Antti Peltokorpi

Time‐based management of patient processes

PURPOSE The purpose of this paper is to present a conceptual framework that would enable the effective application of time based competition (TBC) and work in process (WIP) concepts in the design and management of effective and efficient patient processes. DESIGN/METHODOLOGY/APPROACH This paper discusses the applicability of time-based competition and work-in-progress concepts to the design and management of healthcare service production processes. A conceptual framework is derived from the analysis of both existing research and empirical case studies. FINDINGS The paper finds that a patient episode is analogous to a customer order-to-delivery chain in industry. The effective application of TBC and WIP can be achieved by focusing on through put time of a patient episode by reducing the non-value adding time components and by minimizing time categories that are main cost drivers for all stakeholders involved in the patient episode. RESEARCH LIMITATIONS/IMPLICATIONS The paper shows that an application of TBC in managing patient processes can be limited if there is no consensus about optimal care episode in the medical community. PRACTICAL IMPLICATIONS In the paper it is shown that managing patient processes based on time and cost analysis enables one to allocate the optimal amount of resources, which would allow a healthcare system to minimize the total cost of specific episodes of illness. Analysing the total cost of patient episodes can provide useful information in the allocation of limited resources among multiple patient processes. ORIGINALITY/VALUE This paper introduces a framework for health care managers and researchers to analyze the effect of reducing through put time to the total cost of patient episodes.

Managing urgent surgery as a process: Case study of a trauma center

OBJECTIVES Industrial management principles could be used to improve the quality and efficiency of health care. In this study, we have evaluated the effects of a process management approach to trauma patient care. The major objective was to reduce the waiting times and increase the efficiency of the hospital. METHODS Urgent surgery care was analyzed as an overall process. The process development followed the Plan-Do-Check-Act (PDCA) cycle and was based on statistical analysis of certain performance metrics. Data were collected from hospital databases and by personnel interviews. To develop the process, the anesthesia induction was performed outside the operating room, better process guidance was developed, and patient flow was reorganized. The transition time for these changes was 1 year (2002 to 2003). RESULTS Waiting times decreased by 20.5 percent (p < .05), nonoperative times in the operating room were reduced by 23.1 percent (p < .001), and efficiency was increased by 9.7 percent (p < .001) after reengineering of the care process. Overtime hours decreased by 30.9 percent. CONCLUSIONS Managing urgent surgical care as a process can improve the productivity and quality of care without a need to increase personnel resources. The focus should be on reducing waiting times and waste times.

How do strategic decisions and operative practices affect operating room productivity

Surgical operating rooms are cost-intensive parts of health service production. Managing operating units efficiently is essential when hospitals and healthcare systems aim to maximize health outcomes with limited resources. Previous research about operating room management has focused on studying the effect of management practices and decisions on efficiency by utilizing mainly modeling approach or before-after analysis in single hospital case. The purpose of this research is to analyze the synergic effect of strategic decisions and operative management practices on operating room productivity and to use a multiple case study method enabling statistical hypothesis testing with empirical data. 11 hypotheses that propose connections between the use of strategic and operative practices and productivity were tested in a multi-hospital study that included 26 units. The results indicate that operative practices, such as personnel management, case scheduling and performance measurement, affect productivity more remarkably than do strategic decisions that relate to, e.g., units’ size, scope or academic status. Units with different strategic positions should apply different operative practices: Focused hospital units benefit most from sophisticated case scheduling and parallel processing whereas central and ambulatory units should apply flexible working hours, incentives and multi-skilled personnel. Operating units should be more active in applying management practices which are adequate for their strategic orientation.

Time-based analysis of total cost of patient episodes: a case study of hip replacement.

PURPOSE Healthcare in the public and private sectors is facing increasing pressure to become more cost-effective. Time-based competition and work-in-progress have been used successfully to measure and improve the efficiency of industrial manufacturing. Seeks to address this issue. DESIGN/METHODOLOGY/APPROACH Presents a framework for time based management of the total cost of a patient episode and apply it to the six sigma DMAIC-process development approach. The framework is used to analyse hip replacement patient episodes in Päijät-Häme Hospital District in Finland, which has a catchment area of 210,000 inhabitants and performs an average of 230 hip replacements per year. FINDINGS The work-in-progress concept is applicable to healthcare--notably that the DMAIC-process development approach can be used to analyse the total cost of patient episodes. Concludes that a framework, which combines the patient-in-process and the DMAIC development approach, can be used not only to analyse the total cost of patient episode but also to improve patient process efficiency. ORIGINALITY/VALUE Presents a framework that combines patient-in-process and DMAIC-process development approaches, which can be used to analyse the total cost of a patient episode in order to improve patient process efficiency.

Operating room cost management in cardiac surgery: a simulation study

The high variability in the required operating room (OR) time of open heart surgeries with approximately four and a half hours average overall duration is the main challenge in managing OR utilisation. We evaluate, with a discrete-event simulation model, how three different process changes - a four-day OR week, better accuracy in OR time forecasting and having anaesthesia induction take place outside the OR - impact on cost-efficiency in the OR that is dedicated for open heart surgeries. Doing anaesthesia induction outside the OR has the biggest potential effect on the average OR cost per patient. The paper provides new information about the effects of multi-intervention changes on OR cost per patient in open heart surgery. 111 2 3 4 5 6 7 8 9 1011 1 2 3 4 5 6 7 8 9

Increasing operating room productivity by duration categories and a newsvendor model

PURPOSE Previous studies approach surgery scheduling mainly from the mathematical modeling perspective which is often hard to apply in a practical environment. The aim of this study is to develop a practical scheduling system that considers the advantages of both surgery categorization and newsvendor model to surgery scheduling. DESIGN/METHODOLOGY/APPROACH The research was carried out in a Finnish orthopaedic specialist centre that performs only joint replacement surgery. Four surgery categorization scenarios were defined and their productivity analyzed by simulation and newsvendor model. FINDINGS Detailed analyses of surgery durations and the use of more accurate case categories and their combinations in scheduling improved OR productivity 11.3 percent when compared to the base case. Planning to have one OR team to work longer led to remarkable decrease in scheduling inefficiency. PRACTICAL IMPLICATIONS In surgical services, productivity and cost-efficiency can be improved by utilizing historical data in case scheduling and by increasing flexibility in personnel management. ORIGINALITY/VALUE The study increases the understanding of practical scheduling methods used to improve efficiency in surgical services.

Improving economic efficiency of operating rooms: production planning approach

Managing surgical services efficiently is essential when maximising the produced health with limited resources. This study aims at understanding the efficiency of operating rooms from the production planning and control point of view. Economic efficiency measure that includes the process costs and output was developed and tested in a real-life context. Daily efficiency was mostly dependent on the number of used operating rooms (beta ?0.42, p < 0.01). Speed of surgery, number of delayed surgeries and planned utilisation rate also had an effect on the efficiency. Compared to the previous literature the role of staffing in improving operating room efficiency is emphasised.

Modularizing specialized hospital services: Constraining characteristics, enabling activities and outcomes

Purpose Modularity promises to relieve problems of complexity in service systems. However, limited evidence exists of its application in specialized hospital services. The purpose of this paper is to identify enablers, constraints, and outcomes of modularization in specialized hospital services. Design/methodology/approach A qualitative comparative study of a hematology unit with modular service architecture and an oncology unit with integral service architecture in a university hospital is performed to analyze the service architectures, enablers and constraints of modularization, and outcomes. Findings A framework and five propositions combining the characteristics of specialized hospital services, enabling activities, and outcomes of modularization were developed. Modular service architecture was developed through limiting the number of treatment components, reorganizing production of standardized components into a separate service unit, and standardizing communication and scheduling in interfaces. Modularization increased service efficiency but diluted ownership of services, decreased customization, and diminished informal communication. This is explained by the specific characteristics of the services: fragmented service delivery, professional autonomy, hierarchy, information asymmetry, and requirement to treat all. Research limitations/implications Modularization can increase efficiency in specialized hospital services. However, specific characteristics of specialized care may challenge its application and limit its outcomes. Practical implications The study identifies enabling activities and constraints that hospital managers should take into account when developing modular service systems. Originality/value This is the first empirical study exploring the enablers, constraints, and outcomes of modularization in specialized hospital services. The study complements literature on service modularity with reference to specialized hospital services.

Managing business networks for value creation in facilities and their external environments: A study on co-location

Purpose The purpose of this paper is to increase understanding of the logic of business network formation among the co-located and external actors of a facility. Design/methodology/approach The research adopts a theory-building approach through developing propositions inductively from the empirical case study on four purposefully sampled modern service station facilities. The focus is on analyzing how a facility and its inherent co-located actors represent an entity that forms a business network with external actors in the facility’s environment. Findings The findings propose that when co-located with a large number of actors, the facility and its actors represent an entity that is connected to a wide business network of multiple external actors. On the other hand, when co-located with a small number of actors, the facility becomes a part of the overall supply in the surrounding business environment with a differentiated offering for competitive advantage. Practical implications The research suggests that an appropriate co-locating strategy, for example, when planning the tenant mix of the facility, can contribute to creating a vivid business network in the external environment, which raises the facility to a role of a central entity in such a network. Originality/value The findings explaining how co-location affects the businesses within the facility and within a wider networked environment are novel to the scholarly knowledge on co-location. The research bridges the theories of co-location and business networks that have been treated as separate discourses in previous research.

Five focus strategies to organize health care delivery

PURPOSE The focused factory is one of the concepts that decision-makers have adopted for improving health care delivery. However, disorganized definitions of focus have led to findings that cannot be utilized systematically. The purpose of this paper is to discuss strategic options to focus health care operations. DESIGN/METHODOLOGY/APPROACH First the literature on focus in health care is reviewed revealing conceptual challenges. Second, a definition of focus in terms of demand and requisite variety is defined, and the mechanisms of focus are explicated. A classification of five focus strategies that follow the original idea to reduce variety in products and markets is presented. Finally, the paper examines managerial possibilities linked to the focus strategies. FINDINGS The paper proposes a framework of five customer-oriented focus strategies which aim at reducing variety in different characteristics of care pathways: population; urgency and severity; illnesses and symptoms; care practices and processes; and care outcomes. RESEARCH LIMITATIONS/IMPLICATIONS Empirical research is needed to evaluate the costs and benefits of the five strategies and about system-level effects of focused units on competition and coordination. PRACTICAL IMPLICATIONS Focus is an enabling condition that needs to be exploited using specific demand and supply management practices. It is essential to understand how focus mechanisms differ between strategies, and to select focus that fits with organizations strategy and key performance indicators. ORIGINALITY/VALUE Compared to previous more resource-oriented approaches, this study provides theoretically solid and practically relevant customer-oriented framework for focusing in health care.