We first will apply the service blueprinting concept to find out what factors influence the quality of e-Health service delivery. Since internal operational factors serve as the foundation for service delivery quality, we will also include literature relevant to these topics in our discussion of service blueprinting below.
2.1 Service blueprinting
Service blueprinting is a very versatile technique that can be used for both innovation and service improvement. It may well be the best method for measuring service success and may also hold the key to future service innovations (Bitner, Ostrom and Morgan, 2008). Service blueprints can be described as service roadmaps -- tangible, visual documents that lay out where and how customers and companies interact. More specifically, blueprints are information-laden documents made up of five components that, when drawn up together, can help make the customer-company relationship and customer experience clear (W.P. Carey, 2008). The five components of a typical service blueprints are as follows:
Customer actions: include all of the steps that customers take as part of the service delivery process.
Onstage/visible contact employee actions: the actions of frontline contact employees that occur as part of face-to-face encounters with customers.
Backstage/visible contact employee actions: non-visible interactions with customers, such as telephone calls, as well as other activities that employees undertake in order to prepare to serve customers or that are part of their role responsibilities.
Support processes: all activities carried out by individuals in a company who are not contact employees, but whose functions are crucial in carrying out the services process.
Physical evidence: all of the tangibles that customers are exposed to or collect during their interaction with a company.
Service blueprinting has been widely used in many industries, including the healthcare industry. For example, Marie Stopes International, organization providing reproductive health information, has used service blueprinting to examine who is
"on-stage" and what needs to be communicated. The company specifies the customer contact point via physical evidence, solves human resources and operations problems, and finally links them to each moment-of-truth. To sum up, by using a modified service blueprinting tool that incorporates physical evidence, service scripts for onstage personnel, and operations necessary for each moment of truth to be successful, blueprinting has been able to improve the service quality at clinics (Bitner, Ostrom and Morgan, 2007).
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More specifically, there exists a definite cause and effect relationship between the five components. Support processes influence the backstage contact employee actions, which in turn affect the performance of onstage contact employees and, by extension, customer satisfaction. The first two processes are generally recognized as internal service operations. The quality of internal service operations has been identified as one of the essential elements of an overall service quality strategy (Feldman, 1991;
Nagel & Cilliers, 1990). Sincethe focus of our research is on internal service performance, we will introduce literature relating to support processes and backstage contact employee operations and focus our discussions on the field of e-Health care service delivery.
2.2 Support processes in the service delivery system
Support processes are defined as activities that support employee services and help employees to achieve their task conveniently and effectively. After reviewing past literature, we found out that many sources on e-Health have highlighted two main, supporting activities in e-Health delivery: IT activities (Harnett, 2004; Graschew, 2008; Shelman, 2008) and employee training activities (Rowe, Savigny, Lanata and Victora, 2005). IT activities focus on data and service system integration for service delivery processes, and employee training activities focus on the enhancement of knowledge, abilities and skills.
2.2.1 IT Support processes
A number of firms have employed IT to build service capabilities into their products, greatly improving the speed and accuracy of their service. For example, Federal Express has adopted an information system to minimize unexpected factors that might delay package deliveries (Thomas, 1992). Extending this, Thomas (1992) has made the following conclusions about the impact of IT on service processes:
Automation: Eliminates human labor from service process.
Informational: Captures information about process performance, which can then be analyzed by humans.
Sequential: Changes the sequence of processes or enables parallelism in order to achieve cycle-time reductions.
Tracking: Closely monitors process status and objects.
Analytical: Improves analysis of information and decision making.
Geographical: Coordinates processes across distances.
Integrative: Provides information on various aspects of the process stored in databases spread throughout the organization is consolidated in a desktop workstation.
Intellectual: Captures and distributes intellectual assets; enables knowledge to be shared across the firm.
Disintermediation: Eliminates inefficient intermediaries from service processes.
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healthcare staff to evaluate patient conditions; in addition, integration of IT would help healthcare staff to record patient statistics for future references. In summary, IT plays a vital role in the support processes of service industries, provides for the informational and integrative needs of the company (Harnett 2001, Graschew 2008), and thus, influences service quality.2.2.2 Training support processes
Since employees at the front stage interact with customers directly, their service quality greatly influences customer satisfaction; for this reason, employee training is a necessity in the success of e-Health service delivery. According to past literature such as Bartel (1994), and Saibang et al. (1998), good employee training not only increases productivity, but also enhances the image of the company.
In 1997, Summers et al. developed an evaluation framework, known as the
―Knowledge Skills Abilities‖ (KSA) test to evaluate training performance. In this context, knowledge refers to an organized body of information associated with facts or procedures which, if applied, makes adequate job performance possible. Skill refers to a proficiency in manual, verbal or mental manipulation of data or things; examples of this include typing on a keyboard or operating a vehicle. Ability refers to the power to perform an observable activity at a given time, e.g., the ability to plan and organize work. More specifically, ability stems from the individual drawing upon previous experience from similar activities or behaviors to complete the job. Anthony et al.
(1996) have stated that KSA is a very useful tool in determining who the best applicants are when several candidates qualify for a job.
In summary, IT and employee training are two important dimensions of support processes in service delivery. Without well-integrated IT, loading and manipulating data would be difficult, and without appropriate training, employees would be lacking in the knowledge, skill, and ability needed to perform their jobs.
2.3 Communication in service delivery systems
Organizational communication has been widely recognized as a method for resolving gaps, misunderstandings, and non-synchronized messages within organizational units.
Stephen & Arnold (1997) have outlined four communication flows within the intra-organizational context: upward communication, downward communication, horizontal communication, and diagonal communication.
Upward communication occurs when information flows from the lower levels of a hierarchy to the higher levels. The goal is to encourage managers to listen to their employees‘ suggestions and to provide employees with a channel to ask their upper-level managers for advice. In our service blueprinting architecture, upward communication would allow e-health staff to consult with doctors within the training support process.
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inform employees about what is important, what is valued, and how to perform a task in the best possible way. In our service blueprinting architecture, downward communication would allow doctors to transfer information and advice to e-health staff within the training support process.Horizontal communication occurs wheninformation is shared among people at the same level in the organization, community, or peer group; it is usually used as a means of coordinating efforts. In our service blueprinting architecture, horizontal communication would allow e-health staff to help and support to each other within the training support process.
Diagonal Communication occurs between people who are at different levels of the organizational hierarchy and in different departments or units (Eleanor and Philip, 2007). Members within an organization can solve problems, share information across different work groups, and coordinate tasks between departments or project teams (Papa et al. 1997). In our service blueprinting architecture, diagonal communication would allow IT staff to help e-Health staff with IT support problems and troubleshooting.
These four communication flows are formed in order to eliminate misunderstandings and to improve the performance of intra-organization (Stephen &
Arnold, 1997).
In an e-Health context, the four communication flows can be described as the following: the flow from doctors to their healthcare staff (downward communication), healthcare staff to doctors (upward communication), healthcare staff to healthcare staffs (horizontal communication), and healthcare staff to IT staffs (diagonal communication). More specifically, in downward communication, doctors can relate to healthcare staff important knowledge regarding what is important, what is valued, and how to perform a task in the best possible way. In upward communication, healthcare staff can consult doctors with what they don‘t know or ask a superintendent for advice. In horizontal communication, healthcare staff can coordinate with each other to accomplish tasks, support colleagues, and solve problems together. In diagonal communication, IT staff can help healthcare staff to understand how to use IT devices and to provide technical assistance when needed.
2.4 Summary
After reviewing past literature, we found that several sources have put too much focus on what the delivery systems produce (Harnett, 2004; Graschew, 2008; Shelman,
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2008), and too little on how they perform. To address this issue, it is important to understand more about employee internal performance (Spil and Schuring, 2006).
Therefore, in our research, we will apply the service blueprinting technique to explore factors that would impact the performance of internal service operations. We believe that it is important to take the KSA-oriented training (Summers, Timothy and Suzanne, 1997) and IT integration into the concern, when evaluating the quality of employee service. Moreover, we will look at the four communication flows (Stephen and Arnold, 1997), while discussing the elimination of intra-organizational barriers and gaps to make organizations more united and efficient. We propose that through improved support processes and communications, organizations will enhance employee service quality, which in turn will improve customer satisfaction and lead the success of e-Health services.