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The Productivity Triangle of New Integrated Care Service Concepts

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A multi-dimensional approach to assess the productivity of social services

Joachim Hafkesbrink1, Janina Evers2, Guido Becke3
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Rhein-Ruhr Institut für angewandte Systeminnovation, Duisburg, Forschungszentrum Nachhaltigkeit, Universität Bremen

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The aim of the joint research project COCKPIT1 is to develop an integrated instrument for designing and implementing productive innovative care services that balances the different productivity expectations of care providers concerning increased efficiency; and careworkers for the better quality of interactive work; and people in need of care (clients) for their capacity to act and their quality of life, according to a triple-win situation in the so-called “Productivity Triangle”. This instrument considers the entire supply chain of care services, and comprises parameters such as careworkers’ interaction competencies; motivation and job satisfaction; and extended clients’ needs (for example; including their private social networks) within the assessment tool.

.1 Introduction
The conceptual framework “Cockpit” merges different findings from (1) economic, (2) labour studies, and (3) nursing sciences regarding the drivers of services productivity. Concerning the economic situation, and as a result of the uno-actu-principle (production and consumption of the service coincide) in which clients (patients, or more general: people in need of care) become ‘prosumers’ as they also play a part in generating the nursing service, the overall service productivity incorporates both provider and consumer productivity, as well as interactive productivity of the coactions in the emergence of services (see Fließ, 2009; Büttgen, 2007; Lasshof, 2006). In networks of care services (e.g. in new quartiers concepts for autonomous habitation, mutual assistance and empowering one’s own initiative), additional productivity effects result from economies of scale and scope, and modified transaction costs may appear (see Iivonen; Haho, 2006; Conrad; Dowling, 1992, 86). From the perspective of labour studies and industrial psychology, the relevant drivers for productivity are, specifically, problems related to the coordination of action in new integrated care services, and a lack of careworkers’ recognition that can decrease work motivation and may evoke burn-out and productivity slumps (cf. Maslach et al., 2001; Büssing; Glaser, 2003).

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The research underlying this paper relates to a joint research project, supported by the German Ministry for Education and Research (BMBF), reference number 01FL10030.

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Nursing sciences stress certain characteristics of care quality as being the most important drivers for service productivity, such as the degree of desired services being considered as necessary; the degree of desired self-organization capabilities of people in need of care (Arend; Gastmans, 1996); and the degree of desired selfdetermination by people in need of care about their own life (see Rinderspacher et al., 2009) etc. With this background the Productivity Triangle assessment tool embraces multi-level quantitative ratios and qualitative indicators for the evaluation of service productivity within a three ‘pillar’ model. Specifically, these are: (1) efficiency ratios based on an extended transaction cost model of the service process (Hafkesbrink; Evers, 2011); (2) effectiveness indicators covering expectations and perceptions of people in need of care regarding a high quality care service and resulting life quality (see Kumbruck et al., 2010; Rieder, 2005; Kumbruck, 2008), operationalized by indicators such as the “capacity to act” and “self-determination”; (3) qualitative indicators to assess the quality of work in care services taking into account care workers’ work experiences, expectations and perceptions (Becke et.al., 2010). These may include, for example, respect for social recognition in the workplace, job control, options to translate their professional ethics into reality at work, and resources that promote health at work. Methodologically, it is necessary to explore the inter-relationships of the three pillars of the Productivity Triangle, since the different dimensions will impact each other. For instance: self-determined standards of good service quality (careworker) will affect the perceived quality of services on the demand side (clients); a good process quality in terms of a sound work situation will decrease the transaction cost of careworker turnover etc.

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social services need to be aligned individually to the different needs of customers (Merchel. who have different care levels. such as rationalization of work processes. may have different effects in terms of work quality on the one hand. The production and consumption of the service coincide (unoactu principle) -. and the employees´ willingness to acquire new skills. by way of example. In addition. An example is the needs of customers in domestic environment. 2003. personal social services are interactive and are provided directly to the person. such as time. learning aptitude. “quality of work” and “quality of care” are related to each other . To measure. or the provision of a service system. errors and customer satisfaction (Reichwald. and on the efficiency and effectiveness of social services on the other hand. ambulant and in-patient care facilities. and its underlying measurement concept. The “Productivity Triangle” model. and the increase of indicators. the variables “performance indicators” (efficiency and effectiveness). Bienzeisler. Baumgärnter. different opportunities of participation in and different demands on their social services. 3 . Möslein. Moreover.customers are co-producers of the service.. 1995. 6). assess and increase the productivity of social services. and are focussed on the social services sector. Key elements of service providers’ productivity are. are based on the assumption that the implementation of the provision of services. as well as their possibilities of interaction. costs.2 Productivity Triangle In the joint research project “Cockpit”. 2006). further measures and indicators are needed beyond traditional ones.

the ‘process productivity and quality’ of providers and customers.g. The measurement of “outcomes” by service provision is measured both quantitatively and qualitatively. Services productivity / quality: to obtain the “structural capability” (= input in the process of provision of service). backstage. measures on-stage. 1 Customer activities.process productivity/ quality 8) Client. Organizational Measures Work organization1) Style and structure of leadership2) Skills development3) Organizational impacts on the perceived quality of work Communiaction and information4) Esteem/ corporate culture5) …. skills. (1) The quantitative and monetary indicators may be condensed from the bottom-up into efficiency measures.structure productivity/ quality 7) Client.g. values??. models etc. empathy etc. externally 5) Recognition. revenue/hour). “social recognition”. and “work-life balance”. Performance indicators: the different aforementioned indicators are used to operationalize the key performance indicators of service delivery. e. “availability of health resources in work and organization”. Organizational impacts on the productivity and quality of services 6) P otential of service provider. of potential ) 2) Integrity. (2) The effectiveness of the service process includes indicators 4 • • Qualitative Output 12) Health promotion Social inclusion . as clients/hour. In this process. of support.Productivity and quality of provided services structural capability process perf ormance outcome performance Perceived quality of work Opera tiona tion liza a m surem of nd ea ent indica tors Efficiency (cost efficiency) Effectiveness (customer satisfaction) Output Input Reliability. motivation 7) P otential of customers. integration potential 8) A utonomous activities of providers in the process 9) A utonomous activities of customers in the process 1 Interactive stages in the process 0) 1) Quantitative results 1 1 Qualitative results 2) Table. e.process productivity/ quality 9) Development / learning opportunities Salary to secure existence Productivity Cockpit “Social Services” Work-Life-Balance Interaction productivity/ quality 10) Quantitative Output 11) …. or as a profitability index on a value basis. motivation 3) Service-oriented and customer-related skills development 4) Flow of communication internally. as well as the ‘interactive productivity and quality’ (interaction of provider and customers / clients). Indicators Supplier-structure productivity/ quality 6) Supplier. the ‘performance potential’ of providers and the ‘potential for the integration of clients’ are used. “work-related action and decision latitudes”. “psycho-physical stress”. are used. performance. The Productivity Triangle connects systematically the following areas of impact of the implementation of social service delivery by a set of indicators: • Perceived quality of work: using indicators such as “opportunities of development and learning”. To obtain “process performance”´ (= throughput).1: Productivity Cockpit “social services” model. the ratio ‘output to input’ is usually used as a key performance indicator (either quantitatively as a productivity index.

2009). costs explosion.and thus the quality of the offered service) are used here on an equal footing (Fließ. an expense limit for nursing services (e. different input variables are used. as well as output variables. In this process. 2007. and in most cases. reduction of charges. the provision of care services – comparable to pension benefits – is regarded as more and more difficult to obtain financing for in the future. on the one hand. by social insurances (primarily nursing insurances and health insurances). see Marrs. the quality of outcomes (“good” care) and the perceived quality of work. or at least in restricting the increase of anticipated costs in light of demographic changes. shown in Table 1. It specifically includes the dimensions of process quality (supplier. the number of clients).1 Efficiency and effectiveness: Performance indicators of social services The assessment of productivity.g.. quality and the achievement of (social) services is a much debated topic because of the tightening situation in the nursing area (demographic change. 2. personnel savings and further austerity measures (such as more favourable purchases. the providers rely on an increase in productivity in terms of improved cost efficiency. private insurances or social assistance authorities. In this context. Efficiency (in terms of cost awareness and cost orientation) and effectiveness (in terms of the goal-attainment of activities to improve the wellbeing of service users . and qualitative variables such as the satisfaction of service users. 2005. more efficient work organization. efficiency and the quality of provided services. The basic principles of these interventions were. 5 . agglomeration of the employees´ performance. Reckenfelderbäumer. material and equipment). The following sections explain in more detail the several "edges" of the Productivity Triangle.g. the providers´ empathy etc. shortage of skilled employees. Different approaches are being developed to a more management-oriented approach to the increasing economisation of social services. In order to ensure the financing of provision of care services. such as reliability.that reveal information about the quality of social services from the clients’ point of view. The provision of care services causes continuously high costs which need to be funded on the one hand by service users. Considering efficiency. by capping hospital per diem charges. particular aspects come to the centre of attention such as effectiveness. and less nursing time per service user) come to the fore. and. the ‘Productivity Triangle’ is also embedded in the concept of sustainable work quality (Becke. etc).). interaction). on the other hand. despite falling per diem rates. 2010). All cost bearers have a fundamental interest in reducing costs. 395. In this respect. and. performance competencies. Senghaas-Knobloch. such as quantitative aspects (e. For this reason. responsiveness. such as resources (staff. 2008. Marra. customer. or the employment of less qualified nurses. as well as indicators for the providers´ quality of work. the strengthening of market mechanisms (e. The cost pressure in this sector is very high. on the other hand. Nevertheless. increased interventions in the healthcare market were made in recent years with the aim of cost-cutting.g. Rothgang. producing competition through the admission of new private providers).

Network transaction costs: Costs of establishing and monitoring of the interorganizational infrastructure and inter-organizational processes of business and service 2 SGB = Sozialgesetzbuch (Social Security Code in Germany) 6 . This is also shown in labour and health science research traditions that are influenced by labour psychology. 2010). Interaction skills support employees to cope with heterogeneous expectations and inconsistencies in their customer contact. 2001).With this in mind. Zillmer 2007. it can be proved that a good process quality affects the performance of employees.). and thus improve productivity without sacrificing quality. Bienzeisler and Löffler perceive a starting point for increasing the efficiency of work processes and simultaneously improving the service and quality of work by strengthening the interaction skills of the employees (Bienzeisler. According to these. Standards of performance assessment are not only composed of exclusively economic outcome criteria (e. From a health-science point of view. Internal corporate transaction costs: the costs of establishing and maintaining the motivation and processes of business and service 3. efficiency). 220ff. all coordination services for the establishment of services in form of transaction costs – quasi the residual value – find expression in the investigation of total costs. 2004). Market transaction and market access costs: the costs of initiation. the nursing model of Monika Krohwinkel.. These transaction costs can be divided into three sets (see Stein. 15): 1. it should be avoided that a one-sided focus of economic indicators and evaluation criteria on an increase of the productivity of service provision leads to a decrease of its quality (Bienzeisler. 22). For example. These are taken into conceptual consideration in the process of operationalization of the ‘Productivity Triangle’. which in turn builds the basis for wide areas of the SGB XI2 as well as the concept of ensuring quality by the medical service of health insurance (MDK. These are also fixed benchmarks of current models of care (e. Tuenter. This means that working processes and structures should be organized in such a manner that employees experience them as comprehensible. Müller. 2004). 2003). The transaction costs approach is used as a base for the costs differentiation of the ‘Productivity Triangle’ (see Hafkesbrink. 1997). The MDK submitted tools with respect to § 79 SGB XI (economical examination in the field of in-patient care) with indicators of efficiency and effectiveness which include the profitability and quality of outcomes (effectiveness) of care (see Engel u. cost. 2004. 2005. time. 41. 2005. and thus contributes to an increase of productivity (see Ulich. It is assumed that. 33). To sum up: it is important that all rationalization measures ensure the quality of work and care.g. see Löser.a. but essentially need to take into consideration the quality of life and the ability to act of the service users. a high process quality is supported when the working conditions assist the expectations of employees (see Antonovsky.g. in addition to direct costs for creating added value (“transformation costs” according to North 1992. increase the quality of interaction. manageable and meaningful. Löser. completion and monitoring of (nursing) contracts 2. Löffler.

g. The different types of costs are defined as follows: • Value-added costs: All costs which are connected to a direct value-added progress in service processes (“transformation costs” for the key process which means all activities to increase customer involvement. 2. opportunities for professional development. Three dimensions are of central importance for the quality of work processes (Becke et al. Becke. Kumbruck. Of central importance is the unwritten and implicit ‘psychological contract’ between management and employees (see Schein 1980) and the social recognition of employees and volunteers. interdependent and mutually dependent provided services (see Frommelt. Firstly. 2012). 1979). 2010. Especially significant are the available job control or ‘decision latitude’ (Karasek. It is significantly influenced by the quality of work processes through which a social service is provided. Becke et al. tasks of documentation and billing) • • Social services (service of assistance and nursing) are basically a chain of interconnected. Secondly. The concept of sustainable quality of work is based on the assumption that such outcomes require a high standard of work..In this article we focus on the company's internal transaction costs. For this reason it is of particular interest to define which of the activities of providers and users of the service process listed in the ‘Productivity Triangle’ are in fact added valued or related to this. 2011). 2009). 2010) consists of two interrelated dimensions: The quality of outcomes refers to the quality of social (care and assistance) services. 2006). it is influenced by the quality of coordination of personal care and assistance services as intensive interaction work (see Böhle et al. in ambulant care or in neighborhood-based care concepts. which are invisible to users of service) Transaction costs for support processes: Transaction costs which occur in connection with organizational performance processes which support the key process (e. and which processes represent only support functions. or the reversal of support processes (see Hafkesbrink.2 Quality of work The concept of sustainable quality of work (cf... Such social services require. the quality of process is influenced by work-related cooperation relations in care facilities. a high degree of (self-) coordination between different professional staff. for example. temporal and social respects. volunteers and clients in task-oriented. back-stage processes. 2010). opportunities to realize profession-ethical ideas and standards at work. indicators can be systematically derived for complex interactive services for e.g. work organization measures to strengthen value-added shares of services. and an appropriate ‘work-life balance’ (cf.g. Evers.. 2010). Thirdly the quality of process is influenced by the specific working conditions (Becke et al. On this basis. all visible provider activities) Transaction costs which are related to added value: transaction costs that immediately support recoverable the key process (e. 7 .

2001. Thus. Approaches of “good work” are therefore. Measures to improve productivity and quality of care are ultimately successful if they integrate a health-promoting work organization for careworkers and enable employees to realize professional ideas at work. especially in the emotive area (Kumbruck 2010).g. as well as low-income and few professional development opportunities contribute to a noticeable shortage of qualified care workers. dynamic flexible requirements in respects of working time-. task. Kumbruck. sustainability refers to the preservation and development of health-promoting resources at individual. 1996).. Büscher. Horn. 2010): Care work is influenced by high. It requires in particular sentimental and emotional work (Böhle et al. 2005. It is less and less possible to cope sufficiently with those demands because of the limited time and available staff (Müller. employees are more and more pressed for time. Gaugisch. 2010) which is reflected in the comparatively low income and earning potential of nurses. Siegrist. The promotion of the sustainable quality of work is therefore of key importance to the retention and recruitment of qualified personnel. The high level of strain. This lack of recognition is a main source of the professional dissatisfaction of nurses and can lead to burnout (see Maslach et al. From this analysis. High psychological stress is often a result of the ongoing economization of health systems and the increasing cost pressures of nursing insurance companies. changing and night shifts). 2005.g. Horn. Second. These restrictions contradict to nurses’ professional ethics. 2006). 2008) and an undervalued public recognition is given (Büscher. Glaser. the following comprehensive areas (for ambulant and in-patient facilities) for supporting and dealing with the quality of work are identified in the ‘Productivity Cockpit’: 8 . inconvenient working times (e. 2006). social and organizational level.. as well as the increasing documentation prescribed by law (Weigl. This manifests itself in the fact that care work is defined as non-scientific support to key medical activities (Gottschall. This is necessary for the motivation of employees to perform in the long term. Nurses are also confronted with increased work requirements. first. heavy lifting) and psychological stress. 2010). The heavy workload results in a high number of persons on sick leave and the increased early retirement of nurses in relation to other professional groups (see Klein. 69). Psychological stress is also linked closely with nursing because of high personal interactive work. ideas and standards (Kumbruck.. insufficient social recognition. . to be adapted to changing work environments and job demands: sustainable quality of work is therefore a long-term task. In ambulant and in in-patient care a high demand for the organization of sustainable quality of work exists (see Klein. Care work is characterized by a high level of physical (e. Moreover.and client-orientation. their lack of appreciation is expressed in the invisible elements of their activities which are important for care work and the professional ethos of nurses.“Sustainability” has a double meaning in the concept of the sustainable quality of work (Becke et al. Care work contains a dual recognition problem. nurses have less time to pay attention to the needs of patients for care. 2010). 2005. Gaugisch. 2010). for example to cope with violence of clients against nurses. Because of the understaffing of nursing services. because many patients show more complex mental and physical illnesses and restrictions.

2007).Quality of work organization: this includes mainly labor time and work organization. Quality of leadership: leadership styles are an important factor to support the quality of work. as well as a systematic involvement of volunteers at certain points of the nursing process. health state of the patient)" (DZA. It is divided into i) "structural quality” (e. Despite the relevance of these aspects of everyday care of nursing facilities in the context of quality testing and evaluation this has been so far neglected in the productivity perspective. Quality of communication and information: care work includes the interaction between employees. and iii) “quality of outcomes” (e. training and continuing education. 9 . Quality of esteem: appreciation is a key dimension of high quality work that can impact positively on the commitment of employees. as well as with external service providers and volunteers. ii) “structural process quality” (e. The criterion for this is the perceived quality of work of employees and leaders which is measured and evaluated by means of qualitative and quantitative evaluation methods such as questionnaires.g.g. This also may contribute to a reduction in workload of the managers themselves. 19). It is possible to increase the individual scope of action of employees and to avoid more easily stressful situations by a professionally and socially competent leadership (see Klein. whether they help employees and managers to accomplish their daily tasks well and ensure a high quality of outcomes. An optimal organization of processes and interfaces. 2005). 2005. 8). nursing documentation. 2010. can positively affect the quality of the work organization. by a good organization. The support for a sustainable quality of work (e. staffing.3 Quality of Care Quality of care is the central criterion in the context of statutory quality testing by the MDK. training of new employees.g. through a well defined scope of activities for employees and training opportunities) can contribute both in ambulant and inpatient care to cost efficiency by a reduction of absence from work and a decrease of the employee turnover rate (Müller. processes and communication is needed to best cope with work tasks and the requirements for passing information on to service users. cooperation with other service providers). clients and their families and other caregivers. A good organization of interfaces. For this the interaction of determinants of the quality of work and care and cost efficiency must be balanced with integrated care and assistance services.g. nursing concepts). The quality of such offerings is measured by the fact. level of qualification. the crucial indicator of effectiveness of a care system or a care facility is to ensure the quality of care and assistance. However. Quality of skills development: skills development and the continuous education and training of employees and care service managers are part of the statutory criteria of quality assurance in nursing (see MDS. The aforementioned issues serve as determinants to survey and evaluate the quality of social services within the Cockpit Model. Gaugisch. 2. nutrition and hydration care.

This Charter serves as a "benchmark for the implementation of dignified care and assistance" (DZA. qualifying measures. documentation Equipment features (ambulant: business premises. 2010. state of skin) Health-related issues (nutrition and hydration care. models Process quality Care organization and nursing documentation Training concepts. 2007). planning and implementation of training Quality of outcomes State of care (e.). etc.Indicators of the Medical Service of Health Insurances (MDK) are used in the context of the Cockpit project for recording and measuring the quality of care. and facilities try to implement these standards. Decubitus prophylaxis. inpatient: barrier-free facilities) Quality management. widely recognized and established in 10 . implementation of measures of internal quality assurance Personnel organization (qualifications. 4). 2007) Also recognized is the so-called Care-Charter drafted by various initiatives. which is ". appropriate medication Satisfaction scores from customers or clients Perception of responsibility of leaderships in terms of management tasks. This means that the aforementioned points are surveyed in the context of statutory quality testing. The MDS (2007) considers amongst other things the following criteria to be relevant for assessing the quality of care: Structural quality Care concepts.. nursing goals Evaluation of the nursing process Biographical work Measures for in-patient social care Activating care: acquisition of resources. employment of nurses according to their qualifications Permanent accessibility (especially ambulant) and appropriate staffing (in particular on weekends) Action according to the situation in acute occurrence Care anamnesis. arrangement of agencies). storage of keys.. planning of care strategies. MDK carries out quality tests of ambulant and in-patient facilities on a statutory basis (MDS. skills. problems and deficits of customers / clients Maintaining hygienic standards Table 1: Indicators of care quality (selection) of the MDK (Source: MDS.g. professional checks of nurses. The.

we also use measurement concepts to survey the quality of care by investigating the satisfaction of customers/ clients or their relatives. process and the outcomes which are achieved by the social services. 2010): to gain help for self-help and to be supported in leading a selfdetermined and independent life as possible to be protected from threats to body and soul to be respected in his or her private and intimate life to support service. treatment and qualified care that are oriented to the personal health and needs of the patient to receive complete information about opportunities. exchange with other people and participation in social life to live according to one’s own culture and religion to be able to “die with dignity.Germany " (ibid. is only possible in a subset of people in need of care. "the questioning of insured persons satisfaction.. because a large number of them are incapable of answering questions because of their cognitive impairment" (MDS. 2007. Wingenfeld. In surveys of ratings from customers or clients. the users' perspective in evaluating the quality of care (see also: MDS. The above mentioned areas for organizing work quality are also used here because these are the same factors involved in quality of care (see e. 3... 6). 2007. " Nevertheless. 2003) In addition. quality of work and quality of care in the Productivity Cockpit The productivity of social services is determined by interactions and mutual relationships between the various elements of the Productivity Triangle. MDS. 43. In addition. 2010. 2003) is only one effectiveness criterion to be measured. it is assumed that the quality of care is measured by the structural. Wingenfeld. Interrelationships and interdependencies of performance indicators. a very high level of satisfaction in terms of both ambulant and in-patient services is usually reached (MDS. care and treatment on appraisal. Thus. BMFSFJ/BMG. we return to aspects that are already used as part of quality testing in the MDK framework. Against the background of care quality standards of the MDK. translation by the authors). 2007. 2007. 2010). advice. and has to be looked at carefully because of a certain bias. as well as of the approach to decent care not only in the context of health outcomes (Care-Charter). The aim is to 11 . assistance. It contains eight items to which every person in need of care has the right (BMFSFJ/ BMG. DZA.g. to support the Cockpit measurement tool for the evaluation of care quality and the impacts of productivity.

as well as our own project findings. of support. The scores relate to the earlier discussion of in-patient and ambulant social services.process productivity/ quality 8) Client. empathy etc. but also for the quality of work as it can reduce the long-term transaction costs. as it also detects synergies between the three pillars of the Productivity Triangle and identifies the unintended problematic consequences of measures to increase productivity. performance. Table 2 shows these relationships. Productivity and quality of provided services structural capability process performance outcome performance Perceived quality of work Opera tiona tion liza a m surem of nd ea ent indica tors Efficiency (cost efficiency) Effectiveness (customer satisfaction) Output Input Reliability. motivation 3) Service-oriented and customer-related skills development 4) Flow of communication internally. Indicators Supplier-structure productivity/ quality 6) Supplier. Organizational measures to design social services. a positive (+) or no (0) relationship is suspected between the variables. integration potential 8) A utonomous activities of providers in the process 9) A utonomous activities of customers in the process 1 Interactive stages in the process 0) 1 ) Quantitative results 1 1 Qualitative results 2) Qualitative Output 12) + + + + 0 Health promotion Social inclusion 12 . The interdependencies between the dimensions of the Productivity Triangle are usually not of a zero-sum nature. models etc. 5) 6) P otential of service provider. motivation 7) P otential of customers. backstage. the results in each dimension can be negative (race-to-the bottom) or positive (win-win situation). and their empirically documented and anticipated effects in terms of the quality of labor and care.where reciprocal effects need to be observed. On the contrary. an implementation of education and training is not only of use for the quality of care in certain dimensions.process productivity/ quality 9) Development / learning opportunities Salary to secure existence Productivity Cockpit “Social Services” Work-Life-Balance Interaction productivity/ quality 10) Quantitative Output 11) + 0 + + 0 …. of potential ) 2) Integrity. The organizational design areas of the Productivity Cockpit are oriented towards such measures and instruments which can both improve the quality of work and care as well as improve cost efficiency. measures on-stage. It was noted that the design areas are not targeted specifically to a particular social service. skills. 1 Customer activities. The analysis therein shows for each case.structure productivity/ quality 7) Client. quality of care and labor . whether a negative (-). Measures are also included that are checked by quality tests: e.g.analyze or estimate potential conflicts of interests and expectations of involved care service actors. externally 5) Recognition. Operational measures for increasing the productivity in this context may be those that influence cost efficiency. are presented in Table 2. values??. but concern domestic care as well as inpatient facilities. Organizational Measures Work organization1) Style and structure of leadership2) Skills development 3) + + + 0 + + 0 0 + + +/+ + + + 0 0 + 0 0 +/+ + 0 0 + + + 0 0 0 0 0 + 0 + + + + + 0 + + + 0 + + + + + Communiaction and information4) Esteem/ corporate culture ….

19. 2007). 2005. In addition. Gaugisch. 2005) and thus decrease the work quality. they are generally more familiar with the documentation and can apply this in a way that the quality of care increases (see MDS. the organization of work especially in the area of individual nursing schedules can have different effects on the perceived quality of work.2: Effects of organization approaches to the quality of work and care (see.as well as the investigation of quality and the implementation of documentation. Gaugisch. by individual care and social care support (e. Gaugisch. DZA. Horn. skills development is an important component to support work quality. 2007). The optimal execution of leadership tasks may avoid stress and unclear responsibilities e. Klein. 2010. On the other hand e. lifting and carrying techniques in care) additional mental and physical stress -. 2010). 64) and thereby support the health promotion of nursing staff.g.g. 2005. Thesis 3: Training and education of employees and managers has positive impacts on the process and outcome quality of care. This may lower the transaction costs of conflict management in general and particularly in changing processes among employees and managers. 2005. 2007. Gaugisch.g. days off personnel turnover etc. stress levels in in-patient facilities can be reduced with respect to specific activity peaks during the day (getting up. It may result in different shifts or night shifts with a negative impact for the work-life balance (Klein. On the one hand. In addition. Educated and in the correctly placed employees can reduce transaction costs in the long term: they can perform tasks more efficiently and thus gain working time for social assistance and support for clients. for example as a result of the permanent accessibility and spontaneous reactions of ambulant/ in-patient services on current occurrences and requests from customers and clients. Thesis 2: The exercise of leadership functions is an important benchmark for the implementation of a good care quality (see MDS. This promotes individual learning and development opportunities.Table. In addition. 2005. Müller. 2007). 13 . Müller.g. The involvement of employees in innovation and change processes – of which nursing facilities are affected continually because of permanently evolving standards of quality and financial constraints (see Müller. lunch) (Klein. This includes the involvement of employees and the examination of models and concept development . transaction costs be lowered by documentation tasks. Gaugisch. 31. Through training for behavior prevention (stress management.and thus costs for days off through illness. By reducing peaks at certain times more working time may be made available for customers/ clients. improvement measure and demands) can be reduced. At the same time transaction costs (e. 2005). the quality of leadership is an important indicator of the quality of nursing work (e. conflict management. In addition. have breakfast.g. Monitoring and the assurance of care quality of processes are also management tasks. From Table 2 five exploratory theses are identified for the interaction of performance indicators. This leads to additional costs of coordination and planning.g. Klein. 69) – may improve the quality of work (Klein. Buescher. The question of the assignment of employees in accordance to their qualifications influences positively the structural quality (see MDS. quality of labor and care in the Productivity Triangle: Thesis 1: The quality of care in terms of structures.g. e. can be reduced. by delegating tasks and assigning clear responsibilities and decision-making power. 2005. processes and outcomes can be supported in fields of work organization e. own theories). 2005). Blass. 2005. MDS.

2010). questions. and between nurses and patients or their relatives" (Blass. translation by the authors). Horn. 2005. Figure 1 shows the relationship between the transaction cost approach and the success indicators of the quantitative process effectiveness. At this point the direct value added shares are separated from processes which are related to value added and support. 2005. so reducing the costs of recruiting new personnel. pharmacists. "This concerns the cooperation between management and care. 8. Employees can be supported actively by the involvement of volunteers. 4. see e. public events. This can reduce the costs of personnel turnover and days off work of employees. Gaugisch. between nursing facility and external service providers. volunteers and other caregivers (respecting data protection). between the different working shifts. doctors and volunteers) transaction costs can be reduced for ad-hoc meetings. The respective shares are allocated in a second step into productivity of providers. As a result this leads to high costs of coordination and cooperation (increasing transaction costs). Meeting protocols of shifts. Both internal (social support in teams and by managers) and external (public appreciation of the nursing profession) improvements can be obtained by public relations (press releases. With good communication. The delegation of responsibility and qualification concepts shows as well internal recognition (see Büscher. coordination and cooperation in internal teams and with external service providers (caterers. Bode. 2009). Thesis 5: Appreciation is of particular importance to the quality of work. 32). in working processes and thereby perform some physical and mental tasks. (Klein. A side effect of good public relations is that volunteers and new employees can be recruited through the provision of a better image of the institution and the nursing profession. between fields of nursing and internal functional areas. teams and cases can be accessible to all employees. customers or interactive productivity: 14 . The characterization of individual process steps of providing services is the basis for the classification of the value-added growth in process. etc. Results from an initial test Initial empirical investigations with the extended transaction cost model demonstrate how productivity in a wider sense may be measured using a wider set of quantitative and qualitative indicators. These measures can increase the quality of care: skilled personnel and a clear assignment and delegation of decision-making may positively influence the quality of structures. processes and outcomes. etc.Thesis 4: Care is interactive work and in daily life is stressful. At the same time the quality of care increases: external services and volunteers can be provided with a hih level of information about customers and clients. relatives. This is especially important for part-time employees and new employees who are not always present at meetings and so have a lower information base.g. Dobrowolski.

n2=3) at a psycho-social nursing service with a small sample reveals the following relationships between the added value and support processes: 15 . 1: Transaction cost effectiveness." approach and allocation to the performance indicator "process A pilot test of the instruments (n1=20.Fig.

Value added-related activities of nurses come to 14% (managers.00% Supporting processes AddedValuerelated AddedValue Employees. n= 20 Leaderships. Classifying the test data according to service activities leads to the following illustration: Classification of service activities in psycho-social assistance 31.00% 20. Thus.00% 40. The so-called "interaction productivity " is the lowest share with 31%. The test data show that direct ‘on-stage’ activities (face-to-face contact with clients).21% 36. 16 . the share of the added value of the total working time of nurses comes to only 38.5% of their total working time (managers 66%). indirect activities (all benefits for the client which are invisible) and support processes (those processes which require maintaining the key processes) each take up about one-third of a nurse’s working day of nurses in a psycho-social setting.05% On-stage activities (FaceTo-Face) Back-stage activities (invisible benefits for clients) Supporting processes 32.2: Pilot test of the transaction cost approach in field of social services.00% 60.00% 0.Classificationof addedvalueand transaction costs inpsycho-social assistance 100.3: Classification of service activities in the psycho-social assistance. while support processes of nurses accounts for approximately 47. n= 3 Fig. 24%).5% (compared to 10% for managers).74% Fig.00% 80.

show that there are approaches to increase the efficiency. K. S.. (2012): HR Mindfulness – A Concept for Sustainable Quality of Work in Knowledge-Intensive SMEs. Universität Bremen. Gaugisch. P. 2010) or the demand for improvement in designing interfaces. Tübingen: Dgvt-Verlag. effectiveness and quality of work. Conclusion The tools presented here constitute a promising approach which largely builds on existing data and findings in the social services (e. Wiesbaden. Schmidt. Dobrowolski. 2005). In: Guido Becke (Guest-Editor): Wirtschaftspsychologie. T. Bern: Huber. Bleses. C. Stauss.) (2006): Dienstleistungscontrolling. M. Forschungszentrum Nachhaltigkeit (artec). (2006): Dienstleistungsproduktivität. 17 . Löffler. In: Becke.. Artec-paper Nr. Blass.g.g. Bienzeisler. Becke. Bienzeisler. 2010... A. the high proportion of bureaucracy/documentation (Bode. (1996): Ethik für Pflegende.g. B. H.. as well as findings from the literature.Prävention in Unternehmen der Wissensökonomie. Konzeptionelle Grundlagen am Beispiel interaktiver Dienstleistungen.These test results have already been qualitatively described in the literature. Forum Dienstleistungsmanagement. Buescher. Arend. Additional surveys are needed to demonstrate their applicability in other areas. G. (2010): Nachhaltige Arbeitsqualität – Ein Gestaltungskonzept für die betriebliche Gesundheitsförderung in der Wissensökonomie..: Springer (Forthcoming). The existing test results. 3 . A. 60-68.. Becke. In: Bruhn. P. I. (Eds. e. (eds. 2007). S. (1997): Salutogenese.): Handbook of Sustainability and Human Resource Management. 158. e. G. G. W. In: Ehnert. Horn.. Becke.. Heidelberg et al. References Antonovsky. Bleses.: Nachhaltige Arbeitsqualität: Eine Perspektive für die Gesundheitsförderung in der Wissensökonomie. effectiveness and quality of work in social services (see Chapter 2. M.2. 2005.3).. Baumgärtner. (2009): Das Konzept nachhaltiger Arbeitsqualität – Grundlage für eine gesundheitsförderliche Gestaltung der Erwerbsarbeit in der Wissensökonomie. Zink. 211-229. B. Stuttgart: IRB Verlag. Horn. Buescher. MDS. pp. (2005): Jenseits von Kennzahlen: Interaktionskompetenzen zur Steigerung der Dienstleistungsproduktivität. J. G. Gastmans. 5. Schmidt. in the context of coordination with external service providers and functional areas (. The tools described here will be tested further in the context of specific social services in ambulant and in-patient fields to work out results in terms of efficiency. Harry. pp. and 2. Klein. 2009. B.

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