CHAPTER 4: RESEARCH METHODOLOGY
4.3 Framework Application
In different situations, understanding which service feature is more suitable for different patient segments is essential to the generation of quality service performance.
In this section, we will analyze these interview minutes and apply the service feature applications we proposed in pervious the chapter to the four different cases. The summarized results will be shown in Table 4-5.
ICT Complexity, by definition, is described as “the number of e-sensors or ICT applications used in a service category”; in other words, the higher the ICT complexity, the greater the number of ICT devices or applications involved. ICT devices greatly facilitate the efficient enhancement of service performance. Using these devices, patients are able to check body conditions such as their blood pressure or blood sugar at home, instead of having to go back and forth to a clinic. From the perspective of paramedical personnel, devices also save medical resources.
In the division of post discharge care (A1), only telephones are involved as an ICT device; from the case managers‟ point of view, they don‟t need physiological data like blood pressure or blood sugar from the patient, because they just need to keep track of the patient‟s condition by phone call. “Once patients have different demand or any disease occur that we can‟t handle, we have them admitted to the A2 or A3 service divisions,” one A1 case manager said. Similar comments were also made by the A1 physicians,
“We don‟t use overly complex devices, because it‟s hard for one single device to cover all the needs of the diseases. Additionally, indicators of the patient‟s condition which can be easily measured without a device can be asked through phone”.
Another concern is the “free of charge” policy and cost-spending issue; once complicated ICT devices are involved in the A1 division, the cost of personnel training may increase significantly and, service operations may become too complicated to control “Easy to use, low-cost models are the ideal devices for us,” the physician said. Realistic concerns such like the free of charge policy, high costs, and disease variety are the reasons to limit ICT use.
Six ICT devices involved in cardiovascular disease care (A2) are: the telephone, electrocardiogram, hemadynamometer, glucometer, scales, and thermometer. From a case managers‟ point of view, the reliability and accuracy of the ICT device is of great concern, because case manages have to totally rely on the device to make a judgment on their patient‟s condition. And because the patients in this division are aged, the
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design of the device UI (user interface) is of great concern when operating the device.
“Honestly, our patients are not very familiar with using high-tech devices,” an A2 physician added. The A2 division has to rely on ICT devices a lot; thus, the reliability and accuracy of device are great concerns for improving service performance.
The chronic disease care division (A3) also relies on IT device, though only 3 in total are involved: the telephone, hemadynamometer, and glucometer. A3 introduces two kinds of devices: one, which can be used to measure the patient‟s blood pressure and one to monitor the patient‟s blood sugar. From the physician‟s point of view, an important criteria for case selection includes restricted mobility; not only would the device help doctors monitor patient conditions, but it would also get around the problem of patients having white coat syndrome, which is where a patient experiences higher than normal blood pressure at a clinic in the presence of a doctor, as compared to their blood pressure at home. Therefore, letting the patients stay at home and measure their blood pressure on their own is probably a better idea. A3 thus relies on IT devices for two reasons: to avoid white coat syndrome and provide an easier way for patients to measure their blood pressure.
2 ICT devices, telephone and webcam monitor are involved in the hospice care division (A4). However, from the manager‟s and physician‟s point of views, relying on IT devices is not the proper method to serve patients; only through warm care from the healthcare personnel and other support staff like psychiatrists can proper service be administered. Webcams are only used to monitor patient‟s condition. The A4 department takes the view of relying on device only as a channel to take care of their patients. In summary, we sort the ICT device complexity of each division by ranking them from one or no any device used as low, two to three as middle and four to more as high. In conclusion, we mark device complexity of A1 is low because of only one device involved. A3 and A4 are marked as middle ICT complexity because of two to three devices offered and A2 has the highest ICT device complexity in light of more than five devices involved.
Preference in soft or hard value. Soft attributes are defined as interpersonal factors which are intangible and implicitly expressed, i.e. caring, friendliness, thoughtfulness, and honesty. On the other hand, hard attributes are indicated by easily quantified measurements such as the availability of service packages and response time; these are explicit values that have been widely applied as assessment scales in service quality.
In the post discharge care (A1) division, case managers said that, “usually, we have to make more than 10 phone calls to arrange clinic appointments for the patients
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them to visit the clinic again.” As one A1 physician explained, “Therefore, if patients have any problem during the evening, they can call us immediately.” In this case, hard value components are emphasized by A1, such as the service availability and emergency prevention procedures taken to increase value. The main objective of this division is to monitor the patient‟s condition; “if the patients have any questions or emergence cases, they can call us for medical help” A1 physician added.Hard values especially are emphasized in cardiovascular disease care (A2). From the case manager‟s perspective, these include providing “first aid” service to prevent any problem occurring or giving the patient a way to call in for food or medicine consulting. The case managers could also then inform the patients‟ on matters such as food, medicine, or life style. The call in/ out service is available 24 hours a day, so the patients can call at any time as a key hard value of service availability. Soft value can be also taken as a benefit to patient. “We‟re close to our patients and their families,”
one A2 case manager commented. But from a case physician‟s point of view, the major objective of the service is to find out any problems in advance before any complications occur, to improve the patients‟ quality of life, and to adjust their medicines to the appropriate amounts. The hard values that patients would perceive are food and life-related consultation, and the monitoring of their disease condition;
additionally, they would experience soft values such as friendship with the case manager but this one is not a decisive value patients‟ should perceive, though from the case managers‟ perspective, most close to patients‟ thought, “the most important value is their disease condition can to be monitored intensively in case of any emergency happened. That‟s why our service is 24 hours available. Once they have any question, they can call back soon”. In other word, the hard values like stabilizing patients‟
disease condition or service availability would be the main priority of service. Rather than providing intangible interpersonal values, A4 aims to provide service availability and functionality based on these hard attributes.
The chronic disease care division (A3) provides call in/out service to patients and usually make phone calls three to four times a week. If patients have any questions, they can call in at any time. The responsibility of the physician is to stabilize the patient‟s condition and to make they feel better. Disease-control and empathetic care are the main services provided to patients. Unlike A1 and A2 division, in A3, patients‟
disease condition is stable and need long-term care by case managers so interpersonal value should be emphasized by A3 in order to keep a long term relationship with patients.
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patient stress and stabilizing their minds are the main priorities for this special needs division. If a patient has a particular religious demand, a tutor will be brought to talk with patient and listen their needs. Referring to human-caring service, the key services for the patients include pain relief, mental care, and so on. From a physician‟s point of view, “warm care and quality service are key values we provide to patients through case managers and other support organizations like psychiatrists or life tutors.”Since most services in the A4 division are designed for stabilizing patients‟ inner feelings, we conclude that A4 mainly provides mainly soft value-oriented services.
Customization. Various definitions of customization have been proposed in the past decades. In our case, in order to incorporate all the different categories, we define customization by, “the number of service options offered in the service category”, which indicates that the more service items provided, the higher the possibility that the service can be customized to meet the customer needs.
The following Table 4-3 shows how many service offers are involved in the different service divisions.
In this study, we sort out the degree of service customization into three ranges: high, middle, and low to test out our hypotheses. We‟ve categorized divisions with less than two service items as having low customization, three to four service items as having middle customization, and five or more service items as a high service customization.
Conclusively, A1 provides two service offers, the least number of services offered, so we mark A1 as a low service customization. A2 and A3 are marked as middle service customization because of three to four service offering. A4 is to the highest service customization among four cases by providing more than 6 service offers.
Demand/Supply wave. As far as business goes, understanding the patients‟ demand A1 (2 service offers) tracks patients conditions by phone call, call in
consultation service
A2 (3 service offers) caring phone calls, 24H call in consultation service, monitors patients„ condicions through devices
A3 (4 service offers) call in/out Service, monitors patients„ condicions, medicine usage consultance, helps patients schedule an appointment A4 (more than 6 service
offers)
call in/out service, tele-consultations, customized services (religious, psychologist, spiritual mentor, pain alleviation) Table 4-3. Service offers in different divisions
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In the A1 division, the scheduling to offer phone calls to the patient is designed as a series of progressively less frequent contacts during the period of a patient‟s discharge; in other words, hospital personnel would call the first, third, fifth, seventh, and 30th day after discharge to make sure no emergencies occurred. The schedule is designed to monitor patients‟ condition within 30 days of discharge, because most emergencies usually occur during that time period. Since this only occurs over the period of one month, the demand curve has a high fluctuation, but a short duration.
In cardiovascular disease care (A2), the demand wave according to the patient‟s condition fluctuates in a very interesting way. One A2 physician states that, “I have a patient who feels uncomfortable and has hypertension during clinical visits, which makes it difficult for me to judge whether the hypertension is actually a problem.
It‟s easier to let him stay at home and use our e-Health service to do a daily test.” “In addition”, the physician said, ”since most patients have diabetes, testing their blood sugar at least once a month is a regular task for the case manager.” If chest tightness and pain suddenly occur, the e-Heath service can catch this problem and provide instant-feedback function. As a result of these variable demands, the demand wave tends to fluctuate and takes place over a long time period.
In chronic disease care (A3), the case manager‟s point of view has to test a patient‟s blood sugar three to four times a day; if their blood surge is higher than normal, they will modify the patient‟s eating style. Most patients usually suffer chronic diseases, so they have to go back to the clinic and to get medicine and monitor their conditions at least once every three months; for this reason, the contract agreement term is set to three months The demand of this fluctuation is low, but length is long.
In hospice care (A4), case selection is for the patients who suffer from terminal cancer and need qualitative and comfortable hospicetreatment for their rest of life.
Because patients with terminal cancer are the criterion for case selection for A4, the demand and kind of patient is stable, but the term length is short. The value of services to patients in this category places an emphasis on caring and mental care. For these reasons, the demand wave fluctuation is low and its length is short.
In our assessment, A1 and A2 patients have higher disease urgency and fluctuation so service should be offered intensively in order to meet their fluctuated demand. Base on this point, we mark A1 and A2 high demand wave fluctuation. In A3, patients‟ disease condition is stable and less fluctuated so we mark the demand wave fluctuation is low. As for the condition of A4, the patients‟ disease fluctuation is stable,
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but the mental and spiritual demand of patients is unpredictable so we mark demand wave fluctuation middle.
Process Complexity. We define process complexity as number of operation steps involved in the service. Figure 4-4 (shown on the next page) summarizes the comparison between the four different service divisions.
Usually, service item offers significantly influence the complexity of the process.
For example, in the A1 division, the operations are much simpler than that of other divisions because of its free charge policy. The process of phone call care and call-in service follows a fixed standard of operations that is well-structured. The A1 won‟t be able to provide too many service items and its operation process must be simple in light of cost pressures and other factors. On the other hand, the operation process of departments A2 and A3 have comparatively similar device complexity and service items offers and normally follow the standard operation processes to deliver their services.
Considering service items offerings, the operation process of A4 is the most complicated of the other three divisions.Because the service items provided by A4 are varied, this usually leads to complicated and unfixed processes; for example, if a patient has a need for pressure relief, then a case manager might find and use outside resources, such as linking the patient with a psychologist. A4 case managers have to face a variety of the patients‟ inner needs, each from the spiritual, religious, and/or social welfare perspectives.
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Operation Process in Service Develiver
A1
A2
A3
A4
Case enrolled Keep trace of patient‟s condition by phone (5 times a month)
Case closed
24 Call In service
Figure 4-4. Service operation process in different divisions
Case enrolled Keep trace of patient‟s condition
by phone (more 2 times a week) 24 Call In service
Device installation Upload patient‟s
physiological data daily.
Case enrolled Keep trace of patient‟s condition
by phone (3-4 times a week) 24 Call In service
Device installation Upload patient‟s
physiological data daily.
Case enrolled Caring phone call once a day/
making an appointment for patient
Customized Service (6 offers) lead to complicated process Device installation
24 Call In service
Accompany with patient back to clinic
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Service performance is the dependent variable in our theoretical model. We consider the rate of case completion to be the key measurement in the four cases; in other words, it reflects the rate of case withdrawal and the amount of patient satisfaction in that a higher rate of case completion is associated with lower rate of case withdrawal and, likewise, a lower percentage of dissatisfied patients. The statistical data acquired from the meeting minutes at the NTUH e-Health program were collected on a weekly basis from October 2009 to May 2010. Unfortunately, these meeting minutes are discrete and lacked uniform format because of our research limitations. Then we collected data and summarized it in Table 4-4, showing that in the A1 category, the average rate of case withdrawals was 5.59% from October 2009 to April 2010. In A2, the average rate of case withdrawals was 33.1%, the highest withdrawal rate among the four divisions, which showed that patients were not very satisfied with the service performance. The second highest, A3 was 18.75%. According to the A4 division policy, cases were enrolled on a day to day charge basis; in addition, the patient usually suffered from terminal cancer, so once patient passed away during the term of service contact, the case would be claimed as a “disposed case” rather than a withdrawal. From this point of view, the rate of case withdraw of A4 was zero, as summarized in the simple bar chart shown in Figure 4-5.
A1 case enrolled record A2 case enrolled record Period of Time 2009/10-2010/04 2009/11-2010/05
Case enrolled 423 242
Case withdrawal 23 80
Case completed 400 126
Rate of Case withdraw 5.59% 33.1%
A3 case enrolled record A4 case enrolled record Period of Time 2009/11-2010/01 2009/12-2010/04
Case enrolled 32 38
Case withdrawal 6 0
Case completed 26 30
Rate of Case withdraw 18.75% 0
Table 4-4. Data collection summarized from A1-A4 division
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Number of e-sensors and ICT Applications Used in the
3 Customization Number of Service Options
Offered Low Middle Middle High
4. Demand/Supply wave
Supply to Degree of Demand
Fluctuations Over Time High High Low Low 5.Process
Complexity
Number of Operation Steps
Involved Simple Simple Middle compli
cated Dependent
Variables
1.Service
Performance Rate of Case Complete High Low Middle High
Moderator
Figure 4-5. Rate of case withdraw in A1-A3 division Table 4-5. Analytical result of four cases
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Making a thorough comparison between the four difference cases allows us to clearly determine the relationship between service feature and performance. These analysis results support our original hypothesis about moderation fit. Next, we will discuss our findings from this research.
5-1 Data Analysis
In this section, we analyze the fit for the four cases shown in Table 5-1. Based on research hypotheses made in previous chapter, we evaluate the fits between the patient segmentation and service features of each case in order to test our hypothesis, as proposed in the previous chapter. In order to calculate the total fit scores of the four cases, the fit score is calculated by the percentage of hypotheses are met.. After the calculation, we will assess the fit and summarize all the fit scores of the four cases in Tables 5-1 and 5-2.
A1 perfectly fits the five service hypotheses. In this patient segmentation, its high disease emergency/variety fits with the four service features: ICT complexity, value focus, customization, supply and demand, and process complexity. In our hypotheses, patients with high disease urgency prefer lower device and process complexity in order to prevent the service to becoming too complicated or costly to fit their emergency needs. In the same sense, hard attributes like service availability or functionality would be more highly emphasized than soft attributes. In addition, patients with higher urgency usually corresponded to more highly fluctuating demands that had to be met
A1 perfectly fits the five service hypotheses. In this patient segmentation, its high disease emergency/variety fits with the four service features: ICT complexity, value focus, customization, supply and demand, and process complexity. In our hypotheses, patients with high disease urgency prefer lower device and process complexity in order to prevent the service to becoming too complicated or costly to fit their emergency needs. In the same sense, hard attributes like service availability or functionality would be more highly emphasized than soft attributes. In addition, patients with higher urgency usually corresponded to more highly fluctuating demands that had to be met