Recent Models for Reform in Public Administration - Literature review Example

Table of Contents Table of Contents Literature Review: Introduction 2 Recent Models for Reform in Public Administration 7 Focus on New Public Management Theory 10 The Impact of Public Management Practices in Health Care 12 Methods of Evaluating and Redesigning Processes 14 Action Research 14 Clinical Pathways 15 Service Redesign 15 Operations Management 17 Facilitating Patient Flow 17 Conclusion 22 Bibliography 23 Literature Review: Introduction This literature review looks at concepts from different areas of study that can help analyse and resolve issues affecting the management of operation theatres. The first section (p.7) reviews recent models for reform introduced in the public sector, with special attention on ideas borrowed from business and corporate practices. The discussion focuses on the widely adopted concept called new public management or NPM (p.11). The NPM approach will be used as the framework for this dissertation due to its orientation towards decentralization, devolution, and efficiency, thus, veering away from restrictions over inputs and, instead, stressing the importance of output quality and performance measurement. This review will then investigate the observed impact of NPM on the health sector and the effects of adopting market-oriented concepts, as reported in a study conducted by the World Bank (p.13) Moreover, NPM will be a viable reference because it has been documented to influence the financial policies of many governments. Policy issues directly affect public institutions like hospitals because reduced funding restrictions - a reality in many countries and one of the benefits of the NPM approach - will ultimately have an effect at the operational level. That is, hospitals may be compelled to improve procedures and practices, especially in terms of resource allocation, but they must also strive to improve the level of customer satisfaction. The market orientation of the NPM model will be particularly helpful in this area. Thus, with NPM theories as basis, this review will proceed to investigate process level concepts that are also oriented towards efficiency (p.15), which include action research, clinical pathways, service redesign, and operations management. The final section (p.18) looks at several initiatives that aimed to improve operations and practices in hospitals and especially, in operating theatres. The sources cited in this review are summarized in Table 1. Table 1. Summary of Reviewed Literature Author/s Date Title Subject/Topic Baird 2004 The Global Influence of New Public Management: Case Studies from Africa Explains the use of NPM in several African countries, with special focus on the importance of capacity building, especially in developing countries where governance issues remain a major challenge. Barry-Walker 2000 The Impact of Systems Redesign on Staff, Patient, and Financial Outcomes Discusses the findings of a study introducing "inpatient bed consolidation" and "patient population reaagregation" in a U.S. hospital and how such change initiatives affect staff, patients, and financial performance. Borins 2000 New Public Management, North American Style Lists the characteristics of NPM and how it has influenced the governments of the U.S. and other developed countries in attempts to reform the public sector. Costello 2003 Action Research Provides a useful general reference for managers wanting to undertake action resarch, from planning to reporting. European Communities n.d. Increasing Institutional and Administrative Capacity Establishes the importance of institutional and administrative capacity in socio-economic development programmes, debating the impacts of NPM especially in developed countries. Khaleghian and Das Gupta 2004 Public Management and the Essential Public Health Functions Discusses attempts to improve the public sector and their impacts on providing health services, including adoption of NPM concepts. Mahaffey 2004 Optimizing Patient Flow in the Enterprise Explains how use of technology can enhance hospital operations and facilitate patient flow for better efficiency. NHS Modernization Agency 2002 Step Guide to Improving Operating Theatre Performance One module in a collection of HNS Modernisation Agency guidebooks, which shows how more efficient management of operating theatres can reduce waiting times and cancelled operations. Also provides key performance indicators and diagnostic tools, which can help standardize operations. Ocampo 2002 Models of Public Administration Reform: New Public Management (NPM) Compares the merits of (1) reinventing government (2) business process reengineering (3) and new public management. Discusses how these influence efforts to improve public management. OpenClinical 2004 Clinical Pathways: Multidisciplinary Plans of Best Clinical Practice Provides an introduction to the "clinical pathways" concept, its benefits, problems and barriers, and issues for discussion. Also provides additional references for further research. OpenLearn 2008 Understanding Operations Management Discusses "textbook-style" operations management and related subconcepts. Sawyer 2007 Effective Discharge Begins at Admission Discusses the trend of fragmentation in health services provision and how the "patient flow logistics coordination model" can help alleviate its impact. The University of Surrey n.d. Evaluating Service Redesign Discusses the phased "three-strand 'systems' approach" used by the University to standardize the audit and evaluation of processes. The University of Sussex 2006 What is Operations Management Provides an overview on the operations management concept. UK Department of Health 2007 Service Redesign Discusses the impact of the service redesign initiatives being introduced in NHS organisations: "better use of the skills of frontline staff, increasing day cases, reducing cancelled operations, waiting list management, demand management". Wilson et al. 2005 Perfecting Patient Flow: America's Safety Net Hospitals and Emergency Department Crowding Shows "change initiative" case studies to show how patient flow problems, especially in safety net hospitals and health systems, can be improved. *The "Date" column refers to the year of publication. Recent Models for Reform in Public Administration Ocampo (2002) provides a detailed comparison of three widely used models for reform in the area of public management, particularly: Reinventing government Business process reengineering New public management In their 1993 publication, Osborne and Gaebler introduced the idea of reinventing government, specifically to develop "a radically new way of doing business in the public sector" (cited in Ocampo, 2002). The concept is said to depart from the New Deal paradigm and shifts into a more "entrepreneurial" approach for government. In their investigation, the authors found "36 separate alternatives to normal public service delivery" to be in place, albeit in various levels and circumstances, all across the United States. They also found that even "the federal government already relies heavily on many of these alternatives" (Osborne and Gaebler, 1993). In the book, they offer this overview (italicized text supplied by the authors): Most entrepreneurial governments promote competition between service providers. They empower citizens by pushing control out of the bureaucracy, into the community. They measure the performance of their agencies, focusing not on inputs but on outcomes. They are driven by their goals - their missions - not by their rules and regulations. They redefine their clients as customers and offer them choices... They prevent problems before they emerge, rather than simply offering services afterward. They put their energies into earning money, not simply spending it. They decentralize authority, embracing participatory management. They prefer market mechanisms to bureaucratic mechanisms. And they focus not simply on providing public services, but on catalyzing all sectors - public, private, and voluntary - into action to solve their community problems (cited in Ocampo, 2002). Business process reengineering - or simply, reengineering - is defined by Hammer and Champy (1993) as the "fundamental rethinking and radical redesign of business processes to achieve dramatic improvements in critical contemporary measures of performance, such as cost, quality, service, and speed" (cited in Ocampo, 2002). Compared to reinventing government, Ocampo considers reengineering to be more "inward-looking" and focused on applications of information technologies. According to Fowler (1997), reengineering promotes multi-functional job descriptions, encourages outsourcing where applicable and even overdesigning of processes (cited in Ocampo, 2002). Perhaps, it is such features that have limited its use in the public sector arena, where decisions impact many participants or stakeholders. In fact, reengineering has been criticized for its preference for "flattening, downsizing, and cost-cutting thrusts, regardless of employee morale and motivation" (Ocampo, 2002). Needless to say, such drastic measures - reengineering is not too keen on "incremental" changes - can be especially problematic in the public sector. As Osborne and Gaebler put it, "government cannot be run like a business" (cited in Ocampo, 2002). New public management (NPM) is a reform movement that started in the 1970s and was widely adopted in the United States, the United Kingdom, Australia, and New Zealand (Baird, 2004). The OECD identified eight characteristics to distinguish NPM from other trends in government reform (cited in Ocampo, 2002): strengthening steering functions at the centre devolving authority, providing flexibility ensuring performance, control, accountability improving the management of human resources optimizing information technology developing competition and choice improving the quality of regulation providing responsive service In the account of Borins (2000), he offers another set of factors characterizing NPM: providing high-quality services that citizens value demanding, measuring, and rewarding improved organizational and individual performance advocating managerial autonomy, particularly by reducing central agency controls recognizing the importance of providing the human and technological resources that managers need to meet their performance targets maintaining receptiveness to competition and open-mindedness about which public purposes should be performed by public servants as opposed to the private sector or non-governmental organizations Therefore, whereas reengineering seeks to bundle or re-bundle tasks and functions, the objective of NPM is to decentralize and unbundle them. Of special note is its focus on the principal-agent dynamics, making "a clear delineation between... policy formulation and policy implementation" or, in more practical terms, assigning "outcomes", "outputs", and "service delivery" to different players. Adoption of NPM has varied among countries and depends heavily on "culture-specific structures" (Ocampo, 2002). Focus on New Public Management Theory Baird (2004) claims that current literature does not provide a standard definition for NPM. He goes on to cite that listed by Hope (2002). The adoption of private sector management practices in the public sector An emphasis on efficiency A movement away from input controls, rules and procedures toward output measurement and performance targets A preference for private ownership, contestable provision and contracting out of public services The devolution of management control with improved reporting and monitoring mechanisms. Hope also points out the "rigid separation between policy-making and service delivery" as a key aspect of NPM. According to Baird, NPM "promotes the public sector use of private sector management techniques" although, as shown in the previous section, there are other theories born in the corporate realm that have found their way into the government practice. As has also been mentioned in other sources, Baird explains that NPM started out in the 1970s as a phenomenon in more advanced territories, due to problems encountered by different governments. His paper contrasts that, in developing countries, there are uncertainties over its general applicability, especially where there is limited capacity to implement NPM methodologies. Borins (2002), on the other hand, zoomed in on the NPM experiences of the United States and Canada and, consequently, found some interesting similarities: The importance of "bottom up" reform, in particular the efforts of front-line staff and middle managers, especially if sanctioned from above (for example, the US federal government's reinvention labs), as well as reforms undertaken by sub-national governments The influence of ideas originating in the private sector, such as service quality, total quality management, and business process reengineering The importance of initiatives to improve service quality and to set objectives and measure performance The critical role being played by information technology in two countries that are at the forefront of the IT revolution Rather than major structural reform of government, the use of alternative service delivery mechanisms that cross boundaries of departments and levels of government and that incorporate as partners the private and non-profit sectors. The European Communities (n.d.) produced a sourcebook with a set of more practical NPM guidelines: Hands-on professional management in the public sector Explicit standards and measures of performance Greater emphasis on output controls Stress on customer satisfaction and quality Shift to disaggregating of units in the public sector Emphasis on delegation of authorities to line management Shift to greater competition in public sector Stress on horizontal subsidiarity and outsourcing Stress on private-sector styles of management practice Stress on greater discipline and parsimony in resource use Emphasis on new technologies (ICT) The Impact of Public Management Practices in Health Care In their World Bank working paper, Khaleghian and Das Gupta (2004) looked into how reforms in public sector management - such as NPM - impact the provision of medical services, especially those classified as essential public health functions (EPHFs). EPHFs are considered public goods and include "disease surveillance, health education, monitoring and evaluation, workforce development, enforcement of public health laws and regulations, public health research, and health policy development". The shift from "government by control" to a "government by contract" system under NPM is one of the aspects that affected health care delivery, mainly because it entailed modifications in organizational structure and introduced market orientation. In effect, explained Batley (1999), government changed from "direct service provider" to that of steward in charge of oversight and regulation (cited in Khaleghian and Das Gupta, 2004). There were problems encountered but these did not pertain so much to the use of NPM; the difficulties resulted more from inappropriate application. In some areas, for instance, the same set of practices were adopted across the board when NPM schemes like "purchaser-provider splits, hospital autonomy and decentralization" would be a better fit for curative, as against preventive, care. As a result, there were fewer success stories in locations where preventive services were offered. The World Bank paper also advised caution in implementing market principles in service delivery. As an example, charging fees has been perceived negatively by patients, leading to a decline in immunization rates and even disease control. The authors concluded that, especially for EPHFs, fee-based services would not be applicable and would have to be funded some other way. Donor support and government subsidies are possible alternatives. On the other hand, some NPM principles like contracting and splitting may be useful to some degree but on a more limited scale in developing countries, as already mentioned by Baird. According to Batley (1999): Particularly in the social sectorswhere government retains critical ultimate responsibilities, the transaction costs of radical reforms which create multiple agencies are likely to outweigh the efficiency gains of "unbundling." More modest ambitions and simpler reforms which avoid the creation of complex, interdependent organizational arrangements are more likely to have beneficial effects. With these, NPM appears to be a feasible approach in re-evaluating the public health industry. The next section looks at concepts for introducing changes at the process level. Methods of Evaluating and Redesigning Processes Action Research Frost (2002, p. 25) defines action research as a "process of systematic reflection, enquiry and action carried out by individuals about their own professional practice" (cited in Costello, 2003, p.4). Dick (2002) describes the process as "flexible" and "spiral" because it "allows action (change, improvement) and research (understanding, knowledge) to be achieved at the same time" (cited in Costello, 2003, p.4). Bassey (1998, pp.94-95) offers an eight-stage action research model to analyze problem situations (cited in Costello, 2003, p.8-9). While he qualified the framework for use in the educational arena, it could serve as guideline in various kinds of activity (Costello, 2003). Stage 1: Defining the enquiry Stage 2: Describing the educational situation Stage 3: Collecting and analysing evaluative data Stage 4: Reviewing the data and looking for contradictions Stage 5: Tackling a contradiction by introducing some aspect of change Stage 6: Monitoring the change Stage 7: Analysing evaluative data concerning the change Stage 8: Reviewing the change and deciding what to do next Clinical Pathways The clinical pathways concept, which came about in the United States and the United Kingdom in the 1990s, is also known as "integrated care pathways, multidisciplinary pathways of care, pathways of care, care maps, (and) collaborative care pathways". It is defined by Open Clinical (2004), a knowledge management Web site for health care practitioners, as "structured, multi-disciplinary plans of care designed to support the implementation of clinical guidelines and protocols" that aims to "provide detailed guidance for each stage in the management of a patient...with a specific condition over a given time period, and include progress and outcomes details". As a unique feature, clinical pathways seek to develop "continuity and co-ordination" among the various players in the patient care industry by means of step-by-step decision flow charting, to be able to detail activity timetable, the required intervention, the desired result, and potential variances . Service Redesign Service redesign, accompanied by job redesign, has been used to improve practices in the health care industry. The United Kingdom Department of Health (2007) has developed several programmes in this regard. These include: Better use of the skills of frontline staff, especially expanded roles for general practitioners and nurses Increasing day cases, by conducting majority of elective surgery during daytime Reducing cancelled operations, through the use of incentives, to maximize use of theatre capacity Waiting list management, by distinguishing between "priority" and "routine" patients Demand management, to be able to quantify the capacity, resources, and skills needed The UK Government urges health centres to review opportunities for service redesign, to improve efficiency in use of resources. Campbell (2000) notes wide adoption of randomised controlled trial (RCT) and other audit mechanisms, to limit use of ad hoc approaches (cited in UK Department of Health, 2007). The University of Surrey Healthcare Workforce Research Centre (n.d.) promotes its phased "three-strand 'systems' approach", to be able to provide a "a flexible yet rigorous model for evaluation", especially for advanced care needs. Phase One defines the new processes and structures, as well as the evaluation design and the methods to be used. Phase Two details the evaluation plan by identifying the roles of all the participants and finalising the programme timetable. Finally, Phase Three collects and analyses data by use of various methods, to be able to establish the value of the planned changes and provide a more comprehensive estimate of the resulting benefits. Barry-Walker (2000) defined systems redesign as "fundamental rethinking and revamping of traditional structures, work roles, and critical systems and their related processes used to produce, deliver, or support patient care". In her paper, Barry-Walker reported on a study to measure the effect of aggregating inpatient beds and patient population - commonly used strategies - on hospital staff, patients, and the bottom line. She claimed that removing unnecessary inpatient beds while maintaining larger nursing units for similar patient populations with common care requirements can increase efficiency and minimize training expenses. At the same time, she also warns staff may view such interventions negatively in the beginning but the general perceptions should improve along the change process. Operations Management Operations management focuses on designing, managing, and improving the systems used to deliver the offerings of an organization (OpenLearn, 2008). These include all the functional areas - from human resources, marketing, and product development to finance and administration. The transformational model is one common framework used in operations management, where inputs (resources such as as raw materials, information, and even customers) are converted into outputs (finished products and services) by transforming agents (like company staff and facilities). Operations management is a "transformation process", which aims to add value and be able to achieve competitive advantage (The University of Sussex, 2006). Therefore, operations would also cover: Designing services, products and delivery systems Managing and controlling the operations system Finding ways to improve operations Facilitating Patient Flow Sawyer (2007) looks at one major problem affecting the delivery of health care: fragmentation. As described by the Institute of Medicine, "Health care is characterized by fragmentation - among disciplines, among departments, among organizations, and among geographic locales - while those it serves depend on coordinated effort. The system propagates waste: waste of time, resources, and good will" (cited in Sawyer, 2007). Sawyer also lists three problems in operation brought about by fragmentation: The disparate "islands of excellence" culture of the healthcare system, including the lack of coordination between hospitals and post-hospital care providers. The many "moving parts" of the healthcare delivery process adding complexity to patient care coordination and discharge planning. The limited incorporation of the necessary patient flow logistics technology to address a problem of this magnitude. To demonstrate how one bottleneck can impact the entire system, Sawyer cites delays in discharges. These cause hospital management to lose firm control over bed capacity and, as an effect, incoming patient demand from the emergency department, for example. He stresses that "discharge delays create an upstream tidal wave of patient flow constraints which negatively impacts patient satisfaction, safety, hospital capacity, and financial performance". Sawyer also talks about admissions and the emergency department as the typical "entry points" for patients and how the personnel in these areas tend to have poor control over their "input". Simply put, they are expected to accept all incoming demand. Similarly, he cites the value of the "system aim" concept of W. Edwards Deming, renowned statistician. According to Deming, systems must be managed through "constant facilitation of the interrelationships between all of the components within the system and of the people working in it" (cited by Sawyer, 2007). With these, Sawyer concludes that, to have an effective discharge system, planning and management must start at the point of admission. As did Mahaffey, Sawyer recommends the use of technology via a "patient flow logistics coordination model" to bring about a solution to these patient flow problems. For example, the model can re-connect the "islands of excellence" and their silo culture, which can become apparent in different ways. For instance, patients must be able to move seamlessly "from admission through diagnostics, treatment, nursing units, to day of discharge, and on to post-hospital placement". When one department's priorities conflict with those of another, this is where bottlenecks can happen. As pointed out by Sawyer, the emergency department is a common entry point for patients. Therefore, crowding and delays here will affect capacity in other areas, such as in the operating theatres. In the meantime, related to this, Wilson et al (2005) take note of the impact that patient flow issues can have on staff, especially in cases of manpower shortage. These can lead to errors, quality problems, and morale issues. Thus, he claims that go-to solutions "like expanded primary care capacity, may actually do little to alleviate this crisis". Wilson et al propose adoption of an Input/Throughput/Output (I/T/O) framework of patient flow, which follows the transformation model of operations management theory. Input factors include why people present to an ED... availability of alternative sites of care, insurance status, perceptions of quality, physician referral practices, and other variables. Throughput refers to the actual operations of the ED: How are ED processes designed Are medical specialists and ancillary services available in a timely fashion Is clinical information accessible Output factors address the ability to move an ED patient to his/her next disposition: Is there subsequent care available in the community Does the hospital have the systems and capacity to move sicker ED patients to critical care and other inpatient units While this paper focuses on emergency department, it provides some useful insights for this research. Mahaffey (2004) reports that capacity problems often occur in emergency rooms, operating theatres, and intensive care units, where "demand fluctuates and is seemingly unpredictable". To improve patient flow, he advises hospitals to "combine process management with information technology to redesign patient flow". To adopt a technology-oriented solution, he recommends a four-point blueprint: Vision: To improve patient flow, the health institution must adopt an enterprise-wide vision but it must implement its plan in an incremental manner. A solution cannot be compartmentalized because it will likely create problems for the other departments; however, Mahaffey says it should start in the emergency or operating rooms to help the technology staff to focus on one department. Data capture: To be successful, an initiative to improve patient flow must have an information component that will facilitate the "capture, integration, and sharing... within and across departments". Workflow automation: Information must not only be available; it must be actionable, according to Mahaffey. It must trigger patient-related events through automated reminders, thus reducing time and effort spent on manual and tedious work. Ongoing measurement: Process improvement must be monitored continuously and implemented iteratively. It is not a one-time event. Relevant metrics are required to be able to evaluate success. Use of this framework is preceded by a process mapping activity, to identify problems, bottlenecks, reasons for under- or over-capacity, and other related issues. Specific to operating theatres, the NHS Modernization Agency (2002), a bureau under the United Kingdom Department of Health, developed the "Step Guide to Improving Operating Theatre Performance". The document captures the heart of the matter in a single statement: "patients want short waiting times and to have the operation on the agreed date". As a matter of fact, the HNS Theatre Programme was itself established to improve "patient experience... employee satisfaction and morale... operating theatre performance... quality". The "Step Guide" is a four-stage framework: Planning and management Diagnosis and analysis Improving theatre performance Scheduling With these, introducing quality interventions into the patient flow starts before the patient enters the premises. The hospital management must make sure that the necessary personnel, resources, information, and communication systems, rules, and regulations are in place. Patient process mapping is a key tool to diagnose problems and estimate demand. In the NHS framework, it starts with the identification of the target patient group. It then investigates the scope of the process, that is, the first step up (e.g., making the decision to operate) to the last step (e.g., ordering the patient discharge). It also looks into any parallel processes that may create conflict in the scenario. From these, each bottleneck and its underlying cause (i.e., the constraints) would be detected. The NHS adopts Deming's "system aim" concept, believing that "services to patients cannot be improved if operating theatres are seen in isolation". In fact, this holistic approach seems to be a common denominator among the different studies. This does not necessarily contradict the decentralization tenet of NPM; rather, it gives perspective on how "unbundled" services in a health facility could operate with a single vision but in a coordinated fashion. Conclusion This literature review did not dwell too much on specific country applications because its purpose is to identify general best practices and guidelines that can then be adopted in the target site of the study. However, it must be stressed that any future initiatives intending to improve the management of hospitals and operating theatres - or the practices in any area of the public sector, for that matter - must pay careful consideration to local conditions, especially government regulations and funding issues, as well as cultural elements (at the country and organizational levels). In any case, the planned survey will be guided by such factors, which will be considered during the development of the research methodology and instruments. Bibliography Baird, M. (2004). The Global Influence of New Public Management: Case Studies from Africa. In Pennsylvania, USA: Villanova University. http://www.publications.villanova.edu/Concept/2004/Global%20Influence%20of%20New%20Public%20Management.pdf. Barry-Walker, J. (February 2000). The Impact of Systems Redesign on Staff, Patient, and Financial Outcomes. The Journal of Nursing Administration, 30(2) 77-89. 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In Scotland: OpenLearn. http://openlearn.open.ac.uk/mod/resource/view.phpid=161691. Osborne, D. and Gaebler, T. (1993). Reinventing Government: How the Entrepreneurial Spirit is Transforming the Public Sector. New York, USA: Penguin. (Excerpt available in http://www.amazon.com/) Sawyer, B. (February 20, 2007). Effective Discharge Begins at Admission. In Georgia, USA: Patient Placement Systems. http://www.techworld.com/whitepapers/index.cfmwhitepaperid=4256. The University of Surrey. (No date). Evaluating Service Redesign. In Service Redesign, Surrey, UK: The University of Surrey. http://portal.surrey.ac.uk/portal/page_pageid=931,652731&_dad=portal&_schema=PORTAL. The University of Sussex. (July 10, 2006). What is Operations Management In Technology & Operations Management, Brighton: The University of Sussex. http://www.sussex.ac.uk/Users/dt31/TOMI/whatisom.html. United Kingdom Department of Health. (August 2007). Service Redesign. In London: The Crown. http://www.dh.gov.uk/en/Healthcare/PatientChoice/Waitingbookingchoice/DH_4066204. Wilson, M., Bruce Siegel, and Williams, Mike. (May 2005). Perfecting Patient Flow: America's Safety Net Hospitals and Emergency Department Crowding. In Washington, D.C., USA: National Association of Public Hospitals and Health Systems. http://www.urgentmatters.org/reports/NAPH_Perfecting_Patient_Flow.pdf. World Health Organization. (November 1, 2004). What are the advantages and disadvantages of restructuring a health care system to be more focused on primary care services In Health Evidence Network, Copenhagen: World Health Organization. http://www.euro.who.int/HEN/Syntheses/primaryvsspecialist/20040115_16. Read More