Internship Transferpunt MCL Leeuwarden Jannes Schönlau

(1)

Internship

Transferpunt MCL Leeuwarden

(2)

Jannes Schönlau │MBA Operations & Supply Chains

- 2 -

Analysing and redesigning of the patient transfer process

-August 2012-

Jannes Marvin Schönlau

Student number: 1912453

Camminghastraat 13

9132 EK Ballum

tel.: +31 (0)613473510

e-mail: jannesschoenlau@hotmail.com

University of Groningen

Faculty of Economics and Business

MSc Business Administration

Specialization Operations & Supply Chains

Supervisor/ University of Groningen

Dr. M.P. Mobach

Dr. G.C. Ruël

(3)

- 3 -

ABSTRACT

Purpose- The purpose of this study is to investigate if a redesign of the current process can improve the operational performance of the patient transfer process. Specifically the influence of coordination and information exchange on the operational performance is investigated.

Design/ methodology / approach- This study was made in the context of discovery and exemplification. With interviews, meetings and different kinds of observations as well as measurements the current process was mapped and more than 80 individual transfers were analysed. Based on the outcomes, a new design is recommended.

Findings- The actor-to-actor interdependencies are not managed well. Communication is important ,but is not supported by physical proximity among the involved actors. The current way of information exchange does not support the process. More than 12 hours a week is spend on processing hand-written into digital files. The complexity of certain cases requires mutual consultation between the transfer nurses. There are differences in know-how between the transfer nurses. Some departmental nurses are missing a standard knowledge about follow-up care.

Practical implications-The proposed redesign of the process lay-out considering the mutual interdependencies, communication, physical proximity and information exchange can be used by management to increase the efficiency of the process. Establishing the transfer nurses at the hospital department and using e-transfer as support for the information exchange can improve the operational performance.

Originality/ value-The results of this paper contribute to an efficient patient transfer process as a result of an alternative process layout.

(4)

- 4 -

Preface

This report is written to present a new (improved) design of the patient transfer process at the MCL. The research is executed to obtain the degree of Masters of Operations and Supply Chains at the faculty of economics and business at the university of Groningen.

The research was executed in the period from March 2011 till June 2011 and is initiated by the management of ‘Zorggroep Noorderbreedte’ and the responsible coordinator of the transferpunt at the MCL.

First, I would like to thank my supervisor at the University of Groningen, Dr. Mark Mobach, for his support and advice during my internship period. I would also like to thank my two supervisors at the MCL and the ZNB, Ir. Dirk Tiemersma and Dr. Cees de Snoo, and especially all the transfer nurses who supported me all the time.

In this list of thankful words, I cannot forget my family and especially my parents. They were the ones who supported me during my whole study career, which brought me where I am now.

(5)

- 5 -

- 6 -

4.1.1.2 Process part ‘Noorderbreedte’ ... 31

4.1.1.3 Process part ‘other care provider’ ... 33

4.2 Process analysis ... 33

4.2.1 Analysis Coordination ... 34

4.2.2 Analysis E-transfer ... 41

4.2.3 Analysis Operational Performance ... 45

4.3 Conclusion Analysis ... 47

Chapter 5: Recommanded New Design ... 49

5.1 New layout ... 49

5.1.1 Coordination ... 49

5.1.2 Information exchange (E-transfer) ... 54

5.1.3 Operational performance ... 56

Chapter 6: Conclusion & Discussion ... 58

(7)

- 7 -

CHAPTER 1: INTRODUCTION

As long as there are illness and diseases, there are patients who need to be treated. After a treatment is finished, it does not necessarily mean that the patient is completely recovered. Often they need a certain kind of follow- up care after their discharge. This is mainly true for elderly, but also children and adults can rely on follow-up care. Possibilities reach from assigning to residential homes to the receiving of home care. Within the MCL (Medisch Centrum Leeuwarden), the transferpunt and its employees are responsible for this so called ‘patient transfer process’. This process requires a good coordination mechanism because it involves different parties as patients, nurses, transfer nurses, care providers and more. The starting point is the patient, and his individual needs and circumstances can result in complex cases.

Currently the process shows some bottlenecks, which hinder to perform in the most efficient way. Therefore this research was initiated in order to identify most critical bottlenecks and to provide a way to improve the patient transfer process.

This research is in context of discovery with the aim to design a new structure for the patient transfer process. In this way, the first chapter consists of background and context information of the organization. Chapter 2 includes motivation, problem statement, research design and the methodology part of this research. Important concepts related to certain bottlenecks identified during the mapping of the process are reviewed in literature in chapter 3. The first part of chapter 4 is the process description and describes the actual process layout. The second part is the diagnosis part which analysis the process with the aid of the theoretical concepts of the previous chapter. Chapter 5 presents an alternative design based on the findings of the previous chapter, which should overcome most of the identified problems. Finally, chapter 6 presents the conclusions and discussion of this research as well as suggestions for further research.

1.1 STRUCTURE OF ORGANIZATION

The foundation Zorggroep Noorderbreedte is 100% shareholder of the MCL BV and Noorderbreedte BV. Each sub- part has its own board of direction. Above the board of direction is the governing council consist of 3 members. A supervisory board, consisting of 6 members, supervises and advises the governing council. All interaction between these two boards is managed by the rules of the ‘Zorgbrede’ governance code. Controllers of financial and social affairs support the governing council. The chart in Appendix 1 visualizes the structure of Zorggroep Noorderbreedte.

1.1.1 NOORDERBREEDTE

Zorggroep Noorderbreedte provides hospital care as well as care for elderly to the inhabitants of

Fryslân.

The care for elderly- under the name of Noorderbreedte- occurs at twelve care centres in the

north of

Fryslân

. Additional to this, Noorderbreedte offers home care to special target groups. From the

(8)

- 8 -

The fact that Noorderbreedte consists of different institutions results in a connection of different kinds of care, short queues and an efficient use of people and resources. Problems for individual institutions can be solved through pooling of expertise within the whole group. Noorderbreedte strives for continuous improvement and innovation with focus on professionalism and patient orientation. With it’s about 5000 employees, Noorderbreedte is one of the largest care providers in the Netherlands (Jaarverslag ZNB 2010).

1.1.2 MCL BV

The MCL offers basic care to patients in the northern part of Fryslân. It provides all kind of high qualitative diagnostics, treatments and care based on the most recent insights. Medicals and employees are driven to provide the best possible care in a professional manner. The patient is the central point and teamwork (often in multidisciplinary teams) makes it possible to provide good care. The MCL takes a central part in the province of Frisian between the Universitair Medisch Centrum Groningen (UMCG) and other hospitals in

Fryslân

. It is a member of the “Samenwerkende Topklinische Ziekenhuizen” (STZ). The MCL is a “teaching hospital” and has an increasing number of trainings for medical specialists. In cooperation with the UMCG and other (training) hospitals in the region it is organising trainings for medicine students and AIOS. The MCL offers its services at two different locations: Leeuwarden and Harlingen. There are also two dialysis centres in Heerenveen and Kollum. Within the MCL Leeuwarden there are 20 different departments categorized from A – Z.

1.2 AIM AND TASKS OF THE TRANSFERPUNT

1.2.1 TRANSFERPUNT

(9)

- 9 -

In fact, the employees of the transferpunt are those who are responsible for ‘bridging the gap’ between the different health care providers and delivering a good transmural care process. The transferpunt at the MCL consists of 3 front- desk employees and 6 transfer nurses working in different shifts. Per shift the transfer nurses are assigned to a number of departments, because there are too many departments to handle by only one person.

The specific description of the actual transfer process and involved people at the MCL is given in chapter 4, but generally the tasks of a transfer nurse can be described as follows:

A transfer nurse is a nurse who specifically deals with the arrangement of care after discharge from hospital. Through partially work experience at different care providers and the connection to the care providers of the own organization he/she is aware of the possibilities of care in the region. Besides, he/she should be aware of the current rules concerning the AWBZ, WMO and all changes in care. Transfer nurses maintain close contact to various care providers and the CIZ (Centrum Indicatiestelling Zorg) for the required indication of each care application. The transfer nurse visits the patient at the concerning department in the hospital after the doctor has discussed the care required after discharge with the patient. In consideration with the patient and/or family, the transfer nurse records the required care and requests it. This request goes to the CIZ as well as to the concerning care provider. Besides, the transfer nurse arranges and coordinates all appointments around the care application in order to inform the patient about all information around his care before discharge.

Practical experience shows that care after discharge from hospital can consist of:

1) Home care (outpatient care): this includes wound care; help with washing/ dressing, usage of tools, and information about alert systems and catering. Home care is always additional to that which the direct environment of the patient can deliver. This implies that partners who are in good conditions are expected to help the patient.

2) If the patient (temporarily) is not able/allowed to carry out certain domestic duties, the transfer nurse can advise the patient in which way he/she can request home care at the community of his/her home town. The community is responsible for the WMO (Wet Maatschappelijke Ondersteuning) and determines on basis of legal rules if the patient has the right to get home care. 3) The patient returns to the residential home where he lives and gets suitable care.

4) Temporarily admission in case of valid indication at a:

Nursing home: admission time max. 6 weeks. A place is arranged where suitable care can be provided. The patient can indicate preferences.

Care hotel: Patient has to inform at insurance company which costs can be covered.

Recovery Unit: Is suitable if patient only requires a short rehabilitation period. This counts for admission from min. 4 days to max 4 weeks. The transfer nurse assesses if the patient is eligible for a recovery unit.

Residential home: In case of intensive rehabilitation for an admission time of max. 3 months. The transfer nurse assesses if the patient is eligible for rehabilitation place at a residential home. He/she subscribes the patient at one of the fourteen care centres of Noorderbreedte or others if required. The patient can indicate preferences.

(10)

- 10 -

transfer nurse is able to inform the patient about the possibilities and conditions to stay in such an accommodation. Subsequently he/she tries to arrange a placement of the patient as soon as possible.

The whole patient transfer process can be defined as transmural care provided by the different parties involved.

It can be concluded that the transferpunt is the main switching point if a patient needs follow-up care after his stay in hospital. The transferpunt office is located in the hospital. The hospital department contacts it if a patient is ready for discharge. Some cases can be handled by phone with the front office. Complex cases need a visit of a transfer nurse in order to investigate the kind of care that is needed. The transfer nurse considers together with the patient the possibilities concerning the follow-up care and is able to advice and informs the patient about certain issues. A patient transfer is not possible without involvement of the transferpunt and its employees.

1.3 RESEARCH FOCUS

The transfer process requires good coordination between all involved parties and there are some main steps within the process, which are quite important for the subsequent steps and the overall efficiency of the process. Next to the fact that after first observations, the process seems to be hardly standardizable due to its complexity, and the fact that each transfer is unique, it can also be assumed that within the patient transfer process, in particular information exchange and coordination issues determine the success of a transfer. In the following we try to investigate whether designing/supporting the process in a different way could lead to improvement and whether there are indicators, which make this improvement visible.

(11)

- 11 -

CHAPTER 2: RESEARCH DESIGN

2.1 BACKGROUNDS AND MOTIVATION OF THIS RESEARCH

Starting point of this research was the conception that the patient transfer process as described in chapter 4, is a very complex process with the potential for improvement. The organization of the process and the alignment of the sequenced steps seemed to be essential for the operational performance (in terms of speed and quality) of the transfer. Furthermore, the way in which information is shared during these steps seems to be rather unhandy and take a lot of time. The ‘transferpunt’ already strived to support the transfer process through implementing a software, which would enables smoother information sharing. In this context a good insight in the actual process was required. Chapter 4 delivers this insight and provides an overview of all involved actors including their specific tasks. In the meantime, a project group for process support and the process oriented software is set up. First, observations and interviews indeed highlighted problems, which were not due to the complexity of some cases. Problems within the alignment coordination of several tasks became just as visible as the- in the beginning indicated difficulties regarding the information sharing. Enhancing the performance can be seen as an improvement of the process. It can be assumed that a redesigning of the process can lead to improvement of the process from a patient as well as from an organizational point of view.

2.2 PROBLEM STATEMENT

As mentioned in the previous paragraph, first impressions and conceptions noticed some problems within the actual patient transfer process.

Therefore the main objective of this research was:

“ Analyse and improve the operational performance of the patient transfer process by making a redesign of the process that optimizes the efficiency.”

Therefore the main research question raised by the main objective is:

“Which factors influence the operational performance and how can the actual situation be optimized?”

The operationalisation of performance within the patient transfer process will be explained in the context of chapter 3.

This study is a research in context of discovery with the aim to design a new structure of the patient transfer process in order to improve it.

2.3 CONCEPTUAL MODEL AND SUB-QUESTIONS

(12)

- 12 -

communicate with each other is very important. Boyd and Brandford (1966) discovered that communicating between departments in an organization is a much more difficult problem than intra-departmental communication. Literature states that communication could be improved through physical proximity. Galbraith (2002) stated that there is good evidence that reducing distance and physical barriers between people increases the amount of communication between them. It is also important to define interdependencies between those actors. Van der Vegt and Van de Vliert (2002) stated that people are task interdependent when they must share materials, information, or expertise in order to achieve a desired output or performance. These aspects are taken under the umbrella of coordination and define coordination as a factor of influence of the operational performance and therefore of the efficiency of the patient transfer process. The fact that different departments are involved within one process requires clarity about common goals and interdependencies. Actors have to adjust their tasks in order to operate efficient. As already mentioned, communication between the involved actors seems to be an important issue. Because it concerns around 5 different actors in the case of the patient transfer process, how these actors share their information could be crucial. Possibilities to improve the way of information sharing through information technology could be considered. Literature indicates e-transfer as a solution. It offers evidence based, save and efficient care through electronically information sharing between care institutions and nurses (IOM, 2001). And therefore it is stated to be the second factor of influence on the operational performance. Based on findings gained through observations, conversations and interviews with involved operators and the reviewing of reports, as well as based on the literature mentioned above, the conceptual model is developed and is shown in figure 2.1. It was assumed that the mentioned factors could be of influence on the operational performance and in that way on the efficiency of the patient transfer process. It is assumed that those factors can contribute to the enhancement of the performance in terms of faster handling of patient transfers and a higher quality perception from a patient point of view.

Figure 2.1: Conceptual model

Following questions are answered in the context of the concerning chapters in order to improve the process:

Sub-questions related to coordination.

1) How can coordination be defined?

2) Which aspects of coordination can influence the performance? 3) How could the coordination be improved? (Chapter 5)

Sub-questions related to information exchange (e-transfer).

4) How can information exchange (e-transfer) be defined?

5) Which aspects need to be considered in the context of information exchange (e-transfer)?

Operational performance Coordination

(13)

- 13 -

6) How could the information exchange be improved through e-transfer? (Chapter5)

Sub-questions related to operational performance.

7) Which performance indicators could be improved and why?

8) How can the performance be affected by a redesigning of the process? (Chapter 5)

2.4 METHODOLOGY

This section will elaborate the methodology which is a guideline to answer the research questions. First in section 2.4.1 the research strategy will be alaborated followed by the data analysis in section 2.4.2.

2.4.1 RESEARCH STRATEGY

The classification of the research strategies from Van der Velde et al. (2004) is based on the level of intervention and the level to which the researcher wants to make general valid conclusions. This classification can be combined with the classification of Runkel and McGrath (1972) who distinguished between generalization, precision and realism. The combinations of those classifications are shown in the figure 2.2.

Figure 2.2: Classification of research strategies

As already mentioned, there are different research strategies. Case studies, surveys, theoretical research count to the main strategies in the field of Operations and Supply Chains (Welker and Broekhuis, 2010). In this research, a combination of these strategies is chosen to answer the main research question and the several sub-questions.

(14)

- 14 -

Research question Research strategy Data gathering method

Coordination

How can coordination be defined? Theoretical research Archiving data Which aspects of coordination can influence the

performance?

Theoretical research and case study

Archiving data, Interviews, Observations, Surveys How could the coordination be improved? Case study Archiving data, Interviews, Observations

Information exchange (e-transfer)

How can information exchange (e-transfer) be defined?

Theoretical research Archiving data Which aspects needs to be considered in the

context of information exchange (e-transfer)?

Archiving data, Interviews, Observations, Surveys How could the information exchange be

improved through e-transfer?

Case study Archiving data, Interviews, Observations

Operational performance

Which performance indicators are of importance regarding the patient transfer process?

Archiving data, Interviews, Observations How can the performance be affected by a

redesigning of the process?

Archiving data, Interviews, Observations

Table 2.1: Research questions, Research strategy, Data gathering method

2.4.2 DATA ANALYSIS

This section will distinguish the data strategies mentioned in the previous section based on the gathering methods: (1) interviews, (2) archiving data, (3) observations, (4) surveys.

Interviews

Knowledge, facts and opinions/attitudes of individuals are very important for this research. In order to get insight in the current patient transfer process, several interviews of involved operators and parties were taken. Semi-structured interviews were held to give a direction of the subject of the interview but also leave space for the interviewee that can lead to additional information. In terms of parties the transferpunt and the ‘Klantenservice’ are interviewed. In terms of operators, 6 transfer nurses and 2 care consultants were interviewed. The interviews are shown in Appendix 2 and 3.

Archiving data

(15)

front-Jannes Schönlau │MBA Operations & Supply Chains

- 15 -

office employees) was held. The aim of the meeting was the same as of the first one. Again bottlenecks were indicated, compared to other bottlenecks obtained by the first meeting and gained during conversations with several operators. In this way the current problems are analysed and the gathered data is used in chapter four and five in order to design an alternative process layout. The final gathering of identified bottlenecks is checked again afterwards in interviews with the transfer nurses (Appendix 3).

Observations

Direct observations and participant observations were done to 1) control the given information for deviations, 2) gain insight in, and to map and visualize the current process and 3) support running projects. In that way the process could be captured best in terms of reality and context (Yin, 2003). In this way the identified bottlenecks could be confirmed or refuted. As stated by Welker and Broekhuis (2010), observations the transfer nurses and also being physical located between them, offered the possibility for quick conversations, response and feedback in case of questions and unclear circumstances. This data was often directly processed into the outcome in chapter four. Generally this type of data can be identified as primary data.

Surveys

(16)

- 16 -

CHAPTER 3: THEORETICAL FRAMEWORK

Chapter 2 provided the conceptual model, the main research question, and several sub-questions and illustrated the research strategy and data gathering. After a short introduction, chapter 3.1 and chapter 3.2 will subsequently describe the different variables of the conceptual model. Finally in chapter 3.3 the conclusion of the theoretical framework will be elaborated.

3.1 INTRODUCTION

In their article `Redesigning Geriatric Healthcare’, Andrews et al. (2001) stated that organizations that are recognized for having created sustainable cost and quality advantages in competitive environments often incorporate two strategic initiatives. First, the establishment of cross-functional teams empowered with decision-making capability, and second the practice of continuous process improvement. The cross-functional teams in this case refer to a certain kind of organizational structure, decision-making and management style. Dickson (1997) already stated that more bureaucratic modes result in less innovative and less efficient processes. In this manner successful organizations are relentless in their pursuit of process improvement, whereas process refers to organizational routines that create and deliver services and products. Process improvement, according to Andrews et al. (2001) therefore, begins by examining how functional areas contribute to or impede routines. Their starting point (two strategic initiatives) is related to this research and forms a rough base for evidence on different levels, in which coordination and communication as well as the way of information exchange can lead to better operational performance and in that way to improvement of the process.

3.1.1 COORDINATION

How can coordination be defined?

Reviewing relevant literature about coordination shows that there are various views on coordination. According to Simon (1947) coordination is related to the (decision-making) behaviour of individuals

within an organization. Coordination constitutes the provision of everybody with insight into everybody else’s behaviour, so that every individual is capable of making the right decision.

Thompson (1967) described coordination by the interdependencies between activities. His categorization of types of interdependencies is the distinction between pooled, sequential and reciprocal interdependencies.

In line with that is the view of Malone and Crowston (1994) who defined coordination as the managing of dependencies between activities.

Galbraith (1977) stated that coordination is the key ingredient of organization design. Organization design is seen as the search for coherence between the goals or purposes for which an organization exists, the people that do the work, and the patterns of division of labour and inter-unit coordination.

(17)

- 17 -

In order to describe a coordinating mechanism in terms of interdependencies, it is chosen to follow Thompson (1967) who stated that interdependence means the extent to which departments depend on each other for resources or materials to accomplish their tasks. Low interdependence means that departments can do their work with minimal interaction, consultation or exchange of materials with other departments. High interdependence requires the continuous exchange of resources between departments.

Thompson defined three types of interdependence (pooled, sequential or reciprocal) to describe the intensity of interactions and behaviours within an organizational structure figure (2). The study of interdependence helps business owners understand how the different departments or units within their organization depend on the performance of others. He hypothesizes three coordination mechanisms:

standardization, plan and mutual adjustment-used in response to the three different patterns of dependencies:

Pooled interdependence is the most basic form of interdependence among departments. In this form, work does not flow between units. Each department is part of the organization and contributes to the common good of the organization, but works independently. This creates an almost blind, indirect dependence on the performance of others wherein one department’s failures could lead to the failure of the overall process. The management implications associated with pooled interdependence are quite simple. Thompson (1967) argued that managers should use rules and procedures to standardize activities across departments.

Sequential interdependence occurs when interdependence is of serial form and parts produced by one department, become the inputs to another department. The effectiveness of the next department in the chain depends upon the effective performance of the preceding department. This is a higher level of interdependence than pooled interdependence, because departments exchange resources and depend on others to undertake their tasks. The management requirements for sequential interdependence are more demanding than those for the pooled interdependence. Coordination among the linked departments is required. This interdependence implies a flow of materials; so extensive planning and scheduling to ensure this flow are generally necessary. Some day-to-day communication is also needed to handle unexpected problems and exceptions as they arise.

Reciprocal interdependence is the highest level of interdependence. This exists when the output of operation A is the input to operation B, and the output of operation B is the input back again to operation A. The output of departments influences those departments in reciprocal fashion. “ Hospitals are an example for organizations where reciprocal interdependence occur. They provide coordinated services to patients” A patient may move back and forth between X-ray, surgery and physical therapy. Because reciprocal interdependence requires that departments work together intimately and be closely coordinated, a horizontal structure may be appropriate. This structure

(18)

- 18 -

allows frequent communication and mutual adjustment. Managers from several departments are likely to be jointly involved in face-to-face coordination, teamwork and decision-making. Reciprocal interdependence is the most complex form of interdependence and the most demanding to organize effectively.

Thompson (1967) theorized that the correct way to get departments within an organization working together effectively is to structure respective work tasks by intensity of interdependence, and then manage each of those interdependencies with different coordination methods. For example, a pooled interdependency requires standardization in rules and operating procedures, while the coordination methods for the other two interdependencies are slightly more flexible. A sequential interdependency is managed through mildly adaptive planning and scheduling, while reciprocally interdependent departments are managed through constant information sharing and mutual adjustments.

It can be concluded that overall most organizational conceptions of dependencies view them as arising between actors and describe patterns of actor-to-actor dependencies. Besides, several researchers have viewed the actors and their tasks and therefore the dependency as given and sought to identify the mechanisms used to manage dependencies, although some have suggested assigning tasks in order to create desired dependencies or minimize undesired ones.

In order to describe a coordinating mechanism in terms of organizational structuring, it is chosen to follow Mintzberg (1979) who stated that organizational structuring focuses on the division of labour of an organizational mission into a number of distinct tasks, and then the coordination of all of these tasks to accomplish that mission in a unified way. He suggests that this coordination can be effected in at least five basic ways:

In direct supervision, one individual (manager) gives specific orders to others and thereby coordinates their work.

In the standardization of work processes, the work is coordinated by the imposition of standards to guide the doing of the work itself- work orders, rules and regulations, etc.

In the standardization of outputs, the work is coordinated by the imposition of standard performance measures or specifications concerning the outputs of the work.

In the standardization of skills, the work is coordinated by the internalization by individuals of standard skills and knowledge, usually before they begin to do the work.

And in mutual adjustment, individuals coordinate their own work, by communicating informally with each other.

The literature on organizational structuring focuses on a number of mechanisms organizations are able to design their structures- in effect, the levers they can turn to effect the division of labour and coordination. Possible important ones in the context of this research could be:

(19)

- 19 -

horizontal and vertical senses usually fall into the category called ‘unskilled’, those specialized horizontally but ‘enlarged’ vertically are usually referred to as ‘professionals’.

Behaviour formalization is the design parameter by which work processes are standardized, through rules, procedures, policy manuals, job descriptions, work instructions, and so on.

Training is the design parameter by which skills and knowledge are standardized, through extensive educational programs, usually outside the organization and before the individual begins his job. This is a key design parameter in all work that is professional.

It is advocated that coordination can be described by the interdependencies between activities. Thompson (1967) and Mintzberg (1979) stated that coordination could be affected by certain design parameters. The analysis of the actual situation will focus on the interdependencies between the actors within the process, how these are arranged and which design parameters are used and required.

Which aspects of coordination can influence the performance?

(20)

- 20 -

of employees working in different departments, another -also very important- aspect in the context of this process is the distance and communication between the employee (transfer nurse) and the patient. The contact moment between transfer nurse and patient occurs only once in the current situation, at the moment that the transfer nurse visits the patient (figure (4)). It can be defined as face-to-face contact. Allen (2007) distinguishes between different communication media that can be used, classified from face-to-face to telephone. Furthermore there is often referred to the richness of information. Information richness is the ability of information to change people’s understanding within a certain time interval; interactions that can change understanding in a timely manner are considered to be rich. In context of the Media Richness Theory (Kahai & Cooper, 2003), Daft and Lengel (1986) stated that organizational design could provide information suitable richness. Communication media differ in the way they are able to process rich information. It is advocated that face-to-face contact is the richest medium because it provides immediate feedback so that interpretation can be checked. It also provides multiple cues (body languages, tone of voice), and it supports personalization. Regarding the complexity of certain cases, and the importance of the shared information between transfer nurse and patient, this way of communicating seems to be the most efficient one. Now switching from intra-departmental and departmental communication to communication among organizations, Datta and Christopher (2011) stated that central coordination with supply chain wide information sharing across different members is found to be essential in managing supply chains effectively. The transfer of the patient from hospital to another institution requires a lot of information sharing and coordination in order to make this process as efficient as possible.

Figure 3.2

Sub conclusion

(21)

- 21 -

(22)

- 22 -

3.1.2 INFORMATION EXCHANGE (E-TRANSFER)

How can e-transfer be defined?

To define e-transfer (electronically information transfer), we first address the general role of IT, because there are barely processes which cannot be supported by IT (Information technology), and in that way it has an important influence on performance. IT facilitates the integration of business functions at all levels in an organization by making corporate-wide information more readily accessible (Scott- Morton, 1991). Hung (2006) advocated that changes in IT systems also accompany the transformation to a horizontal management style. Powell and Dent-Micallef (1997) observed that IT should be used along with other business processes to enhance organizational and operational performance. This counts for manufacturing processes as well as other processes in all kinds of areas, like the patient transfer in the area of healthcare.

Using IT in terms of information sharing within the patient transfer process is called “e-transfer” and is based on a computerised health information system. That contains that the information between the involved parties/actors is transferred electronically. Paper-based records have been in existence for centuries and their gradual replacement by computer-based records has been slowly underway for over twenty years in western healthcare systems. However, those that have been implemented are mainly used for administrative rather than clinical purposes. A prerequisite in the sense of any computerised health information system is an electronic medical record system (EMR). "A patient record system is a type of clinical information system, which is dedicated to collecting, storing, manipulating, and making available clinical information important to the delivery of patient care. The central focus of such systems is clinical data”(IOM, 1997). Electronic medical record systems lie at the centre of any computerised health information system. Without them other modern technologies such as decision support systems cannot be effectively integrated into routine clinical workflow.

The 2003 IOM Patient Safety Report describes an EMR as encompassing:

1. "a longitudinal collection of electronic health information for and about persons 2. (immediate) electronic access to person- and population-level information by

authorized users;

3. provision of knowledge and decision-support systems (that enhance the quality, safety, and efficiency of patient care) and

4. support for efficient processes for health care delivery.

Point 4 ‘ the support for efficient processes for health care delivery’ of this definition is crucial for the patient transfer process, because the goal is offering evidence based, save, efficient and effective care through electronically information sharing between care institutions and nurses (IOM, 2001).

(23)

- 23 -

To capture data at the point of care

To integrate data from multiple internal and external sources To support caregiver decision making

Furthermore, literature indicates several benefits related to EMR’s:

Replace paper-based medical records which can be incomplete, fragmented (different parts in different locations), hard to read and (sometimes) hard to find. Provide a single, shareable, up to date, accurate, rapidly retrievable source of information, potentially available anywhere at any time. Require less space and administrative resources.

Potential for automating, structuring and streamlining clinical workflow.

Provide integrated support for a wide range of discrete care activities including decision support, monitoring, electronic prescribing, electronic referrals radiology, laboratory ordering and results display.

Maintain a data and information trail that can be readily analysed for medical audit, research and quality assurance, epidemiological monitoring, disease surveillance....

Support for continuing medical education.

Bosivaly et al. (2006) stated that promoting the continuity of care definitely requires the information sharing about the patients health-condition between diverse care-providing agencies. Hartwood et al. (2003) concluded in their research, that increasing demand for an integral approach of care (care continuity) and the cooperation between different forms of care (cure and care) have an increasing and formally status within the organisations, but acceptation of data exchange through electronically files and information sharing is scarcely implemented. Previous research shows that the usage of an information system by nurses enhance the quality of the report. The report becomes complete and accurate to a higher degree (Hayrinen & Saranto, 2009). Looking at the total process (e.g. record in hospital to record in residential home), Lee and Billington (1992) maintained that to overcome pitfalls within supply chains (e.g. inaccurate delivery status, inefficient information systems, and poor coordination) integrating databases throughout the supply chain are needed. In this context, ‘e-transfer’ cannot only support one process or one organization (intra-organizational), but it crosses the organizational border and is able to support the information sharing throughout the whole chain (inter-organizational). The analysis of the current situation will focus on the current way of information is sharing, which problems occur throughout the whole process due to this way of information sharing, and which improvements could be offered by e-transfer.

Which aspects need to be considered in the context of e-transfer?

(24)

- 24 -

actions can be observed at the MCL. But overall it could be concluded that it is not sufficient enough to switch from paper to an electronically exchange of medical records. Especially organizational changes are required (Schabetsberger et al., 2006) if the organizational structure is not suitable yet. However, it can be suggested that this switch positively influences the operational performance and improves the process. Patients themselves are enthusiastic about the possibility to share information about their condition electronically, as can be concluded after research in the United States. They perceive this possibility of exchange as an improvement of quality and security in healthcare, but they are worried about the fact that this improvement can decrease the degree of privacy and enhance the risk of abusing personal information. Literature shows that the introduction of ‘e-transfer’ always goes in line with standardization of certain procedures or sub-parts of the process. In order to clarify the role of standardization in this context, we take the example from the ‘Standard Nursing language’ of Westra et al. (2008). They stated that if nursing care counts as an essential part of the total care provided, then standardized terms are absolutely required for the success of electronic data files. The current process shows that information about the patient is collected in different forms (discharge forms). According to Helleso (2006), the usage of structured and standardized templates in discharge forms lead to a more complete, structured and content information transfer, and in that way it can influence the overall operational performance. Usually, discharge forms are designed from and for one specific party, without any directions for usage of different terms and requirements (Hubner & Giehoff, 2002). During the development of e-transfer, it is important to explain context related information and in that way to meet the needs of other involved actors and parties (Helleso et al., 2005; Helleso, 2006).

Sub conclusion

(25)

- 25 -

3.2 OPERATIONAL PERFORMANCE

Which performance indicators are of importance regarding the patient transfer process?

Examining the performance of a certain process, we can refer to Slack & Lewis (2008) who stated that for operations strategy to be effective, performance must be assessed in some way, and an obvious starting point is to consider the operations range of stakeholders-the people and groups, who may be influenced by, or influence the operation’s strategy. They indicate that there are internal and external stakeholders. Internal are operation’s employees and external refer to customers. In this case the operation’s employees are the departmental nurse and the transfer nurse as well as any other operator involved. The customers are the patients and their families. Slack & Lewis (2008) mention that there are five generic performance objectives that have meaning for all types of operation and relate specifically to operations’ basic task of satisfying customer requirements. These five are:

Quality: conformance to specifications

Flexibility: degree of coping with unpredictable situations

Speed: time between the moment of demand and the moment of delivery Dependability: degree of meeting the arrangements agreed

Costs: any financial input to the operation that enables it to produce its service and product They may be used to mean slightly different things depending on how they are interpreted in different operations. After mapping the current patient transfer process, it could be assumed that the performance objectives ‘speed’ and ‘quality’ would be most affected by a redesign of the current process in terms of coordination and e-transfer activities. Taking into account this assumption we shed some light on these two objectives in more detail.

Slack & Lewis (2008) define ‘speed’ as the elapsed time between the beginning of an operations process and its end. Internally oriented they use the example of the time between when material enters an operation and when it leaves fully processed. For the patient transfer process this could mean the time between the moment where the patient becomes aware of the fact that he needs follow-up care after discharge and the moment that he is actually placed in a residential home etc. or the moment that he is back home and receives home care. Slack & Lewis (2008) interpreted it from a customers’ view that the total process starts when they become aware that they may need the product or service and ends when they are completely satisfied with its ‘installation’. In one way this concerns a fast response to the customer, but speed inside the operation (transfer process) is also important (Slack et al., 2004). Internal speed is for example caused by speedy decision-making or speedy handling of a certain tasks. By decreasing internal throughput times, the total time of the process will reduce. Groover (2007) interprets this in the same way. He relates this to the workers performance. He states that when manual work takes place and the workers performance increases, the time to accomplish the work cycles decreases.

(26)

- 26 -

service needs to use several dimensions of specification to define its nature (Slack & Lewis, 2008). They also distinguish between hard and soft aspects of specification quality. In the case of the patient transfer process, we can define quality as part of a soft dimension, because soft dimensions are associated with aspects of personal interaction between customers (patients) and the service (Slack & Lewis, 2008). Finally, Slack & Lewis (2008) mentioned in their definition of quality, that in general the conformance to soft dimensions of quality is more difficult to measure and more difficult to achieve, because the soft dimensions are related to interpersonal interaction and in this way depend on the response of individual customers relating with individual staff. Translating this to the patient transfer process, it becomes obvious that the quality of the process also depend on the way how the transfer nurse treats the patient. That way can differ due to character of the individuals and other circumstances. In that way, the quality of the service could be the best assessed as the perceived quality by the patient (e.g. the length of the visits, friendliness of transfer nurses).

Sub conclusion

It can be concluded that considering the process characteristics, ‘speed’ and ‘quality’ are the most appropriate performance objectives which could be affected through certain operational changes. The performance objectives are incorporated in this section in order to try to make the efficiency of the transfer process more visible. These objectives will help to determine the success of a new design. It could be observed what time is needed for certain actions in the current situation and what changes within the context of mentioned factors would save some time during the fulfilling of certain tasks. If a new design of the process, considering the factors mentioned in chapter 3, enhances the efficiency of the process, this could be recognized through a better performance in terms of a faster transfer (‘speed’) and through the interactions between patient and nurses in terms of more content information exchange (‘quality’).

3.3 CONCLUSION THEORETICAL FRAMEWORK

This literature study discussed several factors, which could be of influence on the operational performance and in that way on the efficiency of the patient transfer process. These factors are coordination and information exchange (E-transfer). All aspects regarding both factors are also related to each other, and considering this relationship could lead to a way for developing a more efficient process design.

(27)

- 27 -

medium and definitely applicable within the context of the transfer process. Besides, proximity in terms of the physical distance between operators (transfer nurse; departmental nurse), and operators and patients is indicated as an important aspect, which could have significant influence. A decrease of this distance contributes to an increase of the amount of communication (Galbraith, 2002). In order to improve the coordination, which in turn could positively influence the operational performance, these aspects should be considered by trying to achieve this goal. In the context of the

research strategy, the process should be mapped and it should be investigated which interdependencies are present. Taking surveys among the operators and making observations of the communication process required for a single transfer should investigate if there are certain coordination problems which could be improved through adapting the current design by decreasing the physical proximity and in that way enhancing the possibility of face-to-face contact. A small physical distance to the patient with more communication (face-to-face) could be positively influence speed and quality.

The current way of information sharing is barely supported by IT. Literature states that e-transfer offers a possibility to support the information transfer. Nurses in hospital confirmed the statement of Goossen (2009) that there is an increasing need of information sharing in the chain between nurses among each other and between care providers in healthcare. E-transfer could offer evidenced based, save and efficient care and besides, it could positively influence the operational performance in terms of speed and quality. So, moving from hand-written to electronically data transfer could

enhance the operational performance. Measurements at different points where information needs to be processed or shared among the operators can indicate the required amount of time for this current way of information exchange. That could indicate at which points within the process there are problems regarding that way and thereby it should indicate where e-transfer might improve these drawbacks.

(28)

- 28 -

CHAPTER 4: ANALYSIS

According to

MCLaughlin and Hays (2008) it is important to firstly know the process in order to be able to improve it. In this way chapter 4.1 starts with a detailed process description. Chapter 4.2 follows with an analysis based on the concepts of the conceptual model in chapter 2.

4.1 PROCESS DESCRIPTION

The analysis of the process will first start with a detailed description of the actual process (4.1.1) divided into two sub-parts (Process-part MCL and Process-part Noorderbreedte). Secondly, chapter 4. 2 will show the analysis of the different concepts.

4.1.1 THE ACTUAL TRANSFER PROCESS

One part of the total process takes place in the MCL itself and involves the Transferpunt (TP) as switching point, the concerning department where the patient stays at that moment, and the patient as starting point of the whole process. Focussing on 'Zorggroep Noorderbreedte', the other part involves the ‘Klantenservice’, the location/service where the patient wants to make use of, and the client administration of Noorderbreedte. The entire process is given in Appendix 8. In order to simplify the analysis of the process, it will be distinguished between the two parts (MCL part and Noorderbreedte part) in this description section. The process description is based on an iterative process with the management of the MCL, 'Norrderbreedte' and the involved actors in order to map the current sequence of the process steps. After several refinements, the actual process could be defined (figure 4.1 and figure 4.2).

4.1.1.1 PROCESS PART ‘MCL’

As already mentioned, the process parts, which actually take place at the location MCL, involve the client (patient), the hospital department and the transferpunt. This part will describe first, because the whole process starts with the patient. It is important to describe and to design the process stepwise, because research in process management (Flynn et al. (1995) and Saraph et al. (1989)) shows that it is of high priority to build quality into the product/service during the production/development stage. This means that failures in one step could influence the subsequent steps and ultimately could lead to bad performance or insufficient quality of the process and in that way resulting in non-fulfilment to the client.

The first phase of the patient transfer process is represented in figure 4.1 and is as follows:

1) Starting point is the patient who is almost finished with his treatment at the hospital. Interaction occurs between patient and hospital department.

2) The hospital department then informs the transferpunt that the patient is almost finished with his treatment and that he needs follow-up care. The hospital department is responsible. 3) The transferpunt (front-office) receives the notification, administrates the patients data and

(29)

- 29 -

4) After receiving the ‘order’, the transfer nurse visits the department (departmental nurse/patient). First there is a consultation between transfer nurse and departmental nurse about the patient. This includes information about the date of discharge and the kind of care which is needed after discharge. The hospital department is responsible for reporting certain data about the patient and hand it to the transfer nurse. The transfer nurse lists the data provided and then visits the patient. During this visit the patient indicates which care he wants, from which care provider he wants to receive the care and maybe he addresses some other, for him important issues concerning the care and personal circumstances. The patient is allowed to give 1 preference choice of a care provider or location. All these mentioned points are considered together with the transfer nurse. Generally, the transfer nurses have more insights about possibilities and conditions about certain kinds of care than the patient. In this step all 3 parties (client, department and transferpunt) are involved.

5) Most of the time, the transfer nurse already records the required data in the previous step. There are cases where this is not happens, then it will be done within this step. In other cases some data is directly delivered to the front office (by phone) or it derived in the EPD (Elektronisch Patienten Dossier). The front-office then processes the concerning data.

6) All reports and data delivered from the transfer nurse or directly delivered as described in step 5 are processed by the front- office. The patient is registered in the system. In case the patient needs to stay in a nursing or residential home, he will be put on a waiting list. In case of home care the data will be saved in another file.

7) In case the patient needs home care, the transfer nurse requests the care at the care provider (the CIZ needs this information for the indication). If the care provider agrees with the request, it can go on with step 8.

8) Based on the data (the patients needs) the transfer nurse now requests an indication at the CIZ.

(30)

Jannes Schönlau │MBA Operat

Figure 4.1: MCL part

Once again looking at the step step 4 is the most important information exchange between th All three parties are involved, a discussed between those three. failures or difficulties. A good sufficient and correct information

After the consultation at the de office and executes the next req steps.

MCL

Patient Hospital Depa

erations & Supply Chains

stepwise description of this part of the process, we nt step, which requires a good coordination, c

the involved actors (departmental nurse, transfer d, and all-important issues around the follow-up ee. It is obvious that in this context step 4 offers d preparation of the case by the departmental tion provided to the transfer nurse) is the enabler fo

e department and visiting the patient, the transfer n required steps. Data processing is a main issue i

MCL

l Department Transferpunt (TP)

- 30 -

, we can conclude that n, communication and sfer nurse and patient). up care needs to be fers most potential for tal nurse (in terms of er for a smooth step 4.

(31)

- 31 -

The process scheme is used as starting point for the analysis of the process (chapter 4.2) and the new design in chapter 5.

4.1.1.2 PROCESS PART ‘Noorderbreedte’

If the main steps within the MCL are fulfilled, the second part of the patient transfer process lies in the hand of Noorderbreedte. The green rectangles in figure 4.1 and figure 4.2 indicate where the two process parts fit together. The main part at Noorderbreedte is done by the ‘Klantenservice’, which stays in direct contact to the transferpunt. The employees of the Klantenservice, which are contacted by the transfer nurse, are called ‘care consultants’. Other parties involved are the coordinator at the residence/location, and the “Cliëntenadministratie’ of Noorderbreedte. In the last steps of this process part, there is direct contact between the Klantenservice and the hospital department/patient, which is not represented in figure 4.2. This step is mentioned in step 5 and at the end of the description.

The second phase of the patient transfer process is represented in figure 4.2 and is as follows:

1) The care consultant is contacted by the transfer nurse and gets a note about the application of the patient by phone. At the same time the care consultant receives an affirmation by the transferpunt. This includes the receiving of the (preliminary) information transfer form by mail (from paper converted into mail).

2) The application and the information transfer form are checked for completeness by the care consultant. Important checkpoints are preferred residence, kind of care, expected length of care/stay and expected indication/validity.

3) The care consultant checks the occupation list in order to find out whether there is enough capacity at the 1) preference NB- location or 2) other NB- location.

4) If the care consultant determines available residence, the care coordinator at the location will be contacted in order to adjust the desired kind of care, record date/time/duration, and apartment/room for concerning residence. If adjustment is successful, it can be moved on to step 5. Otherwise it has to be returned to step 3.

5) The care consultant directly contacts the hospital department and checks the current status, the medication list, the identification card of the patient and the physical transport from/ to the residence.

6) The care consultant informs transferpunt about care arrangement by phone and mail. This information includes the name of the residence and record date as well as record time. The same mail will be send to the care coordinator at the location and the Cliëntenadministratie. 7) The care consultant registers the patient on the occupation list.

(32)

Jannes Schönlau │MBA Operat

No

Customer Service

Figure 4.2: Noorderbreedte part

At the ‘Noorderbreedte part’ operator. The transfer nurse info ‘MCL’ part is fulfilled. At that time

erations & Supply Chains

Noorderbreedte

Location/ Coordinator Client administration

art’ of the process, the care consultant can be de informs the consultant about the application of th

time the responsibility of the case lies at the care co

- 32 -

(33)

- 33 -

to find a suitable -and also very important- the requested residence for the patient, if there was a preferred location. During this search, the care consultant needs correct and adequate information about the kind of follow-up care required. The transfer nurse provides this information as indicated earlier. In this way, good communication and information sharing between those two parties is required. If the care consultant finds a suitable location and this location agrees with the record of the patient, the consultant directly informs the hospital department. Here, the care consultant checks the current status of the patient and arranges other things like personal information and physical transport of the patient. Within the last step, he informs all involved parties (transferpunt, coordinator location, Clientenadministratie) about the 'care accord'.

4.1.1.3 PROCESS PART ‘other care provider’

It is possible that the patient does not want to make use of the care provided by Noorderbreedte (either home care nor a residence of Noorderbreedte). In this case the transfer nurse does not contact a care consultant of Noorderbreedte, but a consultant of another care provider or home care. The process is comparable to the process described in section 3.2. Of course there can be some differences, but these are less important for this research and will not be discussed in detail. It is important to note, that the transfer nurse is involved in the process until the patient is actually placed at a care provider. So, if the first preference choice of the patient concerns a service of Noorderbreedte and the care consultant of Noorderbreedte is able to mediate the desired care, the task of the transfer nurse is fulfilled. If this is not the case, the transfer nurse endeavours to find another acceptable provider for the patient.

After the description of the actual process, the subsequent part will provide a deeper analysis of the current patient transfer process through answering the sub-questions of chapter 2 related to the concepts presented in chapter 3 and the discovery of certain bottleneck within the current process. An alternative solution in form of a new design will be presented in chapter 5 in order to overcome these bottlenecks and to enhance the overall efficiency of the patient transfer process.

4.2 PROCESS ANALYSIS

(34)

- 34 -

afterwards refined once again. The management of the ZNB and the transferpunt were also involved during this process. This iterative process resulted in an exact and detailed process scheme (see Appendix 8). Chapter 4.1.1 divided this process into two parts and clearly illustrated both of them. In context of the research focus, the first part of the process is chosen, and the concerning process scheme is used as starting point for further investigation. The main actor within the MCL-part is the transfer nurse.

Subsequently it was tried to create a similar situation as in the first organized session, but this time only the most important actors of that specific part (transfer nurses and front-office employees) were present. They were asked to run through the new created process scheme and to indicate bottlenecks they encounter. The result was compared to the bottlenecks of the first meeting. Ultimately all points were collected and those who occurred the most and seemed to be the critical ones were compared and combined with the bottlenecks derived from interviews and observations. Those were partly the same, because some of the interviewees were also present at the first meeting. But the new session provided the possibility to focus on the first part of the process specifically. With the aid of the new scheme the operators were able to be more precisely about the identified problems, what allowed a more specific categorization (assigning) to the discussed concepts of chapter 3.

The following sections will illustrate most of the uncovered bottlenecks within the context of the actual situation. Because of the complexity and the context, observations and professional insights were crucial during the diagnosis phase. Different measurements and surveys were used to underpin and confirm certain bottlenecks. These are further elaborated in Appendix 7. The current situation is analysed with the aid of the theoretical framework of chapter 3. First, the coordination concept will be discussed before the information exchange (e-transfer) will be elaborated.

4.2.1 ANALYSIS COORDINATION

This section discusses the current situation with the aid of the coordination concept as provided in chapter 3. First, the coordination will be described by identifying the kind of interdependencies within the patient transfer process. Secondly, the process will investigate by looking the aspects, which could have influence on the performance and by the aid of the identified bottlenecks.

How can coordination be defined at the MCL?

Internship Transferpunt MCL Leeuwarden Jannes Schönlau

Internship

Transferpunt MCL Leeuwarden

- 2 -

Analysing and redesigning of the patient transfer process

-August 2012-

Jannes Marvin Schönlau

Student number: 1912453

Camminghastraat 13

9132 EK Ballum

tel.: +31 (0)613473510

e-mail: jannesschoenlau@hotmail.com

University of Groningen

Faculty of Economics and Business

MSc Business Administration

Specialization Operations & Supply Chains

Supervisor/ University of Groningen

Dr. M.P. Mobach

Dr. G.C. Ruël

- 3 -

ABSTRACT

- 4 -

Preface

- 5 -

TABLE OF CONTENTS

- 6 -

- 7 -

CHAPTER 1: INTRODUCTION

1.1 STRUCTURE OF ORGANIZATION

Fryslân.

Fryslân

- 8 -

Fryslân

1.2 AIM AND TASKS OF THE TRANSFERPUNT

- 9 -

- 10 -

- 11 -

CHAPTER 2: RESEARCH DESIGN

2.1 BACKGROUNDS AND MOTIVATION OF THIS RESEARCH

2.2 PROBLEM STATEMENT

2.3 CONCEPTUAL MODEL AND SUB-QUESTIONS

- 12 -

- 13 -

2.4 METHODOLOGY

- 14 -

- 15 -

- 16 -

CHAPTER 3: THEORETICAL FRAMEWORK

3.1 INTRODUCTION

3.1.1 COORDINATION

- 17 -

- 18 -

- 19 -

- 20 -

- 21 -

- 22 -

- 23 -

- 24 -

- 25 -

3.2

OPERATIONAL PERFORMANCE

- 26 -

3.3 CONCLUSION THEORETICAL FRAMEWORK

- 27 -

- 28 -

CHAPTER 4: ANALYSIS

According to

4.1 PROCESS DESCRIPTION

- 29 -

- 30 -

- 31 -

- 32 -

- 33 -

4.2 PROCESS ANALYSIS

- 34 -