Improving client-centered
care and services: the role of
front/back office configurations
3
This chapter is based on:
Broekhuis, M., de Blok, C., Meijboom, B. (2009).
Improving
client-centered care and services: the role of front/back-office
configurations. Journal of Advanced Nursing 65(5), pp. 971-980.
48
Abstract
This paper is a report of a study conducted to explore the application of designing front-
and back office work resulting in efficient client-centred care in healthcare organizations
that supply home care, welfare and domestic services. Front /back-office configurations
reflect a neglected domain of design decisions in the development of more client-centred
processes and structures without incurring major cost increases. Based on a literature
search, a framework of four front/back-office configurations was constructed. To illustrate
the usefulness of this framework, a single, longitudinal case study was performed in a large
organization which provides home care, welfare and domestic services for a sustained
period (2005-2006).The case study illustrates how front office/back office design decisions
are related to the complexity of the clients’ demands and the strategic objectives of an
organization. The constructed framework guides the practical development of front/back-
office designs, and shows how each design contributes differently to such performance
objectives as quality, speed and efficiency. The front/back-office configurations presented
comprise an important first step in elaborating client-centred care and service provision
to the operational level. It helps healthcare organizations to become more responsive and
to provide efficient client-centred care and services when approaching demand in a well-
tuned manner. In addition to its applicability in home care, we believe that a deliberate
front/back-office configuration also has potential in other fields of healthcare.
3.1 Introduction
Several proposals on future care and cure provision have advocated a shift in the
organizations involved, putting the patient or client rather than the care supplier at
the centre of processes and structures. Hence, the needs and expectations of patients
and clients are now being viewed as the starting point in a thorough re-orientation of
roles, tasks, operational processes, organizational structures and inter-organizational
cooperation in the promotion of a client-centred approach (Mead and Bower, 2000).
More specifically, redesigns have been developed, such as clinical or care pathways
(de Bleser et al., 2006), focused factories (Skinner, 1974, Casalino et al., 2003) and
integrated care (Ouwens et al., 2007). A characteristic of these new designs is that
they have been developed for a particular, often well-defined client or patient group.
As a result, care delivery is becoming more client-centred without sacrificing too
much efficiency, which is another pressing factor healthcare providers must take into
account (Bohmer, 2005).
One relatively neglected issue in these redesign discussions concerns the effect of
work executed either in the front office (FO) or the back office (BO). From operations
management literature, we infer that FO and BO work each contribute differently to
operational performance (Chase, 1981, Metters and Vargas, 2000, Safizadeh et al.,
2003, Zomerdijk and De Vries, 2007). In general, moments of client contact can create
customization opportunities and increase the quality of customer relations. In contrast,
Modular
Care Provision
49
BO work is sealed off from client contacts so that it offers more potential for efficiency
improvements (Chase, 1981, Larsson and Bowen, 1989, Metters and Vargas, 2000,
Zomerdijk and De Vries, 2007). A closely-related second design issue that has been
discussed in the literature as having an impact on operational performance dimensions
is the structure of FO and BO work or activities. In general, extensively breaking a
process into its BO or FO components and subsequently segregating these activities
into distinct jobs – that is, decoupling – increases productivity (Chase, 1981), whereas
coupling facilitates interaction with clients (Larsson and Bowen, 1989). The trade-
offs involved in denominating tasks as either FO or BO and coupling or decoupling
activities seem to be related to the target of many healthcare organizations to deliver
client-centred services without increasing or with even decreasing costs (Metters and
Vargas, 2000). In the present study we addressed these two relevant aspects of client-
centred design: (1) the denomination of tasks as FO or BO work, and (2) the coupling
or decoupling of FO or BO activities into distinct jobs. The potential value of these
design decisions to deliver efficient client-centred services underpins the relevance
of this study and drives us to investigate whether and how these two design decisions
can contribute to different performance objectives in healthcare.
The remainder of this paper is structured as follows. First, we discuss relevant literature
with regard to FO/BO design decisions, and investigate how these can be applied in
a healthcare context. This yields a framework of four FO/BO configurations that can
support the healthcare organization in the design of efficient patient or client-centred
care. We clarify and illustrate this framework in a longitudinal case study. This case
study took place in a ‘home care plus’ context, that is, a large diversified company
acting in the Dutch market for home care and related welfare and domestic services.
We describe the findings of this case study and draw conclusions, including future
research directions and the managerial implications of our study.
3.2 Background: FO/BO configurations in healthcare and
welfare
In the literature, FO activities are defined as those involving direct encounters between
a client and a representative of providers that take place at the same time, but not
necessarily in the same place (phone, e-mail) and give the opportunity for interaction.
BO activities are defined as those performed without contact with clients (Chase and
Tansik, 1983, Zomerdijk and De Vries, 2007). Generally, the specification and delivery
of home care, welfare and domestic services requires either physical presence or a form
of interaction with the client (system) and therefore takes place in the FO. All other
activities can be carried out in the BO, for example, administrative tasks and discussing
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