Organising health services through modularity

From hospital-centered care to home-centered care of older people: propositions for research and development

PURPOSE

Providing high-quality and cost-efficient care of older people is an important development priority for many health and social care systems in the world. This paper suggests a shift from acute, episodic and reactive hospital-centered care toward longitudinal, person-centered and proactive home-centered care. The purpose of this paper is to contribute to the knowledge of a comprehensive development strategy for designing and providing home-centered care of older people.

DESIGN/METHODOLOGY/APPROACH

The study design is based on qualitative research with an inductive approach. The authors study development initiatives at the national, regional and local levels of the Swedish health and social care system. The data collection methods included interviews (n = 54), meeting observations (n = 25) and document studies (n = 59).

FINDINGS

The authors describe findings related to policy actions and system changes, attempts to achieve collaboration, integration and coordination, new forms of care offerings, characteristics of work settings at home and differences in patients' roles and participation at home and in the hospital.

PRACTICAL IMPLICATIONS

The authors suggest home-centered care as a solution for providing person-centered and integrated care of older people and give examples of how this can be achieved.

ORIGINALITY/VALUE

The authors outline five propositions for research and development related to national policies, service modularity as a solution for customized and coordinated care, developing human resources and infrastructure for home settings, expanding services that enable older people living at home and patient co-creation.

Service design in healthcare: a segmentation-based approach

Purpose

The study aims to explore how segmentation as a methodology can be adapted to the healthcare context to provide a more nuanced understanding of the served population and to facilitate the design of patient-centric services.

Design/methodology/approach

The study was based on a collaborative project with a national healthcare organization following the principles of action design research. The study describes the quantitative segmentation performed during the project, followed by a qualitative interview study of how segments correspond with patient behaviors in an actual healthcare setting, and service design workshops facilitated by segments. A number of design principles are outlined based on the learnings of the project.

Findings

The segmentation approach increased understanding of patient variability within the service provider organization and was considered an effective foundation for modular service design. Patient characteristics and life circumstances were related to specific patterns of health behaviors, such as avoidance or passivity, or a persistent proactivity. These patterns influenced the patients' preferred value co-creation role and what type of support patients sought from the care provider.

Practical implications

The proposed segmentation approach is immediately generalizable to further healthcare contexts and similar services: improved understanding of patients, vulnerable patients in particular, improves the fit and inclusivity of services.

Originality/value

The segmentation approach to service design was demonstrated to be effective in a large-scale context. The approach allows service providers to design service options that improve the fit with individual patients' needs for support and autonomy. The results illuminate how patient characteristics influence health and value co-creation behaviors.

Service modularity in e-learning programs: an analysis from the perceived usefulness perspective

Purpose

This study investigates the effects of service modularity on the perceived usefulness (PU) of e-learning programs through the perceived ease of use (PEoU) and service customization.

Design/methodology/approach

Structural equation modeling was used to test four hypotheses with survey data from 517 undergraduates in Turkey.

Findings

Results show that service modularity affects the PU of e-learning programs through the PEoU. Service customization negatively moderates the effect of service modularity on the PEoU, but positively moderates the effect of the PEoU on the PU of e-learning programs.

Practical implications

This study offers insights that support the decisions of policymakers and higher education institutions on how to design appealing e-learning programs cost-effectively.

Social implications

This study reveals the determinants of the PU of e-learning, which could support the democratization of access to higher education in emerging countries where barriers to higher education are relatively greater than in developed countries.

Originality/value

The concept of service modularity is explored in the e-learning context from the students' perspective. This study shows that the standardized interfaces across course modules increase the PU of e-learning programs by improving the ease of use. It also shows, interestingly, that service customization, enabled by modularity, is not always appreciated by service consumers, because of the potential extra effort demanded in communicating their unique needs to service providers.

How service modularity can provide the flexibility to support person-centered care and shared decision-making

Background

Today’s healthcare provision is facing several challenges, that cause the level of complexity to increase at a greater rate than the managerial capacity to effectively deal with it. One of these challenges is the demand for person-centered care in an approach that is tuned towards shared decision-making. Flexibility is needed to adequately respond to individual needs.

Methods

We elaborate on the potential of service modularity as a foundation for person-centered care delivered in a shared decision-making context, and examine to what extent this can improve healthcare. We primarily focused on theory building. To support our effort and gain insight into how service modularity is currently discussed and applied in healthcare, we conducted a scoping review.

Results

Descriptions of actual implementations of modularity in healthcare are rare. Nevertheless, applying a modular perspective can be beneficial to healthcare service improvement since those service modularity principles that are still missing can often be fulfilled relatively easily to improve healthcare practice. Service modularity offers a way towards flexible configuration of services, facilitating the composition of tailored service packages. Moreover, it can help to provide insight into the possibilities of care for both healthcare professionals and patients.

Conclusions

We argue that applying a modular frame to healthcare services can contribute to individualized, holistic care provision and can benefit person-centered care. Furthermore, insight into the possibilities of care can help patients express their preferences, increasing their ability to actively participate in a shared decision-making process. Nevertheless, it remains essential that the healthcare professional actively collaborates with the patient in composing the care package, for which we propose a model. Altogether, we posit this can improve healthcare practice, especially for the people receiving care.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12913-021-07267-6.

Exploring enablers of modularity in healthcare service delivery

Purpose

This paper explores the enablers of modular healthcare services.

Design/methodology/approach

A survey-based approach was adopted with specialised hospitals as the unit of analysis. A structural model was developed based on a literature review and assessed using a cross-sectional research design. A 23-indicator questionnaire was circulated among service providers in the healthcare system across India, and 286 valid responses were received. The data were analysed using partial least squares-structural equation modeling (PLS-SEM).

Findings

The results reveal that professional competence, technological versatility, clear division of tasks, channelised flow of information and professional autonomy act as enablers that may drive modular service delivery.

Research limitations/implications

By examining service providers' perspectives, this paper highlights the influence of the identified enablers on modular service delivery in healthcare organisations.

Practical implications

For practitioners, the study provides suggestions for designing patient-centric healthcare services via modular healthcare delivery. The identified structural relationships can facilitate immediate corrective actions and the formulation of future policies. The findings will help practitioners foresee opportunities for patient participation in value co-creation, meet patients' varying needs, decompose service offerings, mix and match components develop sets of rules as interfaces between service modules and design service packages on an ongoing basis.

Social implications

This study underscores the emergence of patient-centric care and may aid the design of processes that deliver health to the patient as a person.

Originality/value

This paper identifies and empirically validates relationships between healthcare service delivery processes and modular service delivery.

Elaborating on modular interfaces in multi-provider contexts

Purpose

This study examines how modular interfaces manifest in multi-provider contexts and how they can improve coordination and customization of services. The aim of the study is to describe interfaces in multi-provider contexts and elaborate on how they support the delivery of integrated patient care.

Design/methodology/approach

A qualitative, multiple case study was conducted in two multi-provider contexts in healthcare services: one representing paediatric Down syndrome care in the Netherlands and one representing home care for the elderly in Finland. Data collection involved semi-structured interviews in both contexts.

Findings

This study provides insight into several types of interfaces and their role in multi-provider contexts. Several inter- and intra-organizational situations were identified in which the delivery of integrated patient care was jeopardized. This study describes how interfaces can help to alleviate these situations.

Originality/value

This study deepens the understanding of interfaces in service modularity by describing interfaces in multi-provider contexts. The multi-provider contexts studied inspired to incorporate the inter-organizational aspect into the literature on interfaces in service modularity. This study further develops the typology for interfaces in modular services by adding a third dimension to the typology, that is, the orientation of interfaces.

Modular service provision for heterogeneous patient groups: a single case study in chronic Down syndrome care

Background

Service modularity could be promising for organizing healthcare delivery to heterogeneous patient groups because it enables cost reductions while also being responsive towards individual patients’ needs. However, no research on the applicability of modularity in this context exists. To this end, we conducted a qualitative single-case study on chronic healthcare provision for Down syndrome patients, delivered by multidisciplinary pediatric Downteams in the Netherlands, from a modular perspective.

Methods

We conducted six semi-structured interviews with coordinators of multidisciplinary Downteams in six hospitals. In addition, we gathered data by means of observations and analysis of relevant documentation. We transcribed, coded, and analyzed the interviews utilizing the Miles and Huberman approach. The consolidated criteria for reporting qualitative research (COREQ) were applied in this study.

Results

In all six Downteams studied, the modular package for Down syndrome patients (i.e. the visit to the Downteams) could clearly be divided into modules (i.e. the separate consultations with the various professionals), and into different components (i.e. sub-elements of these consultations). These modules and components were linked by different types of customer-flow and information-flow interfaces. These interfaces allowed patients to flow smoothly through the system and allowed for information transfer, respectively.

Conclusion

Our study shows a modular perspective is applicable to analyzing chronic healthcare for a heterogeneous patient group like children with Down syndrome. The decomposition of the various Downteams into modules and components led to mutual insight into each other’s professional practices, both within and across the various Downteams studied. It could be used to increase transparency of delivered care for patients and family. Moreover, it could be used to customize care provision by mixing-and-matching components. More detailed research on chronic modular care provision for patients with DS is needed to explore this.

Comparing modular and personal service delivery in specialised outpatient care: A survey of haematology and oncology patient preferences

Background

Oncology and haematology are shifting from inpatient to outpatient care, requiring new care delivery models. This study compares preferences of oncology patients treated by named nurses in a traditional specialty-focused day hospital and haematology patients treated without named nurses in a modularised day hospital.

Methods

Questionnaires to explore patient preferences on number of treating nurses and named nurses, and satisfaction in day hospital care were distributed to 300 haematology and 410 oncology patients. Binomial logistic regressions were performed to study how background variables influenced preferences for having (i) a named nurse or (ii) maximum three treating nurses in the day hospital.

Results

In 2016, 156 (52%) haematology and 289 (70%) oncology surveys were completed and returned. Both groups were satisfied with day hospital care. Haematology patients preferred named nurses less often than oncology patients (odds ratio (OR) = 0.09, p < 0.0005). Haematology patients were less likely to prefer a maximum of three treating nurses (OR = 0.12, p < 0.0005).

Conclusion

This study suggests that patients can be satisfied with outpatient care with or without named nurses. However, as several factors affect patient satisfaction and experience, more in-depth research is needed to understand how modularisation and patient preferences may be linked.

Improving service in an emergency department by designing the health production flow

Background

Most emergency departments have overcapacity with poor service measured by length of stay. We hypothesized that a formal design of the emergency department production flows will improve service. Thus, we propose a methodology that was tested in a large hospital, including new flow implementation.

Results

We implemented new workflows during June to July 2017. A comparison of the patients’ average length of stay from June to September shows a decrease of 26%. Additionally, a comparison with 2016 shows a decrease of 50%. Direct evaluation of the value generated reveals an emergency department admissions increase of 540 monthly, equivalent of a savings of approximately US$250.000 annually. This savings is a very conservative estimate because the most significant value of this work is fast service that diminishes the patients’ risks.

Conclusions

Production design is an important problem in health services in terms of potential service improvements, executable with a formal, systemic, replicable method founded on several disciplines. Thus, we are replicating the approach at other hospitals with extensions to other services.

Service modularity in managing healthcare logistics

Purpose

The purpose of this paper is to examine how modularity is used for enabling value creation in managing healthcare logistics services.

Design/methodology/approach

Material logistics of four different kinds of hospitals is examined through a qualitative case study. The theoretical framework builds on the literature on healthcare logistics, service modularity and value creation.

Findings

The case hospitals have developed their material logistics independently from others when looking at the modularity of offerings, processes and organisations. Services, such as assortment management, shelving and developing an information platform, have been performed in-house partly by the care personnel, but steps towards modularised and standardised solutions are now being taken in the case hospitals, including ideas about outsourcing some of the services.

Research limitations/implications

This paper proposes seven modularity components for healthcare logistics management: segmentation, categorisation and unitisation of offerings, differentiation and decoupling of processes, and centralisation and specialisation of organisations. Thus, this study clarifies the three-dimensional concept of modularity as a cognitive frame for managing logistics services with heterogeneous customer needs in a rapidly changing healthcare environment.

Practical implications

Modularity offers a tool for developing logistics services inside the hospital and increases possibilities to consider also external logistics service providers.

Social implications

Managing healthcare logistics services through modularity has potential social implications in developing healthcare processes and changing the usage of health services. On a wider scale, modularity is helping healthcare systems reaching their goals in terms of service quality and cost.

Originality/value

This paper shows the context-specific antecedents of service modularity and the usage of modular thinking in managing healthcare logistics.

Modularising outpatient care delivery: A mixed methods case study at a Finnish University Hospital

BACKGROUND

Modularisation is a potential means to develop health care delivery by combining standardisation and customisation. However, little is known about the effects of modularisation on hospital care. The objective was to analyse how modularisation may change and support health care delivery in specialised hospital care.

METHODS

A mixed methods case study methodology was applied using both qualitative and quantitative data, including interviews, field notes, documents, service usage data, bed count and personnel resource data. Data from a reference hospital's unit were used to understand the context and development of care delivery in general.

RESULTS

The following outcome themes were identified from the interviews: balance between demand and supply; support in shift from inpatient to outpatient care; shorter treatment times and improved management of service production. Modularisation supported the shift from inpatient towards outpatient care. Changes in resource efficiency measures were both positive and negative; the number of patients per personnel decreased, while the number of visits per personnel and the bed utilisation rate increased.

CONCLUSIONS

Modularisation may support health care providers in classifying patients and delivering services according to patients' needs. However, as the findings are based on a single university hospital case study, more research is needed.

Evolution of modularity literature: a 25-year bibliometric analysis

Purpose

The purpose of this paper is to review and analyze the modularity literature to identify the established and emerging perspectives.

Design/methodology/approach

A systematic literature search and review was conducted through the use of bibliometrics and network analysis. The analysis identified structure within the literature, which revealed how the research area evolved between 1990 and 2015. Based on this search, the paper establishes the basis for analyzing the structure of modularity literature.

Findings

Factors were identified within the literature, demonstrating how it has evolved from a primary focus on the modularity of products to a broader view of the applicability of modularity. Within the last decade, numerous research areas have emerged within the broader area of modularity. Through core-periphery analysis, eight emerging sub-research areas are identified, of which one is the study of modularity in the context of services.

Research limitations/implications

Although bibliographic methods are limited as they are based on common citations within the field, they enable systematic analysis and the identification of structure within an emergent field of research. Such analysis has implications by for a growing and inter-disciplinary field like modularity by providing overview and suggesting future directions.

Originality/value

This paper contributes by conducting a systematic review based on the citation structure within modularity and identifies the established and emerging areas of research on modularity.

Modularizing specialized hospital services

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.

Service modularity and architecture – an overview and research agenda

Purpose

Services are highly important in a world economy which has increasingly become service driven. There is a growing need to better understand the possibilities for, and requirements of, designing modular service architectures. The purpose of this paper is to elaborate on the roots of the emerging research stream on service modularity, provide a concise overview of existing work on the subject, and outline an agenda for future research on service modularity and architecture. The articles in the special issue offer four diverse sets of research on service modularity and architecture.

Design/methodology/approach

The paper is built on a literature review mapping the current body of literature on the topic and developing future research directions in service modularity and architecture.

Findings

The growing focus on services has triggered needs to investigate the suitability and implementation of physical-product-focused modularity principles and theories in service contexts, and to search for principles/theories that enhance services. The expanding research stream has explored various aspects of service modularity in empirical contexts. Future research should focus on service-specific modularity theories and principles, platform-based and mass-customized service business models, comparative research designs, customer perspectives and service experience, performance in context of modular services, empirical evidence of benefits and challenges, architectural innovation in services, modularization in multi-provider contexts, and modularity in hybrid offerings combining service and tangible product modules.

Originality/value

Nine areas are recommended for further research on service modularity and architecture. The introductory piece also discusses the roots of service modularity and provides an overview of current contributions.

Exploring modularity in services: cases from tourism

Purpose

The purpose of this paper is to examine how modularity manifests in the design of services. The study brings new insights on the organization of service firms by empirically exploring and theoretically advancing the intersection of modularity and service design.

Design/methodology/approach

The paper compares two companies that offer similar services in the same geographical region but represent polar case types. A framework grounded on extant literature is constructed and applied to the two cases to assess its practicality and provide theoretical insights.

Findings

The paper demonstrates the effects of modularity and integrality on a range of different analytical levels in service architectures. Taking a holistic approach, the authors synthesize and empirically deploy a framework comprised of the three most prevalent themes in modularity and service design literature: Offering (service concept), intra-firm organization (service delivery system), and inter-firm relationships (service network). They posit that service architectures require the examination of different analytical levels due to the complex and dynamic nature of service business. Additionally, the analysis provides new insights on the mirroring hypothesis of modularity theory to services.

Originality/value

The paper provides a conceptualization of service architectures drawing on service design, modularity, and market relationships. The study enriches service design literature with elements from modularity theory and elaborates on the theoretical implications of service modularity in general.

The influence of dynamic capabilities on hospital-supplier collaboration and hospital supply chain performance

Purpose

The purpose of this paper is to explore the influence of hospital’s visibility for sensing (VFS), learning, coordinating and integrating on hospital-supplier collaboration. Second, it explored the influence of hospital-supplier collaboration on hospital supply chain performance. The author also explored how the technology orientation of the medical chain units influences the above linkages.

Design/methodology/approach

The study adopted a multi-unit study of different hospital supply chains. Consequently, perceptual data were gathered from seven dominant entities in a typical medical/hospital supply chain: hospitals and clinics, accommodation (i.e. hotels), chemistry and pharmaceutical, marketing/public relations/promotion, medical equipment manufacturers, food and beverage and insurance. The responses were gathered using e-mail survey and were analyzed using structural equation modeling.

Findings

Based on 192 completed responses, the author found positive influences of VFS, learning and integrating on hospital-supplier collaboration and a positive impact of hospital-supplier collaboration on hospital supply chain performance. An insignificant influence of hospital’s visibility for coordinating was noted on hospital-supplier collaboration. The study argued hospitals to invest more for enriching their dynamic capabilities to diagnose the changes in the environment so as to sustain their collaborative relationships leading to positive performance implications.

Originality/value

The study is the foremost to investigate the effects of hospital’s dynamic capabilities on its collaborative efforts with its key supplier and their influence on hospital supply chain performance. Also the study is foremost in exploring the importance of technology orientation on hospital dynamic capabilities and hospital-supplier collaboration. An important contribution of the research is the conceptualization of supply chain visibility core components (visibility of sensing, visibility of learning, visibility of coordinating and visibility of integrating) in the context of hospital supply chains.