A mixed-method study of the impact of the operating system on hospital efficiency

CONTEXT Hospitals worldwide face challenging times and are consistently under pressure to control costs and improve quality of care. Research into improving health care should deal with seeking and defining the best methods of organizing and delivering services. In health care, there are two types care processes: sequential (the process is an orderly sequence of steps) and iterative (being composed of multiple cycles of hypothesis propositions and testing, where each cycle builds upon previous ones). These are very different, but both types could benefit if their organization were aligned with a tailored configuration of the operating system adjusted to the specific characteristics of both types of processes. The main purpose of this dissertation is to assess how the design of the operating system impacts efficiency in hospitals. In this dissertation we focus specifically on the sequential care process. METHODS The first part (chapter 2), presents a systematic literature review of the effects of specialized hospitals considering these as focused factories. In the second part (chapter 3), an exploratory database analysis of four hospitals was performed. We investigated whether hospital care processes can be assigned to different groups, resulting in better alignment of type and organization of care. In the third part, an empirical study of how the design of the operating system impacts efficiency in hospitals was conducted. Firstly (chapter 4), a multilevel analysis was performed to distinguish factors that influence flow efficiency in a standardized process (i.e. the cataract surgery process), focusing on the role of the organizations, physicians, and case-mix variables of patients. Secondly (chapter 5), a comparative benchmark study with a mixed-method design was conducted to compare sequential care processes between hospitals. We examined how the cataract surgery process operates in hospitals and which design of the operating system is preferable. RESULTS Considering the effects of specialized facilities as a strategy for standalone facilities that excel, we found no compelling evidence demonstrating the added value of these specialized facilities in terms of quality or cost. In addition, their corresponding impact on full-service general hospitals remains unclear. There are groups of patients with inherently different degrees of variation in length-of-stay due to illness and treatment patterns. However, there are significant differences in the distribution of variation groups between the hospitals suggesting that there are clear process differences which led us towards further investigation of the sequential hospital care processes in this dissertation Investigating a sequential care process (i.e. the cataract surgery) in hospitals, we found (1) controllable and uncontrollable factors influencing flow efficiency and (2) that treating sequential care processes in an operating setting specifically dedicated to such processes enhanced flow- and resource efficiency. In these settings, we not only found higher capacity use, but also shorter turnover times and significantly lower staffing levels, without affecting efficiency and resulting in lower costs. DISCUSSION The importance of differentiating distinct processes for health care problem-solving lies in the added value of different approaches to their design and management. Thus, different services and processes require different operating systems. Our results demonstrate that aligning structure and process components with the design of the operating system positively influences operational performance. The sequential care process (e.g., cataract surgery) is designed in line with a standardized process; however, differences in the design of the operating system between the hospitals illustrate the impact on operational performance. We must emphasize the importance of differentiating the types of variation and noting the presence of, as the goal must be to eliminate the unwarranted U+201CartificialU+201D special-cause variation and manage warranted, common-cause variation. This dissertation provides practitioners and academics with a fresh perspective on the practices of sequential care processes and the factors limiting them. It also serves as a foundation for future initiatives aimed at improving operational performance in hospitals.

Jaar van publicatie:2015