Aligning service processes to the nature of care in hospitals : an exploratory study of the impact of variation

Operational management (OM) approaches typically aim to reduce the variation in processes by removing clearly identifiable causes of variation -the so-called special causes of variation - leading to improved efficiency and quality. In healthcare, OM must deal not only with special-cause variation, but also with the type of variation that cannot be eliminated: inherent or common-cause variation. Using an exploratory database analysis of four hospitals, this article investigates whether hospital care processes can be assigned to different groups defined by their kind and size of variation, resulting in better alignment of type of care and organization of care. A detailed analysis of the length-of-stay of All Patient Refined Diagnosis Related Groups suggests groups with high and low within-group variation, which might indicate that there are groups of patients with inherently different degrees of variation in length-of-stay due to illness and treatment patterns. As is well-known, hospital care can be divided into sequential and iterative processes. Some patients groups may be classified as high-variation in one hospital but as low-variation in another, which clearly shows that deliberate choices in the design of the operational system of hospitals - i.e. special-cause variation - must be taken into account when analyzing the length-of-stay performance of hospitals. Furthermore, separating common-cause from special-cause variation will increase the likelihood of identifying the right type of process (sequential versus iterative) and business model for the right type of patients

Health care redesign: managing a changing health care environment

Introduction: Hospitals are changing from functional and bureaucratic organizations towards process-oriented service-line organizations [1,2]. At the same time, management techniques originating from industrial practices are diffusing throughout hospitals [3-5]. This results in the awareness that there should be a better fit between the customer needs and the service delivery processes in the future design of hospital care, which requires a rethinking of the business models used by hospitals. Moreover, to date, the majority of hospitals use one business model to treat patients with very different needs. Understandably, This ‘one-size-fits-all’ model has been criticized and more ‘focused’ delivery systems have been proposed [6,7]. Some authors make the distinction between ‘solution shops’, focusing on patients with a high degree of uncertainty in the care delivery such as in the diagnostic stage, ‘value adding process business’ (VAP), focusing on the efficient and safe treatment of patient paths with a limited amount of uncertainty, and ‘facilitated networks’ focusing on integrated care for chronically ill patients [6](see figure). In summary, uncertainty, as reflected in the amount of variability in the patient delivery path, seems to be an important variable of how to design a hospital delivery system which is more focused to the needs of groups of patients [7]. In this study we want to analyze whether structured and unstructured care can be recognized in the care for a patient population of acute care hospitals when looking at the length-of-stay(LOS) variability in the All Patient Refined Diagnosis Related Groups(APR-DRG), and therefore observe if individual departments already apply a differentiated approach to patient care. Methods: Data were collected in two large Belgian hospitals from March 2009 until April 2011. All Patient Refined Diagnosis Related Groups (APR-DRG) were used for analyses. These data were linked with demographic data (gender, age), administrative data (date of admission, date of discharge, re-admission) and APR-DRG specific data (Medical Diagnostic Categories (MDC), surgery or medicine, charged number of admitted days, severity of illness and risk of mortality). Results: Our analyses show that the patient population of the two hospitals can, to some extent, be separated in different business models (solution shops, VAPs and facilitated networks) by looking at the variability of the length of stay (LOS) and the level of severity of illness within APR-DRG categories. It becomes also clear that both hospitals do take into account the amount of uncertainty and variability in the way they organize the care process (e.g. by using different care coordination mechanisms such as clinical pathways), but are not really designed around these differential patient needs. In other words structured and unstructured care are delivered in the same departments (the so-called ‘all-in-one’ concept) with the same people, but in a differential way . Discussion: Most hospitals still deliver care using a one-size-fits-all model, thereby denying that customers’ needs can be different. Our study shows that, although hospitals are still organized from the perspective of one single business model, individual departments already apply a differentiated approach to patient care. Solution shops, VAPs and facilitated networks are present in hospitals, albeit in an embryonic stage. This shows that health care workers acknowledge the need for a differentiated approach and the change that has to be made is not as radical as one could think. 1. Gemmel, P., D. Vandaele, and W. Tambeur. Hospital Process Orientation (HPO): The development of a measurement tool. Total Quality Management & Business Excellence, 2008; 19: 1207-17. 2. Vos, L., et al. Towards an organisation-wide process-oriented organisation of care: A literature review. Implementation Science, 2011; 6. 3. Mazzocato, P., et al. Lean thinking in health care: a realistic review of the literature. Qual Saf Health Care, 2010; 19: 376-82. 4. Jimmerson, C., D. Weber, and D.K. Sobek. Reducing Waste and Errors: Piloting Lean Principles at Intermountain Healthcare. Joint Commission Journal on Quality and Patient Safety, 2005; 31: 249-57. 5. Herzlinger, R.E. Market-driven health care + Response to Andrew Hacker. Cambridge-Massachusetts, Perseus Book, 1997. 6. Bohmer, R.M.J., Designing Care. Boston, Massachusetts: Harvard Business School press, 2009. 7. Christensen, C.M., J.H. Grossman, and J. Hwang (2009) The Innovator' Prescription A disruptive Solution for Health Care. New York, Mc Graw-Hill books, 2009