Understanding the concept of one-stop-shops in health care: A case study

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Understanding the concept of one-stop-shops in

health care: A case study

Master thesis, Msc BA, specialization Supply Chain Management, University of Groningen, Faculty of Economics and Business

June 23rd, 2014

Meindert van Rij Student number: S2385880 E-mail: M.I.van.Rij@student.rug.nl

Supervisor / university: T. van der Vaart

Co-assessor: M. Zweers

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Management samenvatting

In de afgelopen decennia, hebben er verschillende organisatorische ontwikkelingen

plaatsgevonden in ziekenhuiszorg. Door toenemende druk om kosten te verlagen en kwaliteit te verhogen heeft er onder andere toe geleid tot nieuwe werkmethoden in ziekenhuiszorg.

Voorbeelden zijn het gebruik van klinische zorgpaden en het ontwikkelen van focus klinieken. Daarnaast worden zogeheten ‘one-stop-shops’ steeds vaker toegepast in ziekenhuiszorg. One-stop-shop houdt in dat de poliklinische patiënt in één ziekenhuisbezoek twee of meerdere activiteiten ondergaat, bijvoorbeeld een consult plus een diagnostisch onderzoek. Het concept van one-stop-shop is in meerdere ziekenhuizen in ontwikkeling of is reeds een standaard werkmethode. Het concept resulteert in een klantvriendelijke aanpak met name door het verminderen van het aantal ziekenhuisbezoeken evenals het verkorten van de doorlooptijd. Er is echter nog weinig empirisch onderzoek gedaan naar het one-stop-shop concept. Met name waar het concept eventueel kan worden toegepast en hoe dit vervolgens geïmplementeerd kan worden is onderbelicht in wetenschappelijke literatuur. In deze studie is onderzoek gedaan naar een viertal one-stop-shops toegepast door poliklinieken van een Nederlands ziekenhuis gevestigd in het noorden van het land.

De manier waarop dit onderzoek is uitgevoerd is gebaseerd op basis van gesprekken met betrokken medisch en ondersteunend personeel. Hieruit zijn een drietal condities naar boven gekomen die de basis zouden kunnen zijn voor de besluitvorming van een one-stop-shop. Deze condities zijn: minimale variatie in zorgbehoefte patiënt (homogene groep), vraag- en aanbod, en het afstemmen en samenwerken van verschillende afdelingen ten gunste van het one-stop-shop concept.

De uitkomsten van dit onderzoek waren echter moeilijk te vertalen naar concrete resultaten door het ontbreken van goede referenties vanuit het verleden. Verder onderzoek ten behoeve van het meetbaar maken van de resultaten zou echter nodig zijn om de beoogde efficiëntie en effectiviteit aan te tonen.

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Abstract

The current research investigates the concept of stop-shop applied in health care. A one-stop-shop implies that multiple activities are arranged in a single outpatient visit. Implementing this concept can be beneficial to both the hospital and the patient. In practice, one-stop-shops have been widely applied by hospitals. However, from literature little is known about this concept especially when, under which conditions and how to implement it. In this study we will attempt to answer these questions. Consequently, the aim of this study is to acquire a deeper understanding of one-stop-shops employed by outpatient departments of a hospital and thereby to contribute to current knowledge about this concept. The study is based on a multi-case study involving one regional hospital in the northern part of the Netherlands. The main input for this study stem from interviews conducted with managers, outpatient coordinators, specialists, planners and technicians. Three conditions, routing variety, volume and shared resources have been related to the concept of one-stop-shop. We found that one-stop-shop are implemented for both high- and low volume patient groups with limited routing variety. Shared resources

especially when they are limited are managed by allocating capacity. Furthermore, this study provides information about how a one-stop-shop can be organized for example by means of combining appointments into a single outpatient visit. The contribution of this study lies in potential improvements in the project planning and execution approach of the one-stop-shop concept in order to measure and evaluate its performance.

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In the last three decades, health care service providers have experienced increasing pressure to concurrently reduce cost and improve access and quality of care they deliver. The result has been the development of new concepts of care delivery. These concepts include clinical pathways (Pearson, Goulart-Fisher, Lee, 1995; De Bleser, Depreitere, De Waele, Vanheacht, Vlayen, Sermeus, 2006), focused factories (Hyer, Wemmerlöv and Morris, 2009; McDermott and Stock, 2011) and speciality hospitals (Herzlinger, 1997). In addition, a concept that have been adopted by hospitals are one-stop-shops. One-stop-shops have been set up in different phases of the care process and for a wide range of patient groups. In general, this concept implies that multiple steps in a patients care process are performed in a single outpatient visit. Thus one-stop-shops may contribute to improve hospital performance i.e. to shorten the patients throughput time and improve patient satisfaction (Gabel, Hilton, Nathansonet, 1997; Salam, Matai, Salhab, Hilger, 2006; Gilmartin, Chin, Leonard, 2009).

The concept of one-stop-shop in health care seem to be a trendy topic nowadays. In a brief internet search we have found numerous hospitals in the Netherlands who offer such a concept1. Considering potential performance improvements, hospitals could be interested to implement this concept within their own organization. However, the question is when, under which conditions and how the one-stop-shop concept can be successfully implemented within a hospital. This will be the main focus of the current research.

From literature we know only a few things about the concept of one-stop-shop in health care. What we do know is that there is a wide variation in interpretation and application of the shop concept. Several studies reported the results of the implementation of the one-stop-shop including: increased patient satisfaction, psychological benefits, reduction in throughput time and costs (e.g. Voorbrood, Burgmans, Clevers, Davids, Verleisdonk, Schouten, van Dalen, 2013; Harcourt, Ambler, Rumsey, Cawthorn, 1998; Dey, Bundred, Gibbs, Hopwood, Baildam, Boggis, James, et al., 2002). Limited attention has been given to how a one-stop-shop should be organized. What we do not fully understand are the motivations and conditions when and where the one-stop-shop concept could be introduced. The implementation of the one-stop-shop

concept itself and how to organize the interfaces of several departments needs special attention and guidance to make it successful and depends on good understanding of the one-stop-shop approach.

In this study we will investigate the following research questions:

1) when and under which conditions do they choose to implement a one-stop-shop? 2) how do they organize the one-stop-shop? and

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An exploratory case study has been carried out in one regional hospital in the northern part of the Netherlands. The aim is to understand what the drivers are for hospitals to introduce the one-stop-shop concept, how it can be organized and the experiences gained for both the hospital and the patients. The unit of analysis will be one-stop-shop. The empirical results will contribute to provide more insight in the use and applicability of one-stop-shops in health care. Furthermore, the results might provide healthcare professionals opportunities to improve hospital performance.

2 Literature review

The concept of stop-shop in health care seem to be a trendy topic nowadays. In practice one-stop-shops have been employed by hospitals for different care processes linking for example different diagnostics tests or an outpatient appointment with an X-ray. In this section we will provide an overview of what is known about the concept.

2.1 A description of one-stop-shop in health care

In literature one-stop-shops are generally described as a concept in which multiple activities are arranged in a single outpatient visit. One-stop-shops are applied in both diagnosis and treatment phase of a care process. Typically, one-stop-shops are offered to patients with a well-defined complaint, for example: suspected breast or skin cancer, inguinal hernia repair, cataract, and varicose veins (Gui, Allum, Perry, Wells, Curling, McLean, Oommen, et al., 1995; Harcourt et al., 1998; Harcourt, Rumsey, Ambler, 1999; Eltahir, Jibril, Squair, Heys, Ah-see, Needham, Gilbert et al., 1999; Chan, Berry, Engledow, Perry, Wells, Carpenter, 2000; Hughes, Forrest, Diamond, 2001; Dey, et al., 2002; Salam et al., 2006; Toomey, Cahill, Birido, Jeffers, Loftus, McInerney, Rothwell, et al., 2006; Aldenzee, Houterman, Scheltinga, 2007; van der Geer, Frunt, Romero, Dellaert, Jansen-Vullers Demeyere, Neumann, 2012; Romero, Dellaert, van der Geer, Frunt, Jansen-Vullers, Krekels, 2013; Voorbrood et al., 2013).

Some studies report an extension of the general description of a one-stop-shop. This extension often refer to establish a diagnosis and treatment plan for each patient on the day of the clinic visit (Chan et al., 2000; Gui et al., 1995; Harcourt et al., 1998; Harcourt et al., 1999; Eltahir et al., 1999). These studies do focus on diagnosing women of suspected breast cancer. According to Harcourt et al. (1998) “the pre-diagnostic period in which they await the results of investigative

procedures is a distinct, worrying and stressful time” Therefore it seems reasonable to assume

that a swift diagnosis is psychologically beneficial to the patient in this particular case. This is however pending on the objectives and definition of the one-stop-shop of the health care provider. A diagnosis or treatment plan can be discussed with the patient the same day or if not possible, for example due to awaiting laboratory test results, by telephone, e-mail, or

videoconference without the need for a second outpatient visit.

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2.2 Motivations to implement a one-stop-shop in health care

The main reason of implementing a one-stop-shop discussed in literature is to minimize waiting time in establishing a diagnosis (Dey et al., 2002; Eltahir et al., 1999; Gui et al., 1995; Harcourt et al., 1998; Harcourt et al., 1999; Alderzee et al., 2007) or performing treatment after diagnosis is established (Hughes et al., 2001; Salam et al., 2006; Romero et al., 2013). Reducing waiting time is generally considered as an important aspect of patient satisfaction (Thompson Yarnold, Williams and Adams, 1996). Patient satisfaction is often used as a outcome performance indicator for determining the quality of care delivery.

2.3 Conditions for implementing a one-stop-shop

The primary question when and/or under which conditions hospitals choose to employ a one-stop-shop remain unclear. From literature we know that one-one-stop-shops have been implemented for well-defined complaints related to homogenous patient groups (e.g. patients with suspected breast cancer).

According to Vissers and Beech (2005) clear understanding about care and targets for a well-defined complaint should facilitate a treatment path indicating the different operations interfaces involved in the process i.e. examination activities and its routing support the implementation of a one-stop-shop.

A few studies indicate that high volume patient groups was one of the conditions for implementing a one-stop-shop (e.g. Aldenzee et al., 2007; Voorbrood et al., 2013). Both examples involved a high-volume patient group. (High) Volume could an condition for organizing a dedicated service (Vissers and Beech, 2005) i.e. a one-stop-shop. Furthermore, having high-volume patient groups with no or limited routing variety simplifies capacity allocation because there is often sufficient demand to fill the capacity and the subsequent steps can be easily predicted (Drupsteen, van der Vaart en van Donk, working paper).

2.4 One-stop-shops in practice

Three recent contributions give us more insight in the concept of one-stop-shops in health care and how they could be organized (Drupsteen, van der Vaart and van Donk, 2013; Voorbrood et al., 2013; Romero et al, 2013). Similar to what has been discussed in the previous paragraph, these studies also refer to high volume patient groups with a well-defined complaint (e.g. total hip or total knee replacement, skin cancer and hernia repair).

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between anaesthesiology and orthopaedics with dedicated capacity slots for these patient groups. Allocated capacity is a necessity since anaesthesiology capacity is a shared resource with other patient groups. If this resource is not available on time, the success of the one-stop shop concept would diminish.

In a simulation-based study Romero et al. (2013) investigated the effect on patient throughput time by implementing a one-stop-shop for the treatment of new patients diagnosed with skin cancer (basal cell carcinoma). The aim was to establish a diagnosis in the morning and to perform treatment in the afternoon all within a single hospital visit. To achieve one-stop-shop a fixed amount of surgery capacity was dedicated in advance for patients with the diagnose skin cancer.

In a similar vein, Voorbrood et al. (2013) reserved a fixed amount of surgery capacity dedicated to one-stop-shop patients requiring hernia repair. This amount was determined by the available number of surgical procedures during a morning or afternoon session. Maximum four out of seven surgical procedures were dedicated for shop patients. In the event that a one-stop-shop surgical procedure remained unexploited one week before expected surgery regular patients i.e. non-one-stop-shop were planned instead. We may conclude that allocating capacity can be considered as a way for organizing a one-stop-shop.

2.5 Experiences with the one-stop-shop concept

Several studies reported the effects of one-stop-shops including: increased patient satisfaction (e.g. Hughes et al., 2001), psychological benefits due to a lower level of anxiety involving

suspected breast cancer (e.g. Harcourt et al., 1998; Harcourt et al., 1999), reduction in throughput time (e.g. Romero et al., 2013) and costs (e.g. Dey et al., 2002).

Research about one-stop-shops and throughput time reduction however remains scarce. One contribution by Romero et al. (2013) investigated the effect of a one-stop-shop on throughput time and concluded that treatments of new patients can be decreased with more than 90% even with the same resource level. It is noteworthy though that this particular one-stop-shop combined both diagnosis and treatment in a single visit. The reduction in throughput time was mainly the result of a reduction in the average of waiting time that a patients spends between the diagnosis and treatment. A similar result was found by Salam et al. (2006). They found that the

implementation of a one-stop-shop resulted in a reduction in the overall waiting time.

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One of the few studies that give detailed information about the effectiveness (and efficiency) of a one-stop-shop is the study by Hughes et al. (2001) who evaluated a one-stop-shop for cataract surgery. Patients invited to the one-stop-shop clinic had an initial assessment in the morning and underwent surgery during the afternoon. However, due to various reasons (inappropriate referral, patient declined surgery, unsuitable for local anaesthesia etc.) not all patients received treatment the same day of the diagnosis. Resulting from this unpredictability on average 82% of patients had surgery on the same day but this rate could be as low as 50%. Consequently this led to inefficient use of (expensive) theatre time. To overcome the problem of inefficiency non-one-stop-shop patients were informed that there was a chance of surgery that day and to come prepared for this surgical procedure. These non-one-stop-shop patients could fill in gaps in case of fewer than the expected one-stop-shop surgeries. Although this type of one-stop-shop may be beneficial to patients who live a considerable distance from the hospital, it does have potential short-falls in particular the risk of underutilized theatre time. It is noteworthy that this short-fall has been ignored or at least not discussed by other studies who also investigated the effectiveness of one-stop-surgery (e.g. Romero et al., 2013).

2.6 Summary

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3 Theoretical Background

We expect a fit between implementing a one-stop-shop and conditions in terms of volume, routing variety and shared resources. If there is a fit, a one-stop-shop could lead to performance improvements. Performance improvements in terms of lead time, utilization and planning effort. The nature of this research is inductive rather than deductive. The start was an in situ one-stops-shop clinic review to establish guiding principles for initiating a one-stop-one-stops-shop approach. The aim of a hospital is to provide outpatient care within a single outpatient visit. Our aim is to contribute a more in-depth operations management knowledge to guide hospitals in developing a one-stop-shop treatment for patient groups with similar complaints.

From an operations management perspective we expect that routing variety, volume and shared resources are relevant for a one-stop-shop.

3.1 Routing variety

Routing variety refers to the number of possible routings of the patient through a care process i.e. the one-stop-shop process. High routing variety would suggest that you do not always know in advance which route a patient will follow. Considering that each route may consists of different (types of) resources, high routing variety could influence effective allocation capacity to these resources. A mismatch in allocating capacity may lead to underutilization of expensive resources which is undesirable from an operations management perspective. On the other hand, allocating insufficient capacity may lead to situations in which the one-stop-shop cannot be completed and hence the intended service cannot be delivered.

Low routing variety would suggest that, all or at least most, patients follow the same routing for homogenous patient groups and thus would simplify to organize a one-stop-shop for this

particular group. In this case low routing variety can be considered as a condition for implementing a one-stop-shop.

3.2 Volume

We would expect that a one-stop-shop is offered to a high-volume patient group. The volume of patient flow supports the decisions whether or not it makes sense to develop and to implement a dedicated service for a patient group (Vissers and Beech, 2005). Moreover, having high-volume patient groups with no routing variety simplifies capacity allocation because there is often

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11 3.3 Shared resources

A one-stop-shop might be organized by dedicated resources, shared resources or a combination of both. Vissers and Beech (2005) state that “ a care process that requires many shared resources is more difficult to organize than a process with no or limited shared resources. This is because patient groups must compete for resources”. By our definition of a one-stop-shop two or more activities are performed within a single outpatient visit. These activities may require two or more types of resources. These resources must be available at the right time to achieve the desired patient flow i.e. one day. One-stop-shops involving many shared resources asks for intelligent and accurate planning of these resources. From literature (e.g. Vissers and Beech, 2005) we know that, this can be arranged by assigning capacity of the resources required. This is especially applicable for shared resources that are limited. In this case we expect that one-stop-shops that use various and limited shared resources are managed by allocating capacity in order to assure the one-stop-shop successful.

4 Methodology

Limited knowledge exists about when, where and how hospitals organize their one-stop-shops, we have opted for an exploratory case study as suggested by Eisenhardt (1989) for such

situations. In fact, this methodology is considered very useful when the research aims to answer “why” and “how” questions (Karlsson, 2009:164). Considering the aim of this research a case study seem to be the right research design. Furthermore, we decided to conduct multiple cases since it can augment external validity, and help to guard against observer bias (Karlsson, 2009:170).

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Table 1 Overview of cases

Case Patient volume (annual 2013) No. of combined activities

Dyspnea one-stop-shop 19 8

Asthma one-stop-shop 17 4

Cardiac one-stop-shop 531 3

Cardiac (2) one-stop-shop 7 6-7

Qualitative data is gathered by conducting semi-structured interviews. These interviews were held with key staff representatives involved in either implementation or execution of one-stop-shops. The representatives involved were: the patient logistics manager, the head of the outpatient departments, three outpatient coordinators, two specialists, the manager of the radiology department, one technician of the lung function department, two technicians of the cardiac function department, and one planner of the service department. The outpatient

coordinators have been interviewed twice. In the first interview the relevant one-stop-shops were discussed whereas the second interview was conducted to verify our observations and findings. The interview protocol in Dutch can be found in appendix I.

Interviews are conducted by two interviewers. All interviews have been recorded with a tablet after approval to record. All representatives gave us permission to record the conversation. After the interview recordings have been transcribed. Both transcriptions and field notes were the main input for the analysis.

Quantitative data to determine patient volume have been gathered from the hospital management system. Data were collected between January 2013 and December 2013. Data have been

processed by using a spreadsheet program in order to make pivot tables and relevant calculations (mean, standard deviation and coefficient of variation). See appendix II.

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5 Results

5.1 Case 1: Dyspnea one-stop-shop

Background

This one-stop-shop is organized within the outpatient department for dyspnea which has been developed by two specialisms: pulmonology and cardiology. Pulmonology focus on lung related problems whereas cardiology focus on heart related problems.

This outpatient department exclusively provides care to new patients who experience shortness of breath or breathlessness, called a dyspnea. This particular symptom can be an indication to either a lung problem or a heart problem. For that reason this department is managed by both specialisms.

All dyspnea patients are offered a one-stop-shop. During this one-stop-shop visit a diagnose and a treatment plan is established which is required to determine the right specialism i.e.

pulmonology or cardiology for further treatment.

Dyspnea one-stop-shop Diagnose Referral to department of pulmonology Referral to department of cardiology Lung related Cardiac related End No

Figure 1 Flow diagram dyspnea

In the past, patients suffering from a dyspnea were referred by the general practitioner for a consult to either a cardiologist or a pulmonologist. After this first consult diagnostic tests where scheduled in a second outpatient visit. The test results were discussed during a second consult. As a result the patient had to visit the hospital multiple times before a diagnosis was determined. Furthermore, if for example, the patient was referred to a pulmonologist but was not able to establish a diagnose the patient needed to be referred by the general practitioner to a cardiologist for another review. As a result, the patient had to accept a long throughput time before a

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The old situation was inconvenient to the patient and the hospital approach on how care should be delivered to the patient was subject for improvement. This has also been recognized by two of the respondents we have interviewed who stated (translated):

“The main reason that we offer this one-stop-shop is that we want reduce the

inconvenience to the patient of visiting the hospital five or six times before a diagnosis is established. Now the patient visit the hospital only once and a diagnosis and treatment plan is established the same day of the visit”,

outpatient coordinator of department pulmonology.

“With the dyspnea one-stop-shop, we also provide a service to the general practitioner because it is not always clear to which specialism, cardiology or pulmonology, a dyspnea patient should be referred to. Now a general practitioner can refer the dyspnea patient to this one-stop-shop where the patient is seen by both specialisms in a single hospital visit. Moreover, it not only enables a swift diagnosis but also the follow-up treatment can be started sooner making it much more effective”, pulmonologist.

These remarks seem to be in line with literature especially in terms of improving patient satisfaction and quality of care delivery.

Process

By means of the one-stop-shop the patient is seen by both the pulmonologist and the cardiologist within a single day. The average of the one-stop-shop is two dyspnea patients a week on a Friday morning. Capacity (e.g. specialist time and diagnostic equipment) is allocated by using

appointment slots which is a requirement for flawless execution of the one-stop-shop. The outcome of the one-stop-shop is a diagnosis and a treatment plan the same day. A patient with a diagnosis is either referred to the cardiologist or the pulmonologist for further treatment. The advantage of the one-stop-shop concept is the synergy of both specialisms which especially benefits the dyspnea patient.

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The one-stop-shop process consists of eight activities. Firstly, the patient visit the pulmonologist for a consult. Next, the patient undergoes two lung function tests followed by two cardiac function tests. These tests are performed by the function department of the hospital. This

department performs various diagnostics tests for different specialisms. An X-ray is made at the radiology department. Blood samples are collected by the laboratory. Both activities taking an X-ray and collecting a blood sample follow a walk-in system. Finally, the patient visit the

cardiologist for a consult. The test results are discussed by either the cardiologist or

pulmonologist at the end of the morning. The entire process is depicted in the figure below.

Referral by the general practitioner Processing one-stop-shop referral First Consult (20 min.) Lung function tests (15 +15 min.) Cardiac function tests (45 +3 min.) X-Ray (~ 5 min.) Collecting blood samples (~ 5 min.) Second consult (20 min.)

Figure 2 Process diagram dyspnoe one-stop-shop

Routing variety

We would expect that the one-stop-shop is offered to patients with a well-defined complaint. Diagnosing a well-defined complaint with a high level of routing predictability should follow a predetermined routing for a flawless one-stop-shop. The one-stop-shop dyspnea is offered to patients with a well-defined complaint: shortness of breath or breathlessness. Examining this symptom often involve standard tests which are needed to collect sufficient information to enable a proper diagnosis. This has also been recognized by one of the respondents we have interviewed who commented (translated):

“The predictability of the process of dyspnea patients is generally high. We know what activities these patients need to undergo and which route they will follow. This is different from, for example, patients diagnosed with lung cancer. In this case the pulmonologist proceed in a step by step way and depending on outcome of tests subsequent steps are determined. Hence for these patients a standard route is often not possible”, outpatient coordinator of

department pulmonology.

This remark indicates that there is a clear understanding in which situation a one-stop-shop is suitable i.e. in situations when there is low routing variety.

Volume

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However, in this case the demand for the one-stop-shop is modest and fluctuates as stated by one of our respondents (translated):

“The demand for this one-stop-shop is often not more than one or two patients a week. In addition, the number of patients for this one-stop-shop varies. Sometimes there are two patients a week and sometimes there are three patients a month”, outpatient coordinator of department pulmonology.

According to the figures of previous year, demand is even lower from what is experienced by the outpatient coordinator. Last year demand for the one-stop-shop accounted for nineteen patients with a relatively high coefficient of variation (CV = 1,8797). A high variation means that there is more uncertainty in demand. Consequently, there may not always be sufficient demand to fill capacity risking underutilization of expensive resources. However, this risk is managed by cancelling the one-stop-shop appointment slots of that week if no dyspnea patient is scheduled. This slot need to be withdrawn three days before planned date. As such, allocated capacity becomes available to other patients to prevent underutilization of resources. This flexibility would justify the low-volume dyspnea patient group.

Shared resources

The dyspnea one-stop-shop shares several resources like diagnostic equipment and specialists at the radiology department, lung function department, cardiac function department and laboratory with other patient groups. From the perspective of the one-stop-shop concept, it is evident that these resources must be available at the right time. To achieve this objective, appointment slots are reserved in agreement with the relevant departments for each resource that is required to carry out the dyspnea one-stop-shop. As a result, six appointments are scheduled for a single one-stop-shop dyspnea patient: one appointment slot for the consult with the pulmonologist, one appointment slot for the consult with cardiologist, two appointment slots for two long function tests (spirometric and diffusion test), and two appointment slots for two cardiac function tests (echocardiographic and electrocardiographic). All these appointments are scheduled on a Friday morning.

This particular approach of managing shared resources proves that there is a good understanding of the criteria for a one-stop-shop concept.

Mechanisms

The one-stop-shop is organized by means of a combined appointment and a walk-in system (blood sample and X-ray). In a combined appointment two or more appointment slots are linked across the relevant (function) department schedule by using dedicated planning software. The motivation for organizing the one-stop-shop by means of a combined appointment is that, alignment of all different capacities like specialists, diagnostic function tests etc. are available at the time required. According to the patient logistics manager, this approach is needed to

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The principle of the combined appointment is as follows. A single appointment, called a plan code, is used to define the appointment for the dyspnea one-stop-shop. This plan code includes several sub-appointments in this case six in total (one sub-appointment for each activity). These sub-appointments are linked to the plan code. The planner only have to book a dyspnea patient to the dyspnea plan code. Consequently, the patient is booked for all sub-appointments. Main benefit for the planner is that this technique contribute to improve convenience and efficiency i.e. less time is spend on booking a patient. This benefit is experienced by outpatient coordinators of different departments (cardiology, pulmonology, and pediatrics).

Since the dyspnea one-stop-shop is offered on an average two patients a week, two plan codes are used to book dyspnea patients. The plan codes represent the sequence and time in which activities are arranged. For example, patient number one starts with a consult by the

pulmonologist followed by diagnostics and finishes with a consult by the cardiologist. Patient number two starts with a consult by the cardiologist followed by diagnostics and finishes with a consult by the pulmonologist. In this way, patients can be seen by both the cardiologist and the pulmonologist on a Friday morning.

As mentioned before, appointment slots for dyspnea patients are reserved in advance of booking. In the event of a non-booking three days before the planned date, the dyspnea one-stop-shop will be automatically cancelled to prevent loss of capacity. This one-stop-shop appointment slot is made available for other patients.

“Unused appointment slots for dyspnea patients expire three days before appointment date. This gives us sufficient time to schedule another patient for a lung function test. If this parameter was set, for example to one day, it would be much harder for us to find and schedule a patient on time if not impossible”,

technician and planner of the lung function department.

In addition, planners at the function department ask patients who are not scheduled for a one-stop-shop i.e. regular appointments whether they are willing to be rescheduled if a slot becomes available. This give the planners additional flexibility to fill empty slots in case of a one-stop-shop cancellation.

Embedded in the one-stop-shop is the walk-in system. For the activities like collecting blood samples and X-ray, the dyspnea patient can walk-in without any appointment requirement. These activities are performed in between appointments i.e. during idle time. Main reason for this is that these activities needs short processing time in combination with sufficient capacity.

Performance and Analysis

Since the particular symptom of a dyspnea can be an indication to either a lung or cardiac problem the patient is seen by both specialisms required to determine a diagnosis.

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In general, the one-stop-shop dyspnea substantially reduces the throughput time from first consult to diagnosis. This is appreciated by the dyspnea patients according to both the outpatient coordinator and the pulmonologist. This finding is based on a recent survey. Furthermore, the access time for this one-stop-shop is approximately two weeks according to the outpatient coordinator.

The outpatient coordinator, pulmonologist and the technician of the lung function department do not experience any problems with the one-stop-shop dyspnea and are generally satisfied with the one-stop-shop.

This one-stop-shop is characterized by a low volume demand and with considerable demand uncertainty. High demand uncertainty may result in the risk of underutilization of expensive resources. However, this risk is managed by an expire date in case of lack of an one-stop-shop appointments.

High demand uncertainty and the risk of underutilization of capacity is not experienced as a critical problem by the outpatient coordinator of pulmonology department, head of the outpatient departments and the manager patient logistics as long as a cancellation policy is used providing relevant departments sufficient time to schedule new patients which is confirmed.

One of the respondents we have interviewed commented (translated):”I don’t experience any

problems with the one-stop-shop for dyspnea patients”, technician lung function lab

5.2 Case 2: Asthma one-stop-shop

Background

The one-stop-shop is organized within the department of pediatrics of the hospital. At this outpatient department patients of which are all children, ranging from newborns to acute and chronically ill patients, are treated. Care is provided by a team of six general pediatricians and four nurse practitioners. Each pediatrician has a specialist interest, for example: diabetes, allergies or lung diseases. Two of the pediatricians have a special interest in lung diseases and are involved in this one-stop-shop.

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Additional reasons for implementing a one-stop-shop have been mentioned as well, for example, one of our respondents stated that (translated):

“By offering care in this particular way (one-stop-shop) it helps to communicate a hospitals’ ranking of expertise. By selection of hospital for treatment, it is important to show what your level of expertise is and which health services you can offer to a patient. Moreover, it helps to distinguish your hospital from other hospitals”, pediatrician.

Process

By means of the one-stop-shop the patient undergo two diagnostic tests and is seen by both a pediatrician and a nurse practitioner within a single day. In general, the one-stop-shop is offered to two patients once a week on a Wednesday (1) and Thursday (1) morning. Similar to case one, capacity is allocated in favor of the one-stop-shop. The outcome of the one-stop-shop is a diagnosis and a treatment plan (advise) the same day. Furthermore, a decision is made whether the patient should remain under supervision of the patients general practitioner or supervision by the pediatrician is more appropriate.

In case of the patient is referred to his own general practitioner the balance in care can be seen as an improvement of cooperation.

Similar to the previous case, the process starts with processing the referral of the general practitioner by the planner.

The one-stop-shop asthma consists of four steps. Firstly, the patient receives two lung function tests performed by the function department of the hospital. This department performs various diagnostics tests for different specialisms. After these tests the patient visit the pediatrician to discuss the test results and the diagnosis. If a diagnosis asthma is made a treatment plan will be established. Finally, the patient gets advice from a nurse practitioner related to treating asthma. The entire process is depicted in the figure below.

First test (Spirometric) (30 min.) Referral by the GP Processing one-stop-shop referral First Consult (30 min.) Second consult (30 min.) Second test (Diffusion) (30 min.)

Figure 3 Process diagram asthma one-stop-shop

Routing variety

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The final activity within the one-stop-shop (second consult) is however dependent on the outcome of the diagnosis. If there is no diagnosis established indicating that the symptoms are caused by asthma, the final activity is not required anymore resulting in some idle time

(approximately half an hour). According to the outpatient coordinator this happens only rarely and is not experienced as a critical problem. One of the respondents (secretary) we have interviewed explained (translated):

“last week we had a patient who suffered from dysfunctional breathing which had nothing to do with asthma. So, we referred the patient to a physiotherapist. The consult by the nurse practitioner was not required. I think this happen in one out of ten patients”, outpatient coordinator.

Volume

Similar to our expectations of the previous case one, we would expect a one-stop-shop

implemented for a high-volume patient group with no or very limited routing variety. However, demand for the one-stop-shop asthma is rather low. Moreover volume was not found to be a criteria for implementation:

“volume is not important to me. I think that it is more important to develop a service to a patient for a specific complaint. I do understand though, that it would not be realistic and even financially viable to setup a one-stop-shop for one or two patients a year. But a one-stop-shop can work rather well for only a little number of patients”, pediatrician.

Last year demand for the one-stop-shop accounted for seventeen patients with a relatively high coefficient of variation (CV = 1,9834). A high variation means that there is more uncertainty in demand. Consequently, there may not always be sufficient demand to fill capacity risking underutilization of expensive resources. To manage this risk the one-stop-shop appointment slot is automatically cancelled if no patient is scheduled eight days before actual planned date. The motivation for eight days is that asthma is less urgent and therefore short access time is less important in comparison with dyspnea .

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Shared resources

Similar to the one-stop-shop dyspnea, this one-stop-shop shares several resources (including diagnostic equipment and specialists at the lung function department) with other patient groups. From the perspective of the one-stop-shop concept, it is evident that these resources must be available at the right time. Also similar to the dyspnea one-stop-shop, appointment slots are reserved in agreement with the relevant departments for each resource that is required to carry out the asthma shop. As a result, four appointments are scheduled for a single one-stop-shop asthma patient: one appointment slot for the consult with the pediatrician, one appointment slot for the consult with nurse practitioner, two appointment slots for two long function tests (spirometric and nitric oxide test). All these appointments are scheduled on a Wednesday or Thursday morning.

Again, this particular approach of managing shared resources proves that there is a good understanding of the criteria for a one-stop-shop concept.

Mechanisms

The one-stop-shop is organized by means of a combined appointment. This approach assures that the one-stop-shop can be offered to the patient within acceptable access time. It is the same principle similar as applied to the one-stop-shop dyspnea. However, different from the dyspnea one-stop-shop is that there is no difference in the time and sequence of activities. Each asthma patient follow the activities in the same order.

Different from what we expected is that the one-stop-shop is implemented for a low-volume patient group with a high uncertainty in demand. It is obvious that effective management is more difficult for this stop-shop concept. The risks of low volume is that the awareness of the one-stop-shop will disappear, however in this case it is not experienced as a problem.

A one-stop-shop for low-volume patient groups and high uncertainty in demand organized by combined appointments may lead to inefficient use of resources. This is not experienced due to cancellation policy and sufficient demand of regular patients.

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In general, both the outpatient coordinator and the pediatrician are generally satisfied with the one-stop-shop asthma. However, problems experienced in the one-stop-shop have been discussed in one of the interviews. One of the respondents we have interviewed explained (translated):

“the one-stop-shop for asthma does conflict with another one-stop-shop (spirometric + consult), especially on the Wednesday morning during Summer holidays when we have limited staff capacity available. I usually then cancel the one-stop-shop for asthma patients”, technician and planner of the lung

function department.

Note, asthma is not an urgent complaint. This may have taken into account while making the decision to cancel the one-stop-shop asthma and to give priority to the other patients.

This issue has also been experienced by the outpatient coordinator of department of pediatrics:

“ We are aware of this. At the moment, we demand only a limited amount of capacity in terms of lung function tests for the one-stop-shop. Therefore we receive lower priority. This can be very annoying especially in Summer months. We cannot do anything about this. But bear in mind that asthma is never acute”, outpatient coordinator of the department of pediatrics.

We may view this problem as a man power problem rather than a problem that is related to either routing variety, volume or shared resources or to the use of combined appointments.

Planning of man power requirements must be improved to avoid this problem. 5.3 Case 3: Cardiology one-stop-shop

Background

This one-stop-shop is organized within the department of Cardiology. Patients who are suspected of a cardiac problem are be scheduled for this one-stop-shop. The one-stop-shop is executed by a team of six cardiologists.

To establish a diagnosis of this problem, multiple tests and consults with the cardiologist are often required. As a result, the patient may need to visit the hospital more than once. To prevent this inconvenience the one-stop-shop consists of multiple activities done in a single hospital visit. Reducing patients inconvenience would suggest that, similar to the previous cases, patient

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“The main reason for this one-stop-shop is that we like to offer good service to our patients by reducing the number of hospital visits. Bear in mind, that most of our patients are elderly. They are often dependent on friends and family for arranging transportation to and from the hospital. And if three or four diagnostic tests are needed but arranged in separate visits, than it will be rather inconvenient to both the patient and their families. This inconvenience is something we like to prevent”, outpatient coordinator cardiology.

In the past, new patients were scheduled for a consult with a cardiologist but without an

echocardiography (echo) on the same day. The cardiologists experienced that on average 75% of the patients did required an echo. This finding was an additional argument to look for ways to combine both activities i.e. consult and echo within a single hospital visit.

By means of the one-stop-shop a new patient is first seen by the cardiologist. Subsequently, the patient undergo both an electrocardiography (ECG) and an echo. Both tests are standard

activities and are required for all new cardiac patients. Capacity is allocated by using

appointment slots which is a requirement for flawless execution of the one-stop-shop. This is done in advance of patient booking. The one-stop-shop can be extended with an additional test i.e. ergo metric test. If needed, this test is scheduled on the same day as part of the one-stop-shop.

The requirement of an ergo metric test is determined by the cardiologist based on the referral by the general practitioner. However, in this case we will only focus on the two main diagnostic tests (ECG and echo) since the demand for the additional test is low according to the outpatient coordinator (in 2013 only 55 ergo metric tests were scheduled).

Process

The one-stop-shop is offered from Monday to Friday. Twenty-six patients can be scheduled for the one-stop-shop per week. The number of patients is distributed by week, day and amongst the six cardiologists. Similar to the previous cases, capacity is allocated for this one-stop-shop. Different from the previous cases is that no diagnosis or treatment plan is established on the same day. More time, approximately 1 or 2 days, is needed by the cardiologist to review the echo and to establish a diagnosis. The results are discussed with the patient directly or via the patients general practitioner at a later time.

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The one-stop-shop consists of three main activities. Firstly, the patient visits the cardiologist for a consult. Next, the patients undergoes an ECG followed by an echo. Both tests are done by the cardiac function department. The entire process is depicted below.

Referral by the GP Processing one-stop-shop referral First Consult (20 min.) First test (ECG) (~3 min.) Second test (Echo) (45 min.)

Figure 4 Process diagram cardiac one-stop-shop

Routing variety

The predictability of the process was one of the drivers to implement this one-stop-shop as previously described. Based on experience of the cardiologists an echo is often needed to collect sufficient information and to enable a proper diagnosis. This standardization simplifies to

organize a one-stop-shop for this process. This is in line with our expectations.

Volume

Similar to our expectations of the previous cases, we expect a one-stop-shop implemented for a high-volume patient group with no or very limited routing variety. Last year demand for the one-stop-shop (consists of consult, electrocardiography, and echocardiography) accounted for more than 530 patients with a relatively low coefficient of variation (CV = 0,4147). A low variation means that there is less uncertainty in demand. Less uncertainty in demand simplifies capacity allocation as there are always patients to fill the capacity. This is in line with our expectations. Although the CV is low, there still remain some variation in demand for the one-stop-shop. Since echo capacity is reserved in advance of patient booking there is a risk that, in practice, demand may be lower or higher. This is due to variability in demand. If there are less echo’s requested by the cardiologists than echo capacity might remain unexploited. This underutilization of resources is inefficient from an operations management perspective. To manage this risk the one-stop-shop appointment slot is cancelled if no patient is scheduled. This is done fourteen days before the planned one-stop-shop appointment.

Shared resources

This one-stop-shop shares several resources (including diagnostic equipment at the cardiac function department) with other patient groups. From the perspective of the one-stop-shop concept, it is evident that these resources must be available at the right time. Similar to all previous cases, arrangements for reserving capacity are made with the cardiac function

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However, allocating capacity does not always guarantee good performance of the one-stop-shop. For instance, access time for the one-stop-shop has increased considerably resulting from a lack of capacity at the cardiac function department (echo capacity) and an increase in demand. Access time sometimes exceeds six to eight weeks. According to the outpatient coordinator, options are therefore offered to the patient, for example: next week visit with the cardiologist but diagnostic tests in separate hospital visits or to wait six to eight weeks but all activities within a single hospital visit. Note, that the first option deviate from the one-stop-shop approach.

Mechanism

This one-stop-shop is organized by means of a combined appointment. Applying this approach guarantees that the one-stop-shop can be offered to the patient within acceptable access time (approximately 2 weeks). It is the same principle as applied to the previously discussed one-stop-shops.

Different from all previous cases discussed so far, this one-stop-shop is characterized by a high volume demand. In addition, echo capacity need to be managed well since there is a lack of capacity in combination with high patient volume as experienced by the outpatient coordinator of cardiology department. By this high volume the echo capacity is under pressure (bottleneck) and planning is critical to offer by this demand a one-stop-shop.

This one-stop-shop is organized by means of a combined appointment. According to the head of outpatient departments, the number of combined appointments scheduled for an echo exceeds the number of regular appointments. Limited options remain to schedule regular appointments although there is still a considerable amount of these appointments.

The combined appointment and regular appointment seem to act as communicating vessels in the sense that allocating echo capacity to the former automatically reduces the available capacity that is left for the latter, and vice versa. This could be an indication that one-stop-shop patients

receive a higher priority at the cost of non-one-stop-shop patients and may thus be a side effect of the concept.

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5.4 Case 4: Cardiology one-stop-shop for physically disabled patients

Background

Similar to the previous case, this one-stop-shop is organized within the department of cardiology. However, different from the previous case is that this one-stop-shop is organized for patients who are physically disabled and are suspected of a cardiac problem. The reason for

implementing this one-stop-shop was to improve patient satisfaction.

“The one-stop-shop is in essence an extra service initiated by the cardiologists. Main purpose of the one-stop-shop is to prevent multiple hospital visits and thus to increase patients convenience”, patient logistics manager.

Process

By means of the one-stop-shop patients undergo several diagnostic tests e.g. ECG, echo, collecting blood samples, and X-ray and finally a consult with the cardiologist. Similar to the case three, an ergo metric test can be added on request and is dependent on the referral of the general practitioner by indication that ergo metric test is required or by the decision of the cardiologist. In general, the one-stop-shop is offered on a Monday ( 1 patient). Different from case three is that this one-stop-shops requires a whole day (from 09:00 – 16:00) to complete. The outcome of the one-stop-shop is a diagnosis and a treatment plan.

Similar to the previous case, the process starts with processing the referral of the general practitioner by the planner.

The one-stop-shop process consists of six to seven activities. Firstly, the patient is first seen by the cardiologist at the outpatient clinic. This step is required to assess which tests need to be executed. Next, an ECG test is performed. An X-ray is made at the radiology department. Blood samples are collected by the laboratory technician. Both activities taking an X-ray and taking a blood sample follow a walk-in system. Next, the patient proceed to the clinic department where an clinical echo (mobile echo device) is carried out by a technician of the cardiac function department. If needed also an ergo metric test can be arranged within the same visit. This test will also be carried out at the clinic department by a technician of the cardiac function

department. In addition, this test follows a walk-in system without an appointment requirement. Finally, after this test the patient visit again the cardiologist to discuss the results and further actions. Referral by the GP Processing one-stop-shop referral First Consult (20 min.) ECG (~3 min.) X-Ray (~ 5 min.) Collecting blood samples (~ 5 min.) Echo (45 min.) Ergo metric test Second consult (20 min.)

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Routing variety

In general, the route of this one-stop-shop is predefined i.e. each patient follow the same activities in the same order. The requirement of the ergo metric test is determined on the day of the hospital visit because it is either not required or the patient who has a physical disability may not be able to perform the test.

Benefits are obtained from the flexibility related to the way this one-stop-shop is organized i.e. some activities are arranged by means of a walk-in system.

Volume

Similar to our expectations of the previous cases, we would expect a one-stop-shop implemented for a high-volume patient group with no or very limited routing variety. However, demand for the this one-stop-shop is very low. Last year, demand for the one-stop-shop accounted for seven patients with a high coefficient of variation (CV = 2,9527). A high variation means that there is more uncertainty in demand. This is uncertainty is managed by exploiting flexibility through cancelling the one-stop-shop appointment (eight days before one-stop-shop appointment) if no patient is booked.

Shared resources

Similar to the previous cases, the one-stop-shop shares several resources (including diagnostic equipment) with other patient groups. Different from the other cases is that these resources are not only shared with outpatients but also with clinical patients (this particular one-stop-shop patient is considered as a clinical patient and not an outpatient). To assure flawless execution of the one-stop-shop, the patient is announced for the required tests at the function department. The function department use their flexibility and float to execute these requests and is similar to a walk-in system. The two consult appointment slots are scheduled for the cardiologists at the beginning and at the end of the one-stop-shop.

Mechanism

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At the moment of writing, limited information is available about the performance of this one-stop-shop. We know that the number of patients is very low. Due to the limited amount of patients and the availability of flexibility, this one-stop-shop can be easily embedded in the overall hospital activities of relevant departments. For that reason this one-stop-shop is not in discussion.

6 Interpretation of results

As mentioned in the introduction of this study, health care service providers are under pressure to concurrently reduce costs and improve quality of care they deliver. One way to achieve this is to organize care delivery more efficiently. At an outpatient department level this can be achieved by aggregating services and thereby gaining efficiencies through economies of scale. This is the principle of pooling. Statistically, the benefit of pooling is credited to the reduction in variability resulting in efficiency gains (Vanberkel, Boucherie, Hans, Hurink and Litvak, 2010; Cattani and Schmidt, 2005). Furthermore, a pooled system can help to mitigate the negative effects of variability i.e. reducing expected waiting time (Cattani and Schmidt, 2005).

Within this line implementing a one-stop-shop disaggregate an outpatient service. This would result in losses in economies of scale and thereby create deficiencies. Furthermore,

disaggregating the outpatient service into a regular service and a one-stop-shop service increases variability. This is the result of un-pooling the outpatient clinic service. Especially, in case one, two and four we have observed considerable variability in patient arrival. This variability lead to fluctuations in demand. A decrease in demand compared from what was expected is managed by a cancellation policy to prevent underutilization of resources. A demand increase compared from what was expected is however, more difficult to manage especially on short term given the one-stop-shop approach (multiple capacity resources available at the right time). This may lead to a longer waiting time for the one-stop-shop patient. This needs further research.

In case three we observed that, one-stop-shop appointments and regular appointments seem to act as communicating vessels in the sense that allocating echo capacity to the former

automatically reduces the available capacity that is left for the latter, and vice versa. We argued that this might be an indication that one-stop-shop patients receive a higher priority at the cost of regular patients and may thus be a side effect of the concept.

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7 Discussion

In this study we have shown that one-stop-shops have been implemented for different patient groups but with a similar objective namely, to improve patient satisfaction by reducing the number of hospital visits. In literature however, more attention is given to patient satisfaction in terms of reducing waiting time in establishing a diagnosis (Dey et al., 2002; Eltahir et al., 1999; Gui et al., 1995; Harcourt et al., 1998; Harcourt et al., 1999; Alderzee et al., 2007). One-stop-shops may be implemented with different objectives.

The one-stop-shops that we have investigated involved patient groups with a well-defined complaint which is in line with literature (e.g. Dey et al., 2002; Gui et al., 1995). Offering a one-stop-shop for a patient group with a well-defined complaint with a predetermined routing is a criteria for the one-stop-shop approach.

From literature we know that one-stop-shops have been implemented for high-volume patient groups (Aldenzee et al., 2007; Voorbrood et al., 2013). Although this does not seem to be an important condition since we have identified one-stop-shops for low volume patient groups as well, for example the dypnea and asthma one-stop-shop.

Besides routing variety and volume, we expected that shared resources is another condition that should be considered while implementing a one-stop-shop. From literature (e.g. Vissers and Beech, 2005; Voorbrood et al. 2013) we know that, shared resources can be managed by reserving and allocating capacity. This is even more important when the resource involved has limited capacity. In line with literature, we observed that one-stop-shops that use various and limited shared resources are managed by allocating capacity in order to assure the one-stop-shop successful.

In literature, limited attention has been given to how a one-stop-shop should be organized. In our study however, we provide information how a one-stop-hop can be organized by both a

combined appointment and walk-in system. In a combined appointment two or more appointment slots are linked across the relevant (function) department schedule by using dedicated planning software. A requirement for organizing the one-stop-shop by means of a combined appointment is that, alignment of all different capacities like specialists, diagnostic function tests etc. are available at the time required.

The use of combined appointments however, may result in performance problems especially in situations of limited capacity, high demand for the resource and multiple patient groups to satisfy. Such a situation has been described and analyzed in case three. Main finding is that if priorities are not assigned in the right order between one-stop-shop patient and regular patients in relation to the available capacity waiting time may increase. Additional research could provide a more in-depth analysis of this finding.

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8 Conclusion

In the current study we examined when and under which conditions outpatient departments choose to employ a one-stop-shop. Moreover, we investigated how this concept can be

implemented and is experienced by representatives who have been involved in implementation and execution of the concept.

First in this study, we discussed that improving patient satisfaction by reducing the number of hospital visits was one of the drivers to employ a one-stop-shop. Improving patient satisfaction seems to be in line with current developments in health care and its approach in care delivery. A one-stop-shop can be viewed as a way of care delivery.

Second, we discussed three conditions, routing variety, volume and shared resources that are considered when implementing a one-stop-shop. One-stop-shops investigated in this study, have been implemented for different patient groups with a well-defined complaint. The variety in routing of these patient groups was limited. Furthermore, one-stop-shops have been implemented for both high and low volume patient groups. This was different from what we expected. Main reason to offer a one-stop-shop for a low-volume patient groups is that this group is easy to manage. The third condition is shared resources, and more specifically shared resources that have limited capacity. In all cases we found that these resources are managed by planning arrangements by means of combined appointments and allocating the required capacity. We get the impression that the one-stop-shop approach is sometimes driven by public developments and outpatients opinion rather than clear improvement charters.

Non objective criteria is noted in the responses of the interviewed respondents, they expressed several times the so called “good feel factor” instead of using objective criteria to measure achieved results for both hospital and outpatient. It is not possible to justify the experienced improvements by lack of performance indicators.

The one-stop-shop approach in the literature does rarely highlight the use of key performance indicators and reporting requirements how to measure the achievements in comparison with for example a base line reference (historical measurements before introducing one-stop-shop). This needs further research to develop a measurable system to prove and evaluate that the

implemented one-stop-shop approach contribute to a more efficient use of equipment and resources.

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9 Recommendations

 We advise hospitals, if they consider to develop and/or introduce a one-stop-shop to organize this as a project. A clear project execution plan including existing workflow, planning impact and other historical information should be the basis for an accurate base line reference. This to enable to develop criteria for key performance indicators.

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health care”, London and New York: Routledge

Understanding the concept of one-stop-shops in health care: A case study

Understanding the concept of one-stop-shops in

health care: A case study

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