Modularising outpatient care delivery: A mixed methods case study at a Finnish University Hospital

Abstract

Background

Modularisation is a potential means to develop health care delivery by combining standardisation and customisation. However, little is known about the effects of modularisation on hospital care. The objective was to analyse how modularisation may change and support health care delivery in specialised hospital care.

Methods

A mixed methods case study methodology was applied using both qualitative and quantitative data, including interviews, field notes, documents, service usage data, bed count and personnel resource data. Data from a reference hospital’s unit were used to understand the context and development of care delivery in general.

Results

The following outcome themes were identified from the interviews: balance between demand and supply; support in shift from inpatient to outpatient care; shorter treatment times and improved management of service production. Modularisation supported the shift from inpatient towards outpatient care. Changes in resource efficiency measures were both positive and negative; the number of patients per personnel decreased, while the number of visits per personnel and the bed utilisation rate increased.

Conclusions

Modularisation may support health care providers in classifying patients and delivering services according to patients’ needs. However, as the findings are based on a single university hospital case study, more research is needed.

Keywords

healthcare healthcare delivery mixed methods case study modularisation operations management outpatient care

Modularisation, a concept derived from operations management, can be defined as ‘building a complex product or process from smaller subsystems that can be designed independently yet function together as a whole’.¹ Because health care organisations and healthcare service fields differ in service production, modularisation may be implemented and applied differently in different contexts. In health care, clinical pathways are an example of modularisation, as they are composed of clear modules or steps and combinations of different modules, enabling customisation.² From an organisational perspective, different units of a healthcare service, such as a ward or an outpatient clinic, are independent modules, and the different operations in these units are components of the service module. Modularisation of health care services relates to the identified need for cooperation between health care service providers to improve the continuum of care³ and coordination of services.⁴

In modularisation, larger systems such as haematology services are divided into smaller parts^5,6 that have clearly defined functions and interfaces.⁷ A modular composition of services may allow the configuration of services to fulfil customer needs as services can be assembled from a predefined set of service modules.^7–9 Standardised interfaces connect services and service providers,⁹ and enable the combination of different modules and components.^5,10–12

Limited knowledge of the application of modularisation and its outcomes exists in health care. At present, empirical health care modularisation studies are scarce, and most of these studies have focused on elderly or mental care.^{10,11,13–15} Fewer studies have focused on hospital care.^3,4,8

Previous studies have indicated that the effects of modularisation may vary. Modularisation may enable the delivery of more flexible, yet transparent and structured, health services^9,16 and reduce costs.^3,8,11 However, other studies have argued that modularisation may affect costs in various ways.¹⁶ It is not clear whether the benefits of developing a modular treatment scheme outweigh the costs.¹⁴ Modularisation has also been seen as a potential means to decrease information asymmetry between the patient and service provider.¹⁶ In some cases, modularisation allows flexibility in situations that also require standardisation.⁹ The operating model has been thought to either increase customisation of care¹⁷ or restrain¹⁶ it. Because research findings are inconclusive regarding the effects of modularisation and because most studies offer only a conceptual perspective, a need for quantitative-level analyses of the effects of modularisation has been identified.¹⁸ In addition to quantitative studies, there is a need for mixed methods studies to understand the mechanisms underlying the outcomes in modularisation.

Traditionally, hospital services have been specialty based, and each specialty has had its own service delivery units, such as wards, outpatient care units and day hospitals. Today, many health care providers are redesigning service delivery towards multispecialty wards and day hospitals. At the same time, hospital care is moving from inpatient- to outpatient-focused care.

The aim of this study is to explore how modularisation may support the transition from inpatient to outpatient services in hospital care and how this transition may influence process and resource efficiency.

Methods

Description of the case

The research was generated through the possibility of studying an interesting case of modularisation in a hospital context.¹⁹ An exploratory mixed methods case study was selected to enable the use of the full range of evidence within the case context,²⁰ because limited knowledge exists on the outcomes of modularisation in a hospital environment. Following the logic of purposive sampling,^21,22 a haematology unit of a university hospital in which modularisation has been applied and a haematology unit of a university hospital with traditional outpatient care delivery were chosen as the researchers had access to the haematology units of the two hospitals. The reference hospital was used to represent a more traditional service delivery model without modularisation in a similar university hospital context and, thus, gives context to haematology care.

Haematology patients are severely ill, and many have chronic disorders that require medical treatment over many years. From a process management perspective, haematology patients are complex because they often require both inpatient and outpatient care with or without treatments or procedures in varying combinations throughout their long treatment episodes.

Description of the modularised case unit

Traditionally, each hospital specialty has its own day hospital. In 2010, a new day hospital was established at Helsinki University Hospital (HUH) using modularisation.²³ The aim was to design a day hospital in which treatments and procedures could be carried out serving many specialties, both conservative and surgical. The new unit was designed to enhance outpatient care delivery by increasing outpatient capacity and patient volumes, thereby, supporting a shift from inpatient to outpatient care. While applying the new model, the hospital did not expect cost savings.

In the modularisation process, treatments and procedures from different outpatient clinics and wards were moved to the new modularised day hospital (see Figure 1). Hospital staff carried out the modularisation process (the authors did not participate in this). Standardisation of service components and the creation of precise treatment protocols for all outpatient care services enabled modularisation. The interfaces linking the day hospital to the outpatient clinic were standardised, and communication rules between the outpatient clinic and day hospital were created. In addition, clear patient selection criteria were agreed upon to ensure that only the right kinds of patients would be sent to the day hospital. Today, only treatments and procedures that are carried out for at least 20 patients annually are included in the day hospital. Treatments and procedures that are less frequent are carried out elsewhere, mostly in wards. The physicians in the outpatient clinics who are in charge of the patients’ care decide which patient groups are treated in the day hospital.

Figure 1.

The organisation of haematology care before and after the modularisation of the day hospital.

Modularisation of services took place in November 2010. The new modularised day hospital performs 80 different treatments and procedures for more than 20 specialties. Thus, the same process of standardising components and interfaces between the outpatient clinic and the day hospital with clear communication rules took place in all specialties that use the services of the new day hospital. Today, the day hospital carries out approximately 16,000 annual treatment sessions and small procedures, of which approximately half serve haematology patients.

Description of the reference unit

In the reference hospital—Oulu University Hospital—the haematology unit provides both inpatient and outpatient care. The hospital treats similar patient groups as the case hospital, with the exception of allogeneic stem cell transplants, which are not carried out in Oulu. The outpatient services are traditionally organised as the unit has its own day hospital. Thus, the operating model of the haematology unit in the reference hospital is similar to that of HUH’s haematology unit before modularisation (see Figure 1).

Because the reference hospital is situated in a sparsely populated area in Northern Finland, where patients must often travel long distances for physical visits, these visits have been decreased by using phone communication instead.

Data

This study was approved by the Coordinating Ethics Committee of the Hospital District of Helsinki and Uusimaa in Finland. To enable triangulation of information, data were collected from multiple sources within HUH: the modularised units’ databases, eight semi-structured face-to-face interviews with nurses, physicians and ward clerks, treatment instruction documents, field visits and notes.^19,20 The quantitative data included bed counts, service usage data and personnel resource information converted into full-time equivalents (FTEs). In addition, unstructured supporting interviews of physicians and nurses in the haematology ward, the outpatient clinic and the day hospital were conducted.

The semi-structured interviews were conducted in spring, 2015 in the workplace of the interviewees and included both open-ended questions and closed-ended questions to achieve detailed information on modularisation. The interviews covered modularisation aspects such as the design of services, modules, interfaces and outcomes of modularisation. Because health care professionals were interviewed, common language was used in the interviews instead of specialised modularisation terminology.

Researchers distributed background information about the research to all interview participants. All participants who were contacted gave written consent to participate in the research. No non-participants were present during the interviews, which lasted between 37 and 103 (median 57) min and were audio recorded and transcribed. Notes were taken during the interviews. The transcripts were sent to interviewees to verify their correctness and accuracy.²⁴ One of the authors (KS) with no earlier connection to the interviewees performed all interviews.

From the semi-structured interviews, researchers identified service delivery outcomes of modularisation for quantitative data collection. Service usage data were obtained from the HUH information system from time periods before and after the modularisation (respectively, January 2009–October, 2010 and January 2013–October 2014). These data included 5097 patients. Outpatient visits and other patient contacts, inpatient episodes and beginning and end dates of inpatient episodes were included.

In addition to primary semi-structured interviews, additional unstructured interviews of key personnel members (one physician and three nurses) were conducted face to face, on the phone or by email. These were performed to support quantitative analyses, to verify findings in quantitative analysis and to clarify service delivery in different units. The unstructured interviews were not recorded, but notes were taken.

Reference data on changes in haematology care were obtained from Oulu University Hospital. The data were collected from the hospital’s databases, and semi-structured interviews of two ward clerks and the chief physician were carried out to verify the service delivery model and the data. Notes were taken during the phone interviews. Only population-level usage data were available; diagnoses were not. These data were used to better describe and understand the context and the general development of haematology care. These developments included the shift from inpatient to outpatient care, which occurred without signs of modularisation.

Analysis

One of the researchers manually coded the interview data, and the research group repeatedly discussed the coding, findings and grouping of the findings to themes to enable a common understanding of the findings and to explore data saturation. The findings were grouped into themes based on inductive analysis.¹⁹ After a preliminary analysis of the interviews, quantitative usage data were gathered from the hospital. The qualitative and quantitative data were first analysed separately and then combined.

In the quantitative analysis, the primary focus of the study was to analyse the changes in process measures within the haematology unit before and after modularisation; the secondary focus was to study the changes in resource efficiency (Table 1). The measures described in Table 1 were chosen because they demonstrate service delivery from different perspectives. The procedures and treatments are produced in a factory-like environment in the day hospital with high volume and standardisation.²³ To understand how the modularisation of day hospital services has affected the overall service production of a specialty unit, measures describing overall service production are required. As such, the use of a large set of measures in addition to qualitative data enabled the researchers to gain a broad view of the case in hand by allowing them to gather a full range of evidence within the context of hospital services.²⁰

Table 1.

Measures and their definitions.

Measures	Definition
Output measures
Patients	Total number of patients in haematology unit
Outpatients	Total number of patients without admission to hospital. Patients are treated for a short time in hospital facilities to which they arrive from home and are not allocated a bed in a ward.
Inpatients	Total number of patients with admission to hospital, treated in wards. Patients are allocated a bed in the ward. This is ‘traditional’ hospital care.
Outpatient visits	Physician or nurse appointments in outpatient care. Includes all visits that patients have in outpatient care, both in the outpatient clinic and in the day hospital. Phone calls, letters and electronic visits are not included.
Treatment and procedure outpatient visits	Outpatient visits that include treatments and procedures carried out as outpatient care. Patients are not admitted to hospital.
Other outpatient contacts	Contacts other than those defined above: calls, letters and consultations.
Inpatient episodes	Total number of treatment periods of individual patients in wards, i.e. inpatient episodes in wards.
Inpatient net days	Number of net days in wards, calculated as discharge day minus admission day. If the discharge and admission day were the same, i.e. a same-day discharge episode, the value of net days = 1.²⁵
Same-day discharge inpatient episodes	Inpatient episodes in which discharge day is the same as admission day.
Main variables: Process measures
Inpatient episodes/inpatient	Average number of episodes per patient in inpatient care.
Average length of stay	Average length of stay during one inpatient episode. Length of stay calculated as discharge day minus admission day.
Average length of stay without same-day discharge episodes	Average length of stay during one inpatient episode without same-day discharge episodes. Length of stay calculated as discharge day minus admission day.
Outpatient visits/outpatient	Average number of visits per outpatient. Includes all outpatient appointments to nurses and physicians, with or without treatments or procedures. Phone calls, letters and electronic visits are not included.
Other outpatient contacts/outpatient	Average number of other contacts per outpatient. Includes contacts other than visits in outpatient care: calls, letters and consultations.
Secondary variables: Resource efficiency measures
Patients/FTE	All patients/all nurse and physician FTEs carrying out services for haematology patients.
Inpatients/inpatient FTE	Number of inpatients/FTEs allocated to inpatient care.
Outpatients/outpatient FTE	Number of outpatients/FTEs allocated to outpatient care.
Outpatient visits/outpatient FTE	Number of outpatient visits/FTEs allocated to outpatient care. Includes all outpatient appointments to nurses and physicians, with or without treatments or procedures. Phone calls, letters and electronic visits are not included.
Treatment and procedure outpatient visits/outpatient FTE	Number of treatment and procedure visits in outpatient care/FTEs allocated to outpatient care. Includes only visits during which treatments or procedures are carried out.
Bed utilisation ratea	Number of total gross inpatient days/capacity of beds.

FTE: full-time equivalent.

^aThe bed utilisation rate was calculated with gross inpatient days = discharge day − admission day + 1 day.

To analyse the changes in process measures and resource efficiency, the results from January 2009 to October 2010 (before modularisation) were compared with the results from January 2013 to October 2014 (after modularisation). The list of diagnoses of patients was analysed with a haematologist to verify that the haematology patient mix of the whole haematology unit from a diagnosis perspective was similar before and after modularisation in HUH. When applicable, statistical analysis using SPSS Statistics 23 was carried out with the independent-samples Mann–Whitney U Test (null hypothesis = distribution of analysed measures [such as episodes or visits] is the same between the two time periods, i.e., for January 2009–October, 2010 and January 2013–October 2014), as the metrics were not normally distributed. To understand the changes in the general haematology service context during the study period, the changes (%) were evaluated against those reported by the reference hospital, where modularisation had not been carried out.

Results

Service delivery and production outcome findings from semi-structured interviews of the modularised unit

The inductive analysis of the semi-structured interviews resulted in synthesising the interview findings related to outcomes of modularisation into the following four themes: balance between demand and supply; shorter treatment times; improved management of service production; and support in shift from inpatient to outpatient care (Figure 2). Figure 2 also demonstrates how the interview findings were synthesised and grouped into these four themes and displays the number of interviews that yielded findings related to the four synthesised themes.

Figure 2.

Combining the qualitative and quantitative findings of the case study.

The first theme, balance between demand and supply, relates to the aspect that the new day hospital enables larger volumes and more predictability, decreasing waiting times and supporting balance between day hospital treatment demand and supply. The theme shorter treatment times relates to findings indicating that patients are treated in the day hospital for the required amount of time and need not stay in the day hospital for longer than needed. Improved management of service production shows how modularisation has improved management by creating a more organised and calm environment, as well as decreasing treatment costs. Modularisation has supported the shift from inpatient to outpatient care by providing treatments that were once only administered in wards, in the day hospital. This theme was mentioned by one interviewee (No. 2). The additional unstructured interviews of key personnel members supported this finding.

In general, interviewees reported that the new day hospital of HUH worked in a structured way and that service needs could be predicted efficiently in the new system. Today, the larger volumes of the day hospital enable the management to balance the demand and supply of outpatient care delivery. The supporting unstructured interviews also highlighted that, through standardisation of the treatment and procedure components of the day hospital, groups of patients who were previously treated in wards, such as myeloma patients, can now be treated in the day hospital.

Quantitative results

The changes in personnel resources and beds are presented in Table 2, and the output measures, process measures and resource efficiency measures are presented in Table 3. Altogether, 5097 patients were included in the quantitative data of the modularised hospital.

Table 2.

Personnel resource and bed allocation data of Helsinki University Hospital (HUH) collected from hospital databases.

	Outpatient		Inpatient		Total
Period	Nurse FTE	Physician FTE	Nurse FTE	Physician FTE	Nurse FTE	Physician FTE	Bedsa
Before modularisation (Jan 2009 to Oct 2010)	19.3	20.5	92.3	11.3	111.5	31.7	38
After modularisation (Jan 2013 to Oct 2014)	27.7	25.6	97.2	13.3	124.9	38.9	32

FTE: full-time equivalent.

Nurse FTEs in 2009 and 2014 were scaled from the whole-year value, as only 10 months of data were available. Physician FTEs used the real 10-month value.

^aNumber of beds in wards yearly.

Table 3.

Changes in output measures, process measures (primary variables) and resource efficiency (secondary variables) in the modularised unit and the reference unit.

Measures	Modularised unit (HUH)						Reference unit (OULU)
	Jan 2009 to Oct 2010		Jan 2013 to Oct 2014		Jan 2013 to Oct 2014 vs. Jan 2009 to Oct 2010		2013–2014 vs. 2009–2010
	Number		Number		Change in modularised unit (%)	Significance of change in modularised unit	Change in reference unit (%)
Patients	2799		3267		+17		+18
Outpatients	2695		3152		+17		+18
Inpatients	541		574		+6		NA
Outpatient visits	15,096		22,970		+52		+37
Treatment or procedure outpatient visits	8892		13,661		+54		NA
Other outpatient contacts	31,579		35,922		+14		+37
Inpatient episodes	1525		1407		−8		−14
Inpatient net days	18,267		17,253		−6		−13
Same-day discharge inpatient episodes	187		65		−65	P < 0.0005*	NA
Primary variables: Process measures	Mean	Percentiles(10;90)	Mean	Percentiles(10;90)	Change in modularised unit (%)	Significance of change in modularised unit	Change in reference unit (%)
Inpatient episodes/inpatienta	2.8	(1;7)	2.5	(1;6)	−13	P = 0.194	+4
Average length of stay	11.9	(1;32)	12.2	(1;32)	+3	P = 0.002*	+1
Average length of stay without same-day discharge episodes	13.5	(2;34)	12.8	(2;32)	−5	P = 0.549	NA
Outpatient visits/outpatient	6.2	(1;16)	8.8	(1;24)	+42	P = 0.284	+16
Other outpatient contacts/outpatient	12.0	(1;31)	12.2	(1;33)	+1	P = 0.434	+16
Secondary variables: Resource efficiency measures	Ratio		Ratio		Change in modularised unit (%)	Significance of change in modularised unit	Change in reference unit (%)
Patients/FTE	19.5		19.4		−1		+31
Inpatients/inpatient FTE	5.2		5.2		−1		NA
Outpatients/outpatient FTE	67.9		59.1		−13		0
Outpatient visits/outpatient FTE	380.2		430.8		+13		+16
Treatment and procedure outpatient visits/outpatient FTE	223.4		256.3		+15		NA
Bed utilisation rateb	0.77		0.87		+13		NA

FTE: full-time equivalent; HUH: Helsinki University Hospital; NA: not available; OULU: Oulu University Haematology Unit.

^aChange between 2009 and 2014 in the reference hospital.

^bThe bed utilisation rate was calculated with gross inpatient days = discharge day − admission day + 1 day.

*Statistically significant at p < 0.05.

Output measures

The total number of haematology patients increased by 17% in the modularised hospital, and this shift was in line with that in the reference hospital (Table 3). The shift from inpatient to outpatient care was seen in both hospitals. The inpatient net days and episodes decreased in both the modularised hospital and the reference hospital while the total number of visits increased by 52% in the modularised hospital and 37% in the reference hospital. Similarly, other outpatient contacts increased in both hospitals, although the change was greater in the reference hospital. Treatment or procedure visits increased by 54% in the modularised hospital.

Primary variables: Process measures

In HUH, patients had more outpatient visits and fewer inpatient episodes after modularisation, but the changes were not statistically significant. In the reference hospital, outpatient visits per patient increased less than in the modularised hospital while inpatient episodes per patient increased. Regarding inpatient episodes in wards, the average length of stay significantly increased by 3% (p = 0.002) in the modularised hospital. The same-day discharge inpatient episodes decreased by 65% (p < 0.0005).

Secondary variables: Resource efficiency measures

In the modularised hospital, patients per FTE remained nearly the same. The changes were marginal in inpatient care, whereas outpatients per outpatient FTE decreased by over 10%. The reference hospital registered different changes as patients per FTE increased and outpatients per FTE stayed the same. Visits per outpatient FTE increased in both the modularised hospital and the reference hospital. Treatment and procedure visits per outpatient FTE increased in the modularised hospital. The bed utilisation rate, which represents the effective use of bed capacity, increased in the modularised hospital.

Qualitative and quantitative results combined

Figure 2 combines the qualitative and quantitative findings: the interview themes related to service delivery and production outcomes that were inductively recognised from the semi-structured interviews are presented together with quantitative results. Both the qualitative and quantitative findings related to outcomes in service delivery and production support the synthesis of the four themes.

According to the interviewees, the standardisation of treatments and procedures in the day hospital supported the change to more outpatient-focused care, seen in the decrease of beds from 38 to 32 in haematology wards.

From the qualitative analysis of the eight semi-structured interviews, four themes related to outcomes could be synthesised: balance between demand and supply, shorter treatment times, improved management of service production and support in the shift from inpatient to outpatient care. Examples of interview findings are demonstrated in the first column (Figure 2). In addition, the numbers of the interviews with findings that were used in synthesis are listed in brackets underneath each synthesised theme. The quantitative analysis results linked to the four themes are demonstrated on the far right after the column introducing the four themes.

Discussion

This is the first study to combine quantitative and qualitative findings on how modularisation can support changes in hospital care delivery. The findings in this study show that modularisation can support the shift from inpatient to outpatient care. The evaluation of the two units (the modularised and reference units) shows that outpatient care increased and inpatient care decreased more in the modularised hospital than in the reference hospital. However, the resource efficiency changes related to modularisation were both positive and negative.

Both the qualitative and quantitative results indicate that modularisation may support the shift from inpatient to outpatient care. This change in the modularised hospital may have been possible because of the decrease of same-day discharge episodes in wards; short inpatient episode treatments and procedures have been carried out in the day hospital since modularisation. In addition, interviews of personnel members indicate that, because of the standardisation of day hospital treatment and procedure components and the standardisation of interfaces between the outpatient clinics and the day hospital, it has been possible to move some services previously carried out in wards to outpatient care. This standardisation of care delivery and communication enabled the change because, as in other services,¹ the modularisation of hospital services requires early planning of service delivery. However, no quantitative data regarding waiting times for treatments were available, although interview findings indicated that in the new modularised system, the balance between demand and supply of day hospital services can be improved.

Process measures in this study indicated a clear shift from inpatient to outpatient focused care on the patient level. Patients had more outpatient visits than before, while at the same time, patient episodes decreased. These changes were greater in the modularised unit (HUH) than in the reference unit (Oulu). The association between modularisation and process measures has not been studied before. This case study demonstrates that it is possible to apply modularisation in a hospital care context. Prior studies have also demonstrated that the use of modularisation in the hospital context may improve human resource management.²³

The results relating to changes in resource efficiency are partly negative and partly positive, and are in line with prior studies indicating that health care modularisation may either increase or reduce costs.^3,8,14,16 A study of German hospitals reported that the formation of smaller organisational units with relatively smaller staff numbers in modularised hospitals had a negative effect on efficiency.⁴ However, interviews with personnel of the modularised hospital in the present study indicated that treatments can be carried out with lower costs in outpatient care than in inpatient care. These interview findings, the increase in the ratio of treatments and procedures per outpatient FTE after modularisation and the decrease in inpatient episodes per patient after modularisation indicate that modularisation may lead to cost reductions, supporting the findings of previous studies.^3,8 This argument can be made because inpatient care in Finnish university hospitals is more expensive than outpatient care²⁶; thus, the shift from inpatient to outpatient care should cut costs. In addition, the quantitative data demonstrate that outpatient personnel administered more treatments and procedures after modularisation, indicating that the standardisation and modularisation of outpatient care may increase resource efficiency. The changes in bed utilisation rates and treatment and procedure visits/FTE could not be compared with the changes in the reference hospital due to the lack of data.

This study is the first to combine quantitative and qualitative analyses of hospital service modularisation. It is possible that not all outcomes have been identified and that there are more factors not identified in the study that affect the shift from inpatient to outpatient care. However, a reference hospital was used to give context to haematology care and to support the identification of general trends in haematology care delivery. Both hospitals, HUH and Oulu, are university hospitals in which severely ill haematology patients are treated based on similar guidelines. The morbidity and distribution of different haematological cancers are similar in both areas of the two hospitals.²⁷ Although a general shift towards outpatient care has been seen in Finnish hospitals^28,29 and is not limited to the two hospitals in this study, the shift in our study was more defined in the modularised hospital compared with the reference hospital.

This study has focused on the modularisation of haematology care in one university hospital in Finland and, thus, the applicability of findings in different health care service contexts in different countries may be limited. However, there are specialties that have similar service delivery logics, such as rheumatology, in which care episodes are complex from an operations management perspective and care is often delivered in day hospitals. The findings of this study may support modularisation in health care areas with similar delivery logics. More studies in new care contexts and countries are needed to enable the generalizability of the results to other cases of modularisation and to determine the care areas in which modularisation can be used successfully.

This study demonstrated through quantitative and qualitative research that modularisation can be used to support changes in health care delivery towards outpatient care. The standardisation of treatments and interfaces, clear scheduling rules and patient criteria support the shift from inpatient to outpatient care.

Footnotes

Author's note

Katariina Silander is also affiliated to University of Helsinki, Helsinki, Finland

Declaration of conflicting interests

The author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

Funding

The author(s) disclosed receipt of the following financial support for the research, authorship, and/or publication of this article: This study was a part of an Energizing Urban Ecosystems research program carried out by RYM Ltd., - Strategic Centre for Science, Technology and Innovation for Built Environment. The funders had no part in planning or conducting the study or analysing the findings.

Orcid ID

Katariina Silander

References

Baldwin

Clark

KB.

Managing in an age of modularity. Harv Bus Rev 1997; 75: 84–93

McLaughlin

Kaluzny

Building client centered systems of care: choosing a process direction for the next century. Health Care Manage Rev 2000; 25: 73–82

Meyer

Jekowsky

Crane

FG.

Applying platform design to improve the integration of patient services across the continuum of care. Manag Serv Qual 2007; 17: 23–40

Kuntz

Vera

Modular organization and hospital performance. Health Serv Manage Res 2007; 20: 48–58

Voss

Hsuan

Service architecture and modularity. Decision Sci 2009; 40: 541–569

Eissens-van der Laan

Broekhuis

van Offenbeek

et al . Service decomposition: a conceptual analysis of modularizing services. Int J Op Prod Manag 2016; 36: 308–331

Böttcher

Klingner

Providing a method for composing modular B2B services. J Bus Ind Market 2011; 26: 320–331

Bohmer

RM.

Medicine’s service challenge: blending custom and standard care. Health Care Manage Rev 2005; 30: 322–330

de Blok

Meijboom

Luijkx

et al . Interfaces in service modularity: a typology developed in modular health care provision. J Oper Manag 2014; 32: 175–189

10.

de Blok

Luijkx

Meijboom

et al . Modular care and service packages for independently living elderly. Int J Op Prod Manag 2010; 30: 75–97

11.

Soffers

Meijboom

van Zaanen

et al . Modular health services: a single case study approach to the applicability of modularity to residential mental healthcare. BMC Health Serv Res 2014; 14: 210.

12.

Schilling

MA.

Toward a general modular systems theory and its application to interfirm product modularity. Acad Manage Rev 2000; 25: 312–334

13.

de Blok

Luijkx

Meijboom

et al . Improving long-term care provision: towards demand-based care by means of modularity. BMC Health Serv Res 2010; 10: 278–290

14.

Chorpita

Daleiden

Weisz

JR.

Modularity in the design and application of therapeutic interventions. Appl Prev Psychol 2005; 11: 141–156

15.

Weisz

Chorpita

Palinkas

et al . Testing standard and modular designs for psychotherapy treating depression, anxiety, and conduct problems in youth: a randomized effectiveness trial. Arch Gen Psychiat 2012; 69: 274–282

16.

Vähätalo

Kallio

TJ.

Organising health services through modularity. Int J Op Prod Manag 2015; 35: 925–945

17.

de Blok

Meijboom

Luijkx

et al . The human dimension of modular care provision: opportunities for personalization and customization. Int J Prod Econ 2013; 142: 16–26

18.

Dörbecker

Böhmann

The concept and effects of service modularity – a literature review. In: 2013 46th Hawaii international conference on system sciences (HICSS), 2013, pp. 1357–1366. IEEE Computer Society.

19.

Eisenhardt

KM.

Building theories from case study research. Acad Manage Rev 1989; 14: 532–550

20.

Yin

RK.

Case study research: design and methods. Thousand Oaks, CA: SAGE publications, 2003, pp.1–181.

21.

Eisenhardt

Graebner

ME.

Theory building from cases: opportunities and challenges. Acad Manage J 2007; 50: 25–32

22.

Patton

MQ.

Qualitative research and evaluation methods. 3rd ed. Thousand Oaks, CA: SAGE Publications, 2002. pp.230–246.

23.

Silander

Torkki

Lillrank

et al . Modularizing specialized hospital services: constraining characteristics, enabling activities and outcomes. Int J Op Prod Manag 2017; 37: 791–818

24.

Johnston

Leach

Liu

AH.

Theory testing using case studies in business-to-business research. Ind Mark Manag 1999; 28: 201–213

25.

Finnish Consulting Group Ltd, Kansallinen

DRG-Keskus.

NordDRG-opas Suoritekäsikirja manual, 2016.

26.

Kapiainen

Väisänen

Haula

Terveyden- ja sosiaalihuollon yksikkökustannukset Suomessa vuonna 2011. Report for Terveyden ja hyvinvoinnin laitos. Report no.: 3/2014, 2014. THL.

27.

Suomen Syöpärekisteri. Tilastot, http://www.cancer.fi/syoparekisteri/tilastot/ (2013, accessed 14 April 2015).

28.

Häkkinen

Hospital productivity 2014. Report for Terveyden ja hyvinvoinnin laitos. Report no.: 3/2016, 2016. THL

29.

Häkkinen

Sairaaloiden tuottavuus 2011. Report for Terveyden ja hyvinvoinnin laitos; Report Terveys 2013, 2013. THL