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Keywords:

  • case study;
  • client-centred care;
  • framework;
  • front/back office;
  • nursing;
  • objectives;
  • organizations

Abstract

  1. Top of page
  2. Abstract
  3. What is already known about this topic
  4. Introduction
  5. Background
  6. The study
  7. Findings
  8. Discussion
  9. Conclusion
  10. Funding
  11. Conflict of interest
  12. Author contributions
  13. References

Title. Improving client-centred care and services: the role of front/back-officeconfigurations.

Aim.  This paper is a report of a study conducted to explore the application of designing front- and back-office work resulting in efficient client-centred care in healthcare organizations that supply home care, welfare and domestic services.

Background.  Front/back-office configurations reflect a neglected domain of design decisions in the development of more client-centred processes and structures without incurring major cost increases.

Method.  Based on a literature search, a framework of four front/back-office configurations was constructed. To illustrate the usefulness of this framework, a single, longitudinal case study was performed in a large organization, which provides home care, welfare and domestic services for a sustained period (2005–2006).

Findings.  The case study illustrates how front/back-office design decisions are related to the complexity of the clients’ demands and the strategic objectives of an organization. The constructed framework guides the practical development of front/back-office designs, and shows how each design contributes differently to such performance objectives as quality, speed and efficiency.

Conclusions.  The front/back-office configurations presented comprise an important first step in elaborating client-centred care and service provision to the operational level. It helps healthcare organizations to become more responsive and to provide efficient client-centred care and services when approaching demand in a well-tuned manner. In addition to its applicability in home care, we believe that a deliberate front/back-office configuration also has potential in other fields of health care.


What is already known about this topic

  1. Top of page
  2. Abstract
  3. What is already known about this topic
  4. Introduction
  5. Background
  6. The study
  7. Findings
  8. Discussion
  9. Conclusion
  10. Funding
  11. Conflict of interest
  12. Author contributions
  13. References
  •  There is evidence that client-centred designs such as integrated care pathways are valuable, but these designs neglect the added value of different front- and back-office configurations.
  •  There is much information that different front/back-office configurations contribute to various performance indicators differently; however, these insight have not been used nor further investigated in health care.

What this paper adds

  •  In health care, four configurations of front/back-office design decisions can be used to arrive at service provision that is in line with both an organization’s strategic focus and the complexity of client demand.
  •  Assigning activities to the front office will allow for in-depth needs clarification and increasing a client’s care experience; at the same time costs can be controlled by using modular care packages for specified client segments and by making use of information technology solutions.
  •  Linking activities in one job can increase both efficiency and the provision of client-centred care as, in this design, clients have contact with fewer employees, handovers can be reduced and idle time of workers is avoided.

Implications for practice and/or policy

  •  To enhance client-centred process design, care providers should consider which activities to perform in the front office and how to combine activities within specific jobs.
  •  Depending on its strategic objectives, such as efficiency, quality or speed, a healthcare organization should deliberate upon four options for front/back-office configurations.
  •  To explore the potential of the various front/back-office configurations, a care provider should have a thorough understanding of its present and potential clients and its range of supply.

Introduction

  1. Top of page
  2. Abstract
  3. What is already known about this topic
  4. Introduction
  5. Background
  6. The study
  7. Findings
  8. Discussion
  9. Conclusion
  10. Funding
  11. Conflict of interest
  12. Author contributions
  13. References

Several proposals on future care and cure provision have advocated a shift in the organizations involved, putting the patient or client rather than the care supplier at the centre of processes and structures. Hence, the needs and expectations of patients and clients are now being viewed as the starting point in a thorough re-orientation of roles, tasks, operational processes, organizational structures and inter-organizational cooperation in the promotion of a client-centred approach (Mead & Bower 2000). More specifically, redesigns have been developed, such as clinical or care pathways (de Bleser et al. 2006), focused factories (Skinner 1974, Casalino et al. 2003) and integrated care (Ouwens et al. 2007). A characteristic of these new designs is that they have been developed for a particular, often well-defined client or patient group. As a result, care delivery is becoming more client-centred without sacrificing too much efficiency, which is another pressing factor healthcare providers must take into account (Bohmer 2005).

One relatively neglected issue in these redesign discussions concerns the effect of work executed either in the front office (FO) or the back office (BO). From operations management literature, we infer that FO and BO work each contribute differently to operational performance (Chase 1981, Metters & Vargas 2000, Safizadeh et al. 2003, Zomerdijk & de Vries 2007). In general, moments of client contact can create customization opportunities and increase the quality of customer relations. In contrast, BO work is sealed off from client contacts so that it offers more potential for efficiency improvements (Chase 1981, Larsson & Bowen 1989, Metters & Vargas 2000, Zomerdijk & de Vries 2007). A closely related second design issue that has been discussed in the literature as having an impact on operational performance dimensions is the structure of FO and BO work or activities. In general, extensively breaking a process into its BO or FO components and subsequently segregating these activities into distinct jobs – that is, decoupling – increases productivity (Chase 1981), whereas coupling facilitates interaction with clients (Larsson & Bowen 1989, ). The trade-offs involved in denominating tasks as either FO or BO and coupling or decoupling activities seem to be related to the target of many healthcare organizations to deliver client-centred services without increasing or with even decreasing costs (Metters & Vargas 2000). In the present study, we addressed these two relevant aspects of client-centred design: (1) the denomination of tasks as FO or BO work, and (2) the coupling or decoupling of FO or BO activities into distinct jobs. The potential value of these design decisions to deliver efficient client-centred services underpins the relevance of this study and drives us to investigate whether and how these two design decisions can contribute to different performance objectives in health care.

The remainder of this paper is structured as follows. First, we discuss relevant literature with regard to FO/BO design decisions, and investigate how these can be applied in a healthcare context. This yields a framework of four FO/BO configurations that can support the healthcare organization in the design of efficient patient or client-centred care. We clarify and illustrate this framework in a longitudinal case study. This case study took place in a ‘home care plus’ context, that is, a large diversified company acting in the Dutch market for home care and related welfare and domestic services. We describe the findings of this case study and draw conclusions, including future research directions and the managerial implications of our study.

Background

  1. Top of page
  2. Abstract
  3. What is already known about this topic
  4. Introduction
  5. Background
  6. The study
  7. Findings
  8. Discussion
  9. Conclusion
  10. Funding
  11. Conflict of interest
  12. Author contributions
  13. References

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 officeBack 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 demandMore 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
 EffectsImpact on performance
Coupling activities within one jobConcentration 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 tasksQuality (client-centred) Quality (fewer mistakes) Quality (fewer mistakes) Optimal use of resources Work satisfaction
Decoupling activities within more than one jobSpecialized workers Better match between task and worker Lowering costs in cases where BO activities are sealed offAll effects increase quality (technical nursing quality) and work satisfaction
Additional for health care
Makes peer review possibleIncreases 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
DemandLow complex care and servicesHigh complex care and services
High diversityConfiguration IConfiguration II
Employee A determines together with client needs and wishes of client and the service packageEmployee A determines together with client a list of needs and wishes, and employee A consults employee(s) B
Specification activities are mostly performed in FOSpecification activities are performed in both FO and BO
Coupled process: employee A performs most of the tasksDecoupled process: multiple employees involved
Employee A: high level of autonomyEmployees A and B: both moderate level of autonomy
Employee A is highly social and professionally educatedEmployee A is socially educated and Employee B is professionally educated
Strategic objectives
High personal service delivery, minimum of handoversHigh personal service delivery, optimal use of specialized BO employees
Low diversityConfiguration IIIConfiguration IV
Employee A determines together with client the needs and wishes, and the service packageEmployee A makes inventory of specific needs and wishes of client; employee B determines the service package (BO activity)
Specification activities are mostly performed in FOSpecification activities are mostly performed in BO
Coupled process: employee A performs most of the tasksDecoupled process: multiple employees involved
Instruments for standardizing the specification process are developed in BO and used in FOInstruments for standardizing the specification process are developed in BO and used in both FO and BO
Employee A: moderate level of autonomyEmployee A: low level of autonomy
Employee A makes use of standard list of choice optionsEmployees A and B make use of a standard list of choice options
Strategic objectives
Quick delivery, no idle time and minimum of handovers, customized delivery by adapting standard deliveries to specific needsLow 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.

The study

  1. Top of page
  2. Abstract
  3. What is already known about this topic
  4. Introduction
  5. Background
  6. The study
  7. Findings
  8. Discussion
  9. Conclusion
  10. Funding
  11. Conflict of interest
  12. Author contributions
  13. References

Aim

The aim of this study was to explore the application of designing FO and BO work resulting in efficient client-centred care in healthcare organizations that supply home care, welfare and domestic services.

Design

We chose the case-study format because we were investigating a contemporary event (Yin 2003). While we wanted to deepen our understanding of FO/BO configurations using insights from practice, few organizations have already deliberately chosen a particular FO/BO design. We also wanted to know how various FO/BO configurations could be elaborated in practice, and which arguments are used in practice to choose a particular configuration.

The case study took place in a ‘home care plus’ context. In the Netherlands, home care institutions often take the responsibility for coordinating the services provided by various institutions to fulfil the often complex, diverse and chronic needs of their clients. They need to make a fit between patients’ often ambiguous wishes on the one hand and the services available from various providers on the other (van Campen & Woittiez 2003). This means that they have contact with clients (often FO work) and, at the same time, coordinate the care and services of diverse providers (often BO work). For this reason, home care institutions are a good setting for exploring possible FO/BO designs.

Participants

The company we studied had grown into a large diversified organization through several mergers of healthcare and welfare providers, all located in the south of the Netherlands. Consequently, the company faced issues of transparency and accessibility with regard to their full range of care, services and products. Top management was willing and interested in comprehensively discussing the various processes and structures involved in creating new FO/BO designs. An overview of the care provider is given in Table 4. Despite the mergers, the amalgamated providers are still very much treated as separate entities. The organization keeps separate records concerning staff and client ratios for each of the divisions. The numbers of clients cannot simply be added up, as one client might be served by two, or even all three, divisions. Because of this, we present the details for each of the divisions separately.

Table 4.   Overview of the care provider
 Total number of clients% of 55+ (elderly) clientsNumber of employeesCare and services provided
Division A14,51984·22343Home care
Division B12001001500Mainly domestic
Division C355100600Mainly welfare

The company’s mission was to adapt the total range of care and services optimally to their clients’ needs and wishes and to provide these in an integrated fashion, while taking into account financial restrictions wherever possible. Top management initiated a pilot project to create a comprehensive offer of care and services that is better targeted at individual needs. Particularly in the specification phase, the offerings from the various divisions had to be brought together in a coordinated way.

Data collection and analysis

Data collection was carried out in close proximity to the local setting for a sustained period (2005–2006) and contacts are still ongoing. Data were gathered on the current specification process and problems in this process, the number of contact moments with clients and the purpose of each of these moments, client needs and characteristics, coordination of care in the specification phase and future design ideas. The case study relied on data from semi-structured in-depth interviews and documentation review, and two of the authors attended project meetings as observer-researchers. Our main roles were to record remarks and arguments for and against FO/BO and coupling/decoupling decisions and to offer insights from the literature as input for the discussions. We took no part in the decision-making process. We attended six project group meetings and several one-off meetings with project workers. We conducted semi-structured interviews with three members of top management, six support managers (finance, planning, HRM) and 15 employees from all divisions. We also consulted such documents as handbooks, process descriptions and product books, and observed the work processes.

Ethical considerations

Approval from an ethics committee was not required, as no real healthcare clients were involved in this study.

Data analysis

Data were analysed thematically. Multiple sources of evidence were used to facilitate a triangulation process to develop converging lines of inquiry (Miles & Huberman 1994). In a few instances, the data required some processing to make them accessible for analysis (Miles & Huberman 1994). Therefore we created blueprints. Furthermore, we analysed the specification process (number, type and objective of contact moments, problems), the job content of several workers, and the discussions in the project group and the individual meetings to isolate the arguments in favour of redesign.

Findings

  1. Top of page
  2. Abstract
  3. What is already known about this topic
  4. Introduction
  5. Background
  6. The study
  7. Findings
  8. Discussion
  9. Conclusion
  10. Funding
  11. Conflict of interest
  12. Author contributions
  13. References

FO/BO configurations in practice

The first activity in the case study was to make a rigorous description of the specification phase to create clarity about the current structure and content of this process. In Table 5, the first column presents the respective steps taken. The same table provides (a) a classification of activities as FO or BO work, which also included Client work to make clear when the client was involved in this process (columns 2–4); and (b) an overview of the various employees executing an activity, which indicates the degree of decoupling (columns 5–9). The data revealed the following interesting points.

Table 5.   Design of the current process
Process stepClientFOBOCCADCACare managersTeam managerEP
  1. BO, back office; FO, front office; C, client; CCA, central client administration; DCA, decentralized client administration; EP, executing professional.

Announcement of demand for careX       
C receives a C-number; data sent to district office  XX    
C data input in system and some checks  X X   
Preliminary decision on type of care needed  X  X  
C assigned to a care team  X X   
Decision in information system  X   X 
Detailed specifications discussed with CXX    X 
Final decision on the offer  X   X 
Make execution plan  X   X 
Plan sent to professionals  X X   
Start execution X     X
Evaluation of the serviceXX     X
Revision of execution plan  X   XX
Restart execution X     X
Most activities are BO

Older clients usually intend to stay independent as long as possible. It is not always easy to determine exactly what their needs are to make a longer stay at home possible, and these clients often find it hard to express their needs in terms of care or welfare services required. To ease the exchange of information, care providers engage in activities that display compassion, high levels of empathy, trust and sympathy. Therefore, specifying a client’s constraints and tailoring care and assistance services to overcome these constraints are appropriate FO tasks. However, this case study showed that many of these activities are conducted in the BO. Thus, there is only one brief moment of contact in which clients can express their needs and wishes, which probably leads to inadequate specifications and the risk of delivering ‘wrong’ care and services. This lowers both the quality and efficiency of the process because it is likely that work will need to be performed again.

Low and late client involvement in specification process

The client is barely involved in the specification process, and then only relatively late (see step 7 in Table 5, first column). As a result, the client’s needs and wishes can only really be included in the process from this point onward. Moreover, tailoring of the required care and services does not occur until delivery has begun. Because of their low and rather late involvement, clients may perceive the current process as taking place slowly (low speed) as they are not aware of the preparation involved in the delivery of their care. In addition, they may not be impressed by the care received (low quality) because really individualized packages are developed only some time after the start of delivery.

High degree of decoupling

Five types of employee are involved in the current specification process. All perform various tasks that ultimately lead to the delivery of a care package to a single older client. The reason for all this decoupling is not clear. The many handovers cause a loss of information that negatively influences the quality of the process. The narrowness of the employees’ tasks may lead to inefficient use of resources, making the specification process more expensive than needed.

Several divisions, one provider

An important finding was that there was no single, integrated access to all the care and services available in the merged organization. Individual divisions have set up their own specification lines to deliver information on their own care and services. If older clients require services from multiple parts of the organization, they must contact each of these divisions separately. Because of this non-transparency and fragmented accessibility, clients may well be unaware of the full range of services available. The company is also missing out on opportunities for cross-selling and the integral specification of its care and services.

Towards new FO/BO designs

The newly merged organization discussed the options for improving accessibility to all its services and, at the same time, delivering more transparent and customized services. The framework (Table 3) served as a guide to explore how various FO/BO designs could add to these objectives. Initial discussions revealed that the organization first needed a comprehensive understanding of the demands of their potential and present clients and a clear display of the care and services and their various combinations, which they could deliver as a merged organization (see also Johnston & Clark 2005). How could they deliver a customized and transparent care and service package to clients if they did not know the range of demands and options themselves? During ongoing discussions, the organization began analysing the characteristics of their customers’ demands, which resulted first in the identification of client segments, each based on a particular demand (see also Gobbens et al. 2007). These gave a better overview of the diversity of demand in their client population. Examples of older segments were ‘vital’, ‘lonely but coping’ and ‘needy’. Second, the company identified the complexity of the demand in each client segment: how clear cut were the demands, how many problems were involved and how far were these problems interrelated? In the case of a high level of interrelatedness, they discussed what this implied for the delivery of their services. Third, discussions in various divisions and levels of the organization led to the development of generic packages of integrated services. Most of the identified client segments were then assigned their own generic package (except those client segments where demand was substantially more diffuse or ambiguous; see below). Each generic package consisted of several modules, represented here as a well-defined and restricted set of care or service items, for example, ‘cleaning the house’, ‘wound care’, ‘meals-on-wheels’. In summary, the first part of the project resulted in the creation of generic packages for specific patient segments. The modular structure of these packages particularly improved the transparency of what the organization offered. Depending on the specific needs and wants of an individual client, modules are added or withdrawn from the generic package of the segment in a final phase of fine-tuning.

The second part of the project focused on redesigning the specification phase. The company saw little diversity in demand for the main part of their population and assessed the complexity of the demand in most segments as moderate. They developed a design – similar to Configuration III in Table 3– in which FO employees list the specific needs and wishes of a client and categorize them in terms of a certain segment. If clients had any additional needs, the FO employees could customize the service they received by making use of generic packages. In most cases, FO employees could decide on their own which customization was appropriate, and recorded their findings and decisions in a database. Only rarely did an extension of a generic package need to be discussed with a BO employee. As a result, the organization chose Configuration III of the FO/BO designs to improve the overall accessibility and customization of their service delivery for the largest part of their population. In the few situations where BO employees were consulted, the organization applied Configuration IV (Table 3).

However, as mentioned above, the company also identified client segments with a more diffuse and ambiguous demand. Obviously, they could not apply a generic package to these segments, as the needs and wishes of these clients were too diverse. For this group, the company opted for Configuration I, selecting FO employees with excellent contact skills and a broad knowledge of the various services provided by the merged organization. These FO employees had the skills and knowledge to match an extensive range of needs to the required services. In the future, a database including all available services should support the FO employees. In very rare cases, they may consult BO employees with knowledge of specific services or combinations of services (i.e. Configuration II).

In this case study, the ideas for redesigning the specification processes were highly appreciated by all the divisions. Designing coupled jobs that combined client contact with administrative and consultation tasks, and further investment in the development of care and services modules (standardization) were favoured, because of the large number of relatively simple and standard demands. If more customized or complex care and service packages were at stake, the company chose the designs at the top of Table 3, usually Configuration I or, in very complex situations, Configuration II, in order to make optimal use of the expertise available throughout the whole organization.

In conclusion, the organization opted for more coupled FO designs as they were convinced they had to offer a ‘personal face’ to clients with a minimum of handovers, so that the client has contact with only one employee who is capable of assessing the need for additional services. As a merged entity, the organization had to convince clients of their ability to deliver satisfactory services and, even though they are now a large-scale organization, that they are still able to provide customized services.

Discussion

  1. Top of page
  2. Abstract
  3. What is already known about this topic
  4. Introduction
  5. Background
  6. The study
  7. Findings
  8. Discussion
  9. Conclusion
  10. Funding
  11. Conflict of interest
  12. Author contributions
  13. References

This study shows how different FO/BO configurations can contribute in their own way to the provision of both efficient and client-centred care, and it demonstrates the application of different configurations in a home care ‘plus’ setting. The main idea behind these configurations is to emphasize the need to consider which activities should be executed in the FO, and how activities can be combined within specific jobs. The study shows that performing activities in direct contact with customers is not only useful for physical reasons (e.g. washing patients) and to clarify needs and wishes, but also to increase clients’ care experiences by providing ‘a personal face’ and complementary experiences such as warmth and confidence. Although FO activities may be considered a costly way of providing services, efficiency can be increased by making use of standardized modular care and services packages and IT solutions, and by coupling FO and BO activities in one job. Furthermore, revenues can be increased as FO workers have the explicit task of pointing out which complementary care and services could be needed and how these could be provided in an integrated way. All these arguments are highly relevant in a healthcare market in which the provision of efficient care is of the utmost importance in an increasingly competitive environment.

Second, this study demonstrates that coupling activities in one job can increase both efficiency and the provision of client-centred care as, in this design, clients have contact with fewer employees, handovers can be reduced and idle time of FO workers is avoided.

In our case environment, it appeared that identifying client segments and developing care and service modules – in fact ways of standardizing the specification process – supported the feasibility and attractiveness of the design options. Standardization was achieved by identifying client segments and creating a modular way of providing services. In one of the first contributions in the literature on modularity, Starr (1965, p. 138) formulates the basic idea behind modularity as ‘design, develop and produce [...] parts which can be combined in the maximum number of ways’. Nowadays, modularization of products/services means that the individual components included in a product/service are able to be changed or replaced independently, because each component has a separate function (see, e.g. Fixson 2005, Voordijk et al. 2006, Slack et al. 2007). Therefore, for each client, product and service distinctions can be easily achieved through transformation or modification of components (Duray et al. 2000). At the same time, the use of standard components reduces variety when making these components, which allows for cheaper production. Therefore, for the combined provision of home care and related welfare and domestic services, further research on the applicability of modular production seems most relevant.

Another option for increasing the feasibility of each design option is using IT solutions. Advanced IT systems enable various activities to take place at the same time, which induces inherent coupling. More specifically, traditional BO activities, such as opening and assigning files and making appointments, have become less complex, less place-dependent and time-consuming, thanks to contemporary IT. For that reason, such activities can be coupled and even be performed in the FO; in fact, previous BO activities are now often interwoven into FO activities. The effect of IT systems on different FO/BO configurations and, in turn, their impact on performance dimensions is an interesting topic for further research.

Study limitations

An important limitation of this study being a single case study is that it is somewhat harder to generalize the findings to other settings. However, our findings are also based on a literature search, and the reinterpretation of those findings with respect to health care.

Conclusion

  1. Top of page
  2. Abstract
  3. What is already known about this topic
  4. Introduction
  5. Background
  6. The study
  7. Findings
  8. Discussion
  9. Conclusion
  10. Funding
  11. Conflict of interest
  12. Author contributions
  13. References

Thus far, little insight has been gained into how the needs of individual clients can be translated into a client-centred supply of care and services. The concept mainly seems to falter at a policy level, being used by many to express long-term goals, mission statements and organizational visions only. However, the FO/BO configurations presented in this paper enable all kinds of healthcare organizations to approach the operational implications of client-centred care provision. Recognition of the potential of this concept is an important first step in elaborating client-centred care and service provision at the operational level. Adequate organization of specification phase activities in every healthcare field is indispensable for providers who aim to do better in terms of quality and efficiency. This makes our insights of great relevance to both policymakers and practitioners.

Funding

  1. Top of page
  2. Abstract
  3. What is already known about this topic
  4. Introduction
  5. Background
  6. The study
  7. Findings
  8. Discussion
  9. Conclusion
  10. Funding
  11. Conflict of interest
  12. Author contributions
  13. References

This research received no specific grant from any funding agency in the public, commercial or not-for-profit sectors.

Author contributions

  1. Top of page
  2. Abstract
  3. What is already known about this topic
  4. Introduction
  5. Background
  6. The study
  7. Findings
  8. Discussion
  9. Conclusion
  10. Funding
  11. Conflict of interest
  12. Author contributions
  13. References

MB, BM and CdB were responsible for the study conception and design. CdB, MB and BM performed the data collection. MB, CdB and BM performed the data analysis. MB, BM and CdB were responsible for the drafting of the manuscript.

References

  1. Top of page
  2. Abstract
  3. What is already known about this topic
  4. Introduction
  5. Background
  6. The study
  7. Findings
  8. Discussion
  9. Conclusion
  10. Funding
  11. Conflict of interest
  12. Author contributions
  13. References
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