Modularizing specialized hospital services

The impacts of the combination service model of cardiac rehabilitation on patient outcomes: evidence from a hospital experience

This research is to test whether the combination model (CM) (combining cardiac rehabilitation (CR) with other cardiovascular medical services) impact patients' readmissions, physical and psychological outcomes. We found that CM significantly enhances patients' exercise ability and psychological condition and reduces readmission rates after discharged from the hospital, compared to patients that are admitted to non-CM. Departments' physical resources weaken the impact of CM on patients' physical outcomes and readmission rates while increasing patients' psychological conditions. Human resources strengthen the impact of CM on patients' readmission rates while reducing the impact on patients' physical outcomes. Our results provide empirical evidence for hospital resource constraints puzzle and reallocation. These results provide a possibility of introducing CM as a way to deal with CR implementing challenges.

Service design in healthcare: a segmentation-based approach

Purpose

The study aims to explore how segmentation as a methodology can be adapted to the healthcare context to provide a more nuanced understanding of the served population and to facilitate the design of patient-centric services.

Design/methodology/approach

The study was based on a collaborative project with a national healthcare organization following the principles of action design research. The study describes the quantitative segmentation performed during the project, followed by a qualitative interview study of how segments correspond with patient behaviors in an actual healthcare setting, and service design workshops facilitated by segments. A number of design principles are outlined based on the learnings of the project.

Findings

The segmentation approach increased understanding of patient variability within the service provider organization and was considered an effective foundation for modular service design. Patient characteristics and life circumstances were related to specific patterns of health behaviors, such as avoidance or passivity, or a persistent proactivity. These patterns influenced the patients' preferred value co-creation role and what type of support patients sought from the care provider.

Practical implications

The proposed segmentation approach is immediately generalizable to further healthcare contexts and similar services: improved understanding of patients, vulnerable patients in particular, improves the fit and inclusivity of services.

Originality/value

The segmentation approach to service design was demonstrated to be effective in a large-scale context. The approach allows service providers to design service options that improve the fit with individual patients' needs for support and autonomy. The results illuminate how patient characteristics influence health and value co-creation behaviors.

Service modularity in e-learning programs: an analysis from the perceived usefulness perspective

Purpose

This study investigates the effects of service modularity on the perceived usefulness (PU) of e-learning programs through the perceived ease of use (PEoU) and service customization.

Design/methodology/approach

Structural equation modeling was used to test four hypotheses with survey data from 517 undergraduates in Turkey.

Findings

Results show that service modularity affects the PU of e-learning programs through the PEoU. Service customization negatively moderates the effect of service modularity on the PEoU, but positively moderates the effect of the PEoU on the PU of e-learning programs.

Practical implications

This study offers insights that support the decisions of policymakers and higher education institutions on how to design appealing e-learning programs cost-effectively.

Social implications

This study reveals the determinants of the PU of e-learning, which could support the democratization of access to higher education in emerging countries where barriers to higher education are relatively greater than in developed countries.

Originality/value

The concept of service modularity is explored in the e-learning context from the students' perspective. This study shows that the standardized interfaces across course modules increase the PU of e-learning programs by improving the ease of use. It also shows, interestingly, that service customization, enabled by modularity, is not always appreciated by service consumers, because of the potential extra effort demanded in communicating their unique needs to service providers.

Improving Customisation in Clinical Pathways by Using a Modular Perspective

A standardised system of clinical pathways often conflicts with providing patient-centred heterogeneous care. Mental health care organisations are searching for new methods to become responsive towards unique treatment needs. Modularity is a method increasingly suggested to reconcile standardisation and customisation. The aim is to investigate the extent to which modularity can be applied to make clinical pathways in specialist mental health care more flexible in order to stimulate shared decision making (SDM) and thereby customise care processes to patient contexts while maintaining evidence-based standards. Methods consist of literature research and a theory-based case study including document analysis and semi-structured interviews, which were performed at a Dutch specialist mental health care organisation. The results show that in current literature two modularity-based structures are proposed that support flexibility and customisation, i.e., ‘Prototype’ and ‘Menu-based’. This study reveals that departments tend to use the prototype method if they have predictable patient needs, evidence-based methods are available and there is sequency in treatment components. The menu-based method is preferred if there are unpredictable needs, or the evidence needed to create interconnectedness in treatment is lacking. In conclusion, prototype or menu-based methods are both suitable for applying SDM and reaching customisation in practice. The choice is determined by three characteristics: predictability of needs, availability of evidence and the interconnectedness of treatment components.

Exploring enablers of modularity in healthcare service delivery

Purpose

This paper explores the enablers of modular healthcare services.

Design/methodology/approach

A survey-based approach was adopted with specialised hospitals as the unit of analysis. A structural model was developed based on a literature review and assessed using a cross-sectional research design. A 23-indicator questionnaire was circulated among service providers in the healthcare system across India, and 286 valid responses were received. The data were analysed using partial least squares-structural equation modeling (PLS-SEM).

Findings

The results reveal that professional competence, technological versatility, clear division of tasks, channelised flow of information and professional autonomy act as enablers that may drive modular service delivery.

Research limitations/implications

By examining service providers' perspectives, this paper highlights the influence of the identified enablers on modular service delivery in healthcare organisations.

Practical implications

For practitioners, the study provides suggestions for designing patient-centric healthcare services via modular healthcare delivery. The identified structural relationships can facilitate immediate corrective actions and the formulation of future policies. The findings will help practitioners foresee opportunities for patient participation in value co-creation, meet patients' varying needs, decompose service offerings, mix and match components develop sets of rules as interfaces between service modules and design service packages on an ongoing basis.

Social implications

This study underscores the emergence of patient-centric care and may aid the design of processes that deliver health to the patient as a person.

Originality/value

This paper identifies and empirically validates relationships between healthcare service delivery processes and modular service delivery.

Current developments in delivering customized care: a scoping review

BACKGROUND

In recent years, there has been a growing interest in health care personalization and customization (i.e. personalized medicine and patient-centered care). While some positive impacts of these approaches have been reported, there has been a dearth of research on how these approaches are implemented and combined for health care delivery systems. The present study undertakes a scoping review of articles on customized care to describe which patient characteristics are used for segmenting care, and to identify the challenges face to implement customized intervention in routine care.

METHODS

Article searches were initially conducted in November 2018, and updated in January 2019 and March 2019, according to Prisma guidelines. Two investigators independently searched MEDLINE, PubMed, PsycINFO, Web of Science, Science Direct and JSTOR, The search was focused on articles that included "care customization", "personalized service and health care", individualized care" and "targeting population" in the title or abstract. Inclusion and exclusion criteria were defined. Disagreements on study selection and data extraction were resolved by consensus and discussion between two reviewers.

RESULTS

We identified 70 articles published between 2008 and 2019. Most of the articles (n = 43) were published from 2016 to 2019. Four categories of patient characteristics used for segmentation analysis emerged: clinical, psychosocial, service and costs. We observed these characteristics often coexisted with the most commonly described combinations, namely clinical, psychosocial and service. A small number of articles (n = 18) reported assessments on quality of care, experiences and costs. Finally, few articles (n = 6) formally defined a conceptual basis related to mass customization, whereas only half of articles used existing theories to guide their analysis or interpretation.

CONCLUSIONS

There is no common theory based strategy for providing customized care. In response, we have highlighted three areas for researchers and managers to advance the customization in health care delivery systems: better define the content of the segmentation analysis and the intervention steps, demonstrate its added value, in particular its economic viability, and align the logics of action that underpin current efforts of customization. These steps would allow them to use customization to reduce costs and improve quality of care.

Identifying and categorising knowledge reuse activities in electronic repositories

Purpose

Knowledge reuse using electronic repositories, while increasingly important, requires more thorough analysis. Service modularity has been recently applied in services research but has not been integrated into knowledge reuse studies. The purpose of this paper is to draw on both service modularity and knowledge reuse to develop and validate a framework that categorises forms of packaged knowledge in an electronic repository.

Design/methodology/approach

Drawing on knowledge reuse and service modularity research, a model is proposed. The model is empirically tested using a case study research design.

Findings

This research highlighted the value of including both context and process as key dimensions when packaging service knowledge for reuse. This study identifies knowledge types present in modular solutions and how they were configured and reconfigured in the knowledge repository. This research identified five ways modularised services were leveraged. In addition to the traditional scale and stretch approaches, already present, but conflated, in the service literature, three other configurations were identified; shrink, separate and segment.

Research limitations/implications

The findings are based on a single empirical case study which may limit the generalisability of the findings. There is a need for additional research to further validate the model in additional contexts.

Practical implications

This study provides managers with empirical examples of how a modular repository was used in practice and outlines five ways of recombining contextual and processual elements to enable service codification and reuse. It has implications for how knowledge is decomposed and recombined in repositories, suggesting an explicit separation of context and process knowledge while developing modular elements within both.

Originality/value

To the best of the author’s knowledge, this is the first study that explicitly uses context and process as dimensions and draws on service modularity to understand types of knowledge reuse in electronic repositories. In doing so, it adds value by developing and validating a model that identifies five types of reuse.

Providing person-centered care for patients with complex healthcare needs: A qualitative study

Background

People with chronic conditions have complex healthcare needs that lead to challenges for adequate healthcare provision. Current healthcare services do not always respond adequately to their needs. A modular perspective, in particular providing visualization of the modular service architecture, is promising for improving the responsiveness of healthcare services to the complex healthcare needs of people with chronic conditions. The modular service architecture provides a comprehensive representation of the components and modules of healthcare provision. In this study, we explore this further in a qualitative multiple case study on healthcare provision for children with Down syndrome in the Netherlands.

Methods

Data collection for four cases involved 53 semi-structured interviews with healthcare professionals and 21 semi-structured interviews with patients (the parents of children with Down syndrome as proxy). In addition, we gathered data by means of practice observations and analysis of relevant documents. The interviews were audio-recorded, transcribed verbatim and analyzed utilizing the Miles and Huberman approach.

Results

Our study shows that the perspectives on healthcare provision of professionals and patients differ substantially. The visualization of the modular service architecture that was based on the healthcare professionals’ perspective provided a complete representation of (para)medical outcomes relevant to the professionals’ own discipline. In contrast, the modular service architecture based on the patients’ perspective, which we define as a person-centered modular service architecture, provided a representation of the healthcare service that was primarily based on functional outcomes and the overall wellbeing of the patients.

Conclusion

Our study shows that visualization of the modular service architecture can be a useful tool to better address the complex needs and requirements of people with a chronic condition. We suggest that a person-centered modular service architecture that focuses on functional outcomes and overall wellbeing, enables increased responsiveness of healthcare services to people with complex healthcare needs and provision of truly person-centered care.

Elaborating on modular interfaces in multi-provider contexts

Purpose

This study examines how modular interfaces manifest in multi-provider contexts and how they can improve coordination and customization of services. The aim of the study is to describe interfaces in multi-provider contexts and elaborate on how they support the delivery of integrated patient care.

Design/methodology/approach

A qualitative, multiple case study was conducted in two multi-provider contexts in healthcare services: one representing paediatric Down syndrome care in the Netherlands and one representing home care for the elderly in Finland. Data collection involved semi-structured interviews in both contexts.

Findings

This study provides insight into several types of interfaces and their role in multi-provider contexts. Several inter- and intra-organizational situations were identified in which the delivery of integrated patient care was jeopardized. This study describes how interfaces can help to alleviate these situations.

Originality/value

This study deepens the understanding of interfaces in service modularity by describing interfaces in multi-provider contexts. The multi-provider contexts studied inspired to incorporate the inter-organizational aspect into the literature on interfaces in service modularity. This study further develops the typology for interfaces in modular services by adding a third dimension to the typology, that is, the orientation of interfaces.

Designing, writing-up and reviewing case study research: an equifinality perspective

Purpose

Several researchers struggle with designing, writing-up and reviewing case study research, but constructing a template for describing and justifying methodological choices is – in contrast with quantitative research – undesirable due to the creative nature of qualitative research. Therefore, the purpose of this paper is to provide insight into the multitude of paths to rigorous case study research and promote rigorous case study research in the service community.

Design/methodology/approach

Based upon a review of seminal articles and textbooks, different paths to rigorous case study research are identified. Subsequently, these paths are compared with existing practices in case studies in service research published between March 2017 and April 2019.

Findings

Seminal articles and textbooks detail different paths to achieve rigor with regard to research purpose, design, data, analyses and write-up. Overall, the most popular paths in the service community are those proposed by Eisenhardt and Yin. Meanwhile, service researchers increasingly challenge the dichotomy between the inductive and deductive logic by choosing an abductive logic. Transparency and reflexivity are the main points of attention among service researchers doing case study research.

Originality/value

By providing insight into the multitude of paths to rigorous case study research along with their popularity in the service community, this paper helps service researchers to balance rigor and creativity when engaging in case study research. Additionally, this paper offers a framework for reviewing case study research in terms of rigor and creativity.

Modular service provision for heterogeneous patient groups: a single case study in chronic Down syndrome care

Background

Service modularity could be promising for organizing healthcare delivery to heterogeneous patient groups because it enables cost reductions while also being responsive towards individual patients’ needs. However, no research on the applicability of modularity in this context exists. To this end, we conducted a qualitative single-case study on chronic healthcare provision for Down syndrome patients, delivered by multidisciplinary pediatric Downteams in the Netherlands, from a modular perspective.

Methods

We conducted six semi-structured interviews with coordinators of multidisciplinary Downteams in six hospitals. In addition, we gathered data by means of observations and analysis of relevant documentation. We transcribed, coded, and analyzed the interviews utilizing the Miles and Huberman approach. The consolidated criteria for reporting qualitative research (COREQ) were applied in this study.

Results

In all six Downteams studied, the modular package for Down syndrome patients (i.e. the visit to the Downteams) could clearly be divided into modules (i.e. the separate consultations with the various professionals), and into different components (i.e. sub-elements of these consultations). These modules and components were linked by different types of customer-flow and information-flow interfaces. These interfaces allowed patients to flow smoothly through the system and allowed for information transfer, respectively.

Conclusion

Our study shows a modular perspective is applicable to analyzing chronic healthcare for a heterogeneous patient group like children with Down syndrome. The decomposition of the various Downteams into modules and components led to mutual insight into each other’s professional practices, both within and across the various Downteams studied. It could be used to increase transparency of delivered care for patients and family. Moreover, it could be used to customize care provision by mixing-and-matching components. More detailed research on chronic modular care provision for patients with DS is needed to explore this.

Comparing modular and personal service delivery in specialised outpatient care: A survey of haematology and oncology patient preferences

Background

Oncology and haematology are shifting from inpatient to outpatient care, requiring new care delivery models. This study compares preferences of oncology patients treated by named nurses in a traditional specialty-focused day hospital and haematology patients treated without named nurses in a modularised day hospital.

Methods

Questionnaires to explore patient preferences on number of treating nurses and named nurses, and satisfaction in day hospital care were distributed to 300 haematology and 410 oncology patients. Binomial logistic regressions were performed to study how background variables influenced preferences for having (i) a named nurse or (ii) maximum three treating nurses in the day hospital.

Results

In 2016, 156 (52%) haematology and 289 (70%) oncology surveys were completed and returned. Both groups were satisfied with day hospital care. Haematology patients preferred named nurses less often than oncology patients (odds ratio (OR) = 0.09, p < 0.0005). Haematology patients were less likely to prefer a maximum of three treating nurses (OR = 0.12, p < 0.0005).

Conclusion

This study suggests that patients can be satisfied with outpatient care with or without named nurses. However, as several factors affect patient satisfaction and experience, more in-depth research is needed to understand how modularisation and patient preferences may be linked.

Improving service in an emergency department by designing the health production flow

Background

Most emergency departments have overcapacity with poor service measured by length of stay. We hypothesized that a formal design of the emergency department production flows will improve service. Thus, we propose a methodology that was tested in a large hospital, including new flow implementation.

Results

We implemented new workflows during June to July 2017. A comparison of the patients’ average length of stay from June to September shows a decrease of 26%. Additionally, a comparison with 2016 shows a decrease of 50%. Direct evaluation of the value generated reveals an emergency department admissions increase of 540 monthly, equivalent of a savings of approximately US$250.000 annually. This savings is a very conservative estimate because the most significant value of this work is fast service that diminishes the patients’ risks.

Conclusions

Production design is an important problem in health services in terms of potential service improvements, executable with a formal, systemic, replicable method founded on several disciplines. Thus, we are replicating the approach at other hospitals with extensions to other services.

Service modularity in managing healthcare logistics

Purpose

The purpose of this paper is to examine how modularity is used for enabling value creation in managing healthcare logistics services.

Design/methodology/approach

Material logistics of four different kinds of hospitals is examined through a qualitative case study. The theoretical framework builds on the literature on healthcare logistics, service modularity and value creation.

Findings

The case hospitals have developed their material logistics independently from others when looking at the modularity of offerings, processes and organisations. Services, such as assortment management, shelving and developing an information platform, have been performed in-house partly by the care personnel, but steps towards modularised and standardised solutions are now being taken in the case hospitals, including ideas about outsourcing some of the services.

Research limitations/implications

This paper proposes seven modularity components for healthcare logistics management: segmentation, categorisation and unitisation of offerings, differentiation and decoupling of processes, and centralisation and specialisation of organisations. Thus, this study clarifies the three-dimensional concept of modularity as a cognitive frame for managing logistics services with heterogeneous customer needs in a rapidly changing healthcare environment.

Practical implications

Modularity offers a tool for developing logistics services inside the hospital and increases possibilities to consider also external logistics service providers.

Social implications

Managing healthcare logistics services through modularity has potential social implications in developing healthcare processes and changing the usage of health services. On a wider scale, modularity is helping healthcare systems reaching their goals in terms of service quality and cost.

Originality/value

This paper shows the context-specific antecedents of service modularity and the usage of modular thinking in managing healthcare logistics.

Modularising outpatient care delivery: A mixed methods case study at a Finnish University Hospital

BACKGROUND

Modularisation is a potential means to develop health care delivery by combining standardisation and customisation. However, little is known about the effects of modularisation on hospital care. The objective was to analyse how modularisation may change and support health care delivery in specialised hospital care.

METHODS

A mixed methods case study methodology was applied using both qualitative and quantitative data, including interviews, field notes, documents, service usage data, bed count and personnel resource data. Data from a reference hospital's unit were used to understand the context and development of care delivery in general.

RESULTS

The following outcome themes were identified from the interviews: balance between demand and supply; support in shift from inpatient to outpatient care; shorter treatment times and improved management of service production. Modularisation supported the shift from inpatient towards outpatient care. Changes in resource efficiency measures were both positive and negative; the number of patients per personnel decreased, while the number of visits per personnel and the bed utilisation rate increased.

CONCLUSIONS

Modularisation may support health care providers in classifying patients and delivering services according to patients' needs. However, as the findings are based on a single university hospital case study, more research is needed.

Service modularity and architecture – an overview and research agenda

Purpose

Services are highly important in a world economy which has increasingly become service driven. There is a growing need to better understand the possibilities for, and requirements of, designing modular service architectures. The purpose of this paper is to elaborate on the roots of the emerging research stream on service modularity, provide a concise overview of existing work on the subject, and outline an agenda for future research on service modularity and architecture. The articles in the special issue offer four diverse sets of research on service modularity and architecture.

Design/methodology/approach

The paper is built on a literature review mapping the current body of literature on the topic and developing future research directions in service modularity and architecture.

Findings

The growing focus on services has triggered needs to investigate the suitability and implementation of physical-product-focused modularity principles and theories in service contexts, and to search for principles/theories that enhance services. The expanding research stream has explored various aspects of service modularity in empirical contexts. Future research should focus on service-specific modularity theories and principles, platform-based and mass-customized service business models, comparative research designs, customer perspectives and service experience, performance in context of modular services, empirical evidence of benefits and challenges, architectural innovation in services, modularization in multi-provider contexts, and modularity in hybrid offerings combining service and tangible product modules.

Originality/value

Nine areas are recommended for further research on service modularity and architecture. The introductory piece also discusses the roots of service modularity and provides an overview of current contributions.