What do we get from literature on hospital logistics

After some trial and error excercise in literature research I established a fruitful search strategy. My search strategy consisted of three separate searches in three different databases, PubMed, EBSCOhost and JSTOR. I searched on:

Hospital AND Logistics

Hospital AND Flow AND Process

Hospital AND Supply Chain Management

Hospital AND Operations Management

I limited my search to the past ten years – being 2006-2016 – and to articles written in English. That resulted in almost 1,050 unique articles. I screened them all for mentioning logistical parameters. In 291 articles such parameters were actually found. I found 106 logistical parameters.

I have written a scientific paper on this, which is now under review at a journal and hopefully it will be available soon. I will not repeat that article in this blog. First of all because the journal will not appreciate it, but foremost because this blog mostly is about insights emerging from this research, that are not shared in a scientific way.

First let’s see what the 291 articles, mentioning logistical parameters are about. These articles mention one or more logistical parameters. I made an image of all article title words, here presented. All the irrelevant words such as ‘and’ or ‘the’ were left out. The larger a word is shown, the more it is mentioned in the article title. The obvious ones, hospital and logistics are there. Since 83% of all the articles focus on patients, the word ‘patient’ comes out clearly. This is remarkable because the field of logistics, traditionally, mostly deals with material flows, especially when we talk about ‘supply chain management’. There were 48 articles on supply chain management – 16% of all articles – so from this it also appears that logistics in hospitals is not researched on a large scale from a material flow perspective.

Wordle titels art 1

Another observation is that more articles are on a specific department, whereas hospital-wide perspective is rarely shown. Look for the word ‘hospital wide’ in this picture. It’s there, but it is very small. A hint: left side, close to Process. In an earlier blog I mentioned research stating that the coherence and collaboration of the entire hospital is essential for its success, but nonetheless when logistics in hospitals is studied, this is focussed on individual departments, it seems.

Worth mentioning also is the fact that ‘Emergency’ care is a topic seen often. There were 38 articles about emergency care, mostly the emergency department. It is an exciting topic – hospital soap series are usually about the ER too and for a reason – but from a financial perspective the OR or a hospital wide perspective would be much more interesting.

There is much more to say about this picture, but I would like to stress one aspect in particular. Many articles have a focus on improving things and imply a certain ‘makeability’ (I honestly don’t know if this is the correct English word, but what I mean is that we assume things can be made better by people, in popular terms a ‘can do’ or ‘yes we can’ idea). ‘Design’, ‘improving’, ‘improvement’, ‘lean’, ‘effects’, ‘reduce’ are words I associate with that. That is interesting too, because as I was wondering in one of my blogs, when it comes to hospital strategies such as merger or investing in new facilities, logistics – and the associated desire to improve – do not seem to be in the picture. That was my next scoping study: is strategy in hospitals linked to logistical parameters in international literature?

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Logistics in hospitals: what is it about?

With the main question being what role logistics plays in hospital strategy I started literature research in 2016. A more specific question for this research was which logistical parameters were mentioned in relation to hospitals. We (by ‘we’ I mean the PhD team with three (assistant) professors and me, see ‘About me’) took parameters as variables that could be controlled or improved. The type of literature research we chose was a scoping study [1]. A scoping study is used for broad topics and it aims to identify all relevant literature on a certain topic, without assessing the quality or validity of the research done.

Let alone the question I was interested in, the literature research itself was a challenge for me. The last time I did literature research was probably in my Master Thesis and since then (18 years ago) a lot had changed. There is an immense overload of articles and information found on the internet (Google Scholar for example) and there are numerous databases, of which I had never heard. PubMed for example has so much as 27 million citations. As I am a learning by doing person, I just started to search on ‘Hospital AND Logistics’ in PubMed. That led to hundreds of thousands of articles. A screening of the first ten articles that showed up, already pointed out that maybe this was not the literature I was thinking of when it comes to logistics. For example I found: Qualitative study of patients and health-care professionals’ views on the efficacy of the nutrition as medication oral nutrition supplement program. Or: Impact of long-acting local anesthesia on clinical and financial outcomes in laparoscopic colorectal surgery. 

In the abstracts of these articles there were indeed logistical parameters mentioned – operative time, reoperation time, readmission in this case. The word ‘logistics’ was not always in the abstract though. As I found out, PubMed automatically searches for ‘MesH Terms’, a sort of synonyms that PubMed links to terms when a user of PubMed searches for terms in All Fields. In this case the linked MesH terms for ‘Logistics AND Hospital’ were: organization and administration, hospitals. The last one is an obvious one that I would not want to miss out. But searching on both ‘organization’ and ‘administration’ widened my result range in a way that was, perhaps, not right for my research question. Are logistics, administration and organization related? Surely, but they are not the same. I decided to continue my search on the Abstract and Title, only looking for articles in which the actual word ‘Logistics’ and the word ‘Hospital(s)’ was included. This was my first discovery: maybe it was unclear what logistics in hospitals is actually about or rather: perhaps logistics is about everything that is not strictly medical. In any case that meant I had to search in a smarter way than just looking for ‘Logistics AND Hospital(s)’.

[1] If you want to read more on scoping studies, I used the work of Arksey and O’Malley. See: Arksey H, O’Malley L (2005) Scoping studies: towards a methodological framework. International Journal of Social Research Methodology 8(1): 19-32

Research proposal: asking the right question

My most insistent question when starting to write the PhD proposal was how it is possible that large investments are made in mergers and new hospital facilities, that from research and my own observations these investments did not seem to add value, while at the same time there is pressure on hospitals to be more cost effective. That just does not make sense. But, since this seems to be happening in many hospitals, I concluded there must be other explanations for this.

For starters, I looked at research on mergers. There are several studies pointing out that mergers do not lead to better and more affordable care [1-5]. Economies of scale are not feasible according research done by the Technical University of Delft [6] and large hospitals even have to deal with negative impacts of having become this large. Lack of real integration between the merged hospitals is mentioned as an important factor, as well as the finding that the number of hospitals decrease in the Netherlands, but the number of locations does not. Are these mergers merely cosmetic operations or do they aim for ‘big is beautiful’ or for more power?

Interestingly enough mergers and building new hospitals often go hand-in-hand. In the 23 mergers that took place in the Netherlands some years ago, in 19 of these mergers large scale building projects were undertaken. In the past it was government policy to stimulate merger when building a new hospital. But if hospitals have to deal with financial problems after building a new hospital and the consequences of mergers make the hospital less effective, why do both? Perhaps merger is the means to invest in new facilities or is it the other way around? Are building new facilities a means to be able to collaborate and merge, like some kind of major team building activity?

Informally I talked about these issues with several board members of hospitals. Knowing my engineering background, some of these board members lectured me on the topic: merger is not about efficiency Annelies – and no, your models will not change that – it’s about government or insurance companies pushing us in this direction! It is about politics, about two Boards of Directors that have to work together, there are commercial forces to build new facilities, there are local authorities that take an interest in renewing their hospital, there are personal ambitions to create a large and innovative new hospital. In short, efficiency is not the thing. The external or internal forces however were important drivers for many of these transition plans. They also agreed that bringing in a logistical perspective would take out the emotion that was characteristic for many of these processes. They also explained how, to some extent bring, they tried to bring in these kind of analysis into the discussion in their own hospital.

Having read and heard all this my main research question at that point was how strategic decision making processes, related to hospital transformation, work and to what extent logistical arguments were part of these processes. The first step to answer this question was doing literature research.

[1] KPMG, ‘Wie doet het met wie in de zorg?’, KPMG Plexus, Editie 2014.

[2] Weil TP (2010) Hospital consolidations: do they deliver? Physician Exec 36(5): pp 24-27

[3] Preyra C, Pink G (2006) Scale and scope efficiencies through hospital consolidations. J Health Econ 25(6): pp 1049-1068

[4] Zepeda, ED, Nyaga GN, Young GJ 2016) Supply chain risk management and hospital inventory: effects of system affiliation. Journal of Operations Management. Doi: 10.1016/j.jom.2016.04.002.

[5] Kristensens T, Bogetoft P, Pedersen KM (2010) Potential gains from hospital mergers in Denmark. Health Care Manag Sci 13(4): 334-345

[6] Blank, J.L.T, van Hulst, B. L. , ‘Opereren bij schaalnadelen’, TvOF, jaargang 45, nummer 2, Wim Drees Stichting voor Openbare Financiën, 2013.