A general comparison of public and private hospitals in Switzerland

Inpatient care in Switzerland is reimbursed by health insurers at a flat rate based on diagnosis related groups [18]. This system was introduced in Switzerland in 2012 and applies to all hospitals regardless of their ownership status or profit-orientation. In 2013, about 30% of all acute care hospitals in Switzerland were privately owned, and provided mostly standard surgical and elective treatments [18]. Farsi and Filippini have shown that there are generally no significant differences in cost-efficiency between Swiss hospitals of different ownership status; rather, the cost-driving factors are higher levels of teaching activities in some hospitals and a broader range of specialization in others, and both are associated with lower cost-efficiency [19].

Although the two hospitals that participated in our study were private and profit-oriented, they were comparable to public and non-profit hospitals in terms of a wide range of indicators, including the number of outpatient consultations, number of days in inpatient care, staffing (measured in full-time equivalents), and the overall complexity of treatments provided (measured by a case mix index) [20]. However, there are some important differences between the hospitals examined in this study and the average Swiss hospital, public ones in particular. The most important difference is that the majority of specialist physicians in the two participating hospitals were not employed by the hospitals but affiliated with them and hired as locums. These physicians provided treatment to patients by renting the infrastructure of the hospital and a team of supporting physicians (anesthetists, emergency and intensive care physicians). Some of the specialists were nevertheless directly employed by the hospitals or had post-doctoral degrees and a range of teaching tasks, something that would be more typical of a university hospital. Second, compared to the Swiss median, the two hospitals treated a larger proportion of patients who had a private insurance plan. Such plans enable the patients to choose their treating physician and to stay in a single-bed room. Lastly, although both public and private hospitals have the same range of tasks and obligations in Switzerland, private hospitals are not eligible for public funding in certain domains, such as investments in building infrastructure.

Importantly, the two hospitals are not exclusive private clinics, but an integral part of the Swiss health system in their provision of general acute care. In Switzerland, private hospitals are reimbursed in the same manner as public ones, resulting in financial incentives that are independent of ownership status and profit orientation. The Swiss hospital sector comprises a spectrum ranging from non-profit university hospitals funded by public funds that usually treat the most complex cases to niche private hospitals working almost exclusively with privately insured patients and focusing on selective treatments. Overall, the two hospitals we examined are—irrespective of the important features discussed above—fairly similar to what can be described as the average Swiss hospital.

Ethics approval

The study design, the interview guide, and our data management concept were approved by the ethics committee of the Faculty of Business, Economics and Social Sciences of the University of Bern (Date: 2018-05-08; Process number: 180503_1).

Study design

The main purposes of our study design were to (1) explore nurses’ perceptions of kaizen, and (2) derive factors that affect the implementation of the technique from a direct comparison of two acute care hospitals. Based on the Organizational Transformation Model (OTM) developed by Lukas, et al. [21], we created a semi-structured interview guide (the full version of which can be found in the S1 Table). Table 1 provides an overview of the content and structure of the interview guide.

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Table 1. Sample interview questions.

https://doi.org/10.1371/journal.pone.0257412.t001

We would expect that OTM is a suitable framework for our study design because it was developed during a series of case studies in private sector health care organizations. The OTM describes five drivers that are crucial to transforming patient care successfully: (1) impetus to transform; (2) leadership commitment to quality and change; (3) staff engagement in improvement initiatives; (4) alignment of an organization’s goals with resource allocation; and (5) overcoming of boundaries between the constituent parts of the organization so that it operates as a fully interconnected system, pursuing the overarching goals of the organization.

In order to gain insights that would be valuable to both scholars and practitioners [22] and to extend the scope of qualitative research in this area [23], we added an additional driver to the OTM framework—employee commitment—to describe employees’ attachment to the organization or to parts of it, such as their supervisors [24]. Organizational change initiatives may affect employee commitment to the change itself or to the whole organization [25]. Given the positive general association between commitment and participation [6, 26, 27], the opportunity to contribute to the improvement of the workplace may increase nurses’ willingness to stay at a hospital.

Data collection

Following the guidelines of Gill, et al. [28], we conducted semi-structured interviews with 30 nurses in May 2018. The two hospitals (hereinafter referred to as Hospital A and Hospital B) had recently implemented kaizen and were open to the idea of exploring nurses’ experiences with the implementation of the technique. We selected these two hospitals because medical experts and representatives of their management teams (AG, KH, BT) had indicated that the sites were fairly similar in terms of size and specialization, but differed in the way kaizen had been applied. Both hospitals were medium in size, profit-oriented, located in Switzerland, and belonged to the same corporation. The hospitals were comparable in terms of the average length of stay (5.0 vs. 5.6 days), bed occupancy rate (84.8% vs. 84.2%), number of newborns (827 vs. 860), and number of emergency admissions (4,316 vs. 4,212) in the fiscal year 2017/2018. In the same fiscal year, the first hospital (Hospital A) was smaller than the second one (Hospital B) in terms of the number of beds (196 vs. 333), patients (12,198 vs. 18,389), and employees (1,377 vs. 2,128) [29].

In Hospital A, an implementation working group, whose main objective was to set out the conditions for the nursing teams to be able to start contributing ideas, was appointed by the management team of the hospital at the beginning of the implementation phase. To communicate the concept of kaizen to the staff in all units, the working groups defined a set of general and specific aims. While the general aims involved encouraging nurses to seek to identify problems in the workplace and subsequently solve them, the specific ones defined concrete measures intending to facilitate collaboration. Such specific measures included the advice that kaizen meetings should be held on a regular basis and that nurses should aspire to be role models to their colleagues from other units by working with and for each other. Lastly, the process of implementing kaizen was represented graphically in the recreation rooms of Hospital A and defined in five steps as follows: (1) identify waste; (2) make an improvement suggestion; (3) prioritize the suggestion and define action to implement it; (4) take the defined actions; (5) measure the success of the actions.

The initial phase of implementing kaizen was defined in a similar way in Hospital B. Together, the quality management team and the nursing team of the hospital elaborated a strategy to design the way in which kaizen would be implemented in all inpatient care units. The strategy of Hospital B sought to encourage employees to question existing working procedures, inform their colleagues in case action is required, and eventually make a collective effort to improve their workplace. In addition, responsible persons received special training and subsequently served as an important reference point to the rest of team.

By means of purposeful sampling [30], we selected 15 nurses from each hospital to obtain an information-rich sample that was balanced in terms of age, gender, tenure, and specialization. Our sample included nurses from several units, including orthopedics, gynecology, and thyroid diseases treatment. The nurses comprised 28 women and two men, of whom 11 were in training—some of whom had recently started working for the hospital—and 19 had professional qualifications. Five of the latter occupied senior positions, such as head nurse. We informed all nurses in advance that they would receive a small thank you gift after completing the study. After being introduced to the study purpose and design, all participants gave their written informed consent to be interviewed and recorded. Interviews lasted an average of 26 minutes [range: 15–38 min].

Analysis

The interviewer (CP) used the recordings to (1) transcribe the interviews, including pauses, filler words (e.g., “hmm”), and important non-verbal reactions (e.g., laughing), and, (2) to conduct a qualitative content analysis of the transcribed interviews in MAXQDA (Version 18.0.8). First, we identified patterns in the text and grouped these into overarching themes to develop an in-depth understanding of the interviews. The full list of themes, categories, and marker words we used to conduct the content analysis of the transcribed interviews can be found in S2 Table. The next step was to summarize the interviews by exporting quotes into a structured matrix organized by site, interviewee, and question (see S3 Table). Then, we applied the OTM framework revising the influencing factors suggested by Sullivan, et al. [31], who recently validated the framework by assessing the implementation of a pilot health care services program in long-term care facilities. In the next step, to enhance the credibility of analysis [32], two researchers (KS and RB) used the OTM framework to analyze the interviews. The two analysts independently assigned each of the quotes to one of the six influencing factors and their sub-categories: (1) nurses’ perspectives, (2) job commitment and satisfaction, (3) team dynamics and processes, (4) infrastructure availability and adoption, (5) human resources and staffing, and (6) resource allocation and culture. Auxiliary evidence from the interview notes was considered if needed. After an initial agreement of 68% between the two analysts, we refined some sub-categories and developed categorization rules to avoid ambiguity (see S1 Fig for illustration and S4 Table for an overview of the categorization rules). In a second iteration, applying the categorization rules increased overall agreement between authors to 90%. In the final iteration, the two analysts resolved any disagreements in their categorization by reaching consensus through discussion.

After analyzing the interviews using the OTM framework, we interpreted our findings within the scope of the two-factor motivation theory, which posits that certain factors influence employee motivation at the workplace [33]. The theory distinguishes between hygiene factors that lead to dissatisfaction and motivational factors that boost employee satisfaction. The core of the theory is that both types of factor do not build a continuum–that is, hygiene factors cannot yield satisfaction, and motivational factors are not associated with dissatisfaction. More specifically, hygiene factors comprise the working conditions that managers need to provide to prevent their employees from losing motivation and becoming unhappy with their workplace (e.g., due to unsafe work practices or conditions), whereas motivational factors comprise the working conditions that should increase employees’ job satisfaction and keep their motivation high (e.g., work practices promoting employees’ sense of achievement). Even though the validity of Herzberg’s theory has been called into question because working conditions have changed significantly since the theory was initially proposed in the late 1950s, Bassett‐Jones and Lloyd have demonstrated that the underlying idea of the two-factor theory still has utility in a contemporary organizational context [34]. By interpreting our findings within the scope of the two-factor motivation theory, we aim to provide health care practitioners with insights into factors—at the individual and organizational levels—that may either increase or decrease the motivation of nurses to participate in kaizen.

Individual factors

Organizational factors

Positive and negative cases in direct comparison

Noting that the study of kaizen has focused so far on success stories, D’Andreamatteo, et al. [11] and Filser, et al. [12] advocate learning from examples of less effective implementation. With this in mind, we gained insights from comparing both of our participating hospitals in terms of (1) nurses’ attitudes towards kaizen, (2) participative behavior, and (3) the results of implementing kaizen.

First, nurses’ attitudes towards how kaizen had been implemented at the workplace differed between the hospitals. Nurses in Hospital B were less fond of engaging in kaizen, although they expressed their general willingness to contribute to the improvement of the hospital and recognized that kaizen is generally a useful practice. While Hospital B nurses reacted to the implementation of kaizen with a certain skepticism, nurses in Hospital A remained motivated to contribute ideas even if they did not always have time to adopt them immediately. Moreover, many nurses in Hospital B generally experienced kaizen as an additional workload imposed by management, whereas nurses in Hospital A were more likely to understand the approach as an integral part of the hospital’s culture and their work that could help them improve working routines.

Next, the degree of participation in kaizen also differed. Even though kaizen structures were available in both hospitals, participation levels varied, for example due to a lack of leadership in individual units. Nurses who contributed their own ideas constituted the majority in Hospital A, but not in Hospital B. In the latter, it seemed that many nurses hardly ever made suggestions, though they still attended meetings and implemented kaizen projects.

Finally, the results of implementing kaizen differed between the hospitals. In Hospital A, most nurses agreed that kaizen improved their workplace. In contrast, some of the nurses in Hospital B indicated that kaizen did not lead to visible results at all times, which they often attributed to high levels of stress. Although nurses in Hospital A also agreed that nursing was stressful, they did not see a contradiction in taking part in kaizen alongside their other duties, and mentioned a sense of doing something meaningful when engaging in kaizen more often.

Strategies for the successful implementation of kaizen

Additionally, we identified several factors that influenced the implementation of kaizen in hospital care. Overall, the two hospitals we examined implemented kaizen by introducing a specific target to be achieved on a yearly basis, as well as regular discussion rounds and communication tools to facilitate the adoption of ideas. Hospital A seemed, however, to have capitalized on the potential of kaizen because it managed to implement the approach in a more structured and purposeful way, focusing on outcomes more than process. For instance, Hospital A defined the number of kaizen ideas to be adopted on a yearly basis as a target to be pursued by nurses, whereas Hospital B used the number of meetings held. Based on these and our other findings, we suggest six coping strategies for implementing the approach in hospital care. Depending on whether they relate to behavioral patterns that specific team members may need to pursue, or, instead, processes and structures that health professionals might wish to establish, the following strategies are assigned to either the individual or organizational level of acute care hospital systems:

Limitations and further research

Our study has several important limitations, some of which provide opportunities for further research, which we describe and discuss below.

One limitation of this study is that it included a small number of hospitals. Future efforts should strive to incorporate as many sites as feasible bearing in mind the specific constraints of the research project and context. Another limitation is that the two of the researchers (KS and RB) did not participate in the on-site interviews with the nurses. However, these researchers had the chance to familiarize themselves with the data [44] by reading the transcribed interviews, having a series of discussions with the interviewer (CP), and receiving an introduction to the concept of kaizen and its principles by a team of medical experts (AG, KH, BT). Additionally, to help establish the trustworthiness of our qualitative research methods and results [32, 45], we sought to ensure dependability by providing thorough and transparent documentation of our research interest, methodological choices, and qualitative results in the manuscript and its supporting information [46].

Nevertheless, there are two additional points to bear in mind when considering the transferability of our findings. First, the two acute care hospitals we examined in this study were private and profit-orientated. Although previous research on the hospital sector in Switzerland has shown that there is no significant relationship between (1) profit orientation and hospital ownership and (2) cost-efficiency [19], scholars may nevertheless wish to examine whether these organizational characteristics influence the way hospitals engage with continuous improvement techniques. Furthermore, the hospitals we selected had implemented kaizen with differing degrees of success, which poses the further question of which characteristics are shared by hospitals that are equally successful at implementing kaizen. In this vein, it might be worthwhile in future research to enrich our conclusions by selecting organizations that have implemented the technique in a similar way but at different points in order to explore how the participation of employees evolves over time. Future research may also wish to expand the scope of this study by verifying whether its results hold in settings other than that of inpatient acute care, such as outpatient or long-term care.

Data collection is a second factor that should be considered when interpreting the findings of this study and judging their transferability. While the purposive technique we used to select the interviewees enabled us to gain deep insight into the work environment of both hospitals, it may also have led us to place a disproportionate amount of attention to some experiences the nurses had had with kaizen. For example, there were several interviewees who had started working in their unit fewer than six months before the interview and their observations may have been influenced by limited knowledge of the work context, the kaizen approach, or both. Yet, purposive sampling helps researchers obtain an in-depth understanding of the phenomenon of interest [30] and is therefore suited to our exploratory approach. When revisiting our work, future researchers could consider using other or additional sampling techniques such as snowball or maximum variation [47], thus aiming to identify key informants who could contribute additional insights and perceptions that would otherwise remain undiscovered. Moreover, according to the social-desirability argument—a common bias occurring in many areas of social sciences that rely on self-reporting values—interviewees may provide answers that do not reflect their real opinions but rather are convenient or socially acceptable [48]. However, we do not expect reporting biases to have distorted our findings substantially because most nurses were not overly shy in criticizing hospital policies or the behaviors of their supervisors. By giving us an intimate look into their working place, the nurses enabled us not only to capture and explore their perceptions of kaizen, but also to realize that this managerial technique—no matter how beneficial it can be in some situations for both employee and organization—is not necessarily a panacea for all problems and aspirations managers may have.