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1 Introduction

In the healthcare sector, governments around the world are facing significant expenditure constraints, while at the same time trying to improve quality, customization and access to healthcare services for population [1]. Although the quality of medical care is improving for most types of illness, the attention to detail in business systems and processes that transform resources into healthcare services has not kept pace [2], resulting in long waiting times, patients lying on stretchers in hallways, overburdened and stressed medical staff [3]. In this context, while the appropriate use of traditional operations management (OM) concepts could be potentially of great help relying on the hypothesis that the healthcare sector can benefit from the lessons learned in the industrial sector [4], the use of methods, approaches and tools initially established for manufacturing companies has been proved to be challenging because of the differences between manufacturing and healthcare operations [5].

Existing studies in this area offer a collection of frameworks, models and classifications, providing some guidance on how to configure an operations strategy for healthcare providers [6, 7], but are insufficient to provide a complete and detailed picture of medical care delivery. In particular, most of the operations-oriented studies focus narrowly on specific issues [8, 9], with a few examples integrating long-term structural and intermediate operations decisions [4]. However, focusing on one decision area is not enough; on the contrary, developing a congruent operations strategy is the key to improve healthcare providers’ performance [2]. Moreover, though many organizations flounder on internal factors, failure of execution can also be related to environmental features and their evolution [10].

On these premises, this study will address the following research questions: Which are the main variables characterising healthcare operations management? How are the variables connected?

Therefore, a framework providing a set of leverages for strategic Operations Management (OM) in healthcare will be proposed. The framework aims at capturing the key characteristics of operations for healthcare providers, linking such aspects to the overall healthcare system in which they function, including drivers for change and factors that influence decision-making.

In the next section, the research methodology is described. Section 3 presents the initial theoretical model. Section 4 is focused on the discussion of results from an Italian case study and on the novel model for Healthcare Strategic OM in the cardiac rehabilitation area. Section 5 closes the paper with contributions to theory and practice, outlining future research directions.

2 Methodology

Given the explanatory nature of the research (“how”-type of questions), the originality of the field, as well as the criticality of the context, a case study methodology was adopted [11]. In the first phase of the research, a conceptual framework was developed based on a literature review in the following research field: Healthcare, Service and Manufacturing Operations Management and Strategy.

Research issues and interview questions were then developed and included in a research protocol. Then, an in-depth case study was carried out. The case, the cardiac rehabilitation (CR) unit of the “Ospedale Bolognini” (ASST Bergamo Est) in Seriate (Bergamo, Lombardy region, Italy), with 500 patients/year, supported in refining the theoretical model and in exploring how the context influence healthcare operations management characteristics. In particular, the cardiac rehabilitation services, defined as “comprehensive, long term programmes involving medical evaluation, prescribed exercise, cardiac risk factor modification, education, and counselling. These programmes are designed to limit the physiological and psychological effects of cardiac illness, reduce the risk for sudden death or re-infarction, control cardiac symptoms, stabilise or reverse the atherosclerotic process, and enhance the psychosocial and vocational status of selected patients” [12]. Multiple investigators and respondents have been used as a form of triangulation to handle the richness of the contextual data and provide more confidence in research findings. During two visits, six informants from the CR unit have been interviewed: head of the unit, a physician, the head of the physiotherapists, the head-nurse. In the third and final stage the theoretical framework was redefined and relationships between variables characterising healthcare strategic operations management were identified.

3 Literature Review and Definition of the Theoretical Model

The theoretical model is composed of two main dimensions, internal and external. It is intended to capture the general characteristics of healthcare operations strategy.

3.1 Internal Factors

Internal factors represent the structural and infrastructural characteristics that describe how operations are configured. Internal factors have been developed based on the framework proposed by Baines et al. [13], further tailored on healthcare distinctive features. Such framework represents a comprehensive model obtained from the analysis and synthesis of a wide literature on strategic operations management (Table 1).

Table 1 Internal factors of the theoretical model
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3.2 External Factors

The external environment is defined as all of the political, economic, social and regulatory forces that influence on the organisation [20]. Drawing on the model developed by Swayne et al. [16], five main areas are included in the framework:

  • Legislative/Political/Regulatory—defining how governments and legislation bodies intervene in the healthcare economy;

  • Economic—related to healthcare economics;

  • Social and demographic—describing gender, ethnicity, religious and cultural aspects, as well as health consciousness, population growth rate, age distribution, living standards and income level;

  • Technological—including R&D activity, automation, technology incentives and the rate of technological change;

  • Competitive—representing the strategic behaviour of competing actors.

4 Results from the Case Study

The description of the case using the theoretical model previously defined is presented in Table 2.

Table 2 Case description
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5 Towards a Reference Model for Strategic Operations Management in Healthcare

The discussion on how both internal and external factors are connected (Table 3) was the key step for the definition of a reference model for Strategic Operations Management in Healthcare, with reference to cardiac rehabilitation.

Table 3 Relationships between internal and external factors
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From the analysis of the case studies, the following changes have been introduced in the initial model:

  • “Capacity” has been split into two variables: key resources (types of resources for service delivery) and capacity utilisation (utilisation level of the resources);

  • Internal context: including variables describing hospital clinical context (availability of health departments) and hospital operations strategy characteristics. The internal context influences: CR human/key resources, facilities, supply chain positioning and quality control.

6 Conclusion

Nowadays, healthcare delivery actors have to face an increasing number of challenges to create operational efficiency being at the same time financially viable. Therefore, they must apply sound business and operations management, ensuring improvements in clinical and organisational performance. In this context, an integrated framework for strategic operations management was developed and then relationships between variables were defined through an in-depth case study of an Italian cardiac rehabilitation unit. The final framework is composed of internal operations strategy factors as well as variables describing the context, both external and internal. Moreover, it provides relationships between the identified variables and how they influence each other. Therefore, the framework can be used as a tool helping healthcare managers engineer and configure service delivery processes, considering both the external and internal context. It also supports decision-making processes, simulating how acting upon a specific variable or changes in the context affect the other components of the operations strategy. Nevertheless, several limitations and further developments can be outlined. Firstly, more case studies should be carried out to validate the model (selected variables and their links), both for other CR departments and other hospital units operating in different health systems. Then, a system thinking model can be developed for running simulations and scenario analysis to test and optimise configuration choices.