Bayreuth Productivity Analysis—a method for ascertaining and improving the holistic service productivity of acute care hospitals
Mario Alexander Pfannstiel
Chair of Strategic Management and Organization, University of Bayreuth, Bayreuth, Bavaria, Germany
Correspondence to: M. A. Pfannstiel, Chair of Strategic Management and Organization, University of Bayreuth, Prieserstr. 2, 3 OG, Bayreuth, Bavaria, 95444, Germany. E-mail: Mario_Pfannstiel@hotmail.com
The Service4Health project, jointly supported by the German Federal Ministry of Education and Research (BMBF) and the German Centre for Aviation and Space Travel (DLR), develops and implements concepts and programs to boost productivity in hospitals. However, the healthcare sector still lacks a method with which hospitals can measure the extent to which they have achieved their goals in terms of aggregate productivity from both patients' and employees' perspectives. We developed the Bayreuth Productivity Analysis (BPA), which is a holistic method to ascertain service productivity (SP) of acute care hospitals and can be used by management personnel to improve SP through projects targeting productivity growth at hospitals.
Hospitals are service providers pursuing many goals that influence and compete with one another. To ensure individual set goals are reached, SP must be monitored. SP can be specified and determined using indicators, for example, in the form of items. These items comprise a number (indicating the size) and a unit (describing the importance). A system of items can express an objective target or an overall aim. It can show changes and should therefore be vested with a high level of significance to be useful for decision makers. Decision makers require information on what influences most strongly the provision of services, what providers and consumers of services expect, and how these expectations can be met. SP indicates the extent to which resources, such as information, are utilized and transformed into a value for service providers and consumers and whether their needs are met (Grönroos and Ojasalo, 2000; Rutkauskas and Paulavičienė, 2005; Žemgulienė, 2009). Qualitative assessment of productivity depends entirely on the extent to which service providers and consumers appreciate services (Ojasalo, 2003; Johnston and Jones, 2004).
A service is any type of medical or non-medical care performed by one that serves. Services are deemed delivered when service providers have met the needs of consumers with the resources they have available (Rutkauskas and Paulavičienė, 2005). Hospital services are under the direction of hospital staff and are provided to help consumers reach their goals. Furthermore, SP is a core component for hospital management and is influenced by service providers and consumers (Johnston and Jones, 2004; Rutkauskas and Paulavičienė, 2005). While providers bundle resources to create a basic willingness to perform, consumers are integrated in the service process, and the service is rendered (Corsten and Gössinger, 2007). SP is manifested in resources in a process aiming to increase hospital value. SP targets have been reached when a specified productivity value has been attained. Service providers and consumers are considered the point of departure for ascertaining productivity in hospitals because their feedback can stimulate, pilot and control change and improvement. The supply and demand of services needs to be observed to be able to represent holistically the relevance of productivity for individual hospitals. SP in hospitals is impacted by the dynamic relationship among the environment of providers and consumers of services, productivity and service quality (Grönroos and Ojasalo, 2000). Service providers and consumers can be productive only if their environments are arranged in a way that allows maximum productivity of services.
To ascertain productivity effectively, it is necessary to create an index that identifies productivity values from relevant resources, elucidates them and puts them into relation with one another (Grönroos and Ojasalo, 2000). It is possible to make statements on holistic SP only if contributions made to productivity are understandable, comparable, comprehensive and transparent. This means that the individual items must be presented in a way that is clear to ensure appropriate evaluation, be defined according to basic components in order to be comparable, cover the actual situation and be formulated clearly. When ascertaining holistic SP, relevant resources have to be identified, and it must be borne in mind that SP is impacted by cost, time and quality of services (Jääskeläinen and Lönnqvist, 2011; Žemgulienė, 2009; Johnston and Jones, 2004; Rutkauskas and Paulavičienė, 2005). In hospitals, SP can be determined for services consisting of at least one cost-related, time-related or quality-related factor. When services include one of these factors, they are relevant in terms of productivity and services. Currently, no systematization identifying productivity-relevant and service-relevant items exists in the literature. Finally, a boost in productivity can have a potentially positive or negative impact on each of these three parameters in a resource area. Figure 1 provides an initial overview of this relationship.
Examining the concept of productivity
Diverse models and methods for describing the provision of services productivity are to be found in the literature (Parasuraman, 2002; Grönroos and Ojasalo, 2004; Corsten and Gössinger, 2007; Burger, 2008). The models are in part very theoretical, and the methods of determination are often complex, time-consuming and expensive. Applications in hospital settings include special methods for measuring efficiency, such as the data envelopment analysis and the stochastic frontier analysis. It has not yet been possible for hospital managers to determine the overall SP for delivered services in a simple manner. Three groups of people are at the center of service determination and service focus: patients, medical/nursing staff and non-medical staff. Focus on all three groups of people has not been made. It must be noted that until now, analysis of the complex system of service provision in hospitals has been insufficiently undertaken, that is, without comparison, without being holistic and without the same depth among the various groups of people. This gap in research shows that holistic problems with service provision can be approached and managed only in a limited way. An aim of this paper is to fill this research gap. One way to determine and represent the provision of SP with reference to all groups is to be identified here. As a result, the decision makers at acute care hospitals will have a method for increasing and managing the SP for provided services.
According to the aforementioned concepts and theories, productivity can be achieved in hospitals through the performance of individual patients and employees. The productivity of patients comes into existence through the interactive process with hospital staff. This can be determined by evaluating services rendered. The productivity identified in this manner is an expression of the target achievement regarding a provided service. It is to be noted that employees in hospitals provide services to, and perform services on, patients, who are external factors (Alter, 1999; Sibbel and Urban, 2001). Employees are able to perform their work only through an integrative service creation process, meaning through interaction with patients (Dugdale et al., 1999; Kutney-Lee et al., 2009; Lowe, 2012). This interaction implies numerous factors relevant to productivity and services on the provision of services, such as the communication of information (Seelos, 1994; Draper et al., 2001), the organization of tasks (Manser, 2010; Dahlgaard, 2010), the working atmosphere among staff members (Salanova et al., 2005; Weng et al., 2011), the methodical procedures (Kozlowski and Ilgen, 2006; Antoni, 2010), the infrastructure (Haynes, 2007; Haynes, 2008) and the use of technology (Spetz and Maiuro, 2004; Yarbrough and Smith, 2007). The influence of the external factor extends into the service process to various degrees. Providing services is based on the targeted provision of services in a process between the performance and the resources of the provider and the performance and the resources of the consumers. It is necessary to take into consideration the perspectives of service providers and consumers when providing or creating services. However, when calculating holistic productivity, it is important to observe all people as a whole rather than merely individuals. Logically, there is a very close relationship between the productivity and the performance of individuals, and they can be described and studied quantitatively and qualitatively. The theory of productivity needs to be explained in sufficiently concrete terms to be able to assess productivity in general and SP in particular (Johnston and Jones, 2004) and eventually to create measures to improve productivity (Rutkauskas and Paulavičienė, 2005). Furthermore, quantitative and qualitative key parameters can be included in the process of measuring productivity (Grönroos and Ojasalo, 2000). The concept of productivity described here allows us to study these parameters and make detailed and accurate assumptions about them (Žemgulienė, 2009). In other words, we can study generally and holistically the ways that productivity-related theory and practices manifest themselves.
To conduct the BPA, two questionnaires were developed on the basis of extensive research of the literature and input from a group of experts. This group was formed for four reasons: first, to gather and utilize qualitative data; second, to supplement and broaden the existing concept of SP to determine the holistic SP; third, to provide information on the development of items; and fourth, to improve the relevance and representativity of items (Nassar-McMillan and Borders, 2002; Vogt et al., 2004). The group included a moderator and 10 decision makers. The decision makers came from three acute care hospitals and represented the groups of people as follows: four members of the nursing staff, three members of the medical staff and three members of the non-medical staff. Through structured and moderated discussion (Rattray, 2007), six dimensions and 30 items were developed for each questionnaire. These dimensions and items serve, along with the weighting of the dimensions, to determine the SP for the entire patient and employee population in a hospital.
The BPA comprises two main questionnaires—one for patients and one for employees of hospitals—in which five items relevant to productivity and services are combined into one dimension (APPENDIX A). The basic model (Felix and Riggs, 1983; Riggs and Felix, 1984) already has been applied multiple times in studies conducted in the area of service provision (Rahman and Ismail, 2004; Balkan, 2011; Jääskeläinen and Lönnqvist, 2011) to determine the productivity of service provision; however, it has never been applied with reference to all groups of people in the same service areas in a hospital. Respondents assessed the extent to which their service-related targets were reached. To calculate the productivity value, the value of each item per dimension must be added. This is carried out by means of an individual assessment of the items and the resulting productivity value per item. The productivity index is obtained using a calculation grid with six defined dimensions in accordance with the subjective weighting of these dimensions. Aggregate productivity is obtained from the overall contributions to productivity.
Assumptions about determining holistic SP must be made clear and comprehensible. To avoid misunderstanding, a derivation and designation of key assumptions are outlined in the succeeding text. In the hospital, holistic consideration of the SP is based on people, their interaction and services rendered. The attainment of goals by people is focused on the following holistic principle: people first attempt to achieve individual hospital goals and then higher-level goals. If no connection between the types of goals were to exist, then it would be difficult to understand how the SP in hospitals can be influenced by people. Hospital goals must be understood on an individual level by each person; simply assigning goals to people is not productive. For hospital objectives to be understood and achieved, the objectives must be made visible and transparent for all people involved. Attaining goals involves determining the extent to which services were provided and which services between people contributed to the benefit of the entire hospital. To determine and increase the holistic SP, the following main assumptions were made:
1) patients and employees provide services that influence holistic SP;
2) holistic SP can be determined if the contributions by all people to the SP are documented;
3) holistic SP encompasses a value for provided services and shows the extent to which a need was met and
4) on the basis of productivity analyses, effective measures for increasing productivity can be introduced.
Developing the surveying instruments
To develop the patient questionnaire and the employee questionnaire, we first conducted a literature review, consulting the Medline database for medical literature as well as the electronic library of the University of Bayreuth for periodicals. We searched documents with the following key words: patient questionnaire, employee questionnaire and productivity measurement at the hospital. When creating the patient questionnaire, we did not consider the specific forms of therapy for which a questionnaire had been developed. When creating the employee questionnaire, we did not consider the strategic orientation of the survey in the hospital. Instead, we evaluated the questionnaires cited in the literature in terms of their content. We developed our two main questionnaires in three steps: first, we supplemented the content of the researched literature by adding new items and reformulating previously used items; second, we conducted a pre-test to ensure appropriateness of the items on our questionnaires; and third, we determined the SP for specific groups (patients and employees).
Literature on surveying instruments in hospitals
In our literature review, we identified the dimensions frequently used in patient and employee questionnaires to determine the extent to which productivity targets were achieved in hospitals. We found eight patient questionnaires, six employee questionnaires and four theoretical articles with defined dimensions (i.e. key elements in achieving productivity targets of a hospital) and items (APPENDIX B). These questionnaires had been used in quality assurance and human resource development in hospitals. In our evaluation of these questionnaires, we discovered a high level of variability among dimensions and a wide variety of items per dimension. We discussed the applicability of the different items and agreed that the provided services, such as health-related quality of life and effectiveness of care, were indeed relevant but had little explanatory power as individual items. Suitable methods for documenting health-related quality of life are available in the literature (Ravens-Sieberer and Cieza, 2000). In addition, we found that patient questionnaires surveyed the overall impression of a patient's stay in hospital, whereas employee questionnaires surveyed an employee's overall impression of working at a hospital. This holistic approach to surveying should be taken when investigating productivity in order to ascertain the productivity values from the points of view of patients and employees for the same dimensions. This allows studying and demonstrating both secondary and consequential effects as well as interactions when recording the behavior of individuals and groups of people at different times in various study environments such as hospitals. It is possible to add or subtract productivity values quantities (productivity values) of equal dimensions only when calculating the holistic productivity index to allow a comparison of dimensions and subgroups.
Selecting questionnaire respondents
We held a 1-day working session with medical, nursing and administrative decision makers under academic management to discuss productivity of services in hospitals. During this session, we clarified terms to ensure uniform fundamental understanding, and the attendees agreed that it was possible to measure the aggregate productivity of critical dimensions of a hospital only if the views of both patients and employees were taken into account. Together, we decided that these two groups of people would provide input, and accordingly, we developed a questionnaire for each group. The patients were divided into two subgroups (statutory and privately insured patients) to study productivity in greater detail, and the employees were divided into three subgroups (nursing, medical and non-medical personnel).
Determining dimensions to ascertain productivity
We listed the dimensions identified during our literature review and discussed them in terms of their relevance and holistic nature in the hospital during the working session with scientists and practitioners working on the same subject. The patient's point of view was represented by the attending decision makers. Feedback indicated that each of the people attending our workshop previously had gone to a hospital for treatment, meaning they were able to put themselves in the position of a patient and define the dimensions and items for the questionnaire. Certainly, there are various medical aspects decision makers are unable to understand fully, and because of the holistic vantage point taken, they must remain unconsidered. If a questionnaire were to be developed for a specific patient group, such as cardiac patients, the presence of a patient would offer substantial additional value. Information about lack of clarity in the formulation of items should also be gathered by administering a pre-test, and any necessary adjustment of the items should be made. Then, we discussed with the decision makers attending the working session the results from the literature review and six critical dimensions (information, organization, climate, methods, infrastructure and equipment) representing a holistic reflection of SP in hospitals. There was consensus that these dimensions provide a definite conceptual basis. The information dimension (D1) described the productive behavior of people transmitting news. The organization dimension (D2) described targeted cooperation among people in processes and structures in hospitals. The climate dimension (D3) summarized how people perceive and experience cooperation (we talked about a climate of treatment with patients and a working climate with employees). The methods dimension (D4) reflected methodical procedures when treating patients and during employees' work. The infrastructure dimension (D5) encompassed the hospital as a healthcare provider with a space structure designed to meet both patients' and employees' needs. Public, non-profit and privately operated acute care hospitals differ in terms of their targets. Public and non-profit hospitals are geared towards covering their needs, whereas privately operated hospitals focus on gaining profits. The equipment dimension (D6) looked at the use of objects (i.e. equipment, machines and apparatuses). Although the six dimensions were supposed to act as the point of departure for developing the two questionnaires and for ascertaining SP, they were not explored for specific types of therapy or medical treatment. This is because the questionnaire would have been too long, and it would have lost its focus on holistic productivity, which required lowering our sights when establishing applicable dimensions. Furthermore, patients and employees are not able to assess all types of therapy or medical treatment used in hospitals. The dimensions selected ensured that their items could be queried and applied in any acute care hospital with a wide range of wards and types of therapy and medical treatment.
Orientation was placed on the holistic concept of Hatch's organization theory (Hatch, 1997; Hatch and Cunliffe, 2006) to classify the researched and discussed dimensions for the BPA. Hatch described various factors consisting of six conceptual models in a model (Figure 2) influencing organizations relevant to productivity and services. These six models represent a set of theories that are related to and intersect with each other. The central focus of these theories is strategies and goals. According to these theories, hospitals as organizations have a similar model relevant to productivity and services that must be determined. The aim of this study was to identify this model consisting of six dimensions. The dimensions were to serve as starting points for determining the holistic SP. Moreover, each dimension was to be closely connected with the idea of the strategic achievement of objectives in order to be able to evaluate precisely achievement of targets and, consequently, the SP.
To select and define the dimensions and items, the method of ongoing deliberative participation was applied (Alkire, 2007). Current values held by people were identified and prioritized through group discussion and participatory analysis. Decision makers in the working session chose which dimensions and items to include on the questionnaires, keeping in mind that (Vogt et al., 2004; Nassar-McMillan and Borders, 2002) they must be valid for all acute care hospitals and relevant for the questionnaire supervisors as well as respondents. The participatory selection process had the advantage of allowing problems to be discussed in depth and directly with other decision makers on different levels and in relation to affected groups of people. As a result of the group discussions, appropriate dimensions and item sets for each dimension were identified. The aim behind creating dimensions was the documentation of dimensions for the purpose of determining the holistic productivity in an organization.
Step 1:Formulating and checking items
To generate items for the various dimensions, we first discussed and compiled at the working session potential items including those found during our literature review. Then, we developed a questionnaire to assess the selected items for the main questionnaires. In two emails, we asked the people attending the working session to validate these items and assess their significance for SP in hospitals on a 5-point Likert scale (no significance, low significance, medium significance, high level of significance and a very high level of significance). Items with no significance to medium significance were excluded and replaced. Finally, they were asked to provide new and potentially meaningful items and to formulate them in a way that was comprehensible for each group of questionnaire respondents. Items had to be generated for the same dimension from the perspective of both target populations and formulated as recommendations for action in order to uncover ways to boost productivity. We selected conventional items describing one dimension as a single aspect and as holistically as possible in connection with the other items. Among the compiled items, there were many for which no productivity or service relevance could be seen. Ultimately, no item was taken directly as it was found in the literature.
When generating items for the two questionnaires, only positive items were included and prioritized for the selection process. If no relevant items were present, items were created for the selection process. Redundant items were deleted. In the case of some items, the wording was revised to improve understandability. Particular value was placed on using respondents' exact language as closely as possible. An item set was created for all dimensions when appropriate so that an adequate evaluation was possible for the underlying overall concept. The selection process described for the items led to an initial draft of the questionnaire for the particular target population. The participating decision makers (experts) confirmed the validity and appropriateness of the content of the dimensions, items and scales.
Step 2:Pre-test version of the two main questionnaires
The dimensions and items were formulated into a patient questionnaire and an employee questionnaire, both consisting of a general part requesting socio-demographic information (e.g. age, sex, education, how long the patients remained in hospital, how many years employees were in their profession and the subgroups of patients and employees to which the respondent belonged) and a specialized part consisting of six dimensions and an overview of the assessment in both questionnaires to accord relative importance to the dimensions.
A pre-test for the two questionnaires was conducted in a standard service hospital to determine the extent to which patients and employees would accept and respond to the items projected for the six dimensions. The questionnaire was administered to 34 patients and 36 employees in the hospital; they were not informed that they were taking part in a pre-test to ensure that the questionnaire would be used under realistic conditions. A hospital worker whom we briefed on how to supervise respondents was present when the questionnaire was completed. The supervisor answered questions from patients and employees, recorded any problems that occurred as well as the frequency of queries and measured the time needed to complete the questionnaire. The supervisor was asked to be as passive as possible during the survey and simply to observe. The two main questionnaires were administered to people differing in socio-demographic characteristics in order to gather meaningful information on how long it took to complete the questionnaire, how comprehensible the items were and the degree to which the questionnaires were accepted by respondents. In addition to the two main questionnaires, we developed a one-page evaluation form for respondents to evaluate various features of the main questionnaires and to comment on them in general.
Results of the pre-tests and evaluation form
Responses on the pre-test questionnaire (Figure 3) indicated that the three A4 pages of the two main questionnaires were considered too long and tiring. Nevertheless, the respondents found the main questionnaires interesting, well structured and comprehensible. Overall, the patients and employees considered the main questionnaires good measuring instruments. Finally, we studied the results of the pre-test in combination with the evaluation form to see if there was any agreement and then made some necessary changes. The supervisors' insights were considered while improving the two main questionnaires and ensuring they were holistic. The data provided by the supervisor indicated that patients needed more time to answer the defined items and asked more questions concerning interpretation and comprehension than the employees did. That might be because the employees work in a hospital environment and therefore were more familiar with the technical terms in the items on the questionnaire. Finally, we adjusted our surveying instruments in terms of appearance and content based on the outcomes of our discussion with the decision makers and the pre-test findings from scientific literature, and in the end, we had a two-A4-page questionnaire each for patients and employees.
Step 3:Weighting the dimensions for productivity measurement
We weighted the dimensions in terms of their importance within a range of dimensions. Those with high weighting had a greater impact on productivity than those with low weighting. The two main questionnaires were formulated in a way that one respondent would be able to weight subjectively various factors at the end of the questionnaires. The importance of the six dimensions was assessed on a 5-point Likert Scale (not important, hardly important, somewhat important, important and very important).
Target specifications for boosting productivity in hospitals
Boosting productivity in hospitals requires knowledge of current productivity values that can be gained only through patient and employee surveys. The patients assessed the items on the questionnaire individually with reference to the overall impression they had from their stays in hospitals, whereas the employees assessed the items with reference to the overall impression they had of working in hospitals. Each item on the main questionnaires was assigned a 5-point Likert scale (not accurate at all, mostly inaccurate, somewhat accurate, mostly accurate and entirely accurate) for individualized assessment as well as productivity values assessment. At the same time, increases and decreases in productivity reflected through responses to the items indicated a need for action. The critical dimensions and developed items relevant to productivity and services defined for both main questionnaires were used for recording aggregate productivity.
Scale for classifying productivity
A scale can be used to map and evaluate varying degrees of productivity achievement in terms of targets set. The scale developed and employed was as follows: the maximum productivity value of one dimension was obtained by adding the number of items (five) per dimension and the number for the highest degree of productivity (four). An individual assessment of productivity was made for five degrees of productivity (0 = very slight to non-existent productivity, 1 = low productivity, 2 = average productivity, 3 = high productivity, 4 = very high productivity). The potential expressions of target achievement were obtained from the potential productivity values of one dimension divided by the number of items per dimension. Figure 4 illustrates the potential degrees of achievement on a scale of 1–10 making it applicable to all dimensions. The scale value ascertained in a survey for one dimension is mapped on the scale which makes visible the extent to which a productivity target was reached.
Ascertaining the productivity of a specific population
The following procedure should be followed to be able to ascertain the productivity index for both patients and employees of hospitals (Riggs and Felix, 1984; Felix and Riggs, 1983). The ascertained productivity values of the six dimensions (here shown as an example with patients) were entered into the calculation grid (Figure 5, steps 1 and 2). Then, the productivity values were assessed using a system of points reflecting level of productivity for the overall findings (step 3). The level of productivity included a basic and a target value and was simultaneously a scale of targets (Sink et al., 1984; Rahman and Ismail, 2004; Erni, 2009; Balkan, 2011). Whereas (0) indicated the lowest level, (10) indicated the highest level of a productivity value in the period under review based on normal operating conditions (Dervitsiotis, 1995; Tatum et al., 1996; Rahman and Ismail, 2004). The number of productivity points was obtained by comparing the current productivity value and level of productivity (such as D1 = 1.8 ≙ 5). The number of countervalue productivity points equaled the number of productivity points ascertained and was entered into the table in the succeeding text, the current productivity value being a real productivity value (step 4). Weighting the existing dimensions emphasized the relative importance of one dimension with reference to all dimensions (step 5). Altogether, 100 weighting points were distributed over the six dimensions. A minor weight implied that it was not very important, whereas a major weight indicated that the dimension was very important within the range of dimensions (Sink et al., 1984; Balkan, 2011). These assessments should be made by several people and independently of one another to obtain as objective an average value as possible. The weighting coefficients presented in the table below are calculated by adding the weighting points subjectively given on the questionnaire by individuals in a population. The numerical values given in the example are fictional. In the case of a real test, the number of weighting points for a dimension would be calculated according to the following:
average number of weighting points for a dimension =
sum of the number of weighting points for a dimension/number of completed questionnaires for a population
average number of weighting points for all dimensions =
sum of the weighting points for all dimensions/number of completed questionnaires for a population
number of weighting points for a dimension for a population =
(100/average number of weighting points for all dimensions) × average number of weighting points for a dimension
Because the evaluations provided by all persons were anonymous, no open responses were required. Multiplying the number of countervalue productivity points with the weighting points was done to obtain the absolute contributions to productivity (such as D1 = 5 × 18.52 = 92.60) (Dervitsiotis, 1995; Tatum et al., 1996, step 6). Adding the existing absolute contributions to productivity provided the current holistic productivity index for all dimensions of the patients (step 7). Whether the SP had dropped or risen with reference to the six dimensions could be determined by comparing the index values obtained on a monthly or quarterly basis (Jääskeläinen, 2009). Finally, obtaining the SP provided information on the positive and negative effects of measures for improvement introduced for boosting productivity (Tatum et al., 1996).
The aim of service management in the hospital is to increase the productivity in the provision of services. Because of its heterogeneity, immateriality, inability to store as inventory, and individuality, SP, which is often difficult to determine, can be measured and documented only for certain services (Grönroos and Ojasalo, 2004; Žemgulienė, 2009). The approach presented here shows that SP can be determined and expressed as a numerical value. In the literature, there are no other examples for the service field showing the use of the matrix to determine the SP, based on the entire target population in a hospital, or that allow evaluation on the basis of the same dimensions.
Ascertaining aggregate productivity in hospitals
Using the term “aggregate productivity” is both practical and problematic. It gives the impression that it is determined only by the six dimensions defined in a hospital. Although ascertaining aggregate productivity is useful for making a holistic statement on productivity for a significant population size, decision makers are prompted to think only about measures for improvement and to steer their efforts towards establishing appropriate measures for improvement based on the findings of the degree of target achievement in one dimension. The qualitative orientation of these items describes the overall impression of SP in hospitals among patients and employees. Because patients and employees assessed the same dimensions, it was possible to make a statement on the aggregate productivity of a hospital. The maximum index value for the productivity of a population was 1000, and the maximum index value for the aggregate productivity of the four populations shown in Figure 6 was 4000.
The items developed for the two main questionnaires could uncover increases and decreases in productivity in a hospital. Aggregate productivity is described as a construct of six dimensions with five items each, and the current status of productivity could be specified by the items for a significant population size. In addition, with the aid of these items, it was possible to evaluate qualitative targets and to compare targets and actual achievement. Because these items could be used to examine the extent to which a dimensional target was achieved, they are relevant to controlling the productivity of a hospital.
To allow holistic assessment of an issue, the population involved must be large enough and representative of various sides or perspectives. Because establishing productivity is not based on a statistical process but rather a scoring model, it is not possible to specify anything on the population magnitude. However, a high population magnitude is desirable to be able to assess holistic productivity. In turn, assessing productivity depends on various factors concerning the people surveyed, such as their physical and psychological well-being at the time of surveying.
In addition to the responses to items on the main questionnaires, the socio-demographic data supplied by respondents provided important information on productivity. For example, they shed light on unexpected factors impacting productivity. Further, the productivity index ascertained for a significant population size showed the subjectively perceived productivity in the findings. These surveying instruments for ascertaining SP can be considered holistic because they involved both patients and employees of hospitals. The dimensions, items, and target and index values can be set in relation to one another for assessing the degree to which targets are achieved for a significant population size. This means that they function as a criterion for success in implementing measures for improvement. Therefore, we believe the BPA is a holistic method for ascertaining and improving SP in hospitals.
The items on the questionnaires were designed to describe the actual state of productivity and to determine the level of productivity. If surveys and productivity analyses are repeated at regular intervals, it should be possible to see how productivity changes. To learn where productivity comes from, it is necessary to draft explanations for causes and effects and then check them empirically. However, with the items we have developed, it is not possible to understand how productivity can be impacted. This means that the items we developed function as an aid to identify productivity at an early stage, to develop measures for subsequent improvements over time and to categorize what has been achieved with reference to the targets we set. Assessing target achievement enables us to boost the SP achieved with an even higher degree of target achievement and to set new targets for the future as well as measures for improvement to achieve them.
Patients and employees behave with a degree of uncertainty in hospitals, meaning there is the risk of incorrect allocation of resources on both sides. In other words, it is difficult to determine how a patient or an employee of a hospital can make a contribution to SP. This is why it is necessary to depend on items that demonstrate relevance to productivity and service. It is not only the time that patients are in hospital or the employees' number of years in professional service that function as centrally acquired items: personal factors, such as age and sex, have a potential impact on specific productivity items.
If productivity targets have been reached, more ambitious targets with new target values should be set. In any event, decision makers in hospitals always will select the items and dimensions for improvement measures to boost productivity that promise the greatest likelihood of reaching target achievement with reference to the system of targets they have formulated. The specific items of these dimensions function as guidelines for making improvements.
When evaluating and interpreting subjective data on SP, it should be borne in mind, first, that maximum target achievement often is not possible with certain items because of simultaneous targets with complex services as well as mutual impact and, second, that SP can be defined only for a significant population size if a sufficient number of questionnaires have been completed fully. In addition, the time of questioning needs to be considered because patients are able to assess holistic SP only at the end of their stay in hospital. In contrast, employees can judge precisely the particular field of action only if they have been working in that field of action for a significant period of time. For instance, if employees have worked in two different hospitals, some of their impressions on SP will overlap. Furthermore, if patients being interviewed are not in the hospital for the first time, their memory may not be accurate.
For the aforementioned reasons, assessing interviewees' contributions must be done carefully. The goal of the survey and how data will be used should be made clear before applying the BPA in hospital settings. For example, when launching a study on SP, inclusion criteria for individual hospitals should be taken into consideration for patients and employees in order to arrive at meaningful results. It would be interesting not only to have the dimensions outlined on the questionnaire weighted by patients and employees but also to hear how decision makers (such as the managing director, medical director or nursing director) weight various dimensions in the hospital. In any event, there is a greater need for research on the factors impacting aggregate productivity.
The method to ascertain aggregate productivity presented in this paper is suitable for studying SP of various populations in hospitals and can be modified by applying measures for improvement. Regular surveys or analyses can reveal possible fluctuations in productivity, and this can help decision makers take action to boost productivity.
In contrast to the models in previous literature, the BPA takes a holistic approach to productivity in by involving both patients and employees of hospitals. The advantage of this method is that significant contributions to productivity can be incorporated in the direction of specific operative and strategic targets in hospitals with the dimensions defined for patients and employees. Unfortunately, the disadvantage of this method is it does not take either supportive or wasteful behavior into account.
Productivity targets that have been achieved can be described by the contributions they make to productivity and thus help boost motivation in projects aimed to improve productivity. Management personnel with extensive knowledge of the productivity of services and working closely with decision makers should use the BPA. This is the only way to roll out effective measures to boost productivity and actually bring about improvement. Finally, comparing productivity in hospitals of similar standing can contribute to boosting productivity and achieving targets sustainably.
Conflict of Interest
The author declares that he does not have any conflict of interest.
The author would like to thank the two anonymous reviewers for their valuable comments and suggestions to improve the quality of the paper. The research was supported by funding from the German Federal Ministry of Education and Research (BMBF, Project Funding Reference Number 01FL10046).
Patient questionnaire and employee questionnaire items
Items from the patient questionnaire
Items from the employee questionnaire
information in the hospital
information in the hospital
The exchange of information functioned entirely smoothly
The exchange of information functioned entirely smoothly
I was given all of the information I needed
I was given all of the information I needed
Information was transmitted at just the right point in time
Information was transmitted at just the right point in time
There were no problems procuring information
There were no problems procuring information
I did not receive any contradictory information
I did not receive any contradictory information
organization in the hospital
organization in the hospital
Appointments scheduled for treatments/examinations were always kept
Dates scheduled for work were always kept
The staff members of the hospital have all the expertise they need
The staff members of the hospital have all the expertise they need
The contact persons were very well organized
The contact persons are very well organized
The steps in treatment were arranged so that I did not have to wait at all
The steps in work were arranged so that I did not have to wait at all
I was notified at a very early stage of changes in the schedule of treatments
I was notified at a very early stage of changes in the schedule of work
climate of treatment in the hospital
working climate in the hospital
I felt very motivated by the environment of the treatment to contribute to the treatment
I feel very motivated by the work environment to do my work
My opinion was taken into consideration and respected very much in the treatment
My opinion is taken into consideration and respected very much at work
There was a very open and objective atmosphere during discussions
There is a very open and objective atmosphere during discussions
There was a very high level of mutual trust
There is a very high level of mutual trust
All my fears were dispelled during the treatment
All my fears are dispelled at work
treatment procedures in the hospital
work procedures in the hospital
The way we proceeded with the treatment was coordinated very well
The way we proceed with work is coordinated very well
The treatment procedures were highly structured
The procedure at work is highly structured
I was always included in decisions that impacted my treatment
I am always included in decisions that impact my work
The treatment procedures were very target-orientated
The work procedures are very target-orientated
I have the feeling that hospital management were happy to accept suggestions for improvement on the schedule of treatments
I have the feeling that hospital management is happy to accept suggestions for improvement on the schedule of work
spatial structure in the hospital
spatial structure in the hospital
The layout of the hospital was ideal
The layout of the hospital is ideal
The distance between rooms was excellent
The distance between rooms is excellent
I felt very comfortable in the rooms
I feel very comfortable in the rooms
The room furnishings were very well thought out
The room furnishings are very well thought out
I was able to orient myself in the spaces very easily
I am able to orient myself in the spaces very easily
equipment in the hospital
equipment in the hospital
The technical equipment available gave me a very good impression
The technical equipment available gives me a very good impression
The equipment available made the treatment much easier
The equipment available makes work much easier
I felt very secure when equipment was used during the treatment
I feel very secure when equipment is used at work
The equipment functioned during the treatment without any problems
The equipment at work functions without any problems
The equipment needed was very user-friendly
The equipment needed is very user-friendly
Overview of patient questionnaire, employee questionnaire and theoretical frameworks
Study area/number of dimensions
Factors for each dimension/ total number of factors (if described)
Expectations and beliefs about treatment (5), ease of use (5), efficacy (4), desired effects (7), impact on health-related quality of life (7), medical care (5), general satisfaction with treatment (5), 22 items
Relationship with other medical doctors (4), burden and business (5), community (3), relationship with co-medical staff (3), compensation (3), patient care issues (3), global job satisfaction (5), global career satisfaction (2), 28 items
relationship to dicret line manager (10), relationship to direct line colleagues (6), work load (7), conditions of patient care (10), leadership and organizational culture (8), PC-work(-stations) (8), work environment/workplace equipment (7), cooperation ward - supporting unit of organization (6), personnel qualification (5), duty roster (5), coordination and organization (7), meal (4), interpersonal dealings (5), conditions of employment (3)