The Impact of Variability and Patient Information on Health Care System Performance

In the delivery of health care services, variability in the patient arrival and service processes can cause excessive patient waiting times and poor utilization of facility resources. Based on data collected at a large primary care facility, this paper investigates how several sources of variability affect facility performance. These sources include ancillary tasks performed by the physician, patient punctuality, unscheduled visits to the facility's laboratory or X‐ray services, momentary interruptions of a patient's examination, and examination time variation by patient class. Our results indicate that unscheduled visits to the facility's laboratory or X‐ray services have the largest impact on a physician's idle time. The average patient wait is most affected by how the physician prioritizes completing ancillary tasks, such as telephone calls, relative to examining patients. We also investigate the improvement in system performance offered by using increasing levels of patient information when creating the appointment schedule. We find that the use of policies that sequence patients based on their classification improves system performance by up to 25.5%.     

Using Fairness Models to Improve Equity in Health Delivery Fleet Management

Inefficiency and inequity are two challenges that plague humanitarian operations and health delivery in resource‐limited regions. Increasing capacity in humanitarian and health delivery supply chains is one option that has the potential to improve equity while maintaining efficiency. For example, the nonprofit organization Riders for Health has worked to increase capacity by providing reliable transportation to health workers in rural parts of sub‐Saharan Africa; with more motorcycle hours at their disposal, health workers can perform more outreach to outlying communities. We develop a model using a family of fairness function to quantify the efficiency and equity of health delivery as capacity is increased via development programs. We present optimal resource allocations under utilitarian, proportionally fair, and egalitarian objectives and extend the model to include dual modes of transport and diminishing returns of subsequent outreach visits. Finally, we demonstrate how to apply our model at a regional level to provide support for humanitarian decision makers such as Riders for Health. We use data from the baseline phase of our evaluation trial of Riders for Health in Zambia to quantify efficiency and equity for one real‐world scenario.     

Appointment Overbooking in Health Care Clinics to Improve Patient Service and Clinic Performance

The problem of no‐shows (patients who do not arrive for scheduled appointments) is particularly significant for health care clinics, with reported no‐show rates varying widely from 3% to 80%. No‐shows reduce revenues and provider productivity, increase costs, and limit patient access by reducing effective clinic capacity. In this article, we construct a flexible appointment scheduling model to mitigate the detrimental effects of patient no‐shows, and develop a fast and effective solution procedure that constructs near‐optimal overbooked appointment schedules that balance the benefits of serving additional patients with the potential costs of patient waiting and clinic overtime. Computational results demonstrate the efficacy of our model and solution procedure, and connect our work to prior research in health care appointment scheduling.     

Life Is All about Timing: An Examination of Differences in Treatment Quality for Trauma Patients Based on Hospital Arrival Time

In health care, most quality transparency and improvement programs focus on the quality variation across hospitals, while we know much less about within‐hospital quality variation. This study examines one important factor that is associated with the fluctuation of quality of care in the same hospital—the timing of patient arrival. We analyze data from the National Trauma Data Bank and find that patients arriving at the hospital during off‐hours (6 PM–6 AM) receive significantly lower quality care than those who arrive during the daytime, as reflected in higher mortality rates, among other measures. More importantly, we try to uncover the mechanism for the quality variation. Interestingly, we find consistent evidence that the inferior care received during off‐hours is not likely due to unobserved heterogeneity, disruptions in circadian rhythms, or delays in receiving treatment. Instead, it is more likely due to the limited availability of high‐quality resources. This leads to a higher surgical complication rate, a higher likelihood of multiple surgeries, and longer patient length of stay in the intensive care unit. These findings have important implications for optimal resource allocation in hospitals to improve the quality‐of‐care delivery.     

Shifting Concepts of Autonomy in the Hong Kong Hospital Authority

The Hong Kong Hospital Authority is the main provider of public health care services in Hong Kong. It operates 41 public hospitals, 74 general out-patient clinics and 45 specialist out-patient clinics. This article examines the reason for its establishment as a statutory body in 1990 and offers an assessment of its success in meeting the goals of the reformers. A belief that health care service delivery would be improved is largely supported by the evidence, but this may have more to do with budget and policy consistency than management autonomy and flexibility. Statutory independence, with its promise of improved efficiency, has its limits in the highly complex field of health where there are multiple players and where professional autonomy remains a key claim. In recent times, the authority has been subject to several reform attempts and, together with the SARS epidemic in 2003, these have had a significant impact on its organizational structure and practices, in particular, on its degrees of autonomy.

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Improving Humanitarian Operations through Technology‐Enabled Collaboration

Humanitarian supply chains involve many different entities, such as government, military, private, and non‐governmental organizations and individuals. Well‐coordinated interactions between entities can lead to synergies and improved humanitarian outcomes. Information technology (IT) tools can help facilitate collaboration, but cost and other barriers have limited their use. We document the use of an IT tool to improve last‐mile supply distribution and data management in one of many camps for internally displaced persons after the January 2010 earthquake in Haiti, and we describe other current uses of technology in camp management. Motivated by these examples and the interest among humanitarian organizations in expanding the use of such tools to facilitate coordination, we introduce a cooperative game theory model and explore insights about the conditions under which multi‐agency coordination is feasible and desirable. We also outline an agenda for future research in the area of technology‐enabled collaboration in the humanitarian sector.     

Would Allowing Privately Funded Health Care Reduce Public Waiting Time? Theory and Empirical Evidence from Canadian Joint Replacement Surgery Data

This study develops a theoretical model and then, using Canadian joint replacement surgery data, empirically tests the relationship between government policies that promote privately funded health care and patients’ waiting time in the public health care system. Two policies are tested: one policy allows opt‐out physicians to extra‐bill private patients, and the other provides public subsidies to private patients. We find that both policies are associated with shorter public waiting time, and that the subsidy policy appears to be more effective in waiting time reduction than the extra‐billing policy. Our findings are consistent with a dominant demand‐side effect in that these policies would provide patients an option, and some incentive, to opt out of the public health system, shifting the demand from the public health system to the private care market.     

Performance Impacts of Strategy,Information Technology Applications,and Business Process Outsourcing in U.S. Manufacturing Plants

This paper develops a conceptual model to study the role of outsourcing strategies and plant‐level information technology (IT) application infrastructure in the outsourcing of production and support business processes, as well as their subsequent impact on overall plant performance. We validate this model empirically using cross‐sectional survey data from U.S. manufacturing plants. We find that some IT applications are more effective at enabling the outsourcing of business processes than others. For example, the implementation of enterprise management systems is associated with the outsourcing of both production and support processes, whereas operations management systems are not associated with the outsourcing of plant processes. Plants with a low‐cost outsourcing strategy are more likely to outsource support processes than plants with a competency‐focused outsourcing strategy. However, both cost‐ and competency‐based strategies have a positive and similar impact on the outsourcing of production processes. In terms of implications for plant performance, our findings indicate that the outsourcing of production and support processes is associated with higher gross margins. Although plant IT infrastructure is positively associated with favorable on‐time delivery rates, there is no positive association between the incidence of plant outsourcing and on‐time delivery rates. These results have implications for crafting plant‐level outsourcing strategies and for investments in IT systems to facilitate the outsourcing of business processes for enhanced plant performance.     

Linking Process Quality and Resource Usage: An Empirical Analysis

Motivated by an increasing adoption of evidence‐based medical guidelines in the delivery of medical care, we examine whether increased adherence to such guidelines (typically referred to as higher process quality) is associated with reduced resource usage in the course of patient treatment. In this study, we develop a sample of US hospitals and use cardiac care as our context to empirically examine our questions. To measure a patient's resource usage, we use the total length of stay, which includes any additional inpatient stay necessitated by unplanned readmissions within thirty days after initial hospitalization. We find evidence that higher process quality, and more specifically its clinical (as opposed to its administrative) dimensions, are associated with a reduction in resource usage. Moreover, the standardization of care that is achieved via the implementation of medical guidelines, makes this effect more pronounced in less focused environments: higher process quality is more beneficial when the cardiac department's patient population is distributed across a wider range of medical conditions. We explore the implications of these findings for process‐oriented pay‐for‐performance programs, which tie the reimbursement of hospitals to their adherence to evidence‐based medical guidelines.     

Reserving Capacity for Urgent Patients in Primary Care

This paper examines the effect of the common practice of reserving slots for urgent patients in a primary health care practice on two service quality measures: the average number of urgent patients that are not handled during normal hours (either handled as overtime, referred to other physicians, or referred to the emergency room) and the average queue of non‐urgent or routine patients. We formulate a stochastic model of appointment scheduling in a primary care practice. We conduct numerical experiments to optimize the performance of this system accounting for revenue and these two service quality measures as a function of the number of reserved slots for urgent patients. We compare traditional methods with the advanced‐access system advocated by some physicians, in which urgent slots are not reserved, and evaluate the conditions under which alternative appointment scheduling mechanisms are optimal. Finally, we demonstrate the importance of patient arrival dynamics to their relative performance finding that encouraging routine patients to call for same‐day appointments is a key ingredient for the success of advanced‐access.     

Reverse Auctions to Innovate Procurement Processes: Effects of Bid Information Presentation Design on a Supplier's Bidding Outcome

Information technologies (ITs) are being used to innovate various procurement processes. This research study focuses on the supplier‐side effects of IT design choices to conduct reverse auctions, which are increasingly used to procure a wide range of products and services. IT–enabled reverse auctions enhance supplier participation across geographical boundaries, leading to more efficient pricing. However, there are growing concerns about the adverse effects of IT–enabled reverse auctions on a supplier's performance. Supplier‐side issues are gaining prominence in the reverse auction literature and are critical for the long‐term success of reverse auctions. Therefore, we focus on suppliers’ bidding outcomes and assess how the design of an IT–enabled reverse auction facilitates the auction bidding outcomes of participating suppliers. Specifically, we examine the effects of two types of bid information presentation design—full price visibility and partial price visibility—on supplier's auction bidding outcomes, across auctions with different cost certainty and suppliers bargaining power vis‐à‐vis the buyer. The results of this study contribute new knowledge about the ways to use IT for creating effective auction designs and innovating procurement through auctions to enhance both the buyer's and suppliers’ performance. We present the detailed theoretical contributions of our study and discuss the managerial implications for designers of reverse auctions.      

Re‐Organizing Work Roles in Health Care: Evidence from the Implementation of Functional Flexibility

Functional flexibility has been advocated as a mechanism for improving efficiency and service quality and is, it is argued, especially appropriate to service environments. In recent years the UK public health service has been subject to an ongoing programme of reform, designed to modernize the way in which health services are provided. A central feature of the reform involves breaking down traditional boundaries and the re‐organization of work roles. This article is concerned with examining the implementation of functional flexibility in three health‐care settings. Case‐study data are presented, focusing on the responses of employees and managers to initiatives to work more flexibly. For managers the implementation achieved efficiency gains and improvements to service quality, in spite of some resistance from employees. For employees the outcomes were more mixed. There was evidence of ‘humanization’ through greater job variety, challenge and access to training, but there were also costs in terms of intensification, role confusion and stress. The implications of these findings both for understanding the issues raised by the use of functional flexibility and for the implementation of policies in the NHS involving job redesign are discussed.     

Design and Analysis of Hospital Admission Control for Operational Effectiveness

Variability in hospital occupancy negatively impacts the cost and quality of patient care delivery through increased emergency department (ED) congestion, emergency blockages and diversions, elective cancelations, backlogs in ancillary services, overstaffing, and understaffing. Controlling inpatient admissions can effectively reduce variability in hospital occupancy to mitigate these problems. Currently there are two major gateways for admission to a hospital: the ED and scheduled elective admission. Unfortunately, in highly utilized hospitals, excessive wait times make the scheduled gateway undesirable or infeasible for a subset of patients and doctors. As a result, this group often uses the ED gateway as a means to gain admission to the hospital. To better serve these patients and improve overall hospital functioning, we propose creating a third gateway: an expedited patient care queue. We first characterize an optimal admission threshold policy using controls on the scheduled and expedited gateways for a new Markov decision process model. We then present a practical policy based on insight from the analytical model that yields reduced emergency blockages, cancelations, and off‐unit census via simulation based on historical hospital data.     

The psychosocial work environment of district nurses in Sweden

Data were collected from a stratified sample of district nurses in the greater Stockholm area on four occasions during one year using questionnaire techniques (to assess psychosocial working conditions and social networks, and self-reported health sums); as well as physiological measurement techniques. Three groups of district nurses were compared: group A, those working independently in the 'traditional' role but outside primary health care centres; group B, those working independently in the 'traditional' role but in primary health care centres; and group C, those working in the model role as part of primary health care teams. The study focused on the effects of these different work environments on the district nurse's psychological and somatic health, and their physiological state.

The data suggested that district nurses in the primary care teams (group C) had a lower objective work load than those working in the more traditional role. Despite this, they reported a less favourable balance (ratio) of work demands to decision latitude. They reported more 'problems' and 'conflicts' at work than did the other district nurses. However, such 'problems' were diminishing during the study period, which could mean that successive adaptation to the 'new' situation was occurring. The 'conflicts', on the other hand, remained. This may indicate that despite this adaptation, the district nurses in the primary care teams were struggling with their new work roles. It points to the need for organizational support during this important change process. The district nurses in group B (traditional role but in a primary health care centre) had the highest objective work load and showed physiological reactions in terms of elevated plasma cortisol levels in the morning, high systolic blood pressure and sleep disturbances.     

Health Care Supply Chain Design: Toward Linking the Development and Delivery of Care Globally*

This article is motivated by the gap between the growing demand and available supply of high‐quality, cost‐effective, and timely health care, a problem faced not only by developing and underdeveloped countries but also by developed countries. The significance of this problem is heightened when the economy is in recession. In an attempt to address the problem, in this article, first, we conceptualize care as a bundle of goods, services, and experiences—including diet and exercise, drugs, devices, invasive procedures, new biologics, travel and lodging, and payment and reimbursement. We then adopt a macro, end‐to‐end, supply chain–centric view of the health care sector to link the development of care with the delivery of care. This macro, supply chain–centric view sheds light on the interdependencies between key industries from the upstream to the downstream of the health care supply chain. We propose a framework, the 3A‐framework, that is founded on three constructs—affordability, access, and awareness—to inform the design of supply chain for the health care sector. We present an illustrative example of the framework toward designing the supply chain for implantable device–based care for cardiovascular diseases in developing countries. Specifically, the framework provides a lens for identifying an integrated system of continuous improvement and innovation initiatives relevant to bridging the gap between the demand and supply for high‐quality, cost‐effective, and timely care. Finally, we delineate directions of future research that are anchored in and follow from the developments documented in the article.     

Attachment, social support, and responses following the death of a companion animal

This research tested hypotheses concerning attachment, social support, and grief responses to the loss of animal companionship. Participants whose companion cat or dog had recently died (N = 429) completed the Attachment Style Questionnaire, the Inventory of Complicated Grief, and the Multidimensional Health Profile-Psychosocial Functioning questionnaires. Both attachment anxiety and attachment avoidance were found to be positively associated with respondents' grief, depression, anxiety, and somatic symptoms. Social support was found to be negatively associated with these outcomes as well as with attachment anxiety and attachment avoidance. In multiple regression analyses, attachment anxiety incrementally predicted grief, anxiety and somatic symptoms, attachment avoidance incrementally predicted grief and depression, and social support incrementally predicted all outcomes. Interaction effects of attachment and social support in relation to outcomes were not found. The present study's implications and limitations are discussed, as are directions for future research.     

The Effectiveness of Management‐By‐Walking‐Around: A Randomized Field Study

Management‐by‐walking‐around (MBWA) is a widely adopted technique in hospitals that involves senior managers directly observing frontline work. However, few studies have rigorously examined its impact on organizational outcomes. This study examines an improvement program based on MBWA in which senior managers observe frontline employees, solicit ideas about improvement opportunities, and work with staff to resolve the issues. We randomly selected hospitals to implement the 18‐month‐long, MBWA‐based improvement program; 56 work areas participated. We find that the program, on average, had a negative impact on performance. To explain this surprising finding, we use mixed methods to examine the impact of the work area's problem‐solving approach. Results suggest that prioritizing easy‐to‐solve problems was associated with improved performance. We believe this was because it resulted in greater action‐taking. A different approach was characterized by prioritizing high‐value problems, which was not successful in our study. We also find that assigning to senior managers responsibility for ensuring that identified problems get resolved resulted in better performance. Overall, our study suggests that senior managers' physical presence in their organizations' front lines was not helpful unless it enabled active problem solving.     

A Hybrid Methodology for Modeling Risk of Adverse Events in Complex Health‐Care Settings

In spite of increased attention to quality and efforts to provide safe medical care, adverse events (AEs) are still frequent in clinical practice. Reports from various sources indicate that a substantial number of hospitalized patients suffer treatment‐caused injuries while in the hospital. While risk cannot be entirely eliminated from health‐care activities, an important goal is to develop effective and durable mitigation strategies to render the system “safer.” In order to do this, though, we must develop models that comprehensively and realistically characterize the risk. In the health‐care domain, this can be extremely challenging due to the wide variability in the way that health‐care processes and interventions are executed and also due to the dynamic nature of risk in this particular domain. In this study, we have developed a generic methodology for evaluating dynamic changes in AE risk in acute care hospitals as a function of organizational and nonorganizational factors, using a combination of modeling formalisms. First, a system dynamics (SD) framework is used to demonstrate how organizational‐level and policy‐level contributions to risk evolve over time, and how policies and decisions may affect the general system‐level contribution to AE risk. It also captures the feedback of organizational factors and decisions over time and the nonlinearities in these feedback effects. SD is a popular approach to understanding the behavior of complex social and economic systems. It is a simulation‐based, differential equation modeling tool that is widely used in situations where the formal model is complex and an analytical solution is very difficult to obtain. Second, a Bayesian belief network (BBN) framework is used to represent patient‐level factors and also physician‐level decisions and factors in the management of an individual patient, which contribute to the risk of hospital‐acquired AE. BBNs are networks of probabilities that can capture probabilistic relations between variables and contain historical information about their relationship, and are powerful tools for modeling causes and effects in many domains. The model is intended to support hospital decisions with regard to staffing, length of stay, and investments in safety, which evolve dynamically over time. The methodology has been applied in modeling the two types of common AEs: pressure ulcers and vascular‐catheter‐associated infection, and the models have been validated with eight years of clinical data and use of expert opinion.