FO/BO configurations in health care and welfare
In the literature, FO activities are defined as those involving direct encounters between a client and a representative of providers that take place at the same time, but not necessarily in the same place (phone, email) and give the opportunity for interaction. BO activities are defined as those performed without contact with clients (Chase & Tansik 1983, Zomerdijk & de Vries 2007). Generally, the specification and delivery of home care, welfare and domestic services requires either physical presence or a form of interaction with the client (system) and therefore takes place in the FO. All other activities can be carried out in the BO, for example, administrative tasks and discussing the condition and needs of a client with other professionals to agree on which care and service package a client can or needs to be offered. However, a closer look at the reasons for performing activities in either the BO or FO shows that there could be many other motives for performing activities in either place (Table 1).
Table 1. Advantages of performing specification activities in front office or back office
|Front office||Back office|
|Opportunities to customize the service†,‡ Provision of additional services§ Possibility of controlling quality with clients and provide in-process feedback§ Instant provision§ Physical presence of client (system)†,¶||Efficiency potential†,‡,¶ Possibilities for specialization and centralization†† Efficient use of resources (no wasted time due to clients not showing up)¶|
|Additional in health care|
|Creating a ‘personal face’ for the providing organization(s) Provision of additional experiences (trust, confidence, faith in the provision) Capable of dealing with a high level of uncertainty and ambiguity in demand||More convenient and easier to coordinate multi- and interdisciplinary care Possibility of controlling quality, e.g. by peers|
Table 1 shows the advantages of FO and BO work. Some of the advantages listed are based on empirical studies, which were not undertaken in the healthcare or welfare sectors. We have added some possible additional advantages of both types of work that are particularly relevant in health care and welfare.
Performing activities in the front office enables delivery of additional experiences to clients and makes in-process monitoring, control and feedback possible (Larsson & Bowen 1989, Chase & Hayes 1991, Safizadeh et al. 2003). Additional emotional support can also be given in health care. New wishes and needs can be signalled earlier and services can be delivered quickly and adjusted to a wide range of client demands. Back office activities have the advantage of performance efficiency and the optimal use of resources (Chase et al. 1984). In health care, consultations with peers usually take place in the BO.
In addition to the decision to perform activities in either FO or BO, another design decision involves the coupling of FO or BO activities within specific jobs. Activities can be coupled in a specific job to provide flexible and responsive services or to reduce idle time (reduction of cost, higher productivity). Alternatively, they can be decoupled to exploit employee expertise (high quality, customized service delivery) or to realize potential efficiency benefits (cost) (Metters & Vargas 2000). These coupling or decoupling approaches add fresh ideas to FO/BO configurations as, for example, they emphasize that coupling activities in one job can offer new strategic opportunities such as costs savings or a focus on high quality service and customer relations. One study of banking processes showed that coupled jobs prevent handovers, which can enhance efficiency and quality as workers have broad tasks and client knowledge is concentrated in one job (Zomerdijk & de Vries 2007). For clients, coupled jobs offer the likelihood of meeting as few different workers as necessary. For example, when dealing with outpatient consultations, the FO providers may also execute the follow-up work themselves. In contrast, decoupled processes enable centralization, specialization and counterchecks. They also offer more options for matching workers and tasks (Zomerdijk & de Vries 2007). Decoupled jobs offer the opportunity to free contact personnel for sales and service delivery. For instance, professionals provide the service while clerical personnel provide administrative support (making appointments, typing out medical letters).
Both FO and BO activities can be decoupled in order to present employees with the opportunity to specialize in a certain task. A coupled job may be a combination of FO and BO activities, or consist solely of FO or BO activities. In the case of primarily FO activities, personal skills and ‘active’ knowledge (i.e., knowledge available on the spot) are more relevant, while in the case of predominantly BO activities, supportive knowledge and skills (administrative or professional) are required. Information technology makes it possible to overcome the drawbacks of both coupled and decoupled designs and to execute activities that were previously BO tasks in the FO or the other way round. For example, an information system can enable the integration of administrative tasks in the contact moments with clients, which eliminates follow-up activities. Table 2 sums up the advantages and disadvantages of coupling and decoupling; again, we draw a distinction between the advantages revealed through our literature review and possible additional advantages for health care.
Table 2. Decoupling or coupling back office (BO) and front office (FO) activities in jobs
| ||Effects||Impact on performance|
|Coupling activities within one job||Concentration of knowledge on clients’ wishes and needs†,‡ Facilitates interaction§ Decrease in number of handovers¶ Reduces idle time in cases where BO activities are performed during idle time‡ Employees have broad tasks¶||Quality (client-centred) Quality (fewer mistakes) Quality (fewer mistakes) Optimal use of resources Work satisfaction|
|Decoupling activities within more than one job||Specialized workers‡ Better match between task and worker¶ Lowering costs in cases where BO activities are sealed off‡||All effects increase quality (technical nursing quality) and work satisfaction|
|Additional for health care|
|Makes peer review possible||Increases technical (nursing) quality|
Tables 1 and 2 show the advantages of design decisions in terms of how each decision contributes to different strategic objectives. In fact, strategic objectives are a relevant contingency factor that should be considered when choosing a particular configuration, which has been shown in much research (see, e.g. Mintzberg 1979). Organizational theory shows that the characteristics of demand are another important contingency factor (Van de Ven & Delbecq 1974, Mintzberg 1979) that is also applied in healthcare redesigns. For example, de Bleser et al. (2006) distinguish various types of clinical pathways based on differences in the complexity of demand. Complexity implies that patient demand comprises several, sometimes interrelated problems or that the demand is not clear or unambiguous. In the case of ambiguity, the available information is inconsistent or unequivocal such that multiple and conflicting interpretations of a problem are possible (Molleman et al. 2008). In addition to complexity of demand, distinctions can be made in the degree of diversity or variety of demand (see, e.g. Slack et al. 2007); organizations can supply services to populations with more or less diversity or variety in demand. Taking these contingency factors into account, we have constructed a framework of various FO/BO configurations (Table 3).
Table 3. Four design options for front office/back office (FO/BO) configurations in home care and welfare
|Demand||Low complex care and services||High complex care and services|
|High diversity||Configuration I||Configuration II|
|Employee A determines together with client needs and wishes of client and the service package||Employee A determines together with client a list of needs and wishes, and employee A consults employee(s) B|
|Specification activities are mostly performed in FO||Specification activities are performed in both FO and BO|
|Coupled process: employee A performs most of the tasks||Decoupled process: multiple employees involved|
|Employee A: high level of autonomy||Employees A and B: both moderate level of autonomy|
|Employee A is highly social and professionally educated||Employee A is socially educated and Employee B is professionally educated|
|High personal service delivery, minimum of handovers||High personal service delivery, optimal use of specialized BO employees|
|Low diversity||Configuration III||Configuration IV|
|Employee A determines together with client the needs and wishes, and the service package||Employee A makes inventory of specific needs and wishes of client; employee B determines the service package (BO activity)|
|Specification activities are mostly performed in FO||Specification activities are mostly performed in BO|
|Coupled process: employee A performs most of the tasks||Decoupled process: multiple employees involved|
|Instruments for standardizing the specification process are developed in BO and used in FO||Instruments for standardizing the specification process are developed in BO and used in both FO and BO|
|Employee A: moderate level of autonomy||Employee A: low level of autonomy|
|Employee A makes use of standard list of choice options||Employees A and B make use of a standard list of choice options|
|Quick delivery, no idle time and minimum of handovers, customized delivery by adapting standard deliveries to specific needs||Low costs through standardization and optimal use of BO employees, customized delivery by adapting standard deliveries to specific needs|
Table 3 shows four FO/BO configurations that aim to perform well in terms of both clients’ needs and wishes and efficiency. ‘Employee A’ is used to referring to an employee working in the FO; ‘employee B’ works in the BO. All the design options highlight the need for early involvement of clients in the process to enable ‘first-time right’ diagnosis, and to enhance the transparency of the potential offerings of a home care or healthcare organization such as a nursing home. The four configurations focus on the specification phase – the part of operations in which mutual understanding is created about what should, can and will be delivered – as this phase offers the most potential for switching tasks between FO and BO and the coupling or decoupling of activities.
Configuration I implies that employee A discusses a wide variety of care services with patients and clients. These workers have ‘active’ knowledge of the integrated services on offer and the social skills to communicate these well to clients. With employee A, the client determines which services will be supplied and the same or another employee may actually deliver the services. This configuration stresses the importance of high quality (no mistakes) and customized service delivery. The broad scope of the task and the worker’s autonomy mean that idle time can be reduced, which saves costs. Other employees could execute some administrative tasks in the BO, but most of these tasks will be performed by employee A as well.
Front/back-office Configuration II emphasizes the highly professional character of client-centred care and services. BO employees are specialists in the specification of client-centred and often integrated care and services. Employee A makes an inventory of the client’s needs and wishes and consults employee B before stating what the organization can offer. In this configuration, highly complex demands can be handled easily. Costs are reduced because employee B can recommend potential services, which prevents shopping around, and idle time can be reduced as employee B may work for more than one employee of the type A.
In Configuration III, employee A makes use of instruments that simplify and standardize the specification process. This employee discusses the individual clients’ needs and wants, and determines the offer. The BO staff do not execute the plans but are involved in the writing of protocols or work instructions, or developing administrative support systems. Costs are decreased by standardizing services and preventing idle time. Customized delivery is possible through adapting standardized services to the client’s specific needs.
In Configuration IV, employee B determines the services supplied. Employee A merely inventories the needs of clients using a standard form and transparent work instructions. Mass customized services are delivered as employee B can adapt standard services to specific needs. Costs are reduced by preventing idle time for employee A and by making efficient use of employee B’s expertise as he/she is sealed off from distracting contact with customers.
Thus far, based on the literature, we have shown how FO/BO configurations are promising in terms of performance enhancement. Below we will continue to explore the potential of these configurations in terms of providing input for deliberate design decisions. Our empirical investigation involved a longitudinal case study in a large diversified organization acting in the market for home care, welfare and domestic services.