Hospital Process Orientation From An Operations Management Nursing Essay

Published Date: 23 Mar 2015

Hospitals are aligning and integrating their care processes horizontally in order to meet the modern market requirements. An approach to achieve this is to become more process-oriented. Process orientation (PO) means focusing on begin-to-end processes instead of placing emphasis on functional and hierarchical structures. Although research interests in hospital PO are growing, no research has been directed towards a systematic development of a measurement tool to assess PO from an operations management (OM) perspective by addressing the alignment, integration and coordination of activities within patient care processes.

Objectives. -To identify and operationalize constructs to measure PO in hospitals in OM terms and develop and practically test a new measurement tool for Hospital Process Orientation Operationalization (HPOO).

Design. -Multicenter, exploratory case studies.

Setting. -Ophthalmic practices of three different types of Dutch hospitals: one large university hospital, one large eye specialty hospital and one large general hospital.

Participants. -A total of 26 participants from three disciplines: management, team leaders and health care professionals/ophthalmologists.

Results. -39 items distributed over the five dimensions of an existing instrument were formulated to create the new HPOO measurement tool to assess and measure the degree of PO within hospitals. The application of the HPOO measurement tool, the 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 the refinement of the measurement tool/items after practical testing is a set of 41 items (2 new items were added after testing) to measure the degree of PO from an OM perspective within hospitals.

Conclusions. -By developing and practically testing a new and more reliable measurement tool, this research improves the understanding and application of PO in hospitals. In addition, this research identifies specific future research directions to objectify the assessment and measurement of PO in hospitals.

Keywords. - Health services, Business Process Management, hospital process orientation, measurement tool, operations management

Introduction

Hospitals face increasing pressure to reduce costs, improve operations and provide evidence of the quality and efficiency of their organizations (Mango & Shapiro 2001, Kujala et al. 2006). This dramatic change has led to an increasingly competitive health care industry (Swayne et al. 2008). As competition intensifies, service quality, patient satisfaction and efficient resource management are turning into important indicators for healthcare delivery performance (McDermott & Stock 2007, Cowing et al. 2009). As a result, healthcare organizations have started to adopt many of the management principles and techniques that originate from the manufacturing and service industries to respond to and meet the modern healthcare market demands (Walston 2004, Langabeer 2009, Hellström et al. 2010). An example of the adopted techniques is business process management (BPM), and its associated managerial practices such as business process reengineering (BPR) and business process orientation (BPO). BPM is a best practice management principle that helps companies sustain competitive advantage by improving business processes and ensuring that the critical activities that affect customer satisfaction are executed in the most effective and efficient manner (Hung 2006).

From an operations management (OM) perspective, process management involves the design, control, improvement and redesign of processes (Silver 2004) and it consists of:

BPO efforts: to view, map and manage business processes by creating a management structure for the processes that span across departments and by harnessing mechanisms for continuous improvement (Hellström & Eriksson 2008, Armistead & Machin 1997);

BPR efforts: to incrementally or radically change processes by identifying and taking advantage of value creation opportunities to optimize productivity by increasing throughput of a process (volume or throughput time), reducing costs and/or variability (Childe et al. 1994, Langabeer II 2008).

Regardless of whether the organization is applying the BPM concept for the purpose of BPO or BPR, it is concerned with the management of its business processes (Armistead & Machin 1997, Kohlbacher & Gruenwald 2011). As organizations accumulate efforts in process management and process improvements, they gain experience and become more process-oriented. This implicates that the process-oriented approach in some organizations will be more mature than others. But how can a hospital identify whether it is process-oriented or not? And how can a hospital measure the degree of process orientation (PO)?

In this paper, we investigate PO from an OM perspective in order to develop a new measurement tool for Hospital Process Orientation Operationalization (HPOO). First we present a review of the literature on PO in section 2 in order to:

introduce and conceptualize the meaning of PO for organizations and more specifically for hospitals;

identify existing method(s) to study and measure the extent of PO.

The review of the literature assisted the identification of gaps within current research which in turn was used as input for the development of the new HPOO measurement tool. Section 3 describes the research approach. In section 4, the operationalization of the PO theory for hospitals and the development of the HPOO tool will be discussed. First the measurement tool most commonly used to measure PO will be examined: the BPO instrument developed by McCormack (1999). Afterwards, we incorporate the operationalized components of PO into the five dimensions of the McCormack instrument. At last, we present a holistic view of BPM which integrates the dimensions of PO and present the HPOO measurement tool.

In section 5, the empirical results of the HPOO measurement tool testing by means of the three case studies are presented. In section 6, we discuss the results of the case studies. Based on the results of the case studies and conclusions of this study, recommendations for further development of the measurement tool are provided in section 7.

Review of process orientation literature

Background and rise of the PO movement

In 1990, Michael Hammer (1990) and Thomas Davenport & James Short (1990) published their articles on the two new tools that may boost organizational performance: information technology (IT) and business process reengineering (BPR). Even though the authors had different principles in mind on how organizations should utilize these new tools, both articles pleaded for leaving outdated process designs, work & communication mechanisms and fundamental assumptions behind, which are contravening operations. According to the founding fathers of PO the combination of IT and BPR, two natural partners, will in their own words enable the reengineering and development of modern business processes. Business processes with a broader, cross-functional and customer-driven scope (Hammer 1990, Davenport & Short 1990).

PO in the 21st century

Different factors such as strategy, technology, people, etc. influence organizational performance, but the organizational capability of managing and improving the organization's business processes combine all the separate organizational factors and represent, thereby one of the most important determinants of organizational performance (Deming 1981, Thorp 2003, Kohlbacher & Gruenwald 2011). McCormack & Johnson (2001) defined PO as 'An organization that, in all its thinking, emphasizes process as opposed to hierarchies with special emphasis on outcomes and customer satisfaction.' The horizontal, process-oriented, organization emphasizes the need to reshape the internal boundaries and break down vertical silos of the organization in order to make sub units work together horizontally. The design and arrangement of the organization along horizontal workflow processes aiming at linking organizational capabilities to customers and suppliers will improve internal coordination and communication (Anand & Daft 2007). In this context, PO considers a process as both a business imperative and a means of understanding and explaining business activities - the way customer requirements are being transformed into goods and services (Smart et al. 2009). PO establishes an approach to link organizational strategy to implementation within operational processes and a manner of putting external emphasis on outcome and customer satisfaction rather than internally driven hierarchical structures or functions (Armistead 1999). By focusing on activities that create value for customers, and view the organization as linked chains of activities, PO delivered a promising solution for a variety of perceived organizational problems in the healthcare industry and other functional structured organizations (Hellström & Eriksson 2008, Hellström et al. 2010).

Process orientation in hospitals

Hospitals and healthcare organizations in general have started to move from relatively functional and hierarchical structures to structures focussing on cross-functional teams and flattened organizational structures (Vos et al. 2009). The central idea is that the transition to become more process-oriented will lead to more patient-centred care, cost reductions, and quality improvements (Vera & Kuntz 2007, Kohlbacher 2010). As illustrated in figure 1, the process to become more process-oriented involves all levels of organizational design: governance, structure design and delivery system (Degeling et al. 2004, Lega 2007, Vos et al. 2010). For years, the organization principles and structural design of hospitals have been labeled as a professional bureaucracy. As a result, the health service delivery processes in hospitals are frequently complex and fragmented across departments because they are being organized according to medical skills/specializations, and not according to the way/process patients are cared for (Lee & Clarke 1992). This leads to a lack of control and coordination of the care activities within a patient care trajectory, which in turn affects the efficiency and the quality of care delivery (Nyssen 2007, Vos et al. 2011). The traditional functional structure of hospitals will have to be replaced by a structure which takes a holistic and systematic view of healthcare delivery as a service business process and enables the optimization of healthcare delivery performance (Parnaby & Towill 2008). This means restructuring the health delivery processes in hospitals into integrated care trajectories for nominated patient groups, which are manageable, measurable, and therefore accountable (Berg et al. 2005, Jain et al. 2006). In order to achieve this, the way clinical work is conceived, performed and organized will have to be altered.

Insights from different fields (not only medicine) will have to be combined in an integrated approach (care program) in order to attain the full potency of clinical, organizational and interpersonal processes involved in each patient care trajectory, for example, treatment of glaucoma or replacement of the hip joint (Degeling et al. 2004, Berg et al. 2005).

Figure 1: Governance, structure design and care delivery in a functional hospital or in a process-oriented hospital (based on Degeling et al. 2004, Vos et al. 2010)

Existing tools for measuring process orientation

Different authors have addressed the question of conceptualizing and measuring PO. Some authors have addressed it from a management & organization theory, others from an information systems perspective and Kohlbacher & Gruenwald (2011) were the first to assess PO from a general, multidimensional perspective and have created and validated a model for the manufacturing industry to assess PO on the basis of PO constructs (Table 1). From a management & organization theory perspective, PO is a firm-level construct that supports the streamlining of (core) processes by more closely linking functional units. From an information systems perspective, PO is based on the information flows associated with the process activities considering that any process with distinct tasks and activities requires information to progress and move forward (Andersson et al. 2003, Berente & Vandenbosch 2009). The information flow in hospitals is dependent on their information system to collect and spread large amounts of data among various disciplines within a hospital.

While interdepartmental dynamics (management & organization theory) and information flows (information systems theory) are important factors for cross-functional process management, these levels of assessing PO do not address the design, planning, and control (improvement) of aligned, integrated and coordinated process

activities (OM perspective).

Patient care processes often involve several medical disciplines, each with their own characteristic attitude and work approach (Mans 2011). The design, planning, and control of aligned, integrated and coordinated activities within patient care processes is therefore essential for hospital PO since the sequential/serial modelled process activities compromising several medical specialties require coordination to manage the interdependencies of the process activities (Malone and Crowston 1994, Mans 2011). As a process is defined as a 'lateral or horizontal organizational form, that encapsulates the interdependence of tasks, roles, people, departments and functions required to provide a customer with a product or service' (Earl, 1994), and it is known that a process consists of (information) flows and activities (Hammer & Stanton, 1999), we can state that there is an overlap between the management & organization, information systems and OM perspective on processes. By specifying the theoretical implications of PO for hospital operations, we will be able to identify characteristics of PO for hospitals and derive constructs to assess PO on the level of process activities and measure the integration, alignment and coordination between these activities.

Table 1: Existing tools for measuring PO

Deficiencies of the three existing tools to measure hospital process orientation

Kohlbacher & Gruenwald (2011) stated that the PO literature is adopting the concept without questioning its scope. Consequently, PO is usually being measured with proxy variables or unidimensional measures which are insufficient to capture the richness of such a complex concept (Kohlbacher & Gruenwald 2011). As a result, PO constructs/measures are generally broad and ambiguous. For instance, Vera & Kuntz (2007), who were the first to investigate whether the implementation of process-based organizations in hospitals is advisable, used organizational items that were very broad. As a result, measuring their items (e.g. clinical pathways, performance-based payment) leaves much room for measurement error and doesn't measure the degree of PO justifiably. Gemmel et al. (2008) who developed the first measurement tool for hospital PO came across other shortcomings by not defining the PO scope. Their measure did not include all five dimensions of PO specified by McCormack (1999). The measurement tool developed by Gemmel et al. (2008) was only based on the three dimensions (Process View, Process Jobs and Process Measurement and Management) that were validated by McCormack & Johnson (2001) for the e-businesses. But this particular fact cannot be self-evident to the hospital setting where care processes are delivered by different specialties and a framework to define the process management team (Process Structure) and adequate team effort, interdisciplinary communication and interpersonal skills (Customer-focused Process Values and Beliefs) are crucial factors. In fact, according to Armistead (1996) BPM can only work when attention is given to people, processes and systems in the context of the organization structure and organizational culture. Another deficiency is that the measurement tool of Gemmel et al. (2008) focused on health care professionals only while process management is intended to link operational processes (patient care processes) to direction setting, managerial and support processes (Armistead & Machin 1997).

At last, the model developed by Andersson et al. (2003) is not suitable to measure the alignment, integration and coordination between process activities because their model is intended to support the development of health information systems (HIS) embedded in process-oriented healthcare work.

Hospital Operations Management Theory

Assessing PO from an OM perspective deals with different deficiencies of existing measurement tools brought forward in the previous sections. The OM perspective adds a conclusive scope (systems thinking and systems engineering) which links strategic choices to operational, managerial and support processes (Armistead & Machin 1997). Operations in hospitals can be grouped into operations types which utilize the same resources (input). From a logistic point of view the homogeneity of operations types lies in the underlying sequence, timing and execution of patient care activities by the hospital staff (Măruster et al. 2002). According to Vissers (1994) the identification of key operations corresponds to the first stage in 'the analysis, design, planning and control of all the steps necessary to provide a service for a client'. The second stage is to understand the ways in which operations use and consume resources (Vissers 1994). These two stages are the two essential elements of operations. When the elements of operations along with their corresponding duration and workload are added together, it generates the overall set of transforming processes required to deliver a product/ service for a client. Consequently, a particular health service can be produced by simultaneously linking the individual diagnostic & therapeutic activities and the resources (inputs) that they use (Măruster et al. 2002, Vissers & Beech 2005). Vissers & Beech (2005) named this a chain or overall process and defined it as 'the chain of operations that need to be performed to produce a particular health service.' The awareness of the 'links' in the chain of operations enables reflection on key characteristics of patient care processes (e.g. elective/appointment, semi-urgent, urgent, complexity, variability, length of a process, volume, decoupling points, shared resources and predictability) and helps to establish appropriate control systems which enlightens decisions about the allocation of resources in order to achieve operational effectiveness. Operational effectiveness is dependent on the efficiency of resource inputs and usage, and the effectiveness of overall management (Langabeer II 2008). A hospital that is operationally effective is creating value by converting inputs (resources) into efficient and effective outputs (healthcare services), see Figure 2.

Figure 2: The Operations Management Process (Langabeer II 2008)

By designing and delivering healthcare services to meet the needs of patients in the most effective and efficient manner OM can contribute to the evolving 'climate' in which healthcare services are delivered (Vissers & Beech 2005). Hence, this research offers an approach to address the shortcomings of current research discussed in the review of the PO literature by examining the development towards a process oriented organization of hospital care from an OM perspective in order to develop a new measurement tool to assess hospital process orientation in more operational terms.

Methods

The conventional research approach is to develop a measurement tool first and subsequently provide evidence for the statistical validation. But given the exploratory nature of this study where the conceptualization and measurement of a rich concept (PO) will be executed from a new angle (OM perspective) in highly complex institutions with complex environments (hospitals), it was more appropriate to practically test the measurement tool than to statistically validate a possible deficient measurement tool.

During the development phase, a new measurement tool based on existing theories, concepts and measures was developed. The five dimensions of the most frequently used instrument for measuring PO, the McCormack's BPO instrument, were conceptualized and operationalized to fit the hospital setting. The conceptually developed measurement tool was pilot tested in a non-participating general hospital by an internal management consultant, an ophthalmology department manager and an ophthalmologist. Since we had indications that the importance of each dimension/item of PO varies (McCormack & Johnson 2001, Reijers 2006), we held an OM expert meeting (focus group) to develop a scoring system for the items in our HPOO measurement tool.

After the development phase, we empirically tested the measurement tool by means of a small number of multiple (in-depth) case studies. Case selection should be based on replication logic rather than sampling logic, when building or testing a theory from case studies (Voss et al., 2002). For this reason, the criteria for case selection were: 1. predicts similar results and 2. produces contrary results but for predictable reasons. To correspond to this criterion, this research studied the same branch of medicine, i.e. ophthalmology, in a variety of contexts.

Ophthalmology is an ideal healthcare practice for the development and testing of the HPOO measurement tool due to the fact that it is a comprehensive area of medicine with well-defined processes (de Korne et al. 2010).

The case studies will be performed in the ophthalmic practices of three Dutch hospitals: one large university hospital, one large eye specialty hospital and one large general hospital.

The choice to include three different types of hospitals into our research is for the purpose of comparing how three different types of hospitals perform on the PO assessment. In addition, applying the HPOO measurement tool to different hospital environments will improve its generalizability (Wacker, 1998).

Since the objective of this study was to identify design requirements for a new measurement tool, to develop it and to give recommendations for further development of the tool, we used a limited number of participants to empirically test the new HPOO measurement tool. For this reason, we only included hospital staff able to state and illustrate the organizational and operational system. The participants to this study are from three disciplines: management, team leaders and health care professionals/ ophthalmologists. To test whether the participants' perception of the extent of PO in their hospital corresponds to quantitative data on hospital operations, we collected data on thirteen indicators for hospital production, service and available resources/capacity (Appendix 1).

Hence, the case studies allowed a full understanding of the nature and complexity of the complete phenomenon (PO) from which recommendations to improve the developed measurement tool for the hospital setting could be given.

Measurement of process orientation

According to Hellström et al. (2010) processes can be studied from an organization, division or department perspective. This research will study processes from the ophthalmology department perspective of the four participating hospitals and try to identify how these processes fit in the organization (hospital) perspective. Multi-site case studies aiming to identify, describe and link critical variables should be performed by applying structured interviews or survey questionnaires as techniques to collect data (Handfield & Melnyk 1998, Stuart et al. 2002). Due to the fact that PO is a difficult and complex concept to measure, we chose not to apply the large sample survey methodology (e-mail or online surveys). The disadvantages and limitations of applying this method did not fit the objective of our study and we did not want to follow the footsteps of our predecessors, i.e. Gemmel et al. (2008). Gemmel et al. (2008) developed and provided extensive statistical evidence for the validation of a measurement tool for hospital PO. However, their research and tool did not provide more clarity to the assessment of PO in hospitals. Therefore, we opted for a combined method of collecting data. First, the participants filled in the questionnaire which consisted of 39 measures/items. For each measure, participants were asked to provide the extent to which they agree or disagree with the subject using a four-point Likert scale. Afterwards, the filled-in document was discussed with every participant according to a semi-structured interview. The combined approach allowed comprehensibility testing of the items (statements) of the HPOO measurement tool and the verification of the respondents "perceptual" estimate/response. Thus, the combined method is more likely to yield highly productive research output with lowered risk of biased findings (Boyer & Swink 2008). In analyzing the descriptive results, the nominal Likert scale was converted into values of 0-3, retaining, respectively, the ranking of responses with 0 for "completely disagree" and 3 for "completely agree".

Hospital Process Orientation Operationalization: development of the measurement tool

McCormack's BPO instrument

McCormack (1999) presented PO as a concept which consists of five dimensions: Process View (PV), Process Structure (PS), Process Jobs (PJ), Process Measurement and Management (PMM), and Customer-focused Process Values & Beliefs (PVB). The five dimensions have been used, tested and validated throughout the years (McCormack & Johnson 2001, Lockamy III & McCormack 2004, McCormack et al. 2009). Based on their definitions, we operationalized the five dimensions as follow:

Process View (PV) - Personnel on all levels of the organization has knowledge and understanding of process steps, activities and tasks of cross-functional processes as a result of a thorough documentation (visual and written) of strategic to operational and begin to end processes and a widespread vocabulary which allows different job functions to communicate.

Process Structure (PS) - Supporting framework for the structure in which the other domains operate; functional "compartments" are altered and the process management is defined.

Process Jobs (PJ) - Jobs focus on entire processes and have horizontal (instead of vertical) responsibilities; cooperation to achieve common targets.

Process Measurement and Management (PMM) - Measures to continuously evaluate the performance of processes and the application of process improvement techniques to manage processes and reward improvements.

Customer-focused Process Values & Beliefs (PVB) - Commitment to a collective endeavour to focus on customers and continuously improve the business processes within the organization.

OM operationalization of the PO theory for hospitals

Process View (PV)

The PV dimension is to encourage the personnel to view individual actions as links in a chain of events crossing traditional functional barriers - viewing the organization as an integrated set of processes (Armistead 1996). To accomplish PV, organizations must develop a system architecture in which understanding of the organization and improvement opportunities are established by identifying and mapping the (high-level) business processes (Hellström & Eriksson 2008, Cinquini et al. 2009). PV is the first step towards PO; to begin to look at the organization in a new way by linking business strategy and customer needs to all aspects of process design and management by providing a clear view of the interrelationships inside and outside the organization and by establishing a common language for change management (McCormack & Rauseo 2005). Linking business strategy and patient needs to process design, means designing processes to deliver health services to target patient groups. From an OM perspective, this dimension was conceptualized for the HPOO measurement tool as 'the progress towards organizational focus on integrated business processes by designing, documenting and managing begin-to-end patient care processes to deliver care to defined target patient groups.' The PV dimension was operationalized and measured with 11 items.

Process Structure (PS)

Following the principle 'structure follows process' a process-oriented organization must adapt its structure to the PV (Vera & Kuntz 2007, Kohlbacher & Gruenwald 2011). The key in process-oriented organizations is to identify how different work activities are holistically accomplished in the organization, map and manage these cross-functional processes and use multidisciplinary process teams to carry them out (Anand & Daft 2007). The use of team structure empowers staff, decentralizes decision-making, and allows greater learning across the organization. Interdisciplinary communication and collaboration between different hospital units and medical disciplines are prerequisites for PO. The interdisciplinary cooperation along the patient treatment processes requires the support of information technology (IT) for the collection, management and spreading of information and knowledge about medical treatment processes and organizational processes (Lenz & Reichert 2007). The correlation between medicine, organization and information is high. Therefore, organizational structures and IT systems need to offer optimal support to both medical treatment processes and organizational processes. Some organizations are not able to align all activities along processes. For that reason, Vanhaverbeke & Torremans (1999) suggested a multidimensional structure (combination of functional and process-based structure) with process ownership as a solution for organizations (such as hospitals) that cannot adopt a purely process-based structure. The existence of process owners is the most visible difference between a process-oriented and a traditional organization (Hammer & Stanton 1999). A process owner must have leadership experience and the authority to act in the interest of the process and take all measures necessary to coordinate and improve the business process (Hinterhuber 1995). The way a process-oriented organization is structured needs to be supported and promoted by top and middle management also (management commitment to PO); otherwise the process oriented initiatives are less likely to secure benefits (Edwards et al., 2000). This dimension was conceptualized from an OM perspective as 'a organizational structure and IT system fit to coordinate, manage and improve patient care processes' and was operationalized and measured with 7 items.

Process Jobs (PJ)

Process performers must have appropriate knowledge of how to execute the process; otherwise they won't be able to implement the process design (Hammer 2007a). Emphasis on cross-skill training and the importance of gaining wider experience by working with different people within different processes are both vital factors to align employees' expectations and aspirations with the process-oriented organization (Armistead 1996). The knowledge management processes which a process-oriented organization must focus on are those for the creation of knowledge, transfer & sharing of knowledge and the embedding & use of knowledge (Armistead 1999). According to Hammer (2007a) employees must be skilled in team work, problem solving, process improvement, and decision techniques. Employees must also embrace the collaboration and the continuous improvement mentality, and feel responsible for these activities. Furthermore, the organization must have a cadre of experts in change management, process (re)design, and process improvement methodologies (Hammer 2007a). From an OM perspective, this dimension was conceptualized as 'the alignment and management of skills, information, knowledge, expertise, traits, and motives of employees to execute and improve patient care processes'. The PJ dimension was operationalized and measured with 6 items.

Process Measurement and Management (PMM)

Congruence and common focus across separate organizational units can be achieved by focusing measurement on processes instead of functions (Hammer 2007b). Since a business process can only be controlled and managed if it can be measured, BPM is only achievable if organizations implement indicators for performance and take corrective and preventive actions when necessary (Hinterhuber 1995). Presenting the process performance results to employees allows them to timely react on bad performance of processes or it can motivate employees and improve adherence (Hammer 2007b, Kohlbacher & Gruenwald 2011). This dimension was conceptualized as 'indicators to periodically measure performance of begin-to-end patient care processes and measures to manage these processes (e.g review process objectives, rewards etc.).' The PMM dimension was operationalized and measured with 9 items.

Customer-focused Process Values & Beliefs (PVB)

Processes are the central core from which business is conducted, as long as they are supported by the people within the organization (Jeston & Nelis 2008). Therefore, the cultural fit in process-oriented organizations is an important source of failure or success in PO initiatives (Armistead & Machin 1997). According to Hammer (2007a) only a culture based on teamwork, willingness to change, customer orientation, personal accountability, and a cooperative leadership style fits organizations applying a process approach. A patient-focused culture is also being encouraged by the modern healthcare requirement where healthcare providers and consumers/patients work together to create and/or co-produce value (Tien et al. 2009). The cultural context of a process-oriented hospital needs to fit the just specified process approach culture (Vom Brocke & Sinnl 2011). According to Vom Brocke & Sinnl (2011) a cultural context consists of national, organizational and work group cultures. This research will not study national cultures. As a result the PVB dimension was conceptualized as 'an organizational and work group culture in line with a process approach' and was operationalized and measured with 6 items.

Holistic view on hospital process orientation

The five BPO dimensions described by McCormack (1999) correspond with the six clusters of implications of BPM for operations management presented by Armistead & Machin (1997): 1. organization coordination; 2. process definition; 3. organization structuring; 4. cultural fit; 5. improvement; 6. measurement. But both approaches (McCormack and Armistead) describe the PO dimensions as isolated domains. According to Willaert et al. (2007), to apply the dimensions of PO in organizations a more rigorous methodology, a holistic approach, is necessary to integrate and connect the PO efforts (Willaert 2007). Willaert et al. (2007) argued that an organization must adopt a holistic view on the techniques, principles and factors influencing the implementation and application of BPM in order to apply BPO effectively. In addition, we share the view of Meredith (1993) and Smart et al. (2009) that by specifying a common framework which provides a platform (pre-theory) to engage in both academic research and practitioner debate, will provide significant opportunities for both understanding and application of BPM in hospitals.

Building a common, holistic process view of the organization is achieved by developing and agreeing on common understanding of the mental model (cognitive map) of the organization (Senge 1990, McCormack & Rauseo 2005). To achieve this, hospitals (directors, head of departments, managers and health care professionals) must first reach consensus and understanding on the elements of their high-level business process (healthcare delivery concept) considering the strategically targeted patient groups (conform to their environment). The high-level hospital process and sub processes will have to be subject to a continuous improvement cycle in order to continuously improve health care delivery performance. Figure 3 gives an overview of such a holistic view on BPM for hospitals.

Figure 3: The House of Hospital BPM: an integrated framework

The House of Hospital BPM has facilitated the identification of six contingency factors for process-oriented hospital care design:

external environment (pattern of demand, evolving regulations, and emerging technologies),

the strategic plan (mission, vision, priorities, planning, implementation and control cycle) for reaching the objectives of the organization (strategic BPM),

strategic choices for segmenting the target market in begin-to-end processes (target patient groups),

design and documentation of the begin-to-end care processes (healthcare delivery system),

national, organizational and work group cultures that fit the application of BPM (cultural context),

improvement cycle (process modelling, configuration, execution and analysis) to continuously improve the begin-to-end care processes (continuous improvement of the healthcare delivery system).

Given this holistic approach, we might argue that the BPO dimensions concord in this framework:

process modelling corresponds with the PV dimension,

process configuration corresponds with the PS dimension,

process execution corresponds with the PJ dimension and the process management element of the PMM dimension,

process analysis corresponds with the process measurement element of the PMM dimension.

the cultural context that needs to fit the process approach culture corresponds with the PVB dimension.

As a result, the items in our HPOO measurement tool overlap each other (cycle) and do not deal with the dimensions as isolated domains (e.g. item on process goals in the PV dimension, item on process owner tasks and attitude in the PJ dimension, item on presentation of process performance results in the PVB dimension). Appendix 2, shows the listing of the items in the final HPOO measurement tool after testing.

Results

Case studies

Hospital (1) is a large university hospital, which strives to attain balance between their three organizational objectives: patient care, education and research. The department of ophthalmology consists of 9 ophthalmologists and a total of 12 residents and senior house officers (not specializing). The supervisee to physician ratio is higher than 1 (=1,33). This reflects the mission of medical education within this hospital.

In 2010, the university hospital performed approximately 24.000 outpatient visits, 2900 surgical procedures/medical interventions and 550 hospital admissions. The percentage of (surgical) procedures that were performed during inpatient admissions was high (=19%). This due to a variety of reasons, but a high case mix index (CMI) was given as the most plausible cause. The university hospital is well experienced in working with and according to processes. In 2008 a project was started to stimulate the design and definition of entire care processes in the form of clinical pathways. The two process descriptions that have been developed for the ophthalmology department are well documented.

Hospital (2) is a large hospital specialized in eye care. It is a major referral center in the Netherlands and it has a workforce of 30 ophthalmologists and a total of 21 residents and senior house officers (not specializing). The supervisee to physician ratio in this hospital is lower than 1 (=0,7). The eye specialty hospital has its own ophthalmic institute and it has always strived to promote international cooperation between eye hospitals by founding the European Association of Eye Hospitals (EAEH) and the World Association of Eye Hospitals (WAEH). In 2010, they performed a grand total of almost 144.000 visits, 18.500 surgical procedures and 960 hospital admissions (only 5% of all procedures were performed during an inpatient admission). The eye specialty hospital has the most experience with clinical pathways, over 10 years. The team leaders at the eye specialty hospital have to lead the care teams, which have been assigned to the various patient groups treated in this hospital (e.g. cataract, strabismus, macular degeneration etc.). The number of well-defined care processes in this hospital is eight.

Hospital (3) is a large general hospital. The number of ophthalmologists working at this hospital is 8. The night shifts are staffed by 4 senior house officers (not specializing), who work on rotating night shifts. The residency program in ophthalmology has not been accredited yet, therefore the department of ophthalmology at this general hospital has not been able to train any residents until now. A process-oriented organization of care is very much stimulated by the Board of Directors. The ophthalmology department has at the moment only one care process elaborated as care pathway and is planning to elaborate a second care pathway.

The function of each participant within each of the three categories included in this study is presented in table 2.

Management

(N=8)

Team leaders

(N=8)

Healthcare professionals

(N=10)

Hospital 1

University Hospital

(N=9)

Head of the department, an ophthalmology medical-manager, and a staff functionary (quality)

A unit leader and a team leader

Four ophthalmologists.

Hospital 2

Eye Specialty Hospital

(N=9)

A member of the Board of Directors, Head of multidisciplinary treatment teams, and a staff functionary (OM)

Three team leaders

A ophthalmologist, a staff nurse, and a optometrist/ ophthalmic optician

Hospital 3

General Hospital

(N=8)

A member of the Board of Directors and a sector manager

Three unit leaders

Three ophthalmologists.

Table 2: Participants per hospital and per discipline

Results per hospital

Different outputs resulted from the application of the HPOO measurement tool. The first result is the possibility to identify the differences and the areas of improvement within each hospital. Another result is the possibility to understand these differences through the broad notion of the three ophthalmic practices formed by interviewing the participants. Outputs of the application of the HPOO measurement tool are provided in tables 3 and 4. The total average dimension scores of all three hospitals were below 2, between 'agree' and 'disagree'. Hence, from the participants' perspective all three hospitals performed moderately in terms of process orientation. The PMM and PV dimensions scored the lowest, and the PJ and PVB dimensions scored the highest. The low PMM score was probably due to a lack of outcome indicators to measure the performance of begin-to-end care processes (entire patient trajectories) or the use of mainly financial or production measures for organizational performance. When asked to name a few indicators a number of participants gave examples of external indicators, for instance from the Health Care Transparency Programme (Zichtbare Zorg) or the Dutch Health Care Inspectorate (IGZ). These external indicators are first of all to measure the quality of data registry and second of all to measure the performance of processes (process indicators). Hence, these indicators have little input for the improvement of internal care processes as both measures are not able to predict the results of the care processes. Another issue is that financial/production measures are predominantly used to measure organizational success. Organizational success is not only dependent of financial/production objectives, but also on how well the organization adapts to their external environment or the service concept/level it offers to its clients. In addition, financial/production performance comes from the results of management actions and organizational performance. They are not the results of the core processes in healthcare, the clinical interventions.

The low score on the PV dimension is probably due to a limited amount of well-defined care processes within Hospital 1 and 3 or a high-level description of care processes. According to Cinquini et al. (2009) the process view will have to be based on a detailed process model (activity level). The process model has to indicate the system of rules and responsibilities of actors across the organization, facilitate the assessment of resource consumption accurately, facilitate allocation of resources among units by exemplifying a profile capacity usage, and enable the realization of detailed variance analysis (Cinquini et al. 2009). The process models or clinical pathways that are being developed in the participating hospitals were not able to provide this kind of support to hospital workflows/processes.

PO

dimensions

Hospital 1

(N=9)

Hospital 2

(N=9)

Hospital 3

(N=8)

Total

(N=26)

Comprehensibility

(N=25)

Reliability

(N=25)

PV

1,63

1,84

1,83

1,77

89%

90%

PS

1,73

2,03

1,71

1,82

86%

88%

PJ

1,87

1,94

2,15

1,99

95%

94%

PMM

1,48

1,70

1,73

1,64

91%

91%

PVB

1,76

1,76

2,18

1,90

96%

92%

Total

1,69

1,85

1,92

91%

91%

Table 3: Average dimension-scores per hospital with corresponding comprehensibility and reliability percentages

The comprehensibility degree was operationalized as the percentage of the number of items stated as clear by the participants,

and the reliability degree as the percentage of the number of unchanged responses after the interview.

The "high scores", for instance on the PJ and PVB dimensions were expected since hospitals are a working environment for well trained and licensed medical professionals and a multidisciplinary approach, teamwork and a patient-focused culture have been applied and exercised for years in hospitals all over the Netherlands. A result that was not foreseen was that Hospital 3 came out with the highest average score. There was no evidence found to back-up this result. Even though the response of the participants in Hospital 3 did not always correspond with the performance based on documentation (in particular for PV and PMM dimension), the HPOO measurement tool was able to identify the potential areas for improvement from a PO point of view. Their low score (PS) was due to the fact that hospital 3 has given priority to patient-centeredness (Planetree) and a business unit organisational structure. As a result, process management within this hospital might be less developed. Table 3 also reports on the comprehensibility and reliability degree per dimension. We were not able to interview one of the participants, so we only included the item scores of the non-interviewed participant as research data. Comprehensibility and reliability were treated as missing values. The items in the HPOO measurement tool performed excellently on the measures to assess the comprehensibility and reliability. Both were above 90%. Still, all of the items were rechecked and about twelve items were revised and two items were added, based on the experiences with the original survey.

Out of the results in table 4 there can be tentatively concluded that the PO perception seems to be higher for disciplines that are at more distant from clinical practice. This conclusion is true for two hospitals except for the university hospital. In general, the average PO score of healthcare professionals was usually lower than the average score of the team leaders. In the university hospital it was the other way around. There the team leaders' average score was often lower than the average score of the healthcare professionals. A plausible explanation for this is the specialized work delivered by physicians in university hospitals.

In most cases the perception of management participants had a larger positive influence than the perception of the other categories, and their overall score played a dominant role in the higher average score on the PO dimensions. This applies especially to Hospital 3.

Hospital 1

Hospital 2

Hospital 3

PO

dimensions

Manag-ement

(N=3)

Team leaders

(N=2)

Healthcare professionals

(N=4)

Manag-ement

(N=3)

Team leaders

(N=3)

Healthcare professionals

(N=3)

Manag-ement

(N=2)

Team leaders

(N=3)

Healthcare professionals

(N=3)

PV

1,94

1,36

1,59

2,24

1,85

[1,42]

2,14

[1,67]

[1,70]

PS

1,95

1,57

[1,68]

2,48

1,81

[1,81]

2,14

1,62

1,38

PJ

1,94

2

1,67

2,33

2,06

1,44

2,33

2,39

1,72

PMM

1,74

1,17

[1,53]

2,22

[1,52]

1,37

1,83

1,81

1,56

PVB

1,94

1,58

1,75

2,06

1,72

[1,50]

2,58

2,11

1,83

Table 4: Average dimension-scores per hospital/ per discipline

Scores in brackets indicate that there were large differences in the item scores between participants. The reason for the large differences were that the participants did not have the same opinion on: what is a process description and how detailed it should be (PV), the existence of a process owner as indicated in the measurement tool (PS), whether the performance of complete patient trajectories were measured by means of indicators, and whether a continuous improvement culture existed within their hospital (PVB).

Discussion

The purpose of this study is to develop and practically test a measurement tool to measure hospital PO in operations management terms. The intention to develop such a measurement tool is to measure the design, planning, and control of aligned, integrated and coordinated cross-functional processes in hospitals. The results from the practical testing of the measurement tool show that the developed tool was able to measure the differences between hospitals from the proposed OM perspective.

There were indications that the measurement tool is vulnerable to over-positive or over-negative responses due to own interests, motivation or expectations of the participants. The measurement tool will therefore have to be complemented by metrics for each dimension. The use of perceptions alone to assess the internal degree of PO is subjective and can be manipulated. Furthermore, the used Likert-type scale was not satisfactory. The scale was too narrow and did not reveal patterns of the scaled items/dimensions that would indicate significant differences. Normally an average difference between a 1 and a 2 is not significant, but in our research it was. A four-point Likert scale was used for two reasons: 1. we did not want a neutral scale item in our Likert-type scale, and 2. we did not want the participants to spend too much time in scaling the statements/items.

An important limitation of this study is the small sample size. However, from the purpose of this study, the sample size was satisfactory. The objectives were to practically test the measurement tool and its content (items/statements) and not to present statistically tested differences or (in)consistencies of the measurement tool.

To a different degree and for distinctive reasons all three hospitals had some difficulties with the PV and PMM dimension. These two dimensions are at the core of managing process orientation within an organization. Hellström et al. (2010) already presented this problem as: "the hospital as an organisation itself in many ways becomes an obstacle to the achievement of a process-oriented management style". First off all, to acquire a process-oriented management style consensus for each care process has to be reached among a variety of healthcare professionals, managers, staff functionaries and patients in a particular healthcare setting. Subsequently, the hospital will have to adapt existing medical guidelines to local circumstances and preferences in order to define a care process description, which is evidence-based and adjusted to the local care setting. This is one of the biggest obstacles to acquire an adequate process view in hospitals. Lillrank & Lukko (2004) classified processes in healthcare into three groups: standard, routine and non-routine. Our recommendation would be to start with the standard processes and the routine processes first. Once consensus is reached, organizations will have to take the next step and compose indicators to measure the performance and outcomes of begin-to-end care processes. For an extended debate on how to measure and manage healthcare performance, the articles of Dey et al. (2008), Keung (2000) and Bouckaert & Halligan (2006) provide support.

Conclusion and recommendations for further development

This research improves the understanding and application of PO in hospitals by developing and practically testing a new measurement tool. The study suggests that by measuring the 41 items, a hospital can assess the degree of PO of the organization. The total of 41 items reflects the magnitude and complications to develop into and become a process-oriented hospital. Nevertheless, hospitals will have to use the whole range of items and include distinct disciplines in order to get a complete assessment. The developed measurement tool can not only be used to assess the degree of PO, but can also be used to review the internal progress of process-oriented organization of hospital care. However, there are a number of areas to improve the HPOO measurement tool and for future research. We recommend the use of a broader scale than a four-point Likert scale, e.g. a 7-point Likert scale. Research will have to be conducted to search for metrics to identify and measure each dimension objectively. An example of such a metric for the Process View dimension can be: 'the percentage of the total patient population treated according to a well-defined and agreed upon care process'. The use of supplementary metrics in combination with the HPOO measurement tool will increase the reliability of the output of the internal PO assessment. A last remark is that a degree of PO is merely an indication for how the structure design and work within an organization is organized, and it is not a measure for organizational performance. Research will have to be conducted to link the PO dimensions or defined PO constructs (e.g. process owner role, allocation and assignment of resources to care processes etc.) to hospital performance (e.g. patient outcomes (group-level), throughput time etc.).