Focus assessment of three example units
Table
4 provides data on the range of services in each focus dimension for the three sample units in the SLL case study. The first row, Knowledge areas, shows the number of medical specialties among the employed physicians in each unit (for NKS, 43; for Sabbatsberg, 13; and for Danderyd hospital, 21). The same row shows the minimum potential number of medical specialties (1), i.e. the number for a hospital where all employed physicians belong to the same medical specialty, and the maximum potential number (44), i.e. the number for a hospital that employs at least one physician from each of the medical specialties listed by the Swedish National Board of Health and Welfare. The minimum value represents the highest possible focus; the maximum value represents the lowest.
The second row, Procedures, shows the number of unique codes for surgical, medical and diagnostic interventions that were recorded at the unit over a one-year period (for NKS, 4160; for Sabbatsberg, 644; and for Danderyd hospital, 2982). For this dimension the maximum number is defined as the number of unique codes that were recorded at all SLL healthcare units during the same time period (7113).
The third row, Medical conditions, shows the number of unique codes for patients’ main diagnosis that were recorded at the unit over a one-year period (for NKS, 6119; for Sabbatsberg, 1189; and for Danderyd hospital, 4804). As for the previous dimension, the maximum is defined as the number of unique codes that were recorded at all SLL healthcare units during the same time period (8439).
The fourth row, Patient groups, shows the share of privately funded patients (for NKS, 0%; for Sabbatsberg, 30%; and for Danderyd hospital, 0%). This is based on the finding that the main differentiator between the analysed clinics in the Patient groups dimension is source of funding (in another context it could be more relevant to base the assessment on age groups targeted by different units). Degree of focus in this dimension could be measured by counting the number of different patient groups in terms of funding, i.e. one group for NKS and Danderyd hospital (public patients) and two groups for Sabbatsberg (public and private patients). However, private medical insurance is unusual in Sweden, and the absolute majority of all patients seek healthcare through the public (tax-funded) healthcare system (98% of all healthcare consumption). We therefore view units that accept public patients as unfocused and units that specifically target the small privately funded patient group as focused. In some cases, such as Sabbatsberg, some of the hospital’s clinics are open for public patients whereas other clinics are for private patients, and to reflect this, we measure the degree of focus as the percentage of privately funded patients. The minimum value, representing the highest possible focus, is then defined as 100% and the maximum value, representing the lowest possible focus, as 0%.
The fifth row, Planning horizons, shows the units’ emphasis on either elective care or emergency care. Degree of focus in this dimension could be measured in terms of narrowing the range of services – in this case Sabbatsberg would have a high degree of focus, since they only have elective care. While correct, we believe that this way of measuring is less meaningful for large hospitals that are required to always have at least a small amount of both elective and emergency care. Yet the difference in demands placed on operations from a 50–50 split of elective and emergency care, compared to a 95–5 split, is vast. Our interviewees have witnessed the difficulties of combining the two planning horizons when faced with large volumes of both elective and emergency care, e.g. in surgery scheduling. To capture this aspect we instead measure focus as emphasis on either category in this dimension. For Sabbatsberg, the table shows the unit’s emphasis on elective care (100%). For NKS and Danderyd hospital, the table shows each unit’s emphasis on emergency care (for NKS, 30022 emergency admissions of 47,341 total admissions results in 63% emergency care; for Danderyd hospital, 37,787 of 45,805 admissions results in 82% emergency care). Based on the interviews, we believe that the calculated values for emergency care at these two units are probably somewhat low. The reason is that some patients that seek urgent care are eventually admitted as elective patients. As an example, a patient with a leg fracture who is received in the emergency room is often sent home after diagnosis and scheduled for surgery later in the same week, which is then recorded as elective care. The minimum value, representing the highest possible focus, is defined as 100%; the maximum value, representing the lowest possible focus, as 50% (i.e. an even split between the two different planning horizons).
The sixth row, Levels of difficulty, shows each unit’s emphasis on secondary care or tertiary care. Degree of focus in this dimension could be measured by counting the number of care levels at each unit, i.e. primary care, secondary care, and tertiary care. Similar to the previous dimension, we believe that this way of measuring, although correct, is less meaningful for large hospitals, and that the focus configuration is more aptly captured by measuring focus as emphasis on the dominant care level. In the SLL case, we calculated this emphasis based on the allocation of the highly specialised surgical interventions, since these make up the most well-defined part of tertiary care (Inquiry into Highly Specialised Care
2015). Hence, the sixth row in Table
4 first shows the overall number of surgeries at each unit (for NKS, 110373; for Sabbatsberg, 15,236; and for Danderyd hospital, 87,146). Then the table shows the number of highly specialised surgeries for each of the three units, which indicates an emphasis on tertiary care, as defined by the Swedish National Board of Health and Welfare as part of the Inquiry into Highly Specialised Care (
2015, pp. 255-259). For NKS, the number of highly specialised surgeries is 3406; for Sabbatsberg, 0; and for Danderyd hospital, 360. The highly specialised surgeries as a percentage of all surgeries is then calculated for the three units (for NKS, 3.1%; for Sabbatsberg, 0%; and for Danderyd hospital, 0.41%) and compared to the overall percentage of 0.55% for SLL as a whole (in all SLL units 6227 highly specialised surgeries are performed annually out of a total number of 1,137,175 surgeries). NKS is much above the SLL average and thus emphasise tertiary care; the unit performs 55% of all highly specialised surgeries in the region but only 9.5% of remaining surgeries. The minimum value, representing highest possible focus on tertiary care, is calculated by allocating 100% of the highly specialised surgeries within SLL to the same unit (NKS) which would amount to 5.6%. Sabbatsberg and Danderyd hospital perform less highly specialised surgery than the SLL average and thus have an emphasis on secondary care. The minimum value, representing highest possible focus on secondary care, corresponds to 0% highly specialised surgeries (i.e. that all surgeries are secondary care level). For all units, the maximum value that represents the lowest possible focus is a split in line with the SLL average, i.e. 0.55%.
After assessing the degree of focus in all six dimensions for the three example units, the resulting values have been normalised to the range of 0 to 1 (see Table
5). The purpose of normalisation is to simplify plotting of values in the spider chart in Fig.
2, and also to facilitate interpretation and comparison between focus values in the different dimensions. However, it is possible to plot the original focus values in Table
4 in the spider chart without normalisation, using different scales on each of the six axes, i.e. scales ranging from the minimum values (stated in Table
4) in the chart centre to the maximum values at the outer edges. The data was normalised using the min-max method, with the minimum and maximum values as defined in Table
4 and with 0 meaning the highest potential degree of focus and 1 meaning the lowest potential degree of focus:
$$ \mathrm{Normalised}\ \mathrm{focus}\ \mathrm{value}=\left(\mathrm{focus}\ \mathrm{value}\hbox{--} \mathrm{minimum}\right)/\left(\mathrm{maximum}\hbox{--} \mathrm{minimum}\right) $$
Table 4
Focus assessment of three example units
1) Knowledge areas | Range of medical specialties, measured as number of medical specialties among employed physicians | Base specialties in Sweden according to the Swedish National Board of Health and Welfare | 1 | 44 | 37 | 13 | 21 |
2) Procedures | Range of interventions, measured as number of unique category codes of surgical, medical and diagnostic interventions recorded in 1 year | Swedish Classification of Procedures of Care (Klassifikation av. vårdåtgärder, KVÅ) | 1 | 7113 | 4160 | 644 | 2982 |
Data from July 2017 to June 2018 |
3) Medical conditions | Range of diagnoses, measured as number of category codes of patients’ main diagnoses recorded in 1 year | Swedish version of International Classification of Diseases (ICD-10-SE) | 1 | 8439 | 6119 | 1189 | 4804 |
Data from July 2017 to June 2018 |
4) Patient groups | Share of privately funded patients | In general, patients are funded through the public healthcare system | 100% | 0% | 0% | 30% | 0% |
5) Planning horizons | Emphasis on elective care, measured in number of elective admissions as a percentage of all hospital admissions | Data from July 2017 to June 2018 | 100% | 50% | – | 100% | – |
Emphasis on emergency care, measured in number of emergency admissions as a percentage of all hospital admissions | Data from July 2017 to June 2018 | 100% | 50% | 63% | – | 82% |
6) Levels of difficulty | Number of surgeries in 1 year | Surgical care procedure codes recorded | n/a | n/a | 110,373 | 15,236 | 87,146 |
Data from July 2017 to June 2018 |
Number of especially advanced surgeries (July 2017–June 2018) | Surgical procedure codes that represent especially advanced surgeries according to the Swedish Ministry of Health and Social Affairs’ Inquiry into Highly Specialised Care ( 2015, pp. 255-259) | n/a | n/a | 3406 | 0 | 360 |
Data from July 2017 to June 2018 |
Emphasis on secondary care, measured in share of especially advanced surgeries relative to other SLL units | Defined as having a lower share of advanced surgeries compared to the SLL average percentage of 0.55% (6227 advanced surgeries out of 1,137,175 total surgeries). Highest possible emphasis on secondary care would be no advanced surgeries at all (i.e. 0%) | 0% | 0.55% | – | 0% | 0.41% |
Emphasis on tertiary care, measured in share of especially advanced surgeries relative to other SLL units | Defined as having a higher share of advanced surgeries compared to the SLL average percentage of 0.55% (6227 advanced surgeries out of 1,137,175 total surgeries). Highest possible emphasis on tertiary care would be that all advanced SLL surgeries were concentrated to this unit (i.e. in this case 6227 advanced surgeries out of 110,373 total surgeries or 5.6%) | 5.6% | 0.55% | 3.1% | – | – |
Table 5
Normalised focus assessment of three example units
1) Knowledge areas | 0.84 | 0.28 | 0.47 |
2) Procedures | 0.58 | 0.09 | 0.42 |
3) Medical conditions | 0.73 | 0.14 | 0.57 |
4) Patient groups | 1.00 | 0.70 | 1.00 |
5) Planning horizons | 0.74 | 0.00 | 0.36 |
6) Levels of difficulty | 0.50 | 0.00 | 0.75 |