Exploring the admission planning function in hospitals: An organizational perspective

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MSc THESIS

Exploring the admission planning function in hospitals:

An organizational perspective

Michiel Zantinge S2193159

m.r.zantinge@student.rug.nl

MSc Supply Chain Management – University of Groningen

24-7-2017

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ABSTRACT

The admission planning function in hospitals plays a key role in increasing the effectivity and efficiency in hospitals. The aim of this thesis is to research the admission planning from an organizational perspective. It is argued in the literature that the level of centralization of the admission planning is an important organizational design factor. First, in this research it is examined how this level of centralization influence the admission planning performance. Second, disadvantages of both structures lead to a need for coordination. Therefore coordination mechanisms are identified and evaluated as moderator of the first research question. To find answers on these questions a case study is executed at the Martini Ziekenhuis in Groningen. At this hospital some specialisms plan their admissions at a centralized admission planning department and other specialisms make the admission planning at the outpatient department. This research have contributed by showing several relations between the level of centralization and different performance indicators. Furthermore, it is found that the coordination mechanisms, standardization, mutual adjustment and plan, could be better implemented and are more effective in situations with a high level of centralization.

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TABLE OF CONTENT

1. INTRODUCTION ... 5

2. THEORETICAL BACKGROUND ... 7

2.1 Admission planning in hospitals ... 7

2.2 Performance of admission planning ... 7

2.3 The level of centralization of admission planning ... 8

2.4 Coordination mechanisms ... 11

2.5 Conceptual model ... 12

3. METHODOLOGY ... 13

3.1 Research method ... 13

3.2 Research setting and case selection ... 13

3.3 Data collection ... 14

3.4 Data analysis ... 16

4. ADMISSION PLANNING AT MZH ... 17

4.1 Organization of the admission planning at MZH ... 17

4.2 Coordination mechanisms at MZH ... 17

5. RESULTS ... 19

5.1 Within-Case Analysis ... 19

5.2 Cross-Case Analysis ... 33

5.2.2 The Relation Between the Level of Centralization and Planning Performance ... 33

5.2.2 Effect of Coordination Mechanisms ... 35

5.3 Validation Step ... 39 6. DISCUSSION ... 41 6.1 Theoretical Contributions ... 41 6.2 Practical Implications ... 42 6.3 Limitations ... 42 7. CONCLUSIONS ... 43 ACKNOWLEDGEMENT ... 45 REFERENCES ... 46 APPENDICES ... 49

Appendix A – Interview protocols ... 49

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List of Tables

Table 1. Summary of findings performance indicators ... 9

Table 2. Advantages and disadvantages of centralized and decentralized admission planning ... 10

Table 3. Hospital Characteristics Martini Ziekenhuis Groningen (2015) ... 14

Table 4. Two different groups of cases ... 14

Table 5. Interview scheme structured interviews ... 15

Table 6. Interview scheme ... 15

Table 7. Score criteria to describe the characteristics of each specialism ... 16

Table 8. Characteristics of the Surgery ... 19

Table 9. Characteristics of the Orthopaedics ... 21

Table 10. The characteristics of the Gynaecology ... 22

Table 11. Characteristics of the oral surgery ... 24

Table 12. Characteristics of the ENT ... 25

Table 13. Characteristics of the Neurosurgery ... 27

Table 14. Summary of findings of influencers on performance indicators ... 29

Table 15. Evaluation of the coordination mechanisms ... 32

Table 16. Influence of the level of centralization on performance indicators ... 35

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1. INTRODUCTION

Healthcare professionals face an increasing pressure to make their processes more and more effective and efficient (Hulshof, Kortbeek, Boucherie, Hans, & Bakker, 2012). Reasons for this pressure are the increasing expenditures in the healthcare and the difficulties to implement operation management tools in a healthcare setting (Hans, Van Houdenhoven, & Hulshof, 2012). Furthermore, patients are increasingly less willing to accept long waiting times and inconvenient appointment systems (Brailsford & Vissers, 2011). Hospitals should try to improve the match between the organizations’ resources and demand in order to achieve a higher customer satisfaction and efficiency, which is facilitated with the planning and control function (Heizer & Render, 2004; Slack, Chambers, & Johnston, 2013).

The planning and control function in a hospital can be regarded as a difficult task because a hospital consists of different units, which share the same resources (De Vries, Bertrand, & Vissers, 1999). When the degree of shared resources is high, this forms a bottleneck in making the processes more effective and efficient (Van der Vaart & van Donk, 2004). The admission planning function plays a key role in the planning and control function in a hospital (Gemmel & Van Dierdonck, 1999). Admission planning has to allocate scheduled inpatients, who are on a waiting list for surgery, to resources such as doctors, operating rooms and beds (Adan & Vissers, 2002). Scheduled inpatients are patients who have been put on a waiting list by a specialist after a consultation at the outpatient department.

In current literature about admission planning, the focus has often been on the mathematical complexity of admission planning. Authors in this field have researched questions such as “How to plan admissions with different patient groups (Adan & Vissers, 2002)?”, “How to plan admissions with a lot of uncertainty (Dellaert & Jeunet, 2009)?” and “How to plan admissions when the ratio between emergency and elective patients is unknown (Jittamai & Kangwansura, 2011)?” Several authors argued that healthcare questions are usually solved with mathematical models (e.g. Cardoen, Demeulemeester, & Belien, 2011; Jha, Sahay, & Charan, 2016). However, McKay et al. (2002) argued that these optimizing models are not used due to the human aspect of planning.

It is therefore important that hospitals also consider organizational and behavioural aspects when improving their planning functions (Cardoen et al., 2010; Cees De Snoo, 2011; Jha et al., 2016). Also Roth & Van Dierdonck (1995) mentioned that it is important to consider organizational design issues at the operational planning level of hospitals. Furthermore, Henneman, Lee, & Cohen (1995) mentioned the importance of the collaboration between the different units, such as admission planning, hospital performance and patient satisfaction. Due to the lack of research on the organization of planning functions in hospitals, it should be useful to examine organizational design choices.

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differences in influence on performance indicators are thus caused by the need for coordination (De Snoo, Wezel, & Wortmann, 2011). Admission planning has a large interdependency to different parties within the hospital, such as doctors, Operating Room (OR) – coordinator and the Nursing Wards (NW) - coordinator. The determination of a centralized or decentralized planning function should aim to reduce the coordination need between these different parties (De Vries, 1999) to increase the performance of the admission planning. The higher the need for coordination, the more coordination mechanisms need to be developed and implemented (Galbraith, 1974). More complexity in coordination mechanisms may have negative impact on performance indicators.

However, to overcome the disadvantages and stimulate the advantages of two different forms of centralization, coordination mechanisms are always needed (Kumar et al., 1993). Logically, it is expected that in a situation of a centralized structure, coordination mechanisms are established to improve the coordination with the doctor and in cases with a decentralized structure coordination mechanisms are developed to improve the coordination with other specialisms. According to Thompson (1967) coordination mechanisms could be divided into coordination by standardization, mutual adjustment and plan. Standardization is the use of constraints such as rules and routines to achieve the desired outcomes. Mutual adjustment is a mechanism in which different parties share information and align goals. Coordination by plan is a technique that establishes schedules and deadlines. For admission planning, it is argued that an information system (Kusters & Groot, 1996) and planning horizons (Vissers & Beech, 2005) are important mechanisms for coordination. However, these mechanisms are not researched in combination with the organizational discussion about centralization.

The goal of this thesis is to explore the relations between the level of centralization and admission planning performance and how this could be moderated with different coordination mechanisms. Answers to these questions will contribute to the research on planning at hospitals from an organizational perspective, to reduce the gap between theory and practice (McKay et al, 2002) and will improve theoretical contribution to the research of hierarchical approaches in hospitals (Roth & Van Dierdonck, 1995), which will help healthcare professionals optimizing their admission planning function and increasing performance. To create a goal in this thesis the following research questions are established:

(1) How does the level of centralization of a hospital’s admission planning function influence the performance of admission planning and (2) what is the effect of different coordination mechanisms on the relation between the level of centralization and the performance of admission planning?

To answer these questions, a case study is executed at Martini Ziekenhuis Groningen (MZH). This hospital can be regarded as an average-size hospital in the north of the Netherlands. Within this hospital, there are several Result Responsible Units (RRUs), such as Surgery, Orthopaedics and Ear, Nose, Throat (ENT), which share the same resources - such as the operating room, staff, beds at the wards, and specific equipment. Some of these units are centrally organized, whereas other units have their own decentral planning. This situation makes it suitable to do this research in this hospital. This is suitable, because the relation between both forms of centralization of an RRU and the performance of admission planning can be researched. Furthermore, the choice for a hybrid structure can also be examined.

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2. THEORETICAL BACKGROUND

2.1 Admission planning in hospitals

In operations management, planning and control can be defined as follows (Slack, Chambers, & Johnston, 2013, p270): “Planning and control is concerned with reconciliation between what the markets requires and what the operations' resources can deliver’. In hospitals planning and control consists of patient scheduling and resource allocation (Vissers & Beech, 2005). A division can be made between strategical, tactical and operational planning and control levels (Hans & Houdenhoven, 2012; Hulshof et al., 2012; Roth & Van Dierdonck, 1995). Admission planning is part of the operational planning level (Gemmel & Van Dierdonck, 1999). This level consists of the short-term decision making about individual patients and resources. Tasks involved in this level include patient scheduling, daily adjustment and performance monitoring (Peltokorpi, 2011). Operational planners have to deal with the capacity limits set in strategic and tactical planning. Operational control is the process of ensuring that activities are executed in an effective and efficient manner. Within operational level, a distinction can be made between offline and online (Hans & Houdenhoven, 2012). Offline operational planning consists of short-term decision making in advance planning of operations. Online operational planning is about monitoring the process and reacting to unforeseen events.

The admission planners have to allocate patients on the waiting list for surgery to various resources. In order to do so, the admission planners need to control the utilization levels, stability of the inflow and the patient mix constitute (Milsum, Turban, & Vertinsky, 1973). This is a complex task due to the different interconnectivities within hospitals (De Vries et al., 1999). Admission planning has an influence on doctors, the operating room planning, the nursing ward planning and admission planning of other specialisms. Furthermore, the customer plays an essential role in making the planning, because the hospital is a service company. A lot of patients have their own specific care paths and constraints, which also adds to the complexity of the task (Vissers et al., 2001). Kusters & Groot (1996) mentioned that admission planning consists of four elements: a set of goals, a waiting list registration system, admission planners and a prediction system. The goal of admission planning is to create an optimal utilization of the doctors, available beds, nursing staff and operating rooms, while ensuring a speedy throughput of patients (Kusters & Groot, 1996). Furthermore, the planners at admission planning have to ensure that the availability of resources for emergencies remains at an acceptable level. To reach these goals, it is important that the necessary information is clearly provided in a registration system. Decisions in admission planning are my made by an admission planner. McKay et al. (2002) indicated that the human factors, such as the organizational structure, are still essential, even when there are several mathematical models designed to make different kinds of planning. The planner has a decisional, interrelational and informational role in the planning role (Jackson, Wilson, & MacCarthy, 2004). A final element is the prediction system. The prediction system can predict the effects of a decision of the admission planner. These effects should be related to the goals set for admission planning (Kusters & Groot, 1996).

2.2 Performance of admission planning

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utilization or throughput times. In practice, it is found that managers often choose either too many or too few performance indicators (Neely, 1999). Too many performance indicators result in information overload and too few performance indicators cause a larger gap between the measures and practice. Purbey, Mukherjee, & Bhar (2007) argued that hospitals face difficulties in measuring its performance, due to its unique characteristics. De Snoo, Van Wezel, & Jorna (2011) have done an empirical study to find different performance indicators of scheduling in general. The important performance indicators they found were adopted after a range of interviews with planners and stakeholders from different industries, with the focus on companies in manufacturing industries. In addition, Kusters & Groot (1996) indicated that next to resource utilization, the throughput time of patients and a stable outflow to the nursing wards are important indicators. Liu, Liang, Wang, Liu, & Xie (2014) expanded the list with indicators for companies in the service industry. In their development of indicators, customer satisfaction was also measured. Milsum, Turban, & Vertinsky (1973) mentioned that customer satisfaction includes waiting time, number of rescheduling and allowances for convenience timing.

A combination of the work of the abovementioned authors leads to a list of potential performance criteria for admission planning (Table 1). The indicators can be divided into three categories: outcome performance, process performance and patient satisfaction. Admission planning outcome performance deals with the consequences of the planning that has been made. Next to resource utilization, also indicators like the planning errors, fulfilments of desired outcomes of stakeholders, the robustness of the planning and the presentation. The second category is the performance of the admission planning process, which consists the development, adaption and communication of the planning (De Snoo et al., 2011). These indicators also cover the organizational and behavioural performance of the planning function. The third category is about patient satisfaction, which is emphasized by Liu et al. (2014) and (Milsum et al., 1973). In Table 1, the descriptions of each performance indicator can be found.

2.3 The level of centralization of admission planning

Admission planning can be organized in different ways. A certain organizational structure should minimize the need for coordination (Galbraith, 1974). Therefore it is important that admission planning is structured in such way that it reflects the tasks and roles of the admission planner (Arica, Buer, & Strandhagen, 2015). This could lower the need for coordination, which has a positive influence on the performance indicators. Several authors mentioned that there is uncertainty about how to determine the optimal level of centralization of admission planning (Dekker & Spenkelink, 2014; Kumar et al., 1993; van Oostrum et al., 2010). Also De Vries (1999) mentioned that in designing a logistical department, the centralization question is essential for the design of the organization.

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Table 1. Summary of findings performance indicators Category Performance indicator Description

Outcome performance

1. Resource utilization – OR Utilization of specialist at OR

2. Resource utilization – nursing wards

Stable inflow in nursing wards

3. Fulfilment of Resource constraints

Shared resources constraints are not exceeded Availability of resources are considered 4. Fulfilment of wishes and

preferences

Doctors’ wishes about session sequence and the treatment of their own “patients”.

5. Fulfilment of external constraints and commitments

Commitments of external companies.

6. Planning robustness Number of changes after initial planning due to external changes

7. Information presentation Clarity of schedule to doctors, OR – coordinators and nursing wards

8. Planning errors Number of errors due to mistakes in planning

Process performance

9. Timeliness Time between making the planning and the executing the planning

10. Communication Quality The quality of the communication of changes

11. Reliability of the initial release

The reliability that the made planning is executed in the expected period

12. Accessibility of the planners Accessibility of the admission planners for the stakeholders

13. Flexibility of planning adaption

The flexibility to make changes in the initial schedule

14. Harmonization quality Harmonization of the different interests of stakeholders in the scheduling and rescheduling

15. The cost of scheduling process

Number of admission planners needed per specialism

Customer satisfaction

16. Time on waiting list Fulfilment of first-come-first-out, but also respect medical priorities.

17. Response time to patient demand

Timeliness of receiving information about the operation date

18. Executed when promised The patient is operated at the promised date.

19. Fulfilment of patients’ wishes and preferences

Patient preferences and wishes are included in decision making

20. Throughput time Throughput times of the care path

admission planners can easily communicate with each other. In a hybrid structure some specialisms in a hospital make their own admission planning and other specialisms make their admission planning at a central department.

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(Van der Vaart & van Donk, 2004). To structure or evaluate a planning function, such as the admission planning, it is important that such contingency factors are taken into account (De Vries, 1999). According to Mintzberg (1993), especially complexity plays an important role in the determination of the level of centralization. When complexity is higher, a decentralized admission planning is more appropriate - and when complexity is lower, a centralized structure is more suitable.

Apart from the suitability of admission planning structure, there are several relationships between the level of centralization and performance indicators. On the one hand, there are authors who argued that more decentralized structures are beneficial for a logistical department (De Snoo et al., 2011). These authors found that when the planning department is closely located to the production department, the need for coordination decreased and mutual performance improved, which had a positive influence on the planning performance. Furthermore, McKay & Wiers (2006) argued that it is easier to negotiate with operators, in a healthcare setting the doctors, about planning choices and changes. On the other hand, there are authors who opt for centralized structures (Jonsson, Rudberg, & Holmberg, 2013; Kumar et al., 1993). These authors mentioned that a centralized structure increases the availability of information to better align different schedules of different parties in the hospital.

Van Oostrum et al. (2010) showed different advantages and disadvantages of both structures, with the help of several dimensions. First, information can be more easily obtained, when planning is made decentrally, due to the accessibility of the doctor. Furthermore, the doctors have more autonomy within this structure, which can be useful when medical insights are needed. Third, with a decentralized admission planning, there is a lower managerial workload at a tactical level, because less management is needed to control the operational planning. When admission are planned centrally, the focus is less on the online operational planning, because this remains in the outpatient department. The integration between different disciplines within the hospital can be increased due to the central position. Furthermore, the robustness increases, because doctors or other employees at the outpatient departments are less able to manipulate the planning in their favour. In addition, the author mentioned that resources, especially the Operation Rooms, will be better utilized and patient flows can be predicted better, but he does not further elaborate on these advantages. An increase in predictability of patient flows is partly related to prediction of the expected availability of resources (Kusters & Groot, 1996). Due to increased information availability, the predictability of these resources may also improve. The advantages and disadvantages mentioned by van Oostrum et al. (2010) are summarized in Table 2.

Table 2. Advantages and disadvantages of centralized and decentralized admission planning

A limitation of the article of van Oostrum et al. (2010) is that their findings are not based on empirical research. Furthermore, these authors do not provide coordination mechanisms to overcome disadvantages and stimulate advantages of the two common structures. Because of the limitations of

Decentralized planning structure Centralized planning structure

Advantages • Full medical specialist autonomy • Requires limited information • Reduces workload at tactical level

• Requires less online operational control • Good integration between units • High robustness against manipulation • high predictability of patient flows • high utilization

Disadvantages • Requires intensive operational control • Results in lack of coordination • Low robustness against cheating • Low predictability of patient flows • Low utilization

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current literature about the relationship between the level of centralization and admission planning performance, the following sub-research question is posed:

1. How does the level of centralization of a hospital’s admission planning function influence the performance of admission planning?

2.4 Coordination mechanisms

It is mentioned by Vissers et al. (2001) that the planners in the operational planning level are interconnected with several stakeholders in the process, such as specialists, outpatient department staff, OR-coordinators and nursing wards coordinators. On the one hand, it is argued that in a more decentralized admission planning structure less coordination with the doctors is needed. On the other hand, more coordination is needed with admission planners of other specialisms and disciplines in the hospital. To align the interconnectivities of the admission planner there are several coordination mechanisms (Galbraith, 1974; Thompson, 1967). Coordination mechanisms are organized devices to coordinate the interdependencies between different organizational parts (De Vries, 1999). Thompson (1967) categorized the coordination mechanisms into three different categories: standardization, mutual adjustment and plan.

Lazzarini & Chaddad (2001) mentioned that there are two types of standardization. The first is a type of standardization that everyone uses the same information system. Kusters & Groot (1996) mentioned that this information system is an essential element in the admission planning. Furthermore, rules and procedures can be developed to create consistency in actions and outcomes of different units (Thompson, 1967). Both types have the goal to standardize the processes of different units. The first type of coordination is especially effective in situations when there is pooled interdependence (Thompson, 1967). Pooled interdependence is an interdependence where several employees are working independently on a shared result. It is therefore important that the results of the employees can be matched with each other. For admission planning, this means that the admission planners of the different specialisms standardize their way of working.

Another type of coordination mechanism is mutual adjustment. These mechanisms stimulate sharing information, communicating with each other and joint decision making (Lazzarini et al., 2001). The goal of such coordination efforts should be that information is shared in an accurate way and mutual alignment is reached efficiently (De Snoo, 2011). For example, De Snoo & Van Wezel (2014) found in their experiment that group decision making within fixed meetings leads to higher planning performances than individual decision making, in which planners can communicate with each other voluntarily. According to Thompson (1967) this type of coordination mechanism is most effective in cases where there is a high reciprocal interdependency. In the case of admission planning, it consists of parties in the network who are dependent on the admission planning, but can also influence the decisions of the admission planning function. An example is the doctor. The doctor has to provide the planning information to the admission planner, but is also influenced by the admission planning.

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Mintzberg (1993) argued that standardization mechanisms and coordination by plan are most useful and effective in situations with a high stability. In more dynamic situations, mutual adjustment mechanisms are more appropriate.

The goal is to understand which coordination mechanisms are used within hospitals and what the influence of these mechanisms is on the relation level of centralization and the performance indicators. Therefore the following two research question is established:

2. How does the use of coordination mechanisms moderate the relation between level of centralization and admission planning performance?

2.5 Conceptual model

In the sections above an attempt is made to substantiate the level of centralization, coordination mechanisms and performance indicators and their relations between each other. The theory described leads to the conceptual model (Figure 1). This model will be used as a theoretical basis for this research.

Level of centralization of the admission planning Coordination mechanismes Standardization Mutual adjustment Plan Admission planning performance Outcome performance Process performance Patient satisfaction RQ 1 RQ 2

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3. METHODOLOGY

3.1 Research method

The aim of this research is to clarify the relationship of the level of centralization of the admission planning function and its performance. Furthermore, the moderating role of the coordination mechanisms standardization, mutual adjustment and plan on this relationship is further examined. In literature about admission planning at hospitals, little attention is paid to these organizational variables. With the use of theories from operational management about the organization of a planning and control function, the conceptual model of Figure 1 has been developed. Because the variables and the relationships between the three variables need to be further examined, a theory building method is suitable for this research. It has been proven that a case study is an appropriate research method for theory building (Wacker, 1998). Furthermore, a case study is suitable for answering ‘what and how’ questions (Yin, 2009), which is in line with the developed research questions:

1. How does the level of centralization of a hospital’s admission planning function influence admission planning performance?

2. How does the use of coordination mechanisms moderate the relationship between level of centralization and admission planning performance?

To conduct a case study in an appropriate way, different steps needs to be executed in an orderly fashion (Voss et al. (2002). These steps include conceptual model building, case selection, data collection, data analysis and a comparison with the conceptual model. In this chapter, it is explained how the other steps were executed.

3.2 Research setting and case selection

The selection of the cases should be done carefully, because cases should contribute the conceptual model and the research questions (Eisenhardt & Graebner, 2007). For this thesis it was chosen to conduct a few–focused case study (Handfield & Melnyk, 1998). A few-focused case study has the advantage that a great depth can be reached (Voss et al., 2002). Due to the described complexity of hospitals and the novelty of the research on soft factors in planning and control functions in hospitals, it was chosen to do the research at one hospital, so that the variables, relationships and setting could be explored elaborately. The cases in this thesis are the different admission planning functions of different specialisms at one hospital. The admission planning functions of a specialism can therefore be regarded as the unit of analysis. Admission planning of each specialism is the about the planning process and the planning outcome of an admission planning for a certain week. Within this process, the admission planner is the decision maker, who tries to meet several performance indicators. A major disadvantage of this kind of case study is the risk of low generalizability (Voss et al., 2002), which is an important virtue of good theory building (Wacker, 1998). To overcome the danger of low generalizability, a validation step is made to two other hospitals.

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Table 3. Hospital Characteristics Martini Ziekenhuis Groningen1₍₂₀₁₅₎ Annual Patient

Admissions

Bed Capacity Employees in FTE

25.887 578 1980

MZH consists of several specialisms, called Result Responsible Units (RRU). There are 8 RRUs which make use of the operating rooms. Admission planning is responsible for the planning of patients who also use this resource. Five of the eight RRUs have a centralized admission planning, while the other three RRUs have a decentralized admission planning structure. The planners of the RRUs with a high level of centralization are located close to each other at a central admission planning department. At this department, the employees plan the admissions for these different specialisms. Each employee is responsible for the admission planning of one RRU, but can also plan the admissions for other specialisms with a centralized admission planning. The RRUs with a low level of centralization are responsible for the planning at the outpatient department. This planning is made by the doctor itself or by a secretary. Due to time and capacity constraints, it was chosen to focus on six of these specialisms. Three of these RRUs are centrally structured and the other three are structured in a decentralized way (Table 5).

Table 4. Two different groups of cases

L ev el o f ce ntr a liza tio n Centralized Group 1 1. Surgery 2. Orthopaedics 3. Gynaecology Decentralized Group 2 4. Oral Surgery 5. Earth, Nose & Threat (ENT) 6. Neurosurgery

3.3 Data collection

To increase the reliability of the results data will be collected in different ways, which increases the data triangulation (Eisenhardt & Graebner, 2007). The process of data collection could be divided into three different steps. First, the current organization of admission planning and the used coordination mechanisms was researched by observations and semi-structured interviews with managers and planners. Because the author of this thesis was contracted at the hospital, he had the opportunity to make such observations (Yin, 2009). Observations was made by joining planning-related meetings and watching the admission planners. Furthermore, the head of the central admission planning department and the advisor of the integral capacity management were interviewed to substantiate the findings of the observations. Furthermore, semi-structured interviews were held with the admission planners of the six different RRUs. From these observations and semi-structured interviews, it became clear how the current the admission planning function is organized, what the characteristics of each case are and which coordination mechanisms are used.

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Second, the admission planners and the important stakeholders of the RRUs were interviewed (Table 6). Interviews with different stakeholders could complete the data and improve generalizability. The goal of these interviews was to further identify the variables and the relationships between the variables described in theoretical background. For these interviews, interview protocols were developed to contribute to the comparability and reliability of the answers (Yin, 2009). These interview protocols can be found in Appendix A. First, in these interview protocols questions were asked with respect to the performance of admission planning. Second, questions were asked about the current coordination mechanisms and how these mechanisms could facilitate better performance. Last, the interviewees were asked to evaluate the admission planning structure of their specialism. The OR–coordinator and the NW- coordinator are not related to a specific specialism. Therefore, the questions about admission planning structure were more open questions. The table shows that more structured interviews were conducted with planners and doctors of RRUs with a centralized admission planning. One reason for this was that the doctor of the ENT is both doctor and admission planner. Furthermore, it was not possible to conduct a structured interview with Neurosurgery (Case 6). Therefore data from the OR–coordinator and semi– structured interviews with the unit head and the secretary of the Neurosurgery were used.

Table 5. Interview scheme structured interviews

Function Level of centralization Case

1. Admission Planner Surgery Centralized 1 2. Admission Planner Orthopaedics Centralized 2 3. Admission Planner Gynaecology Centralized 3

4. Doctor Gynaecology Centralized 2

5. Doctor Orthopaedics Centralized 3

6. Admission Planner Oral Surgery Decentralized 4

7. Doctor ENT Decentralized 5

8. OR–coordinator Decentralized/Centralized 2,6 9. NW–coordinator Decentralized/Centralized 5,2

Third, to increase the reliability and validity of the research, interviews were conducted within two comparable hospitals in the Netherlands. The goal of this step was to research if the same results would be found. The interviews were conducted in two comparable hospitals in the south of the Netherlands. At the first hospital admission, planning is organized in a centralized way. At this hospital, an admission planner of the centralized admission planning department and the unit head of the central admission planning department were interviewed. In the second hospital, the patient admissions are planned at the outpatient department (decentral). At this hospital, interviews were conducted with the admission planner of the surgery and the integral capacity management coordinator. For the interviews with the admission planners of both hospitals and the unit head of admission planning department, the same interview protocols were used as for the admission planners of MZH. The interview with the coordinator integral capacity management was more semi-structured, with a focus on the current performance of resource utilization and the fulfilment of resource constraints.

Table 6. Interview scheme

Interviews Hospital

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3.4 Data analysis

To analyse the data from observations and semi-structured interviews, different graphical methods such as Excel and Microsoft Visio were used. The graphical outcomes of these analyses were validated by middle management. This is done to increase the validity and reliability of the answers. To analyse the data from the structured interviews a within-case and cross-case analysis was done (Eisenhardt & Graebner, 2007). To do these analyses, it was important to reduce the amount of data with the software program Atlas.It. Important quotes received 1st_{order codes. These codes were thereafter grouped in 2}nd order quotes. This way of data reduction was done to find quotes which describe the relations between the level of centralization and performance and the moderating effect of coordination mechanisms on this relation. For the within case analysis, it was examined for each case which performance indicators and coordination mechanisms are mentioned and used, which performance indicators are difficult to achieve, how the interviewees evaluate the usefulness of the coordination mechanisms and how the interviewees evaluate the current admission planning structure.

In addition, for every case the stability and the complexity of each specialism was determined by the following contingency factors: the unpredictability of demand, the elective/acute ratio, the patient volume and the number of shared resources (Table 8). The unpredictability of the demand and the acute/elective ratio reflect the stability; the patient volume and the number of shared resources reflect the complexity. These characteristics were useful to form conclusions about certain outcomes of the interviews. For example, due to the high unpredictability of patient demand, it is difficult for

Surgery to make the planning a few weeks in advance, and to inform the patients of the operation date in a timely fashion.

Table 7. Score criteria to describe the characteristics of each specialism

Dimensions How to measure Low Medium High

Demand unpredictability

Percentage of the number of patients that can be scheduled 5 weeks in advance

≥60% 59% ≥ X ≥ 39% ≥40%

Acute/Elective Ratio

Ratio between acute patients and elective patients (Acute = within 24h)

≤10% 11% ≤ X <19% ≥20%

Patient volume Monthly number of patients ≤100 101≤ X ≤299 ≥300 Shared

Resources

Estimation of the interviewee how often they use critical shared resources

“We only use our own equipment and resources”

“We make use of shared resources”

“In our planning we are often restricted because of shared resources”

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4. ADMISSION PLANNING AT MZH

4.1 Organization of the admission planning at MZH

The admission planners at MZH have the responsibility to fill OR-schedules, which are developed by tactical planners. The tactical planning is constructed eight weeks in advance by unit heads of each specialism. The blueprint for this planning is fixed. However, there are some flex – time slots on which each specialism can apply and specialisms can also release their timeslots for other specialisms. These decisions are based on changes in patient demand or the availability of doctors.

The admission planners should try to utilize the expensive resources in an effective way and meet several constraints. Examples of these constraints at MZH are the availability of shared resources such as IC – beds, the X-ray, navigation equipment and the robot operating room. In addition, the admission planners have to plan the preoperative process for the patient. Preoperative actions are meetings with anaesthetists, nurses and any necessary arrangements for further diagnosis. These preoperative actions have also their planning constraints. Furthermore, the admission planner should monitor the waiting lists and alert when these waiting lists become out of proportion.

In the centralized form of admission planning, seven admission planners are dedicated to the five specialisms. These centralized planners are hierarchically placed under the unit head of the central admission planning. Every planner is dedicated to a specific specialism, but is able to do some planning work for other specialisms. Within the centralized pool of planners a distinction is made between the specialisms. First, the admission planners of Genealogy, Urology and Plastic Surgery (GUP) collaborate as one team and the planners of Surgery and Orthopaedics (SOR) collaborate together. Collaboration means that every planner of a certain team can do all the planning tasks related to the specialisms of the team. Furthermore, commitments can be made with respect to task allocations. The GUP team consists of three planners and the SOR team of four planners. The admission planners have a part-time contract, which consists of 28 hours per week. These planners plan the admissions from the waiting list that has been established by the doctor. The patients, who are planned by these planners have to visit after the consultation with the doctor and after the preoperative process the “admission planning office”. At this office, the patient receives information about the operating date and other practical matters. Patients of other specialism receive this information at the outpatient department.

RRUs with a decentralized admission planning function plan their admissions of patients at the outpatient department. As mentioned in the previous chapter, the three RRUs with decentral admission planning are ENT, Neurosurgery and Oral Surgery. All of these specialisms have organized their planning in a unique manner. At the ENT, the doctors plan the admission of a patient right after the consultation with the patient. Therefore, the doctor can be seen as the admission planner of this specialism. Consequently, the secretaries plan the preoperative process. At the Oral Surgery, one secretary plans the admissions of the patients. This planner also arranges the preoperative process and the necessary materials from the orthodontist and other external parties. The organization of admission planning at the Neurosurgery is almost the same as that of ENT. However, the doctors plan the admissions from a waiting list a week before the operating date and not right after the consultation.

4.2 Coordination mechanisms at MZH

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is the work order for the planner, is send by the doctor. Every admission planner in the hospital works the same system. An exception are the ENT and Neurosurgery. In addition to a standardized information system there are several developed so called ‘game rules’ these planning rules consist of rules such as the sequence of patients at the operating rooms and number of IC – beds, which are can be planned by each admission planner.

For the mutual adjustment there are several meetings, which influence or are influenced by the work of the admission planning. The admission planners of the centralized organized specialism have a weekly team meeting. In this team meeting performance is evaluated, special events or circumstances are discussed, ideas are generated for improvement and planning rules are evaluated and changed when it is needed. Next to these weekly meetings the admission planners of Gyneacology, Orthopaedics and Surgery have weekly meetings with doctors, unit heads and OR - coordinators. In these meetings the made admission planning is discussed, choices are explained and proposals for changes can be made.

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5. RESULTS

In this chapter, the results of this study will be presented. First, a within-case analysis will be done for each case. For each case, the following will be determined: the characteristics for each specialism, the way the level of centralization influences performance indicators and the way coordination mechanisms are evaluated. After the within-case analysis, a cross-case analysis will be presented. In this cross-case analysis, both organizational structures will be analysed and compared. Subsequently, centralized and decentralized cases will be compared. Lastly, the validation step will be presented and compared to the outcomes of the MZH cross-case analysis.

5.1 Within-Case Analysis

Case 1 – Surgery

The first case is that of RRU Surgery. Surgery can be characterized as a complex specialism with low demand stability. Its characteristics can be found in Table 8. Furthermore, Table 8 shows the performance indicators on which this specialism lays focus, and the coordination mechanisms it uses.

Table 8: Characteristics of Surgery. Characteristics

Demand Unpredictability Acute/Elective Ratio Patient Volume Shared Resources

High High High High

Performance Indicators

Outcome Process Patient Satisfaction

- OR-utilization

- Nursing ward-utilization - Fulfilment of resource constraints

- Schedule robustness - Fulfilment of wishes and preferences - Information presentation - Timeliness - Flexibility in planning adaption - Communication quality - Harmonization quality

- Communication quality with patient - Response time to patient demand - Executed when promised - Fulfilment of patients’ wishes and preferences

Coordination Mechanisms

Standardization Mutual Adjustment Plan

- Information system - Planning rules

- Weekly meeting with OR-coordinator and doctor - Weekly meeting with admission planners

- Hospital’s planning procedure

Influences on Performance Indicators

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number of acute patients. When rescheduling is needed, it is necessary to discuss any changes with the doctor in question.

The admission planner indicated that the biggest advantage of a centralized planning structure is the overview of the hospital. This helicopter view takes into account the information an admission planner receives concerning different logistical processes throughout the hospital. Due to their central position, the planner receives information coming from different disciplines. More information on other disciplines results in a higher Harmonization quality, because it clarifies how decisions in one discipline will influence other disciplines. Furthermore, potential external influences that could influence the planning can be predicted earlier. The ability to adapt to these influences early on could improve planning robustness. In addition, thanks to face-to-face communication and alignment, easy access to other admission planners will cause less planning errors, and lead to a better fulfilment of resources constraints and a better flow to the nursing wards.

Evaluation of Coordination Mechanisms

The information system is used as the standard method of communication and decision-making. Even though the system has its limitations when it comes to showing patient specifications, it is considered a well-working system that can be used to increase standardization between different disciplines. According to the planner, this form of standardization positively influences the presentation of information because every specialism uses the same system. Better presentation of information could improve the fulfilment of resource constraints and decrease the number of planning errors.

“That is what standardization entails: everybody has the same way of working and uses the same system.”

In order to ensure mutual adjustment, the surgery admission planner has weekly meetings with a doctor and the OR-coordinator. This coordination mechanism is rated as useful because it allows participants to give feedback, discuss and create alignments.

“The doctor checks whether planned operations can be executed by specific doctors. Doctors can provide feedback in case changes need to be made. It is also a moment for questions about medical priorities. For example, if I have four patients with a high level of urgency, but I can only take in two patients, which of the four patients have the highest priority? I cannot decide this, they have to make that decision. These meetings are useful for such alignments.”

Thus, these sessions improve the accessibility and Communication quality between the planner and other stakeholders, such as the doctor. In addition, the admission planner is involved in weekly meetings with other admission planners. According to the admission planner, this meeting does not have added value for the performance of Surgery admission planning.

As coordination by plan the planning procedure is used (Appendix B). It is difficult for the admission planner to make deadlines, because the unpredictability of demand drives him to make the schedule as late as possible.

Case 2 – Orthopaedics

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hip-operations that can be done in one session. A third of the materials needed are not available at MZH. On the other hand, the admission planner indicated that the stability of demand is high thanks to low demand unpredictability and a low acute/elective ratio.

Table 9: Characteristics of Orthopaedics Characteristics

Patient Volume Demand

Unpredictability

Acute/Elective Ratio Shared Resources

High Low Low High

Outcome Process Patient Satisfaction - OR-utilization

- Fulfilment of wishes and preferences

- Fulfilment of external constraints and commitments - Schedule robustness - Information presentation - Planning errors - Timeliness - Communication quality - Planners’ accessibility - Harmonization quality

- Time on waiting list - Response time

- Communication quality

- Fulfilment of patients’ wishes and preferences

Standardization Mutual Adjustment Plan - Information system

- Planning rules

- Weekly meeting with OR-coordinator and doctor - Weekly meeting with planners

The admission planners mentioned that the fulfilment of external commitments and constraints and the high workload are what make it difficult to plan admissions for this specific specialism. External companies are needed for a lot of the operations. The workload is high due to disturbances and extra tasks that need to be fulfilled by the centralized admission planners.

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Concerning the information system, the orthopaedist mentioned he was able to use it to make his wishes, preferences and remarks known. Furthermore, the admission planner mentioned that the information system, even though it is not always user-friendly, contributes to the standardization of admission planners’ work.

“The information system is built around our way of working. This results in a standardized way of working. This way has to do with the way waiting lists are seen, how input is entered and how things are handled. From waiting list to informed patients.”

To fulfil these constraints planning rules are established. Because these rules are not incorporated in the information system, the orthopaedics admission planner mentioned that mistakes are made often, which can result in changes, errors or a lower fulfilment of resource constraints.

Weekly meetings take place between the OR-coordinator, a doctor, the head of the unit and the orthopaedics admission planner. The admission planner indicated that these meetings are very important for a high level of access to the planner and for the Communication quality. The OR-coordinator and the doctor are able to propose schedule changes to accommodate their preferences, but also to better use resources and meet resource constraints. The OR-coordinator mentioned that currently, too many changes have to be made to proposed schedules.

According to the admission planner the weekly meetings helps the orthopaedics department to look forward to the future, which could result in a more robust admission planning.

“Then you are able to look forward. Then you know what will happen. Now we are already busy with the summer months. I take this knowledge with me when I make the planning.”

“Our head of unit mentioned that Orthopaedics will have more session time in the summer months. Because it is difficult to find patients who are willing to be operated these months I am already working on this planning.”

The admission planner mentioned that the hospital’s planning procedure facilitates schedule checking by different parties, which decreases the room for planning errors, unmet preferences or wishes or the lack of fulfilment of resource constraints. Due to the workload and rescheduling, sometimes it is not possible to send the patient confirmation in writing two weeks in advance.

Case 3 – Gynaecology

The third case is that of Gynaecology. This is the least complex specialism of the RRU, with a centralized admission planning structure.

Table 10: The Characteristics of Gynaecology Characteristics

Patient Volume Demand

Unpredictability

Medium Medium Low Low

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Outcome Process Patient Satisfaction - OR-utilization

- Fulfilment of wishes and preferences - Schedule robustness - Planning errors - Timeliness - Communication quality - Planners’ accessibility - Harmonization quality - Cost of scheduling process

- Time on waiting list - Response time to patient demand

- Communication quality - Executed when promised - Fulfilment of patients’ wishes and preferences

- Throughput time

Standardization Mutual Adjustment Plan - Information system

- Planning rules

- Weekly meeting with OR-coordinator and doctor - Weekly meeting with admission planners

For this specialism, it turns out to be difficult to create a stable flow toward the nursing wards, despite cooperation between the admission planners. In addition, the planners mention that there are a lot of disturbances and little time to finalize the planning.

The admission planner mentioned labour flexibility as an advantage of a centralized structure. The admission planners of the GUP team can easily take over tasks, which can result in lower labour costs. Furthermore, a respondent mentioned that a team of admission planners has a stronger position in the organization than a single admission planner. Their common vote is more important than the vote of a single admission planner, when they are dispersed over the outpatient departments. This could result in a better Harmonization quality because interests and schedules of other parties in the hospital can be better taken into account.

“As group of admission planners you stand stronger. You will not be walking all over the place.”

A third advantage is that it is easier in a centralized structure to create and execute ideas to improve the current way of working and the current systems. Improving the way of working is beneficial to several process performance indicators such as Harmonization quality, timeliness and Communication quality. Furthermore, because planning is centralized there is more information on the consequences of planning decisions, which leads to a better understanding of those decisions. This motivates the admission planner to harmonize interests of different stakeholders within the hospital.

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Another tool is the establishment of planning rules. For Gynaecology, it is especially important that the right doctors are chosen. The rules have been visualized in a document, which serves as tool for the admission planner to properly incorporate all of the rules.

To increase alignment between the doctors, the admission planner has a weekly meeting with the doctors and the head of unit. As it turns out, matters can easily be aligned. In addition it is indicated that a fixed moment in the week for the meeting creates more rest:

“We often came with wishes to make changes. Now, it is not possible to arrange such things anymore. On Mondays we have the meeting, and then things can be arranged. This results in peace of mind for both parties”

During the mutual adjustment meeting, the admission planners provide the tactical planners with feedback. It turns out to be difficult to take into account the tactical planners’ wishes concerning daycare and the ratio of children and adults, when making planning decisions.

For the Gynaecology admission planner, it is difficult to keep the predefined deadlines of the planning schedule (Appendix B). Reasons for this are a number of disturbances that led to less time to finalize the planning. Delay in sending the planning to the OR-coordinator could result in problems when it comes to aligning the OR-planning with the admission planning.

Case 4 – Oral Surgery

For Oral Surgery, the admission planner (secretary of the outpatient department) was interviewed. Oral surgery can be considered a high-plannability RRU. When it comes to resource constraints, the RRU mainly depends on the orthodontist. Within the preoperative process of this specialism, the orthodontist often makes tailored prostheses or fits the patient with braces. Therefore, a lot of time passes between patients being put on a waiting list and the date of the operation. The admission planner is able to plan five weeks in advance.

Table 11: Characteristics of Oral Surgery Characteristics

Patient Volume Unpredictability of Demand

Low Low Low Low

- OR-utilization

- Fulfilment of resource constraints - Fulfilment of wishes and

preferences - Information presentation - Planning errors - Timeliness - Communication quality - Planners’ accessibility - Harmonization quality - Flexibility in planning adaption

- Communication quality

- Executed when promised - Fulfilment of patients’ wishes and preferences - Throughput time

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- Information system - Planning rules

- - Hospital’s planning

procedure

Influence on Performance Indicators

Based on these specialism indicators could be concluded that most of the performance indicators are met. Due to the low complexity and the low influence on other functions in the hospital, it can be concluded that the specialism performs well. Current difficulties are the fulfilment of resource constraints and the incorporation of new patients when standing patients cancel their operation. For the fulfilment of resource constraints in the preoperative process, the admission planner needs to ensure that everything is aligned. Furthermore, when patients cancel, it is often difficult to find new patients on the short term, which results in a lower use of scheduled operating sessions.

According to the admission planner, an advantage of the decentral organization of the Oral Surgery admission planning is that it is in favour of the doctors, who can feel they have control over their own patients.

When it comes to coordination mechanisms, the admission planner uses the information system and tries to fulfil the hospital policy when it comes to admission planning deadlines. The information system is considered a good enough planning system. A problem that was mentioned is that the information provided by the doctors is not always correct. Communication of the expected operating time, for instance:

“I try to plan to 100% and the doctors enter the expected OR time into the information system. The information system uses fixed times for each kind of disease. When the operation time will probably take less time, the doctor has to change the time in the system. When they do not, there will be an unoccupied timeslot.”

Furthermore, when it comes to standardization, the admission planner has developed planning

procedure protocols. That way, other outpatient department secretaries are also able to make

the planning. However, this is difficult for the planning of osteotomy patients due to the

complexity of the preoperative actions.

When it comes to mutual adjustment, the admission planner is not involved in fixed meetings.

Communication and information sharing is done via email and face-to-face contact.

Case 5 – ENT

The patient volume is not very high, the number of shared resources is low, the predictability of demand is high and the acute/elective ratio is low. These combinations show that this specialism is not very complex.

Table 12: Characteristics of ENT Characteristics

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- OR-utilization

preferences

- Information presentation - Planning errors

- Timeliness

- Communication quality

- Communication quality - Executed when promised - Fulfilment of patients’ wishes and preferences - Throughput time

- Information system - -

Resource utilization and response time are considered especially important. Resource utilization in this case means the use of session time.

“The patient knows what to expect very early on. And the patient appreciates that. The patient does not have to wait for a phone call. Especially when it comes to children, it is nice for their parents to know what to expect. For us, it is also beneficial, because we can plan our own program and we know how long the different operations will take.”

This quote shows how the current system can contribute to the following performance indicators: doctors’ wishes and preferences, resource utilization and response time.

The interviewed NW-coordinator mentioned that the TNE-planning stays invisible to them for a long time. Patients are entered into the information system a week in advance. From that moment on, the planning is visible for other parties in the hospital. The NW-coordinator mentioned that this could result in problems when it comes to aligning the nursing ward-planning with the OR-planning.

This specialism does not use coordination mechanisms. The doctors have a monthly tactical meeting. In these meetings, the development of the waiting list is discussed with other doctors. During these sessions, it is possible to make changes to the schedule to balance out waiting lists for different doctors.

Case 6 - Neurosurgery

The last case is that of Neurosurgery. Neurosurgery can be considered a complex specialism to plan for. The demand is unpredictable and the ratio acute/elective is high.

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Table 13: Characteristics of Neurosurgery Characteristics

Medium High Low Low

- OR-utilization

preferences

- Fulfilment of external constraints and commitments

- Information presentation - Planning errors

- Flexibility in planning adaption

- Time on waiting list - Response time

- Communication quality - Executed when promised - Fulfilment of patients’ wishes and preferences

- Planning rules - -

Due to the characteristics of the diseases and the predictability of the demand, the doctors want to stay flexible. Furthermore, according to secretary of the outpatient department, the doctor has the expertise to estimate the degree of urgency of each patient. Therefore, this expertise could contribute to a better approach of the waiting lists. The OR-coordinator mentioned that Neurosurgery arranges their own materials from outside companies and places patients on the schedule when materials are received. This reduces potential planning errors and increases the fulfilment of resource constraints.

“The neurosurgeons determine the date when they want to operate a particular patient with a brain tumour, for example. The outpatient department secretary arranges the materials with the outside company. When the materials are received, the patient can be scheduled and I receive the order number.”

A drawback of this form of organization is that it takes a long time for patients to receive their operation date. On average, patients know that they will be operated two days before the operation. Compared to other specialisms in this hospital, this is quite late. Furthermore, an OR - coordinator mentioned that this form of organization makes it difficult to take different interests into account and align different schedules throughout the hospital.

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department secretaries or the OR-coordinator to overcome the low level of information presentation caused by people not using the information system.

The Orthopaedics admission planner said the following:

“There are things you know will influence another party in the hospital. It is important that this is communicated and shared. The Neurosurgery secretary frequently calls when she want to plan three patients on one day, because she does not use the information system HiX.”

The fact that Neurosurgery plans their admissions very late shows that this specialism does not comply with the hospital’s planning procedure.

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Table 14: Summary of Influences on Performance Indicators Findings

Performance Indicator Case 1 – Surgery Case 2 – Orthopaedics

Addressed Quote Addressed Quote

1. Resource utilization – OR X X

2. Resource utilization – NW X “The bed planning needs to be improved […] Now it sometimes happens that

there are no beds available in the morning and more than thirty beds available in the evening.”

X “In the past we had a system to make a bed planning. The current system does not support this, which make it difficult to optimize the bed planning.”

3. Fulfilment of resource constraints X X

4. Fulfilment of wishes and preferences

X X

5. Fulfilment of external constraints and commitments

X X “There are a lot of things we have to take into account when it comes to constraints. It is not

complex, but there are many rules.”

6. Schedule robustness X X

7. Information presentation X “The unambiguous provision of information is very important to your

receiver.”

8. Planning errors X

9. Timeliness X “When you are busy planning, you will be constantly interrupted. At these

moments, you have to switch constantly.”

X “We want to have more time to plan. Now, we are often interrupted.”

10. Communication quality X

11. Planners’ accessibility “At the central admission planning department, we discuss such things,

because we know it could influence the planning of another specialism.”

X “When the Urology admission planner and I plan both patients on the same IC-bed, it will cause a problem. We will notice it a week beforehand, but that is very late. Because of that, we discuss such decisions.”

Doctor: “I can easily negotiate with the planners by phone.”

12. Flexibility in planning adaption X “You think you have finished the planning and at that moment you receive a

message, which causes you to have to change the whole schedule.”

13. Harmonization quality X “It is important that you do not only take your own planning into account.” X “You have the overview of this department. You receive information about other schedules.

Then you align those schedules.” 14. Cost of scheduling process

15. Time on waiting list X X

16. Response time to patient demand X “Often we have to keep the patients in uncertainty for a long time.” X

17. Communication quality with patient

X X

18. Executed when promised X “Or there is a possibility that the operation has to be cancelled.”

19. Fulfilment of patients’ wishes and preferences

X X