Converging patterns in hospital organization: beyond the professional bureaucracy

Multidisciplinary Collaboration in Hospitals via Patient- and Process-Oriented Units: A Longitudinal Study

Introduction

The complexity of healthcare is increasing, mainly due to the prevalence of multimorbidity in an ageing population. Complex care for patients with multimorbidity requires a multidisciplinary approach. Traditional physician-centered hospital structures do not facilitate the necessary multidisciplinary collaboration. European hospitals are implementing process-based hospital designs with patient- and process-oriented units to stimulate multidisciplinary collaboration. Patient-oriented units are formed based on shared patient groups and focus on care trajectories, while process-oriented units are formed based on having similar processes and focus on efficiency.

Purpose

This study has two aims. First, to study the effect of introduction of these units on multidisciplinary collaboration and perceived impact (efficiency, innovation, and effectiveness). Second, to study whether there are differences between patient- and process-oriented units.

Methods

A survey-based longitudinal evaluation study was conducted in 2020 and 2022 among physicians in a Dutch hospital to measure multidisciplinary collaboration (relational coordination) and perceived impact (efficiency, innovation, and effectiveness). In addition, open questions were used to enrich the data.

Results

Quantitative and qualitative data together suggest that physicians in patient-oriented units notice benefits from the redesign to multidisciplinary units, they perceive higher impact over time. Physicians in process-oriented units achieve a better relationship with the physicians in their unit over time, but they do not perceive impact as high as physicians in patient-oriented units.

Conclusion

A process-based design with patient- and process-oriented units is supportive of multidisciplinary collaboration and perceived impact, especially for physicians in patient-oriented units. Physicians in patient-oriented units are positive about the introduction of these units as they feel it contributes to better multidisciplinary patient care. As the results for physicians in process-oriented units may be less directly visible in terms of quality of care, they are less likely to see positive effects, even though their relationships are improving.

A longitudinal investigation of structural empowerment profiles among healthcare employees

PURPOSE

Research on structural empowerment has typically adopted a variable-centered perspective, which is not ideal to study the combined effects of structural empowerment components. This person-centered investigation aims to enhance our knowledge about the configurations, or profiles, of healthcare employees' perceptions of the structural empowerment dimensions present in their workplace (opportunity, information, support, and resources). Furthermore, this study considers the replicability and stability of these profiles over a period of 2 years, and their outcomes (perceived quality of care, and positive and negative affect).

DESIGN

Participants completed the same self-reported questionnaires twice, 2 years apart.

METHODS

A sample of 633 healthcare employees (including a majority of nurses and nursing assistants) participated. Latent transition analyses were performed.

RESULTS

Five profiles were identified: Low Empowerment, High Information, Normative, Moderately High Empowerment, and High Empowerment. Membership into the Normative and Moderately High Empowerment profiles demonstrated a high level of stability over time (79.1% to 83.2%). Membership in the other profiles was either moderately stable (43.5% for the High Empowerment profile) or relatively unstable (19.7% to 20.4% for the Low Empowerment and High Information profiles) over time. More desirable outcomes (i.e., higher positive affect and quality of care, and lower negative affect) were observed in the High Empowerment profile.

CONCLUSIONS

These results highlight the benefits of high structural empowerment, in line with prior studies suggesting that structural empowerment can act as a strong organizational resource capable of enhancing the functioning of healthcare professionals. These findings additionally demonstrate that profiles characterized by the highest or lowest levels of structural empowerment were less stable over time than those characterized by more moderate levels.

CLINICAL RELEVANCE

From an intervention perspective, organizations and managers should pay special attention to employees perceiving low levels of structural empowerment, as they experience the worst outcomes. In addition, they should try to maintain high levels of structural empowerment within the High Empowerment profile, as this profile is associated with the most desirable consequences. Such attention should be fruitful, considering the instability of the High Empowerment and Low Empowerment profiles over time.

REGISTRATION

NCT04010773 on ClinicalTrials.gov (4 July, 2019).

How will the public health committees develop after COVID-19 pandemic in China? Exploration from mixed methods study in Pingshan District, Shenzhen

Introduction

The Public Health Committee has a long-standing presence in the Chinese Constitution. During the pandemic, it served as a grassroots self-governance organization and made significant contributions to China's community epidemic prevention and control system. Currently, 24 provinces in China have promoted the establishment of community public health committees.

Methods

To gather data, we conducted semi-structured interviews (n = 48) with the heads of superior departments of public health committees, the heads of public health committees, and the heads of community health centers, exploring aspects such as organizational structure, job responsibilities, and job security. In parallel, we administered a capacity-building survey to a sample of 23 community residents (n = 1,986) and performed regression analysis. Finally, we examined the impact of gender, age, and education level on the development of public health committees.

Results

Our study reveals that the development of public health committees displays features of administration across various dimensions, including personnel appointment, top-level design, medical professionalism, funding path dependence, and data path dependence. However, the decision-making function of the organization does not exhibit a significant impact.

Discussion

The construction of the Public Health Committee should demonstrate an "autonomization-administration" pendulum effect. Currently, due to the absence of decision-making functions within the Public Health Committee, autonomous organizations are exhibiting characteristics of administration. To prevent excessive autonomization or administrative nature in the development of committees, public health policies are continuously being refined based on the unique characteristics of public health committee construction. During exceptional circumstances or the initial stages of development, the establishment of public health committees should be primarily guided by administrative principles, utilizing political momentum to drive their progress. In contrast, during routine establishment phases or later stages of development, the establishment of public health committees should be primarily led by autonomization, restoring their capacity for self-decision making. It is essential to fully leverage the role of grassroots self-governance organizations, relying on the community to engage in self-management, self-education, and self-service within public health committees.

Proximity and information sharing in hospitals and nursing homes: Development of an instrument assessing health personnel's perceptions of proximity and information sharing with kitchen personnel

Healthcare services are becoming increasingly specialized, potentially hampering interprofessional care. To provide holistic treatment and care, different professions and departments need to share information. Healthcare services also include support services, such as institutional food services, and health personnel and kitchen personnel need to share information about food and patients to serve food adapted to the patients' nutritional needs. Healthcare institutions mainly use formal information-sharing systems, but informal communication is considered more suitable for exchanging complex information. Physical and social proximity may facilitate informal information sharing across different professions and units. We aimed to develop and test an instrument for assessing health personnel's perceptions of physical and social proximity to, and information-sharing practices with, kitchen personnel and to describe associations between physical and social proximity and information-sharing practices. A survey questionnaire measuring proximity and information-sharing practices was developed and distributed to 368 health personnel. Scale analyses were performed to test the psychometric properties of the measures included in the questionnaire. MANOVA and regression analyses were run to assess associations between proximity and information-sharing practices. The results indicated reasonable validity of the measures, and both physical and social proximity were associated with increased informal information sharing.

The entrepreneurial orientation of general practitioners-Current theory and practice in the Czech Republic

BACKGROUND

Since 2010, the Czech Republic has been experiencing a spontaneous phenomenon in which General Practitioner (GPs) practices have been transferred to a legal limited liability company as defined by the Commercial Code.

OBJECTIVES

Our research attempted to ascertain the reasons that induced GPs to change their legal form, thereby opting for an entrepreneurial orientation (EO). A second objective was to measure the impact of this change on the healthcare performance of GP practices.

METHODOLOGY/APPROACH

We used exploratory research to examine this phenomenon in healthcare service provision. Data from 131 questionnaires was evaluated using an exploratory survey with descriptive statistics. To assess the healthcare performance of GP practices, we used secondary data from the Institute of Health Information and Statistics of the Czech Republic.

FINDINGS

The GPs interviewed considered their practices to be businesses. Their decision to change to a limited company form was influenced by the possibility of selling or transferring the business, employment sustainability and job security, and advantages related to cost structure and taxation. Our study shows that, in a generational exchange, the change in legal form enhances the sustainability and operation of the practice within the context of the current demands for high-quality healthcare.

Towards Process-Oriented Hospital Structures; Drivers behind the Development of Hospital Designs

Hospitals have been encouraged to develop more process-oriented designs, structured around patient needs, to better deal with patients suffering from multi-morbidity. However, most hospitals still have traditional designs built around medical specialties. We aimed to understand how hospital designs are currently developing and what the important drivers are. We built a typology to categorize all Dutch general hospitals (61), and we interviewed hospital managers and staff. The inventory showed three types of hospital building blocks: units built around specific medical specialties, clusters housing different medical specialty units, and centers; multi-specialty entities provide the most suitable structure for a process-oriented approach. Only some Dutch hospitals (5) are mainly designed around centers. However, most hospitals are slowly developing towards hybrid designs. Competitive drivers are not important for stimulating these redesigns. Institutional pressures from within the health care sector and institutional 'mimicking' are the main drivers, but the specific path they take is dependent on their 'heritage'. We found that hospital structures are more the result of incremental, path-dependent choices than 'grand-designs'. Although the majority of the Dutch general hospitals still have a general design built around medical specialties, most hospitals are moving towards a more process-oriented design.

Chain Hospitals in the Health Industry: A Scoping Review of Principles and Definitions

In order to provide quality and cost-effective health care, hospitals have used a variety of organizational models. Chain hospitals are one type of organization and service delivery model. Based on the diversity, multiplicity, and ambiguous nature of concepts related to chain hospitals, this study is an attempt to explain the concepts and components of such hospitals. Five main databases were searched for this purpose. Scopus, PubMed, WOS, ProQuest, and Wiley library databases were accessed from inception to September 2022. English-language studies describing chain hospital models were included. Two independent authors screened full-text papers, and data were extracted using a self-designed form. A thematic analysis was used to identify key components of the chain hospitals. A total of 38 papers from 8472 documents met the inclusion criteria and were included in the study. Among the selected studies, there were 23 quantitative studies, 6 qualitative studies, 5 mixed studies, 3 review studies, and 1 gray report. A review of the results revealed 55 different definitions of chain hospitals, as well as 6 main components and 16 subcomponents. Among the extracted components, 60% were related to the organization dimension, 15% to governance, 9% to decision rights, 8% to policies and procedures, and 4% to service delivery. In order to launch a multihospital system involving chain hospitals in a country, it is necessary first to define the concept of this hospital. The study's findings should be used by policymakers and officials in each country before implementing an inter-hospital cooperation system (MHS, chain hospital, etc.). Future researchers may also find inspiration in the study's findings and focus on these hospitals' establishment, effectiveness, and financial effects.

Impact of empowering leadership on emotional exhaustion: A controlled interventional study in a large French university hospital complex

AIM

The aim of this study is to assess the effect of a systemic intervention on the evolution of empowering leadership and emotional exhaustion in a university hospital sub-centre compared to a control sub-centre, both being part of a large French university hospital complex.

BACKGROUND

Empowering leadership is a promising strategy for developing hospital team engagement and performance. However, the bureaucratic functioning of large hospitals, characterized by a managerial culture of control and a stratified organization, can be a barrier to empowering leadership.

METHODS

The intervention included empowering leadership training, direct field experimentation of empowering leadership and coaching, involving all the sub-centre hierarchical levels for 12 months. Data were collected before and after the intervention. A total of 441 and 310 participants were, respectively, included in the intervention and control sub-centres.

RESULTS

Empowering leadership was decreased, and emotional exhaustion was increased in the control sub-centre, while the scores remained stable in the intervention sub-centre. The increased emotional exhaustion in the control sub-centre could partially be explained by the change in empowering leadership.

CONCLUSION

In a context of decreased empowering leadership and increased emotional exhaustion, the intervention had a protective effect. Implications for the design of future interventions were discussed.

IMPLICATIONS FOR NURSING MANAGEMENT

This study unequivocally showed the benefit of transforming hospital management towards empowering leadership, to prevent increased emotional exhaustion.

REGISTRATION NUMBER

This study is registered on ClinicalTrials.gov on 4 July 2019 (NCT04010773).

Collaboration Between Physicians from Different Medical Specialties in Hospital Settings: A Systematic Review

Health care today is characterized by an increasing number of patients with comorbidities for whom interphysician collaboration seems very important. We reviewed the literature to understand what factors affect interphysician collaboration, determine how interphysician collaboration is measured, and determine its effects. We systematically searched six major databases. Based on 63 articles, we identified five categories that influence interphysician collaboration: personal factors, professional factors, preconditions and tools, organizational elements, and contextual characteristics. We identified a diverse set of mostly unvalidated tools for measuring interphysician collaboration that focus on information being transferred and understood, frequency of interaction and tone of the relationship, and value judgements about quality or satisfaction. We found that interphysician collaboration increased clinical outcomes as well as patient and staff satisfaction, while error rates and length of stay were reduced. The results should, however, be interpreted with caution, as most of the studies provide a low level of evidence.

Dealing with pluralism: the managerial work of CEOs in Italian public healthcare organizations

Background

Healthcare organizations are extremely complex. The work of their CEOs is particularly demanding, especially in the public sector, though little is known about how the managerial work of a healthcare organization CEO unfolds. Drawing from scholarship on managerial work and management in pluralistic organizations, we sought to answer the questions: What is the content of managerial work of CEOs in public healthcare in Italy? How do healthcare CEOs perform their managerial work in complex interactions with multiple stakeholders?

Methods

For this study we adopted a multi-method approach in which we conducted a survey to investigate CEO behaviors, tracked CEO working time for 4 weeks, and conducted semi-structured interviews with senior CEOs.

Results

CEOs in public healthcare devote most of their time to interaction, which half of which is perceived as being occupied with apparently mundane problems. Nonetheless, devoting time to such activities is functional to a CEO’s goals because change in pluralistic contexts can be achieved only if the CEO can handle the organization’s complexity. CEOs do this by engaging in routines and conversations with professionals, creating consensus, and establishing networks with external stakeholders.

Conclusions

CEOs are called to reduce fragmentation and foster cooperation across disciplines and professional groups, with the overarching aim to achieve integrated care. Using an analytical approach we were able to take into account the context and the relational dimension of the managerial work of healthcare CEOs and the specificities of this role.

Trial registration

This article does not report the results of a healthcare intervention on human participants, and the material used in the research did not require ethical approval according to Italian law.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12913-022-08567-1.

Redesigning value-based hospital structures: a qualitative study on value-based health care in the Netherlands

Background

A crucial component of value-based health care concerns the redesign of organizational structures. In theory, hospital structures should follow value creation: addressing medical conditions for specific groups of patients over full cycles of care. In practice, however, it remains unclear how hospitals can reorganize themselves into value-based structures. The purpose of this study is to explore the ways in which Dutch hospitals are currently implementing and pursuing value-based redesign.

Methods

This qualitative exploratory study used semi-structured interviews and a focus group for data collection. Transcripts were analyzed through deductive coding, for which we used Mintzberg’s theory on organizational structures, particularly his work on design parameters.

Results

In their efforts to create more value-based structures, Dutch hospitals often employ a variety of liaison devices, such as project teams and committees. By contrast, the actual formation of units around medical conditions is much rarer. Outcome data are widely used within planning and control systems, and some hospitals partake in external benchmarking. Not all hospitals use cost indicators for monitoring performance.

Conclusions

Value-based redesign is not necessarily a matter of radical changes or binary choices. Instead, as Dutch hospitals show, it can be an incremental process, with a variety of potential knobs to turn to various degrees. Health care executives, managers, and professionals thus have a wide range of options when they aim for more value-based structures. Our conceptualization of “value-based design parameters” can help guide the selection and implementation of strategies and mechanisms for further coordination around medical conditions over full cycles of care.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12913-022-08564-4.

Hierarchy and diffusion of organizational forms

In this paper we first of all summarize and rationalize current typologies of organizational forms, arranging available classifications in a hierarchy of increasing generality. The ensuing structure parallels the classification of living beings into classes of increasing generality such as species, genus, family, order, and so on. Subsequently, we analyze the structure of communications that favored the diffusion of each organizational form. We isolate a few stylized communication structures, pointing to the presence of several sources endowed with global connections as the most efficient diffusion mode. The empirical research that is being carried out on single organizations is close to observing their T-patterns, whereas nothing comparable is in sight for organizational forms as yet. However, at least in some cases, we dare to formulate tentative hypotheses on certain features that the ensuing T-patterns-of-patterns might exhibit.

Reducing health provider stereotypes through undergraduate interprofessional education

Objective

Stereotypes among health professionals can jeopardize the delivery of collaborative healthcare and the achievement of positive patient outcomes. However, interprofessional education (IPE) can promote early clarification of roles, and understanding and mutual respect among trainees from different health disciplines. We studied the effects of IPE activities on the views and attitudes of pharmacy students toward nurse- and physician-trainees.

Methods

Pharmacy students completed a structured written reflection exercise immediately following two separate IPE activities with nursing and medical students, both oriented around diabetes care. We conducted an inductive content analysis of these texts to identify key themes according to the domains of the contact hypothesis theoretical framework: organizational authority, common goals, intergroup cooperation, equal group status and intergroup status. Pharmacy students were also asked how these IPE activities have influenced their views regarding their future pharmacy practice.

Results

Pharmacy students felt that their groups had cooperated to solve the common patient care goals in each IPE activity, and noted no distinction between the nursing and medical students. However, through either explicit or implicit negotiation of overlapping roles, many pharmacy students ultimately assumed deferential positions relative to medical students. Overall, pharmacy students' attitudes and views regarding the abilities and roles of nursing and medical students in patient care were favorably altered through the IPE activities. Notably, nurses' drug knowledge and diagnostic abilities of nurses and physicians' familiarity with the primary literature and prescribing regimens was previously under-rated but became recognized after IPE activities.

Conclusion

Pharmacy students' stereotypical views towards nursing and medical students were positively shifted when IPE activity conditions were optimized for intergroup contact.

An Integrated Two-Level Integer Linear Program (ILP) Model for Elective Surgery Scheduling: A Case Study in an Italian Hospital

The urban population is increasing worldwide. This demographic shift generates great pressure over public services, especially those related to health-care. One of the most expensive health-care services is surgery, and in order to contain this growing cost of providing better services, the efficiency of surgical centers must be improved. This work proposes an integer linear programming model (ILP) considering the case-mix planning (CMP) and the master surgical scheduling (MSS) problems. The case-mix planning problem deals with the planning of the number of operating rooms to be assigned to surgical specialties. The master surgical scheduling is related to when to assign the rooms to the different specialties. The developed model uses a data set from a hospital of the city of Turin, Italy. The results are very promising, showing a reduction from 240 weeks to 144 weeks to empty the surgical waiting list (WL). Moreover, if changes to the hospital situation are implemented, including the introduction of two new surgical teams into one of the hospital’s specialties, the time to empty the surgical WL could decrease to 79 weeks.

Ten-year tenure as a physician CEO at a Nordic university hospital: five lessons learnt

Background

I was a 42-year-old neurosurgeon with experience as department head when I took chair as chief executive officer (CEO) at the University Hospital of North Norway to lead a comprehensive organisational and financial restructuring. This article aims to develop lessons learnt during my 10-year tenure.

Methods

I restructured the organisation and hired a new executive team. We developed a new strategy and measures to implement it. I describe the results, a strategic disagreement that developed and my resignment, and reflect critically over my actions as a leader.

Results

Measures of safety and quality in clinical processes, cost-effectiveness and financial equity improved. We expedited investments in medical equipment, information technology and hospital facilities. Patient satisfaction was stable, but employees’ job satisfaction decreased. After 9 years, a politicised strategic disagreement with superior authorities developed. I was criticised for attempting to influence inappropriately, and resigned.

Lessons learnt

(1) Data-driven improvement works, but comes at a cost. Healthcare organisations should consider to prioritise resilience over efficiency. (2) It is inherently difficult to recognise when and how an issue changes from a professional to a political logic. I should have used contacts in politics and surveilled local media better. (3) During conflict, role clarity is crucial. (4) CEOs should be prepared to resign when strategically unaligned with superior authorities. (5) A CEO tenure should not last more than 10 years.

Conclusion

My experiences as a physician CEO was intense and immensely interesting, but some of the lessons were painfully learnt.

Explaing users' technology acceptance through national cultural values in the hospital context

Background

Current research demonstrates that health information technology can improve the efficiency and quality of health services. However, many implementation projects have failed due to behavioural problems associated with technology usages, such as underuse, resistance, sabotage, and even rejection by potential users. Therefore, user acceptance was one of the main factors contributing to the success of health information technology implementation. However, research suggests that behavioural models do not universally hold across cultures.

The present article considers national cultural values (power distance, uncertainty avoidance, individualism/collectivism, masculinity/femininity, and time orientation) as individual difference variables that affect user behaviour and incorporates them into the Technology Acceptance Model (TAM) as moderators of technology acceptance relationships. Therefore, this research analyses which national cultural values affect technology acceptance behaviour in hospitals.

Methods

The authors develop and test seven hypotheses regarding this relationship using the partial least squares (PLS) technique, a structural equation modelling method. The authors collected data from 160 questionnaires completed by clinicians and non-clinicians working in one hospital.

Results

The findings show that uncertainty avoidance, masculinity/femininity, and time orientation are the national cultural values that affect technology acceptance in hospitals. In particular, individuals with masculine cultural values, higher uncertainty avoidance, and a long-term orientation influence behavioural intention to use technology.

Conclusion

The bureaucratic model still decisively characterises the Italian health sector and consequently affects the choices of firms and workers, including the choice of technology adoption. Cultural values of masculinity, risk aversion, and long-term orientation affect intention to use through social norms rather than through perceived utility.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12913-022-07488-3.

The impact of work-place social capital in hospitals on patient-reported quality of care: a cohort study of 5205 employees and 23,872 patients in Denmark

BACKGROUND

Decision-makers increasingly consider patient-reported outcomes as important measures of care quality. Studies on the importance of work-place social capital-a collective work-place resource-for the experience of care quality are lacking. We determined the association between the level of work-place social capital and patient-reported quality of care in 148 hospital sections in the Capital Region of Denmark.

METHODS

This cross-sectional study combined section-level social capital from 5205 health care professionals and 23,872 patient responses about care quality. Work-place social capital encompassed three dimensions: trust, justice and collaboration. Patient-reported quality of care was measured as: overall satisfaction, patient involvement, and medical errors. Linear regression analysis and generalized linear models assessed the mean differences in patient reported experience outcomes and the risk of belonging to the lowest tertile of care quality.

RESULTS

A higher level of work-place social capital (corresponding to the interquartile range) was associated with higher patient-reported satisfaction and inpatient and acute care patient involvement. The risk of a section belonging to the lowest tertile of patient involvement was lower in sections with higher social capital providing inpatient (RR = 0.39, 0.19-0.81 per IQR increase) and acute care (RR = 0.53, 0.31-0.89). Patient-reported errors were fewer in acute care sections with higher social capital (RR = 0.65, 0.43 to 0.99). The risk of being in the lowest tertile of patient-reported satisfaction was supported for acute care sections (RR = 0.47, 0.28-0.79).

CONCLUSIONS

Although we found small absolute differences in the association between patient-reported experience measures and social capital, even a small upward shift in the distribution of social capital in the hospital sector would, at the population level, have a large positive impact on patients' care experience.

What matters to patients? A mixed method study of the importance and consideration of oncology patient demands

Background

A patient-centred approach is increasingly the mandate for healthcare delivery, especially with the growing emergence of chronic conditions. A relevant but often overlooked obstacle to delivering person-centred care is the identification and consideration of all demands based on individual experience, not only disease-based requirements. Mindful of this approach, there is a need to explore how patient demands are expressed and considered in healthcare delivery systems.

This study aims to: (i) understand how different types of demands expressed by patients are taken into account in the current delivery systems operated by Health Care Organisations (HCOs); (ii) explore the often overlooked content of specific non-clinical demands (i.e. demands related to interactions between disease treatments and everyday life).

Method

We adopted a mixed method in two cancer centres, representing exemplary cases of organisational transformation: (i) circulation of a questionnaire to assess the importance that breast cancer patients attach to every clinical (C) and non-clinical (NC) demand identified in an exploratory inquiry, and the extent to which each demand has been taken into account based on individual experiences; (ii) a qualitative analysis based on semi-structured interviews exploring the content of specific NC demands.

Results

Further to the way in which the questionnaires were answered (573 answers/680 questionnaires printed) and the semi-structured interviews (36) with cancer patients, results show that NC demands are deemed by patients to be almost as important as C demands (C = 6.53/7 VS. NC = 6.13), but are perceived to be considered to a lesser extent in terms of pathway management (NC = 4.02 VS C = 5.65), with a significant variation depending on the type of non-clinical demands expressed. Five types of NC demands can be identified: demands relating to daily life, alternative medicine, structure of the treatment pathway, administrative and logistic assistance and demands relating to new technologies.

Conclusions

This study shows that HCOs should be able to consider non-clinical demands in addition to those referring to clinical needs. These demands require revision of the healthcare professionals’ mandate and transition from a supply-orientated system towards a demand-driven approach throughout the care pathway. Other sectors have developed hospitality management, mass customisation and personalisation to scale up approaches that could serve as inspiring examples.

Practicing Integrated Care Pathways in Norwegian Hospitals: Coordination through Industrialized Standardization, Value Chains, and Quality Management or an Organizational Equivalent to Improvised Jazz Standards

The goal of coordinating pathways for cancer patients through their diagnostic and treatment journey is often approached by borrowing strategies from traditional industries, including standardization, process redesign, and variation reduction. However, the usefulness of these strategies is sometimes limited in the face of the complexity and uncertainty that characterize these processes over time and the situation at both patient and institutional levels. We found this to be the case when we did an in-depth qualitative study of coordination processes in patient pathways for three diagnoses in four Norwegian hospitals. What allows these hospitals to accomplish coordination is supplementing standardization with improvisation. This improvisation is embedded in four types of emerging semi-formal structures: collegial communities, networks, boundary spanners, and physical proximity. The hierarchical higher administrative levels appear to have a limited ability to manage and support coordination of these emerging structures when needed. We claim that this can be explained by viewing line management as representative of an economic-administrative institutional logic while these emerging structures represent a medical-professional logic that privileges proximity to the variation and complexity in the situations. The challenge is then to find a way for emergent and formal structures to coexist.

Assessing hospital performance indicators. What dimensions? Evidence from an umbrella review

BACKGROUND

Patients' increasing needs and expectations require an overall assessment of hospital performance. Several international agencies have defined performance indicators sets but there exists no unanimous classification. The Impact HTA Horizon2020 Project wants to address this aspect, developing a toolkit of key indicators to measure hospital performance. The aim of this review is to identify and classify the dimensions of hospital performance indicators in order to develop a common language and identify a shared evidence-based way to frame and address performance assessment.

METHODS

Following the PRISMA statement, PubMed, Cochrane Library and Web of Science databases were queried to perform an umbrella review. Reviews focusing on hospital settings, published January 2000-June 2019 were considered. The quality of the studies selected was assessed using the AMSTAR2 tool.

RESULTS

Six reviews ranging 2002-2014 were included. The following dimensions were described in at least half of the studies: 6 studies classified efficiency (55 indicators analyzed); 5 studies classified effectiveness (13 indicators), patient centeredness (10 indicators) and safety (8 indicators); 3 studies responsive governance (2 indicators), staff orientation (10 indicators) and timeliness (4 indicators). Three reviews did not specify the indicators related to the dimensions listed, and one article gave a complete definition of the meaning of each dimension and of the related indicators.

CONCLUSIONS

The research shows emphasis of the importance of patient centeredness, effectiveness, efficiency, and safety dimensions. Especially, greater attention is given to the dimensions of effectiveness and efficiency. Assessing the overall quality of clinical pathways is key in guaranteeing a truly effective and efficient system but, to date, there still exists a lack of awareness and proactivity in terms of measuring performance of nodes within networks. The effort of classifying and systematizing performance measurement techniques across hospitals is essential at the organizational, regional/national and possibly international levels to deliver top quality care to patients.

The superior service based on the highest number of visits and income of Hajj Hospital Surabaya in The National Health Insurance era

Background: A hospitals’ superior service is expected to be of higher value than other available provisions, which consequently differentiates the facility from others, as the branding easily attracts the community attention. The purpose of this study, therefore, is to identify the most needed and profitable health services from existing hospitals.

Design and methods: This was a descriptive research performed with a cross sectional study approach. The variables studied include the number of visits, and revenue based on National Health Insurance (JKN).

Results: Findings show that the polyclinics were the highest number of visits between 2016 and 2017 include Cardiac, Internal Medicine, Medical Rehabilitation, Nerve, General Surgery, and also Dental & Mouth. Conversely, those with the most significant income include Heart, Polyclinics, Dental & Mouth, as well as General Surgery Polyclinics. Moreover, the Medical Rehabilitation and Internal Medicine outpatient installations demonstrated negative INA income, while the already running featured Services in high demand were Heart, Nerve, Dental & Oral, and also General Surgery polyclinics.

Conclusions: In can be concluded that not all polyclinics with high traffic generate positive income, hence it is necessary to monitor and analyze National Health Insurance (JKN) monthly income.

Bureaucracy and the balanced scorecard in health care settings

PURPOSE

We explore the relationship between the balanced scorecard (BSC) and neo-bureaucracy by investigating whether the operationalization of the BSC incorporates "neo-bureaucratic" ideas and whether the BSC implemented in a Portuguese Local Health Unit (LHU) demonstrates a neo-bureaucratic approach.

DESIGN/METHODOLOGY/APPROACH

We conduct semi-structured interviews with LHU staff and analyse documents to assess whether features of bureaucratic organization were evident in the use of a BSC by the LHU.

FINDINGS

We found nine bureaucratic features evident in the LHU's BSC. These were systematization, rationality, authority, jurisdiction, professional qualification, knowledge, discipline, transparency and accountability. The BSC used at the LHU demonstrated a neo-bureaucratic approach.

ORIGINALITY/VALUE

Our study helps to demystify bureaucracy and overcome prevailing prejudices regarding some of its principles. Health care managers should recognize and endorse neo-bureaucratic principles in developing a BSC. They should recognize the BSC as involving a neo-bureaucratic approach. The BSC is a valuable management tool that hospital managers should find useful in fostering flexibility, collaboration, innovation and adaptation - all of which should help lead to improved healthcare outcomes.

Coopetition in healthcare: Heresy or reality? An exploration of felt outcomes at an intra-organizational level

This paper deals with coopetition in the healthcare sector, where in developed countries providers are experiencing a growing paradox between cooperation, as encouraged by authorities, and competition, in terms of resources or market share. Via comprehensive research methodology, we carry out a case study on a French Cancer Control Unit that simultaneously competes and cooperates with other local cancer treatment providers. We focus on different professional groups and their perceptions of coopetitive outcomes. Firstly, we show that different generic coopetitive situations exist and can be distinguished according to their degree of spontaneity, complementarity and value creation. Depending on these situations, felt outcomes differ from one professional group to another, highlighting that coopetition is a very complex reality and experienced differently by different individuals. Secondly, harmony created by coopetition is generally under-estimated, whereas it could be used as a catalyst to help managers implement coopetition.

Professional identity in community care: The case of specialist physicians in outpatient services in Italy

Due to changes in social and health needs, the reorganisation of health systems towards community and primary care requires the redefinition of different professional identities and practices. This paper focuses on the specialists in the system: the physicians who work in outpatient services (local health authorities, hospitals, and other institutions) not as dependents but under private contract. This doctor has to balance the professional culture (in terms of autonomy and indipendence of judgment) with the bureaucratic logic that rules the organisations for which he or she works. Our research objective was to identify the identity variables characterising the specialist doctor ("ideal profile") and analyse the extent to which these differed from the doctor's actual identity ("actual profile"). From a methodological perspective, 1) we used a consensus method approach to identify the variables that define the specialist's identity, and 2) using a national web survey, we checked the distance between such characteristics and these professionals' actual identities. Involving different experts in the field of primary care, we identified 27 identity variables that appear to be at the core of specialist expertise. We then asked a representative sample of specialists to indicate how important and feasible these variables were in their work contexts and identified four main factors characterising their identities. The results demonstrate that, among experts, there is a clear perception of the need to build an identity that is linked to integration and to adopt a heuristic approach through teamwork and networking. However, this differs considerably from the logic of the specialists working in outpatient services: What emerges is the perceived difficulty of operational translation due to organisational problems or, otherwise, the constitutive elements of professional identity.

Influence of Social Exchange Relationships on Affective Commitment and Innovative Behavior: Role of Perceived Organizational Support

The current study objective is to investigate how and when leader member exchange (LMX), tie strength, and innovative organizational culture influences employee innovative behavior. In particular, this study uses the social exchange theory to analyze that nurses who demonstrate high affective commitment exhibit a higher level of creativity in the workplace. Based on social exchange theory and perceived organizational support (POS) literature, the current study aims to reveal how perceived organizational support (POS) serves as an imperative mediating process between LMX, tie strength, innovative organizational culture, and employee IB. A questionnaire survey was utilized to collect the data from nurses working in public sector hospitals in Jiangsu province China. A total sample size consists of 325 nurses. Structural equation modeling through AMOS 20 was utilized to analyze the survey data. Results from the structural equation modeling (SEM) analysis indicated that LMX, tie strength, and POS are significantly related to affective commitment and employees’ IB. However, innovative organizational culture has a significant influence on POS and IB, but has no impact on affective commitment. This study covers only public sector hospitals and is limited to Jiangsu province, China. The research could be reproduced in other designated areas in different organizational setups with a bigger sample size to further enhance the understanding of the topic. The key understanding of social exchange theory (SET) is that social relationships can be used appropriately to foster an employee’s IB. It also expands research in the area of LMX, tie strength, innovative organizational culture, and POS as antecedents of affective commitment and IB. This study is a remarkable analysis of LMX, POS, organization culture, commitment, and IB in the Chinese organizational context.

Paradoxes of Practice Guidelines, Professional Expertise, and Patient Centeredness: The Medical Care Triangle

The coexistence of institutionalized evidence-based practice guidelines, professional expertise of medical practitioners, and the patient centeredness approach form a triangle. Each component of this Medical Care Triangle has characteristics that create paradoxes for health care professionals and their patients. The value of a paradox lies in uncovering and utilizing the contradiction to better understand the underlying organizational phenomenon. Method: Following Poole and van de Ven’s (1989) suggested approaches to resolving paradoxes, each paradox of the Medical Care Triangle is defined and analyzed. Results: A total of 10 paradoxes related to practice guidelines, professional expertise, and patient centeredness are revealed. The resolution of each paradox yields insights specific to structuring health care organizations in ways that support the delivery of medical care. Implications: The results renew an emphasis on the centrality of practitioners’ work processes to health care organizations; this has potential benefits for organizations, clinicians/employees, and patients.

Evaluating organizational change in health care: the patient-centered hospital model

BACKGROUND

An increasing number of hospitals react to recent demographic, epidemiological and managerial challenges moving from a traditional organizational model to a Patient-Centered (PC) hospital model. Although the theoretical managerial literature on the PC hospital model is vast, quantitative evaluations of the performance of hospitals that moved from the traditional to the PC organizational structure is scarce. However, quantitative analysis of effects of managerial changes is important and can provide additional argument in support of innovation.

METHODS

We take advantage of a quasi-experimental setting and of a unique administrative data set on the population of hospital discharge charts (HDCs) over a period of 9 years of Lombardy, the richest and one of the most populated region of Italy. During this period three important hospitals switched to the PC model in 2010, whereas all the others remained with the functional organizational model. This allowed us to develop a difference-in-difference analysis of some selected measures of efficiency and effectiveness for PC hospitals focusing on the "between-variability" of the 25 major diagnostic categories (MDCs) in each hospital and estimating a difference-in-difference model.

RESULTS

We contribute to the literature that addresses the evaluation of healthcare and hospital change by providing a quantitative estimation of efficiency and effectiveness changes following to the implementation of the PC hospital model. Results show that both efficiency and effectiveness have significantly increased in the average MDC of PC hospitals, thus confirming the need for policy makers to invest in new organizational models close to the principles of PC hospital structures.

CONCLUSIONS

Although an organizational change towards the PC model can be a costly process, implying a rebalancing of responsibilities and power among hospital personnel (e.g. medical and nursing staff), our results suggest that changing towards a PC model can be worthwhile in terms of both efficacy and efficiency. This evidence can be used to inform and sustain hospital managers and policy makers in their hospital design efforts and to communicate the innovation advantages within the hospital organizations, among the personnel and in the public debate.

Hospital centre performance dimensions and internal stakeholder valuation: a case study

Purpose

Hospital centres (HCs) are the result of a horizontal integration of two or more hospital units. The benefits of this integration have been presented in the literature. The purpose of this paper is to define the hospital performance dimensions most valued by HC internal stakeholders, and to evaluate if the importance given to each dimension is different when comparing professional groups.

Design/methodology/approach

An in-depth HC case study using a quantitative survey based on the Parsons’ social system action theory to achieve this goal was conducted which embraces the four major models of organizational performance. In the final version of the survey, 37 items were retained for analysis. An exploratory factor analysis was conducted for a final sample of 365 participants, through principal component analysis, with oblique rotation and the Kaiser criterion.

Findings

Four factors were retained: “Human resources development and Internal Processes”, “Attractiveness/Openness”, “Public service mission” and “Interpersonal relationships”. The means factor scores only reveal statistical differences between the attractiveness/openness factor and the remaining three factors. A shared view was found in this study among the three groups of internal stakeholders: physicians, caregivers and administrative staff.

Originality/value

The results of this study suggest that the HC performance concept should be expanded and performance measurement frameworks with a greater scope should be used. Interpersonal relationships, the human resources development and the public service are considered important dimensions for the performance measurement of the HC. Additionally, a consensual view regarding the most valued performance dimension could contribute to a beneficial and healthy working environment and improvements in HC performance.

Exploring "patient-centered" hospitals: a systematic review to understand change

Background

The healthcare scenario in developed countries is changing deeply: patients, who are frequently affected by multi-pathological chronic conditions, have risen their expectations. Simultaneously, there exist dramatic financial pressures which require healthcare organizations to provide more and better services with equal (or decreasing) resources. In response to these challenges, hospitals are facing radical transformations by bridging, redesigning and engaging their organization and staff.

Methods

This study has the ambitious aim to shed light and clearly label the trends of change hospitals are enhancing in developed economies, in order to fully understand the presence of common trends and which organizational models and features are inspiring the most innovative organizations. The purpose is to make stock of what is known in the field of hospital organization about how hospitals are changing, as well as of how such change may be implemented effectively through managerial tools. To do so the methodology adopted integrates a systematic literature review to a wider engaged research approach.

Results

Evidence suggests that the three main pillars of change of the system are given by the progressive patient care model, the patient-centered approach and the lean approach. However, there emerge a number of gaps in what is known about how to exploit drivers of change and their effects.

Conclusions

This study confirms that efforts in literature are concentrated in analyzing circumscribed experiences in the implementation of new models and approaches, failing therefore to extend the analysis at the organizational and inter-organizational level in order to legitimately draw consequences to be generalized. There seem to be a number of “gaps” in what is known about how to exploit drivers of change and their effects, suggesting that the research approach privileged till now fails in providing a clear guidance to policy makers and to organizations’ management on how to concretely and effectively implement new organizational models.

Electronic supplementary material

The online version of this article (doi:10.1186/s12913-017-2306-0) contains supplementary material, which is available to authorized users.

Improving care coordination using organisational routines

PURPOSE

The purpose of this paper is to systematically apply theory of organisational routines to standardised care pathways. The explanatory power of routines is used to address open questions in the care pathway literature about their coordinating and organising role, the way they change and can be replicated, the way they are influenced by the organisation and the way they influence health care professionals.

DESIGN/METHODOLOGY/APPROACH

Theory of routines is systematically applied to care pathways in order to develop theoretically derived propositions.

FINDINGS

Care pathways mirror routines by being recurrent, collective and embedded and specific to an organisation. In particular, care pathways resemble standard operating procedures that can give rise to recurrent collective action patterns. In all, 11 propositions related to five categories are proposed by building on these insights: care pathways and coordination, change, replication, the organisation and health care professionals. Research limitations/implications - The paper is conceptual and uses care pathways as illustrative instances of hospital routines. The propositions provide a starting point for empirical research.

PRACTICAL IMPLICATIONS

The analysis highlights implications that health care professionals and managers have to consider in relation to coordination, change, replication, the way the organisation influences care pathways and the way care pathways influence health care professionals. Originality/value - Theory on organisational routines offers fundamental, yet unexplored, insights into hospital processes, including in particular care coordination.

The role of the multidisciplinary health care team in the management of patients with Marfan syndrome

Marfan syndrome (MFS) is a rare, severe, chronic, life-threatening disease with multiorgan involvement that requires optimal multidisciplinary care to normalize both prognosis and quality of life. In this article, each key team member of all the medical disciplines of a multidisciplinary health care team at the Hamburg Marfan center gives a personal account of his or her contribution in the management of patients with MFS. The authors show how, with the support of health care managers, key team members organize themselves in an organizational structure to create a common meaning, to maximize therapeutic success for patients with MFS. First, we show how the initiative and collaboration of patient representatives, scientists, and physicians resulted in the foundation of Marfan centers, initially in the US and later in Germany, and how and why such centers evolved over time. Then, we elucidate the three main structural elements; a team of coordinators, core disciplines, and auxiliary disciplines of health care. Moreover, we explain how a multidisciplinary health care team integrates into many other health care structures of a university medical center, including external quality assurance; quality management system; clinical risk management; center for rare diseases; aorta center; health care teams for pregnancy, for neonates, and for rehabilitation; and in structures for patient centeredness. We provide accounts of medical goals and standards for each core discipline, including pediatricians, pediatric cardiologists, cardiologists, human geneticists, heart surgeons, vascular surgeons, vascular interventionists, orthopedic surgeons, ophthalmologists, and nurses; and of auxiliary disciplines including forensic pathologists, radiologists, rhythmologists, pulmonologists, sleep specialists, orthodontists, dentists, neurologists, obstetric surgeons, psychiatrist/psychologist, and rehabilitation specialists. We conclude that a multidisciplinary health care team is a means to maximize therapeutic success.

‘Black sheep in the herd’? The role, status and identity of generalist doctors in secondary care

Changing patient demographics raise important challenges for healthcare providers around the world. Medical generalists can help to bridge gaps in existing healthcare provision. Various approaches to medical generalism can be identified, for example, hospitalists in the US and the restructuring of care away from medical disciplines in the Netherlands, which have different implications for training and service provision. Drawing on international debates around the definition and role of generalism, this article explores one manifestation of generalism in the UK to understand how abstract ideas work in practice and some of the benefits and challenges. Broad-based training is a two-year postgraduate training programme for doctors recently piloted in England. The programme provided 6-month placements in four specialties (general practice, core medicine, psychiatry and paediatrics) and aimed to develop broad-based practitioners adept at managing complex and specialty integration. Our longitudinal, mixed methods evaluation of the programme demonstrates that although trainees value becoming more holistic in their medical practice, they also raise concerns about being perceived differently by co-workers, and report feeling isolated. Using identity theory to explore the interplay between generalism and existing boundaries of professionalism in healthcare provision, we argue that professional identity, based on disciplinary structure and maintained by boundary work, troubles identity formation for generalist trainees who transcend normative disciplinary boundaries. We conclude that it is important to address these challenges if generalism in secondary care settings is to realise its potential contribution to meeting increasing health service demands.

Where is the pilot? The changing shapes of governance in the European hospital sector

Hospital governance refers to the complex of checks and balances that determine how decisions are made within the top structures of hospitals. This article explores the essentials of the concept by analysing the root notion of governance and comparing it with applications in other sectors. Recent developments that put pressure on the decision-making system within hospitals are outlined. Examples from the UK, France and the Netherlands are presented.

Based on an evaluation of the current state of affairs, a research framework is developed, focusing on the determinants of governance configurations within the national healthcare systems and the wider legal and socio-economic context, as well as on the impact of governance configurations on the efficiency of the governing bodies and overall hospital performance.

The article concludes with a preview of the European Hospital Governance Project, which follows the outlines of the described research framework. New techniques of data mining that are used in this project are explained by means of a real data example.

Operational antecedents of integrated patient planning in hospitals

Purpose

– Hospitals struggle to integrate the planning from different departments; resulting in unacceptable waiting times for patients. The literature mainly addresses general, organizational factors inhibiting or enabling integration and omits important factors stemming from the care delivery process. Therefore, the purpose of this paper is to uncover operational antecedents and to assess their effect on the integration of hospital planning.

Design/methodology/approach

– The study is based on a three-hospital multi-case study. The main findings stem from over 40 in-depth interviews with specialists, nurses, planners, and managers of four specialties that are all involved in the orthopedic internal supply chain.

Findings

– This study identifies five critical operational antecedents: performance management, shared resources, information technology, process visibility, and uncertainty/variability. The latter two are of specific importance in a healthcare context. Three distinctive roles are identified; initiating (performance management and process visibility), facilitating (information technology), and inhibiting (shared resources and uncertainty/variability).

Practical implications

– The authors address how integration can be achieved, rather than merely prescribing integration as a means to improve performance. The identification of specific operational antecedents and their role help managers to find tangible ways to effectively integrate hospital planning which increases hospital performance.

Originality/value

– First, the identified operational antecedents are essential supplementary factors to more common organizational and behavioral antecedents. Second, in contrast to earlier contributions the authors show the effects of antecedents on three different stages of integration, rather than on integration in general.

Making doctors manage… but how? Recent developments in the Italian NHS

Background

Involving doctors in management has been intended as one of the strategies to spread organizational principles in healthcare settings. However, professionals often resist taking on relevant managerial responsibility, and the question concerning by which means to engage doctors in management in a manner that best fit the challenges encountered by different health systems remains open to debate.

Methods

This paper analyzes the different forms of medical management experienced over time in the Italian NHS, a relevant “lab” to study the evolution of the involvement of doctors in management, and provides a framework for disentangling different dimensions of medical management.

Results

We show how new means to engage frontline professionals in management spread, without deliberate planning, as a consequence of the innovations in service provision that are introduced to respond to the changes in the healthcare sector.

Conclusions

This trend is promising because such means of performing medical management appear to be more easily compatible with professional logics; therefore, this could facilitate the engagement of a large proportion of professionals rather than the currently limited number of doctors who are “forced” or willing to take formal management roles.

How to achieve care coordination inside health care organizations: Insights from organization theory on coordination in theory and in action

Understanding how health care organizations can achieve care coordination internally is essential because it is difficult to achieve, but essential for high-quality and efficient health care delivery. This article offers an answer by providing a synthesis of knowledge about coordination from organization theory, where coordination is a central research topic. The article focuses on intra-organizational coordination, which is challenging especially across boundaries such as departments or professions. It provides an overview of the classic coordination mechanisms, e.g., standardization of work processes, but also of recent insights that have identified the conditions that are required to achieve coordination, and how these conditions can be provided by formal mechanisms, such as standardization, but also informally by drawing on features of the emerging situation. Such research highlights the contribution of, e.g., routines like those guided by care pathways or of artifacts like displays. The coordination insights are also discussed as regards inter-organizational care coordination.

Comparative Quality Indicators for Hospital Choice: Do General Practitioners Care?

Context

The strategy of publicly reporting quality indicators is being widely promoted through public policies as a way to make health care delivery more efficient.

Objective

To assess general practitioners’ (GPs) use of the comparative hospital quality indicators made available by public services and the media, as well as GPs’ perceptions of their qualities and usefulness.

Method

A telephone survey of a random sample representing all self-employed GPs in private practice in France.

Results

A large majority (84.1%–88.5%) of respondents (n = 503; response rate of 56%) reported that they never used public comparative indicators, available in the mass media or on government and non-government Internet sites, to influence their patients’ hospital choices. The vast majority of GPs rely mostly on traditional sources of information when choosing a hospital. At the same time, this study highlights favourable opinions shared by a large proportion of GPs regarding several aspects of hospital quality indicators, such as their good qualities and usefulness for other purposes. In sum, the results show that GPs make very limited use of hospital quality indicators based on a consumer choice paradigm but, at the same time, see them as useful in ways corresponding more to the usual professional paradigms, including as a means to improve quality of care.

Reorganising hospitals to implement a patient-centered model of care

Purpose

– The purpose of this paper is to understand how the introduction of a patient-centered model (PCM) in Italian hospitals affects the pre-existent configuration of clinical work and interacts with established intra/inter-professional relationships.

Design/methodology/approach

– Qualitative multi-phase study based on three main sources: health policy analysis, an exploratory interview study with senior managers of eight Italian hospitals implementing the PCM, and an in-depth case study that involved managerial and clinical staff of one Italian hospital implementing the PCM.

Findings

– The introduction of the PCM challenges clinical work and professional relationships, but such challenges are interpreted differently by the organisational actors involved, thus giving rise to two different “narratives of change”. The “political narrative” (the views conveyed by formal policies and senior managers) focuses on the power shifts and conflict between nurses and doctors, while the “workplace narrative” (the experiences of frontline clinicians) emphasises the problems linked to the disruption of previous discipline-based inter-professional groups.

Practical implications

– Medical disciplines, rather than professional groupings, are the main source of identification of doctors and nurses, and represent a crucial aspect of clinicians’ professional identity. Although the need for collaboration among medical disciplines is acknowledged, creating multi-disciplinary groups in practice requires the sustaining of new aggregators and binding forces.

Originality/value

– This study suggests further acknowledgment of the inherent complexity of the political and workplace narratives of change rather than interpreting them as the signal of irreconcilable perspectives between managers and clinicians. By addressing the specific issues regarding which the political and workplace narratives clash, relationship of trust may be developed through which problems can be identified, mutually acknowledged, articulated, and solved.

Organizational development trajectory of a large academic radiotherapy department set up similarly to a prospective clinical trial: the MAASTRO experience

Objective:

To simultaneously improve patient care processes and clinical research activities by starting a hypothesis-driven reorganization trajectory mimicking the rigorous methodology of a prospective clinical trial.

Methods:

The design of this reorganization trajectory was based on the model of a prospective trial. It consisted of (1) listing problems and analysing their potential causes, (2) defining interventions, (3) defining end points and (4) measuring the effect of the interventions (i.e. at baseline and after 1 and 2 years). The primary end point for patient care was the number of organizational root causes of incidents/near incidents; for clinical research, it was the number of patients in trials. There were several secondary end points. We analysed the data using two sample z-tests, χ² test, a Mann–Whitney U test and the one-way analysis of variance with Bonferroni correction.

Results:

The number of organizational root causes was reduced by 27% (p < 0.001). There was no effect on the percentage of patients included in trials.

Conclusion:

The reorganizational trajectory was successful for the primary end point of patient care and had no effect on clinical research. Some confounding events hampered our ability to draw strong conclusions. Nevertheless, the transparency of this approach can give medical professionals more confidence in moving forward with other organizational changes in the same way.

Advances in knowledge:

This article is novel because managerial interventions were set up similarly to a prospective clinical trial. This study is the first of its kind in radiotherapy, and this approach can contribute to discussions about the effectiveness of managerial interventions.

Defining hospital's internal boundaries. An organisational complexity criterion

The aim of this paper is to provide empirical evidences supporting the definition of hospital wards' boundaries in organisational designing processes, by suggesting services aggregation criteria that are focused on organisational complexity. In order to test the research hypotheses, a panel data analysis was conducted on Lombardy hospitals in Italy. Information was gathered both from administrative records - aggregated at in-patient ward level - and general registry offices. The results highlight that the wards offering integrated services perform better than those that are more specialised. However, for growing levels of within-complexity, the positive effects of formal integration between wards tend to reduce. Some guidelines for practitioners engaged in defining hospitals' organisational structures can be drawn from the empirical analysis.

A framework to analyze hospital-wide patient flow logistics: evidence from an Italian comparative study

Through a comparative study of six Italian hospitals, the paper develops and tests a framework to analyze hospital-wide patient flow performance. The framework adopts a system-wide approach to patient flow management and is structured around three different levels: (1) the hospital, (2) the pipelines (possible patient journeys within the hospital) and (3) the production units (physical spaces, such as operating rooms, where service delivery takes places). The focus groups and the data analysis conducted within the study support that the model is a useful tool to investigate hospital-wide implications of patient flows. The paper provides also evidence about the causes of hospital patient flow problems. Particularly, while shortage of capacity does not seem to be a relevant driver, our data shows that patient flow variability caused by inadequate allocation of capacity does represent a key problem. Results also show that the lack of coordination between different pipelines and production units is critical. Finally, the problem of overlapping between elective and unscheduled cases can be solved by setting aside a certain level of capacity for unexpected peaks.

Hospital process orientation from an operations management perspective: development of a measurement tool and practical testing in three ophthalmic practices

BACKGROUND

Although research interest in hospital process orientation (HPO) is growing, the development of a measurement tool to assess process orientation (PO) has not been very successful yet. To view a hospital as a series of processes organized around patients with a similar demand seems to be an attractive proposition, but it is hard to operationalize this idea in a measurement tool that can actually measure the level of PO. This research contributes to HPO from an operations management (OM) perspective by addressing the alignment, integration and coordination of activities within patient care processes. The objective of this study was to develop and practically test a new measurement tool for assessing the degree of PO within hospitals using existing tools.

METHODS

Through a literature search we identified a number of constructs to measure PO in hospital settings. These constructs were further operationalized, using an OM perspective. Based on five dimensions of an existing questionnaire a new HPO-measurement tool was developed to measure the degree of PO within hospitals on the basis of respondents' perception. The HPO-measurement tool was pre-tested in a non-participating hospital and discussed with experts in a focus group. The multicentre exploratory case study was conducted in the ophthalmic practices of three different types of Dutch hospitals. In total 26 employees from three disciplines participated. After filling in the questionnaire an interview was held with each participant to check the validity and the reliability of the measurement tool.

RESULTS

The application of the HPO-measurement tool, analysis of the scores and interviews with the participants resulted in the possibility to identify differences of PO performance and the areas of improvement--from a PO point of view--within each hospital. The result of refinement of the items of the measurement tool after practical testing is a set of 41 items to assess the degree of PO from an OM perspective within hospitals.

CONCLUSIONS

The development and practically testing of a new HPO-measurement tool improves the understanding and application of PO in hospitals and the reliability of the measurement tool. The study shows that PO is a complex concept and appears still hard to objectify.