This study establishes the relationship between surgical volume and cost and quality outcomes, using patient-level clinical data from a national quality registry for bariatric surgery in Sweden. Data include patient characteristics with comorbidities, surgical and follow-up data for patients that underwent gastric bypass or gastric sleeve operations between 2007 and 2016 (52,703 patients in 51 hospitals). The relationships between surgical volume (annual number of bariatric procedures) and several patient-level outcomes were assessed using multilevel, mixed-effect regression models, controlling for patient characteristics and comorbidities. We found that hospitals with higher volumes had lower risk of intraoperative complications as well as complications within 30 days post-surgery (odds ratios per 100 procedures are 0.78 and 0.87, respectively, p<0.01). In addition, higher-volume hospitals had substantially shorter procedure time (17 min per 100 procedures, p<0.01) and length of stay (0.88 incidence-rate ratio per 100 procedures p<0.01). Our results support the claim that increased surgical volume significantly improves quality. Further, the results strongly suggest that increased volume leads to lower cost per surgery, by reducing cost drivers such as procedure time and length of stay. 

Recent studies have found positive effects from hospital focus on both quality and cost. Some studies indicate that certain patient segments benefit from focus, while others have worse outcomes in focused hospital departments. The aim of this study was to establish the relationship between hospital focus and performance in elective surgery. We studied obesity surgery procedures performed in Sweden in 2016 (5152 patients), using data from the Scandinavian Obesity Surgery Registry (SOReg) complemented by a survey of all clinics that performed obesity surgery. We examined focus at two levels of the organization: hospital level and department level. We hypothesized that higher proportions of obesity surgery patients in the hospital, and higher proportions of obesity surgery procedures in the department, would be associated with better performance. These hypotheses were tested using multilevel regression analysis, while controlling for patient characteristics and procedural volume. We found that focus was associated with improved outcomes in terms of reduced complications and shorter procedure times. These positive relationships were present at both hospital and department level, but the effect was larger at the department level. The findings imply that focus is a viable strategy to improve quality and reduce costs for patients undergoing elective surgery. For these patients, general hospitals should consider implementing organizationally separate units for patients undergoing elective surgery.

This thesis tackles the changing landscape of healthcare delivery, with an increasingly fragmented set of healthcare providers and where speciality hospitals increasingly replace or complement traditional general hospitals. There is a need for guidance to policymakers and healthcare providers, on how different set-ups of healthcare delivery facilities, in terms of the scale and the focus of each facility, impacts performance. In spite of this, facility design and other structural elements of operations, have received relatively little attention in the healthcare operations management literature, compared to infrastructural elements such as scheduling and quality management. There is a lack of agreement among researchers on how healthcare facility design - and scale and focus in particular - affects performance in healthcare. Hence, this thesis investigates the relationship between scale (in terms of size or volume of operations) and performance (in terms of quality and cost), and focus (in terms of narrowing the range of services or emphasizing certain services) and performance in healthcare operations.

This thesis builds on two research studies: an in-depth case study of a transformation of a regional hospital network, and a quantitative study using data from the Scandinavian Obesity Surgery Registry. Based on the first study a profile model of focus in healthcare organizations is proposed, where focus is operationalized in six dimensions: Knowledge areas, Procedures, Medical conditions, Patient groups, Planning horizons, and Levels of difficulty. The second study examines the relationships between focus and performance, and between scale and performance, in the context of elective surgery. When controlling for patient case mix in the different hospitals, the study shows benefits of both focus and scale (volume). More focused facilities have fewer complications after surgery and shorter procedure times. Facilities with higher volumes have fewer complications after surgery, shorter procedure times, and shorter length-of-stay in hospital for patients.

The results presented in this thesis contribute to the healthcare operations management literature in four different ways: First, they extend and translate previous operationalizations of focus, developed in a manufacturing context, into the context of healthcare service delivery. Second, they provide evidence for a positive association between focus and cost and quality performance, in the context of elective surgery. Third, they provide evidence for a positive association between scale (volume) and cost and quality outcomes, in the context of elective surgery. Fourth, they support the emerging contingency theory of benefits of focus in healthcare, a theory stating that patients with less complex needs benefit more from focused operations. The results also suggest a complementary contingency condition for benefits of scale in healthcare, finding that more complicated treatments benefit more from an increased scale of operations.

This thesis has implications for management and policy. It provides a framework for understanding profiles of hospital focus, either as a step in the strategy development for a single hospital or as a step in planning patient allocation within a hospital network. Moreover, it gives tentative guidance on the importance of volume and specialization in different types of healthcare services. Following from this, it also provides tentative guidance on which type of facility that is best suited for different healthcare services.

Denna avhandling tar sin utgångspunkt i en sjukvård i förändring, där utbudet av vårdgivare blir allt mer fragmenterat, och där specialistkliniker i allt högre grad ersätter eller kompletterar de traditionella akutsjukhusen med breda uppdrag. Dessa nya organisationer innebär att beslutsfattare och vårdgivare har ett behov av att förstå hur vårdenheternas skala och fokus (specialisering) påverkar resultaten. Trots detta har produktionsenheternas utformning, och andra strukturella aspekter av sjukvårdorganisationer, fått mindre uppmärksamhet i litteraturen om verksamhetsstyrning i sjukvården, än infrastrukturella aspekter såsom schemaläggning och kvalitetsstyrning. Litteraturen saknar en gemensam syn på hur produktionsenheternas utformning, i synnerhet enheternas skala och fokus, påverkar resultaten. Denna avhandling undersöker därför sambanden mellan skala (storlek eller volym) och resultat (kvalitet och kostnad) samt mellan fokus (smalare tjänsteutbud eller tyngdpunkt på en viss tjänst) och resultat i sjukvårdsproduktion.

Den här avhandlingen bygger på två forskningsstudier: en fallstudie av en omvandling av sjukhusstrukturen i en region och en kvantitativ studie med data från kvalitetsregistret Scandinavian Obesity Surgery Registry. Utifrån den första studien föreslås en profilmodell av sjukvårdsorganisationers fokus där fokus beskrivs och mäts i sex dimensioner: Kunskapsområden, Behandlingar, Sjukdomar, Patientgrupper, Planeringshorisonter och Svårighetsgrader. I den andra studien undersöks sambanden mellan fokus-resultat och skala-resultat inom elektiv kirurgi. Studien jämför resultaten mellan olika sjukhus, justerade för case-mix (hur svårt sjuka patienterna är), och finner att såväl ökat fokus som ökad skala har positiva effekter. Mer specialiserade vårdenheter har färre komplikationer efter operation och kortare operationstider. Vårdenheter med högre volym har färre komplicationer efter operation, kortare operationstid och kortare vårdtider.

Avhandlingen bidrar till litteraturen om verksamhetsstyrning i sjukvården på fyra olika sätt: 1) Den breddar och översätter tidigare operationaliseringar av fokus, som utvecklats för att beskriva fabriker, för att få en operationalisering som är relevant i ett sjukvårdssammanhang. 2) Den visar att det finns ett samband mellan fokus och kostnad / kvalitet inom elektiv kirurgi. 3) Den visar att det finns ett samband mellan skala (volym) och kostnad / kvalitet inom elektiv kirurgi. 4) Den ger stöd till den framväxande contingency-teorin för utformning av sjukvårdsorganisationer, som säger att patienter med mindre komplexa behov har större fördelar av specialiserad verksamhet. Den föreslår vidare ett kompletterande villkor: att mer komplicerade behandlingar har större fördelar från ökad volym.

Avhandlingen ger också några praktiska bidrag till beslutsfattare och vårdgivare. Den erbjuder ett ramverk som kan användas för att förstå sjukhus fokusprofiler, antingen som en del i strategiarbetet för ett enstaka sjukhus eller som en del i planeringen av ett nätverk av sjukhus. Vidare ger den tentativ vägledning kring betydelsen av volym och specialisering i olika typer av sjukvårdsverksamhet. Utifrån detta ger den även tentativ vägledning kring vilken typ av vårdenhet som är lämplig för olika typer av sjukvårdsproduktion.

This study proposes an operationalisation of the term focus in healthcare operations. We develop a configuration model consisting of six interrelated dimensions that can be used to characterise hospital focus. The proposed dimensions of focus are Knowledge areas, Procedures, Medical conditions, Patient groups, Planning horizons and Levels of difficulty. The strength of these dimensions is shown through empirical examination, using a three-step methodology to analyse case study data from a unique transformation project where general hospitals were turned into new types of focused specialty hospitals. As our study takes a portfolio approach to the allocation of demand segments to different healthcare delivery units, it contributes to operations management knowledge with a model for segmenting healthcare demand from an operations perspective. This configuration model provides researchers and practitioners with a tool for understanding current configurations as well as for identifying potential new configurations of focus in healthcare.

Purpose - The purpose of this paper is to explore how healthcare managers perceive economies of scale and the underlying mechanisms for how scale/size affects performance. Design/methodology/approach - Data were collected in 20 in-depth interviews with healthcare professionals from 13 healthcare delivery organizations and from a public authority that finances and contracts healthcare services. Data were coded and analysed using content analysis. Findings - The study concludes that the impact of scale on performance is perceived by healthcare professionals to be different for different types of healthcare services: For surgery, significant scale effects related to spreading of fixed cost, the experience curve, and potential for process improvement. For inpatient care, moderate scale effects related to spreading of fixed costs and costs of doctors on on-call duty. For outpatient care, small or no scale effects. Research limitations/implications - The small sample of interviewees from a single geographical region and healthcare system limits the applicability of the findings. Originality/value - The paper provides insights into how healthcare managers experience scale effects and how they consider economies of scale when planning hospital configuration. Also, past studies of economies of scale in hospitals proffer mixed results and the findings in this paper indicate a possible explanation for this inconclusiveness, i.e. differences in service mix between different hospitals.