low-complex inguinal hernia treatments. This particular field of healthcare is most frequently performed worldwide. In the Netherlands, more than 40.000 surgeries are performed, which means this treatment is the most frequently performed surgery in this country as well (www.liesbreuken.nl). Therefore inguinal hernia treatments are a perfect research field in order to find out what a focus strategy implies for the design and performance of an ASC or FHU. Occurrence of inguinal hernia can be a result of congenital factors as well as elevated pressure in the abdomen (e.g. standing presses, coughing, heavy lifting) (Veluwe Kliniek, 2013). According to the European Hernia Society (Simons et al., 2009), the following guidelines need to be followed. A psychical examination should be taken place in order to diagnose a swelling and any resulting pain. In some cases, but rarely necessary, a clinical investigation has to be conducted (e.g. ultrasound, MRI scan). Consequently, there are three possible ways to proceed. A schematic overview is presented in Appendix B.

1. If the diagnosis is an asymptomatic or minimally symptomatic inguinal hernia (without or only minimal complaints), conservative management has to be considered. In other words, consider a method of watchful waiting.

2. When a strangulated hernia is observed, emergency surgery will be necessary.

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teams who regularly perform this surgery. Taken into account the higher cost as well as the reduced post-surgery pain, the treatment of a bilateral inguinal hernia is well suited for endoscopic techniques (provided that necessary expertise is available)(Simons et al., 2003).

In addition to a physician, normally, there is at least an anesthetist involved for possible supportive medication and calamities. Furthermore, an anesthetist’s assistant monitors the blood pressure, pulse, consciousness and circulation. He or she also plays an important role in supervising the patient (Simons et al., 2009).

3.3 Sample selection and case protocol

First, a selection was made of inguinal hernia treatment institutions to contact. The Dutch union for consumers (“Consumentenbond”) analysed the available data regarding the inguinal hernia treatments in Dutch hospitals and ASCs for adults in 2009. The criteria on which hospitals were judged are successively:

* Patients have a say in the time of surgery

* Patients have a say in the choice of surgical technique and method of anaesthesia * What kind of inguinal hernia operation techniques are executed

* How is the information prior to, and after surgery.

The complete list with results is shown in Appendix B. However, this research will be conducted at hospitals which created an inguinal hernia Focused Hospital Unit or organizations which started an Ambulatory Surgery Center. Therefore, the list of possible organizations, which was used to contact possible healthcare organizations, had been narrowed down. The candidates are presented in appendix C.

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ASCs were successfully established, leading to a response rate of 50 percent, based on the ASCs that are still in business.

As mentioned earlier, the main method of data collection were semi-structured interviews (see Appendix D for the interview guide). The interviews were divided into three parts. The first part pertained some general questions to give insight in the various organizations. Questions were asked regarding the motivation behind focus, which group of patients are treated, and what the guidelines are in case of complications. The second part served to gain insight in the design of operations from four perspectives outlined in chapter 2.4. These questions were based upon the previous work of Hyer et al. (2009). The final part served to gain insight in the performance indicators used by the different healthcare organizations. Furthermore, it was a purpose to get insight in the organization scores regarding those performance indicators.

3.4 Data collection and data reduction

The healthcare organizations were visited for data collection once. Data was collected through one semi-structured interview taking forty-five minutes on average. In order to answer the questions, the interviewees sometimes had to consult with their organization’s information systems. During all of the interviews the conversation was recorded by digital devices. All the interviewees gave permission in advance to record the conversations. These recordings along with field notes, helped to accurately summarize the relevant responses made by the interviewees. In order to avoid respondent bias, open questions are used, and at any time respondents were not interrupted in telling their story.

The data collected from the interviews was further refined by first converting the audio files into transcripts. Second, useful data from the interviews was highlighted by coding every transcript. The first codes developed with the objective to describe every organization in a general way. The subsequent codes were related to the design of operations from four perspectives of Hyer et al. (2009); transformation perspective, resource perspective, spatial perspective, and the organizational perspective. Finally, all information regarding performance indicators was given a code.

3.5 General case description

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systematic problems or high risk complications like a heart attack in the foregoing period. ASA4 are patients who are that seriously ill, that it is in advance a hard question if it would be smart to undergo an inguinal hernia surgery anyway. Next, every case will introduced shortly.

FHU1 is a center of expertise for inguinal hernias and abdominal wall fractures. FHU1 is situational separated from the larger hospital which the unit is part of. That separated location performs surgeries for the so-called ASA1 and ASA2 patients, while ASA3 and ASA4 are treated at the hospital because they might have to stay a night. At FHU1 there are no facilities to stay overnight. If there is somehow a complication during the surgery at FHU1, which cannot be remedied at FHU1 itself, then an ambulance is called and the patient will be transferred to the larger hospital. Except delivering high quality service, scientific research and training are also objectives of FHU1. There are periods when guest-surgeons are invited so that they can witness how the processes are designed and carried out. Furthermore, FHU1 is on the forefront of endoscopic surgeries. Shortly they will show their findings in a scientific publication.

FHU2 is a center which is specialized in inguinal hernias treatments. They concentrate on ASA1 and ASA2 patients, however, ASA 3 and ASA4 are redirected to a hospital which is connected to FHU2. If there is a complication during the surgery, there is no need for transporting the patient since FHU2 is located near the larger hospital. Similar to FHU1, this organization points out that there are four objectives next to delivering high quality: innovation, development, research and training. Moreover, they wanted to concentrate low complex care, as well as creating an logistics system which is more efficient in order to reach higher quality and safety for the patient.

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most proper method for surgery. This continuous exchange occurs because it depends very much on who is doing the research, and for what purpose. According to ASC1, research towards inguinal hernia surgery methods has more or less reached its end. What is more interesting nowadays, is the information about the period in which patients are going back to their jobs as well as the pain after the surgery. They are monitoring that data themselves. However, they do not measure huge variations anymore. The interviewee argues that inventing new methods, which almost have no substantial improvement regarding the methods which are already there, is what makes healthcare expensive. It is time to make a certain surgery perfect and then try to be good at it. Simple as it is. He refers to the Shouldice Clinic which is very successful for years already with conducting a surgery procedure which is no longer used in the Netherlands.

ASC2 is an independent surgery center. They have contracts with a nearby hospital in case of complications. This hospital is also 50% shareholder. ASC2 chooses to treat only ASA1 and ASA2 patients. ASA3 and ASA4 are taken over by the nearby hospital. Their objective is to perform surgeries at a high quality, but at low cost. Especially insightful quality is of importance. This means, that it is important that the patient sees what kind of center this is, before he had surgery. Therefore, they want to have all kinds of labels as well as an safety management system. Furthermore, they show all of their professionals and it is possible to rate them after surgery.

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4. Results

4.1 Within-case analysis

4.1.1 Resource perspective

FHU1 is organized in a way where, at days of inguinal hernia surgeries, all professionals are assigned to and dedicated to performing inguinal hernia treatments. Surgeons, anesthetists, operating room assistants, nurses etc. are all focused upon activities regarding inguinal hernia treatments. However, it is not a fixed formation every time inguinal hernia surgeries are performed. Moreover, physicians at FHU1 are very experienced in conducting all kinds of abdominal wall fractures at FHU1. Looking at the technical resources, the operating room is exclusively for inguinal hernia surgeries. That is, for the days that inguinal hernia treatments are planned. FHU1 consists of two operating rooms. Sometimes two operating rooms are used simultaneously with different treatments. It might occur that at the recovery room patients with different treatments are mixed. Furthermore, since the founding of FHU1, they have been concerned with the set of instruments they require. As stated by the interviewee, in the context of making the processes as lean as possible, all unnecessary equipment was removed. Only a standardized set of instruments left. In case of ASA3 and ASA4 patients, they are treated at the general hospital, which FHU1 is part of.

FHU2 is a separate unit from a larger hospital that has all of its resources dedicated to the process of inguinal hernia treatments at days where inguinal hernia treatments are planned. According to interviewee 1: “The improvements in comparison to the old situation are a product of logistical innovation, technical innovation and dedication of the whole unit. Besides having dedicated professionals, this also means dedication of the entire hospital organization, of the policlinic, as well as the anesthetists who have a dedicated consulting hour. The department is completely dedicated at the day of planned inguinal hernia treatments. Even the nurses that day, only deal with inguinal hernia patients.” This is confirmed by interviewee 2 who adds: “There are a few surgeons and anesthetists who are concerned with inguinal hernia treatments. Operation room assistants as well as anesthetist assistants vary in the process”. At FHU2 there are 3 operation rooms, but 1 operation room is reserved for inguinal hernia surgeries. Furthermore, preparing rooms as well as recovery rooms (short stay area) are exclusively for inguinal hernia patients at the times. At days where only one or two inguinal hernia surgeries are planned, it might occur that those surgeries will be postponed due to inefficient use of resources.

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every location has its fixed team of human resources (e.g. surgeon, anesthetist, assistant anesthetist, two operating room assistants, two recovery assistants). Every professional has its own clear tasks and exchanges within teams are minimal. Furthermore, at days of planned inguinal hernia surgeries, operating rooms are exclusively reserved for inguinal hernia treatments. At ASC1, every physician is obligated (and also selected this way) to operate according to the same standardized surgery procedure and thereby obligated to work with the same instruments. Therefore, every set of instruments is similar for every surgery.

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Resource perspective

Organization Human resources Technical resources

FHU 1 - Alternating team formation (unless _{request) with varying assistants}

- Operating room used exclusively for

inguinal hernia treatments -Recovery rooms sometimes mixed

- Standardized (and lean) set of instruments

FHU 2 -Alternating team formation (unless _{request) with varying assistants}

- All required rooms exclusively for

inguinal hernia treatments - Standardized (and lean) set of

instruments

ASC1 - Fixed team members

inguinal hernia treatments - Standardized set of instruments

ASC 2 - Fixed team members

inguinal hernia treatments - Standardized set of instruments

(with exceptions)

Table 5. Summary of the results from a resource perspective

4.1.2 Transformation perspective

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so-called plan-do-check-act cycle. At this moment, FHU1 is concentrated on the check phase in order to look for processes that need to run more smoothly in the future.

The patient process of FHU2 starts with a phone call from the patient. FHU2 has a special phone number which is known by general practitioners as well as presented on the website of FHU2. Consequently, patients are signed in, and receive a date for a policlinic visit which will take place within a week. The physician will meet the patient at this first consult where the whole patient process (including recommended surgery procedure) will be explained. The same day, patients will have an appointment with the anesthetist to discuss the method of anesthesia. Furthermore, patients receive a date of surgery, which will be between 1 day and two weeks maximum. According to interviewee 1: “It has been shown that if you work with fixed checklists, room for error declines. Therefore, we work with strict protocols during surgeries which results in a very low chance of deviating from the norm”. After the surgeries, the physician himself visits the recovery room in order to give some sort of college for the patients about how the surgery went, as well as the important information for the following days after surgery. This is part of their protocol. Two weeks after the surgery, patients are requested to visit FHU2 for a checkup.

At ASC1, the patient process starts with the call from the patient himself, or the call from the

intermediary care organization which arranges agreements between patient and healthcare

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safety management, the interviewee states that: ” We have to optimize this safety system continuously in order to guarantee the highest quality of healthcare. Details vary from the probability of stumbling over a barrier towards the probability of not using sterile instruments or the use of expired medication.” Every detail of the process has to be run through. The risks of every detail are measured and considered if a certain risk is acceptable or not. If not, improvements are discussed. All care-steps are defined in protocols and are applicable to all patients.

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Transformation perspective

Organization Process features

FHU 1

- Appointment by phone - First consult given by surgeon - Anesthetists visit is required - Standardized processes, continually evaluated through plan-do-

check-act cycle - Patient process ends with a phone call and a checkup after 6-8

weeks

FHU 2

- Appointment by phone - First consult given by surgeon - Anesthetists visit is required

- Standardized processes, checklists and strict protocol - Patient process ends with a checkup after 2 weeks

ASC1

- Appointment by phone/internet - Digital medical questionnaire

- Two personal phone calls (1 before and 1 after) by surgeon - One-stop-shop in most beneficial case

- Checklist used in order to control end-to-end process - Process ends with a phone call/checkup without obligation - Process is defined in protocols/safety management system

ASC2

- Appointment by phone - First consult with surgeon

- Digital medical questionnaire

- Process ends with two phone calls and a checkup - Process is defined in protocols/safety management system

Table 6. Summary of the results from a transformation perspective

4.1.3 Spatial perspective

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FHU2 is part of a larger hospital and located in this hospital. However, it is a separated department where inguinal hernia surgeries are performed. According to interviewee 2, the architectural distances between areas where patients stay, pre- and postoperatively is approximately between 10 and 15 meters walking distance. This applies to the operation room, the preparation room, and the recovery room. Therefore, all technical resources are in close proximity within clear physical boundaries. As a result cooperation and communication between professionals is enhanced because of the short distances. During the inguinal hernia surgeries, all areas are exclusively for patients with inguinal hernia problems.

ASC1 fits perfectly in the spatial perspective because it is a group of resources located in close proximity within clear physical boundaries. Despite the fact that ASC1 rent their facilities, all clinics are designed in a way that medical processes can be conducted logically. All professionals can easily assist one another. Since inguinal hernia treatments are performed in a day, each patient process can be easily monitored. Especially at two of the three locations, they work with a small team of professionals which enhances the cooperation. As a consequence this means that instead of having all completely different tasks, there might be some overlap. For example the physician together with the anesthetist and the assistant anesthetist also help to transport the patient towards the recovery room after the surgery. Besides each professional is concerned with one patient at the time, from beginning to the end, and therefore completely available during the process.

At ASC2, the patient arrives at the so-called care-hotel. This is an area where patients are able to dress for surgery. Consequently, patients are brought to the “Holding room”, where the premedication is given in order to bring the patient to sleep a little. Then, the patient goes to the operation room, falls asleep, and the surgery process starts. Finally, the patient will awake at the “Recovery room” and end up in the care-hotel again. All those rooms are designed from a logistics perspective. In other words, the group of resources is located in close proximity within clear physical boundaries. According to the interviewee: “As a result of the smaller lines between professionals, it is easier to anticipate in situations , for example, where an additional patient needs to be included in the planning.” In other words, ASC2 makes use of a location with such a lay-out that the flow of the process improves which enhances the coordination and communication between the team members. A summary of the results is provided at table 7.

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Spatial perspective

Organization Situation/Layout Consequences cooperation/communication

FHU 1 _{hospital (situational and operational)}1 location separated from the larger - Coordination of activities of a high _{standard (moving train)}

FHU 2 1 location separated from the larger _{hospital (operational)} - Short lines of communication _{enhances the coordination}

ASC1

- 1 larger independent facility -2 smaller independent facilities

- flow of process the same

- Smaller location is preferred - Improves cooperation and

dedication in comparison to larger facility

ASC2 - 1 independent facility - Lower thresholds in order to solve problems/create efficiencies

4.1.4 Organizational perspective

FHU1 is part of a larger organization and therefore not controlling its administration and allocated resources completely. Administration is organized centrally. FHU1 registers information about their own activities, which is then processed by the hospital-wide system. Furthermore, negotiations with insurance companies are on a hospital levels as well. When it comes to the responsibility for a high quality standard, the interviewee states that all professionals as a whole are responsible to deliver high care. It starts with every professional individually, however, at the end the hospital can be hold responsible. The plan-do-check-act cycle helps to continually adjust to improve as an organization on all kinds of different levels: logistics, quality, patient care, innovation and research.

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ASC1 is an independent organization that controls its administration and allocated resources. However, there is one exception. The sterilization processes are outsourced to a third party. This third party checks, repairs and distributes the instruments. Furthermore, the organization is responsible for its own performance and improvements. According to the interviewee, basically everyone in the organization is responsible for performing their tasks at a high standard. Of course there is a medical specialist which is ultimately responsible for all protocols. Because of the protocols, everyone is doing their job according to the same methodology. However, in time, minor variations occur, which then again has to be eliminated. They try to avoid those variations by debriefing at a patient-level. In other words, the operating room report is also used for notes which are discussed quarterly with the medical staff. Furthermore, the safety management system supports by reporting incidents.

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Organizational perspective

Organization Organizational independency

FHU 1

- Administration and allocated resources for a large part centrally organized

at the larger hospital - All professionals have their responsibility, in the end responsibility lies with

physician and larger hospital

FHU 2

- Administration and allocated resources for a large part centrally organized

at the larger hospital - All professionals have their responsibility, in the end responsibility lies with

physician and larger hospital

ASC1 - Controls their administrative processes and most of the allocated resources _{- Outsources the sterilization process of instruments}

ASC2 - Independent organization and some activities outsourced (Sterilization/IT) _{- Responsibility towards board of directors / shareholders}

4.1.5 Performance indicators

The interviewee of FHU1 did not have information regarding performance indicators which are important for the inspection. According to the interviewee, additional performance indicators were used through a patient survey which they conducted. For example, the number of patients who recommend FHU1 at a birthday party. FHU1 connects performance indicators especially to patient satisfaction. Safe and friendly healthcare are important factors as well as responsible and transparent quality of care, result oriented, honest and customer oriented.

Interviewee 2 of FHU2 indicates that postoperative pain together with recidivism is an important performance indicator for FHU2. Length of stay is not applicable since inguinal hernia is a daycare treatment. Interviewee1 confirms that chronic pain is probably the most important indicator when it comes to patient satisfaction. Therefore, performing surgery combined with scientific research is very valuable.

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after the surgery; and number of complaints. The interviewee stated: “Last week we had a meeting regarding performance indicators. These days there is discussion about PROMS, which is a very comprehensive set of indicators which is not available for inguinal hernia treatments. However, we are busy developing indicators for this kind of treatments”.

Additional performance indicators which they are using for themselves are referrals to hospitals (ASA3 and ASA4 patients), if operation reports are filled in accurately, number of recidivism, and how many days it takes before patients resume their daily activities. Number of patients with chronic pain is not been tracked because then they are referred to a professional, which might not be ASC1.

According to the interviewee at ASC2, when the inspection visits the organization, they check the entire litigation. It involves accessibility by phone, operation room air treatment (pressure flow, laminar flow), medication protocols, complication registrations, sterilization processes (storage and separation of clean and dirty instruments) etc. In short, all data which involves hygiene and patient safety.

Additional performance indicators which they make use of, which are discussed earlier, are the time-out and sign-time-out procedure in order to minimize system errors. Furthermore, the time between first patient contact and actual surgery is monitored. For ASC2 the goal is to have a two week beginning-t-end process maximum. According to the interviewee, another performance indicator are the two phone calls towards the patient after the surgery. The first one has an empathetic reason, the second one is carried out for medical reasons. Finally, complications and recidivism are indicators which are measured.

4.2 Cross-case analysis

This paragraph will compare the four different perspectives from the within-case analysis on a FHU and ASC level in order to discuss their level of focus regarding operations.

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this regular group. Both ASCs on the contrary make use of fixed teams to perform inguinal hernia surgeries. Especially at ASC2 there are teams who work with each other for years now.

From a transformation perspective, the organization is designed to perform multiple and consecutive care steps on a population of patients who share similar care needs. With the exception of the different surgery procedures (and therefore the anesthesia also), patients follow shared identical care processes within each organization. Between FHUs and ASCs there are actually major differences regarding these care processes. In particular when it comes to the preoperative processes as well as the postoperative processes. Both FHUs and ASCs are contacted by phone, except for ASC1 where the patient has the ability to register through the internet. This provides the advantage that the patient immediately (and beforehand) knows what the length of the waiting list is at each of the surgery locations. Moreover, the medical questionnaire can be filled in digitally, where this should be done at the first consult at the FHUs (ASC2 also works with digital medical questionnaires). Furthermore, while the other organizations have a first obligated consult with the surgeon, this part of the process is handled by phone at ASC1. That is, the surgeon decides after the phone call if a patient needs to visit for a face-to-face consult or not. If not, then the concept of a typical one-stop-shop is applicable. The other major differences are at the end of the patient process. Where FHU2 ends with a checkup after approximately a week, FHU1 contacts the patients after a few days by phone followed by a checkup after 6-8 weeks. In comparison to the ASCs, the patient process at ASC1 ends with a phone call by the operating surgeon followed by an optional checkup. ASC2 goes one step further by contacting the patients by phone shortly after the surgery for empathetic reasons, followed by another phone call for medical reasons. At the end there is also a checkup.

From a spatial perspective, a group of resources is located in close proximity within clear physical boundaries. All four cases are consistent with this perspective because each of the units/centers does control its space, and its boundaries are not crossed by non-inguinal hernia patients, leading to shorter lines of communication and improved coordination. One exception is the fact, which is already discussed earlier, that at FHU1 sometimes inguinal hernia patients and non-inguinal hernia patients are mixed at the recovery room.

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5. Discussion

As described in the literature review, focus of operations leads to lower complexity as well as higher independency. Hyer et al. (2009) showed that above stated cause-effect relationship applied to a the focus strategy of the Trauma Unit. Now, the Trauma Unit case will be compared to the inguinal hernia FHUs and ASCs in order to answer the question what focus implies for the design of operations regarding low-complex treatments.

5.1 Complexity

The trauma unit handles an aggregated patient population consisting of injured adults who are in need for a trauma service treatment. That population is still wide ranged, leading to higher complexity in comparison the population of FHUs/ASCs in this study where it is narrowed down to just inguinal hernia patients. However, the result the aggregation of patients, personnel, and equipment at the Trauma Unit, led to the fact that bedside surgeries became more efficient (Hyer et al., 2009). Therefore, and from a resource perspective, complexity decreased.

In case of low complex care, complexity at ASCs is lower (in comparison to FHUs) because they only work with fixed team formations and highly experienced physicians. Namely, younger physicians are used to fall back on the organization. In other words, younger physicians might get into a situation where they need another physician for advice. In that case, they would have a problem at both ASCs because in this organization a physician is completely on his/her own. Therefore, ASC1 only work with physicians who reached the age of 55+. Furthermore, besides performing the surgeries, at ASC1 a physician is expected to accomplish much more tasks. Namely, it is their responsibility to ensure that the patient process flows in the right direction. For example, they have to support the tasks at reception if there are issues. Another example is the fact that ASC1 physicians have more work to do when it comes to a patient intake. A lot more computer tasks are involved as well as the personal phone calls towards the patients. Even highly experienced physicians need to adjust to these job tasks when they start their job at ASC1.

5.1.2 Transformation perspective

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ASCs, and from a transformation perspective, there is also difference in complexity. Especially, when it comes to the preoperative- and postoperative processes. In order to lower complexity, both ASCs handle activities by phone and internet. In case of ASC1 this leads to the possibility of having an inguinal hernia one-stop-shop.

The Trauma Unit is located in a separate wing of the hospital. Complexity lowered because of the improved coordination as a result of the co-location where physicians review each patient’s status and recent progress in order to determine a plan, while nurses are then responsible for executing much of that (daily) plan (Hyer et al., 2009). However, in case of overflow, stable patients move to another place in the larger hospital. Therefore, the Trauma Unit does not completely adhere to the spatial perspective (Hyer et al., 2009). In contrast, inguinal hernia healthcare organizations perform treatments which are finished within a day. Moreover, FHUs/ASCs do control its space, and its boundaries are not crossed by non-inguinal hernia patients, leading to shorter lines of communication and improved coordination. Overall, complexity declines further in comparison to high complex care.

Complexity of the Trauma Unit increased because they expanded their task with a number of activities (e.g. pain management, minor surgeries, certain lab tests, various therapies, case management, security, etc.) which previously were performed by other departments (Hyer et al, 2009). Especially when compared to low complex care at FHUs where operations regarding surgeries are separated from other treatment within the hospital and administration and allocated resources are centrally organized. ASCs on the contrary control their administration and resources and thereby have their own responsibility for performance and improvements resulting in higher complexity.

5.2 Independency

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(Hyer et al., 2009) leading to lower independency in comparison to the FHUs and ASC which perform low complex care. Namely, the required resources for an inguinal hernia treatments are exclusively for inguinal hernia patients at times of scheduled inguinal hernia surgeries. Moreover, since, inguinal hernia treatments are performed within a day, patients do not need to use resources outside the FHUs or ASCs. This gives higher independency to these organizations.

5.2.2 Transformation

Trauma patients are treated on location, if possible from admission to discharge. However, as mentioned in paragraph 5.2.1, sometimes patients require to visit another part of the larger hospital. In comparison, when looking at low complex care, and taking the transformation process steps into account, it might be easier to control the transformation process from the beginning to the end simply because low complex care often does not take more than a one day process. Therefore, the independency of FHUs and ASCs which perform low complex care is higher, because they are not dependent of other parts of a hospital.

On the one hand, at the Trauma Unit, physicians are not moving around the hospital to visit their patients. Instead “face -time” between doctor and patient is enhanced because they are present on the floor and therefore available their entire shifts (Hyer et al., 2009). Therefore, because of control of the boundaries, independency of physicians is increased. On the other hand, as mentioned earlier, when stable patients move to other parts of the hospital, independency decreases. When comparing FHUs and ASCs that perform inguinal hernia surgeries, there is not a huge difference between independency from a spatial perspective. Both organizations control their space, and its boundaries are not crossed by non-inguinal hernia patients.

IMPACT OF FOCUS ON OPERATIONAL DESIGN AND PERFORMANCE