The new production theory for health care through clinical reengineering: a study of clinical guidelines--Part II

In Part I of this two-part article, in the December 1994 issue of the journal, the author discussed the manufacturing theories of Peter Drucker in terms of their applicability for the health care field. He concluded that Drucker's four principles and practices of manufacturing--statistical quality control, manufacturing accounting, modular organization, and systems approach--do have application to the health care system. Clinical guidelines, a variation on the Drucker theory, are a specific example of the manufacturing process in health. The performance to date of some guidelines and their implications for the health care reform debate are discussed in Part II of the article.     

The Applicability of Porter’s Generic Strategies in the Digital Age: Assumptions, Conjectures, and Suggestions

Because current management theories evolved in the context of brick-and-mortar firms, this paper examines three key questions raised by the advent of e-business: (1) Will the strategy types found among e-business firms resemble Porter’s (1980) generic strategies? (2) Will we find performance differences among e-business firms pursuing different types of strategies? (3) Will we find differences in the strategy-performance relationships of pure online firms (pure plays) and firms with both online and offline operations (clicks-and-bricks)? We conclude that integrated strategies that combine elements of cost leadership and differentiation will outperform cost leadership or differentiation strategies. We also argue that, regardless of business strategy type, clicks-and-bricks firms that closely integrate their on- and offline operations will enjoy performance advantages over their pure play counterparts.     

过程系统管理与技术的综合集成

在激烈的市场竞争中,过程企业不仅要重视技术、更要加强管理,实现全局优化运行。提高过程企业的市场竞争能力必须全面综合集成人、组织、战略管理、经营管理、过程管理及信息自动化技术等因素。本文以石化企业为背景,对过程企业面临的问题及发展趋势进行了分析,并且对过程企业管理模式、过程企业的体系结构以及过程集成与优化技术进行了探讨。     

The hidden competitive weapon supporting innovation in health care

It is trite to say health care is experiencing an era of unprecedented change. However, with the preoccupation with reimbursement and economic reform, it is easy to focus on this single dimension and lose sight of the pervasiveness of the need for continuous change throughout the entire health care organization. Health care organizations that will emerge as leaders within the industry will have incorporated not only radical changes to deal with new patterns of reimbursement, but also simultaneous changes in core medical services--changes that not only incorporate new technology, but also push down costs. They will also have to cope with radical changes in information and quality systems. Physical facilities will look less like citadels, and new flexible architectures will emerge. Coping with transportation logistics and remote site service provision will be part of the new industry. Patients will become full partners in ?health,? requiring very different approaches to patient education and involvement in prevention, not simply treatment. Indeed, without belaboring the almost endless list, it is impossible to think of a single dimension of health care that will be untouched.     

REVISITING ALTERNATIVE THEORETICAL PARADIGMS IN MANUFACTURING STRATEGY

Testing and cross‐validation of theories and paradigms are necessary to advance the field of manufacturing strategy. When the findings of one study are also obtained in other studies, using entirely different databases, we become more confident in the results. Replication alleviates concerns about spurious results and is one motivation for this study. We examine aspects of the tradeoffs concept, production competence paradigm, and a manufacturing strategy taxonomy framework. In regard to the tradeoffs concept, we found evidence of tradeoffs between some, but certainly not all, manufacturing capabilities of quality, cost, delivery, and customization. The relationships get sharper when controlling for process choice. For example, the tradeoff between cost and customization is particularly strong between plants that have different process choices. We find that such tradeoffs can change, or even disappear, however, once the process choice is in place. With respect to the production competence paradigm, our analysis shows a statistically significant correlation between production competence and operations performance in batch shops, but not in plants with other process choices. Finally, using variables similar to those of Miller and Roth, our data produced three similar clusters even though their unit of analysis was much more macro than ours. Controlling for process choice is consistent with the current manufacturing strategy literature that emphasizes dynamic development of capabilities within the context of path dependencies. A major argument of this strand of research is that operations decisions not only affect current capabilities, but also set the framework for development of capabilities in the future. That being the case, controlling for process choice (or other factors such as industry or markets) should contribute to the understanding of capability‐development paths adopted by different manufacturing plants. In short, we found at least partial support for each of the theories examined here, even though the theories seem on the surface to be contradictory and mutually exclusive. Controlling for process choice or other measures of dependency goes a long way in uncovering consistency across different theories and empirical studies in operations management.     

Physician payment in Canada, Germany, and the United States

As the debate about reforming the U.S. health care system intensifies, interest has focused on three alternative delivery systems: the predominantly private-sector model in the United States, the provincial-government health insurance model of Canada, and the social insurance model of Germany. The organization of physician payment is an important part of all these health care systems. To maintain an affordable system that delivers high-quality care, payment to physicians must be sufficient to attract and maintain an able group of doctors, while not exceeding an amount that the country can afford. In this article, these three systems will be examined, and an attempt will be made to apply the lessons learned from Germany and Canada to the direction of physician payment reform in the United States.     

25 Health care trends. What's hot,what's not,and what does the future hold

As we usher in 2003, America's health care system remains in a chaotic state. Will managed care live or die? Will quality improvement efforts pay off? Are we ready for the next bioterrorism attack? Will the shortage of physician soon rival the shortage of nurses? To help gauge where health care stands today and what the future holds, The Physician Executive asked doctors who serve on ACPE's peer review panel to list the hottest health care trends in the U.S right now. Then, we took the list to three respected health care futurists -- Leland Kaiser, PhD, Jeff Goldsmith, PhD, and Russel Coile, MBA -- and asked them for their insights on the trends. Yes, Kaiser, Goldsmith and Coile are opinionated. Yes, they're controversial. But no matter whether you agree or disagree with their views, the three health care futurists' comments could spark discussions that will help shape U.S. health care this year and beyond. The trends are presented in no particular order.     

Lowest Cost May Not Lower Total Cost: Using “Spackling” to Smooth Mass‐Customized Production

Consider a manufacturer who mass customizes variants of a product in make‐to‐order fashion, and also produces standard variants as make‐to‐stock. A traditional manufacturing strategy would be to employ two separate manufacturing facilities: a flexible plant for mass‐customized items and an efficient plant for standard items. We contrast this traditional focus strategy with an alternative that better utilizes capacity by combining production of mass‐customized and standard items in one of two alternate spackling strategies: (1) a pure‐spackling strategy, where the manufacturer produces everything in a (single) flexible plant, first manufacturing custom products as demanded each period, and then filling in the production schedule with make‐to‐stock output of standard products; or (2) a layered‐spackling strategy, which uses an efficient plant to make a portion of its standard items and a separate flexible plant where it spackles. We identify the optimal production strategy considering the tradeoff between the cost premium for flexible (versus efficient) production capacity and the opportunity costs of idle capacity. Spackling amortizes fixed costs of capacity more effectively and thus can increase profits from mass customization vis‐à‐vis a focus strategy, even with higher cost production for the standard goods. We illustrate our framework with data from a messenger bag manufacturer.     

The impact of modular platforms on automobile manufacturing networks

This paper explores the impact on automobile manufacturing networks of adopting modular platforms to replace the standard platforms used to date. Analysis of European manufacturers’ production networks shows that the use of modular architecture improves coordination by increasing manufacturing mobility and thriftiness ability. The changes resulting from this new modular approach also allow manufacturing capacity to be reorganised and overcapacity to be partially eliminated. From the point of view of production systems, the adaptation of manufacturing processes and facilities to this new architecture should aim to increase flexibility by integrating production around a single platform, allowing for different dimensions and for a larger number of models to be produced in a single plant.     

Medicare and Medicaid: the first successful effort to increase access to health care

The passage of Lyndon Johnson's health care legacy, Medicare and Medicaid, in 1965 represents the last time that health reform legislation expanding access to care was successfully proposed and implemented in the United States. Access, of course, represents only half the pie in health reform, the other part being the organization of the health care system. There has never been any major legislation passed through both houses of Congress and signed by a President that changed the organization and delivery of health services. It seems certain that President Clinton will propose legislation dealing with both access to and organization of our health care system. Though it may not have seemed so at the time, President Johnson had it easy compared to the challenges confronting President Clinton.     

测量系统的质量监控技术

在制造业中,测量系统是保证和提高产品质量的必需技术手段。本文提出了将统计过程控制(SPC)技术应用于监控测量过程的思想,首先指出了测量过程与一般生产过程之间的差异,并建立了测量过程的一般模型;在此基础上,引入了监控测量过程的同分布原则和实现技术,并给出了实证分析。     

Cost containment in health care: a model for management research.

Cost containment is a dominant problem in the health care field, but it has not been addressed from a comprehensive management perspective. To fill this gap, we have developed an inclusive model of the cost containment process. The model has implications for management research in several areas: cost containment baselines, incentive systems, organization structures, cost/quality trade-offs, and cost containment constraints.     

Community health assessment: diagnosis and prescription

Community health assessments are ideally a joint effort by all the major health care providers in the community, working in concert with local government, business, and concerned community groups. A noble activity, no doubt, but clearly a lot of trouble. Physicians, whose potential to contribute to community assessments is obvious, frequently avoid them. Whether in management or clinical practice, they ask: Is this really worth my time? Will it make any difference? Isn't there a better way? But, rightly or wrongly, physicians often have a disproportionate amount of influence on the community assessment process. That influence, whether you attribute it to respect, credibility, or power, adds value to the process. The most important quality the physician brings to the process is genuine concern for his or her patients that generalizes to the health of the entire community.     

The ascendancy of primary care: permanent or temporary?

The conventional wisdom strongly suggests a health care provider food chain for the future: Primary care physicians (PCPs), principally family practitioners, on the top playing the lead role, distantly followed by specialists, with hospitals and other ancillary services even further down the line. Is this a reasonable expectation? Will PCPs dominate the new systems? Or will they be but one of many equally necessary components of these developing integrated health care delivery organizations? Looking at the various models now developing, it would seem that future integrated delivery systems will utilize both PCPs and specialists, but with strong augmentation from a diverse assortment of other health care professionals, including nonphysician providers, educators, and administrators. To separate the illusion of primary care dominance of the coming health care system from the likely reality, we should first determine what is driving the apparent present demand for primary care physicians. Next, we will examine the possible and probable reactions to that demand from an economic standpoint and from the points of view of both health care professionals and the public. Finally, we must try to picture how health care provider organizations of the future are likely to look and how they will integrate their health care professionals.     

Design requirements for health care production control systems

This paper addresses the issue of determining design requirements for production control in health care organizations, with a restriction to the internal production control of hospitals. Hospital management has limited possibilities to control hospital production, as hospital production processes are driven by medical specialists who, however, do not manage that process. We consider therefore the hospital as a virtual organization, consisting of a number of relatively independent businesses in a common framework. Each business unit functions as a focused factory for a range of more or less homogeneous products. Production control principles can be applied to each of these businesses, but not to the system as a whole. A number of elements from classical production control theory can be also applied to health care, i.e. the use of decoupling points, the bottleneck-oriented approach, and the operational control between production and market. However, important factors that need to be considered in health production control are that often specifications on quality are not available at the start of the process, and that there is strong interaction between the patient and the process. Our conclusion is that a dedicated framework for approaching hospital production control is necessary. The specific characteristics of hospital care and its state of production control development are the main arguments for this dedicated framework.     

The future of American health care in the "post-reform" era

"As the debate over health care reform rages in Washington, the market is reforming itself. For any given market, it's a question of 'How soon will it hit?', not 'Will it hit?'" Health care reform and market restructuring are ushering in a new era of integrated health care. Although the future is not fully clear, there are at least three competing models for the creation of regional and statewide health systems that will integrate the financing and delivery of services to large enrolled populations of consumers: Payer-driven networks. Provider-sponsored systems. Partnership models. Whatever the future scenario, physician executives will play a larger, more dominant role. Research on integrated health systems has identified three critical success factors for future success: physician-hospital integration, clinical integration and information integration. For managed care to be successful, there must be clinical leadership. The essence of managing care is clinical efficiency, based on "critical-path" treatment protocols and real-time patient care management, supported by integrated information systems.     

Alternate Routing Strategies in Batch Manufacturing: An Evaluation

Batch manufacturing firms are experiencing significant changes because of technological developments in work center design, such as flexible manufacturing systems (FMS) and planning/control tools like computer-aided process planning (CAPP). These new developments provide production managers with some solutions to a number of complex problems. For example, numerical-controlled (NC) machine center installations are effective in providing quality parts because of tight tolerance specifications built into the equipment. However, these highly efficient centers create bottlenecks that constrain shop throughput, since production planners tend to rely too much on them. To help improve manufacturing planning, we introduce an important element to the batch production scheduling component of CAPP's mission—evaluating possible alternate routes. Production scheduling encompasses job route selection as well as machine center assignment (loading), job releasing, and setting due dates. In this paper, three routing strategies requiring different levels of shop floor information are tested and evaluated using computer simulation. Shop performance is measured by total cost and traditional measures of job flow time, lateness, and tardiness.     

QUALITY MANAGEMENT: UNIVERSAL OR CONTEXT DEPENDENT?

Quality management has often been advocated as being universally applicable to organizations. This is in contrast with the manufacturing strategy contingency approach of Operations Management that advocates internal and external consistency between manufacturing strategy choices. This article empirically investigates whether quality management practices are contingent on a plant's manufacturing strategy context, by examining the use of process quality management practices—a critical and distinctive subset of the whole set of quality management practices—across plants representative of different manufacturing strategy contexts. The study strongly suggests that process quality management practices are contingent on a plant's manufacturing strategy, and identifies mechanisms by which this takes place.     

Lampshade Game for lean manufacturing

The purpose of this article is to introduce a new simulation game named the ‘Lampshade Game’ that can be helpful in educating students and industry professionals on lean manufacturing principles. The Lampshade Game is an active learning tool that is capable of demonstrating the advantages and disadvantages of some of the key principles of lean manufacturing (such as quality focus, pull system, flexible manufacturing and visual organisation) in comparison to craft and mass manufacturing by manually simulating the production of lampshades for each of the process types. The game enables the comparison of these three manufacturing methods using different operational and financial metrics such as inventory levels, manufacturing cycle time, customer fill rate, production yield and cost and profit. This article describes the game, its objectives, and shares experiences from several classroom implementations including an analysis of pre- and post-surveys.