Leadership Strategies to Maintain Hospital
Business Office Productivity During a Merger
Section 1: Foundation of the Study
In 2017, healthcare system mergers in the United States set a record with 115
deals made and 11 involved sellers with net revenue of at least $1 billion (Garmon,
2017). Leaders combine hospitals as a strategy for sustainability in consolidated markets
(Zall, 2016). There was a need to investigate hospital strategies for maintaining business
office productivity during a merger. The purpose of this qualitative single case study was
to explore strategies hospital leaders in the southeastern United States market used to
maintain business office productivity as they completed a merger process. I used the
tenets of Business Process Re-engineering (BPR) as a conceptual framework in analyzing
leadership strategies for maintaining hospital business office productivity during a merger
(see Hammer, 1990).
Background of the Problem
As healthcare systems become more competitive, healthcare providers have
consolidated through mergers and acquisitions (Zall, 2016). Healthcare systems are
acquiring physicians’ practices, insurers are acquiring entire healthcare systems, and
hospitals are merging for competitive advantages and survivability for economic health,
market share, and specialization offerings (Postma & Roos, 2016). The merging of two
hospital systems involves the integrating of many different moving parts in a way that
maintains the prescribed objectives of the combined entity (Garmon, 2017).
Hospitals are complex entities even during stable periods. The potential chaos of
unclear processes that can result from merging two hospitals can decreased business
office productivity (Cascardo, 2018). There is some anticipated disruption in business
office productivity as two business offices combine. The state of business office
productivity is dependent on the flow of timely and accurate information (Mindel &
Mathiassen, 2015), the clash of cultures (Gordon, 2015), and the presence of uncertainty.
Decreased business office productivity can destabilize the finances of both the
target and acquiring hospital, threatening the success of the merger and even the
existence of the hospitals (Dobrzykowski, McFadden, & Vonderembse, 2016). The
business office facilitates reimbursement for hospital services (Healthcare Financial
Management Association, 2017). Components of the business office like coding, billing,
follow up, and appeals are crucial when gauging business office productivity (Mindel &
Mathiassen, 2015). A significant decline in crucial business office components directly
affects the hospital’s financial wellbeing. As a result, hospital leaders should consider
strategies to maintain business office productivity during a hospital merger (Jonasson,
Kjeldsen, & Ovesen, 2018).
Problem Statement
Although approximately 83% of all mergers fail (Hirsch, 2015), the number of
mergers continues to increase. Both the acquired business and acquiring business’ total
productivity generally decreases during the merger process while productivity does not
significantly recover to the premerger level until several years after a merger (Sapkota,
Ivanov, Bachman, Vermillion, & Goyal, 2019). The general business problem is the
decline of business office productivity during a merger. The specific business problem is
that some hospital leaders lack strategies to maintain hospital business office productivity
during a merger.
Purpose Statement
The purpose of this qualitative single case study was to explore the strategies
hospital leaders in a southeastern U.S. market used to maintain business office
productivity during a merger. The target population was hospital leaders in two midsized
hospitals in a southeastern U.S. metropolitan area who were able to maintain business
office productivity during a merger. The implications for positive social change include
the potential for hospital leaders to maintain business office productivity during a merger,
to continue to have a positive economic effect on their communities, and to maintain
service quality to patients.
Nature of the Study
The three types of research methods are qualitative, quantitative, and mixed
methods (Lewis, 2015; McCusker & Gunaydin, 2015). I used the qualitative research
method for this study. The qualitative research method is a type of social science research
in which researchers collect and work with nonnumeric data in the form of verbal
communication, documents, observations, or images (Wilson, Onwuegbuzie, & Manning,
2016). Using the qualitative method could aid with exploring the efficacy of abstract
constructs within strategies regarding business office productivity during a merger
process. A quantitative method was not appropriate for this study because quantitative
researchers seek to examine relationships among variables using numerical data to
generalize from a sample (see McCusker & Gunaydin, 2015), which was not the intent in
this study. Mixed methods researchers collect, analyze, and use both quantitative and
qualitative data (Venkatesh, Brown, & Sullivan, 2016), therefore, since only qualitative
data was obtained, a mixed methods approach was also not appropriate for this study.
The design for this study was a single case study. In a case study design, the focus is on a
general situation in a real-life setting (Yin, 2018). Researchers use case studies to acquire
data subject to interpretation in the creation of new knowledge (Yin, 2017). A single case
study design allows researchers to explore real-life, bounded systems through the
collection of detailed data from multiple sources and identify specific themes or patterns
to enable understanding of a phenomenon (Yin, 2018).
I considered ethnography, which is a design that involves studying people in their
cultural context and the ways that culture influences their behavior as individuals or as a
group (see Draper, 2015). The focus of this research was not on the people but on the
strategies used to maintain business office productivity during a merger process making
ethnography not appropriate. In addition, I contemplated a phenomenological approach.
Using a phenomenological design can aid in the study of conscious experiences
(Spaulding, 2015). As the focus of this study was not on the personal meanings of the
individuals experiencing a phenomenon, the phenomenological design was not suitable.
A qualitative single case study was appropriate for exploring the strategies used by
hospital leaders to maintain business office productivity during a merger to understand
the relationship between the strategies applied and the resulting impact.
Research Question
What strategies do hospital leaders use to maintain hospital business office
productivity during a hospital merger?
Interview Questions
1. What was the primary expected benefit of the merger within the business
office?
2. How did you safeguard against overestimating the expected benefit of
streamlining redundant processes that result from combining two business
offices?
3. What strategies did you implement to maintain business office productivity
during the merger at the operating unit for which you are responsible?
4. Please explain any restructuring of organizational processes to improve
service, speed, accuracy, and/or cost performance.
5. What types of measurement was used to understand the existing practices prior
to the merger?
6. How would you describe the personnel interaction or cooperation between the
two merging entities during the merger process?
7. What strategies did the organization for which you are/were responsible
address the top three challenges to maintaining business office productivity
during the merger?
8. How did you measure business office productivity success at the completion of
the merger?
9. What else would you like to add that we have not yet discussed regarding the
strategies used to maintain business office productivity during a merger?
Conceptual Framework
The conceptual framework for this single case study was the business process
reengineering (BPR) model. I conducted an in-depth exploration to identify strategies
used by hospital leadership to reorganize the administrative procedures of two hospitals
to streamline the hospitals into one consolidated procedure. In 1990, Hammer (1990)
established the BPR model to explain how the leadership of large complex organizations
faced challenges eliminating redundant effort. Using BPR can aid in identifying and
tracking challenges in mergers and acquisitions to evaluate leaders’ strategies to maintain
business office productivity during a hospital merger (Brennan, Sampson, & Deverill,
2005). BPR entails thoroughly restructuring organizational processes to improve service,
speed, accuracy, and cost performance (Hammer, 1990). The conceptual framework
provides a potential context from which to understand the strategies under study during
the process of combining two business offices.
Hammer (1990) developed BPR to explain the strategies for maintaining an
adequate level of an organization’s productivity. With this conceptual framework, I
explored strategies used to reconfigure the business model during the merger process.
Key factors that affect business office productivity include setting standards,
corresponding accountability, and using resources (human and material; Brown, 2019).
The BPR model was applicable to this study because the model creates value in the
healthcare field. BPR encompasses (a) the development of method intentions and
business concepts, which is comprised of specific business objectives such as
improvement in the quality of output, time-savings, cost reduction, measurement, and
understanding of existing practices; (b) identification of business practices for
reorganization; and (c) the construction and designing of the model of the new process
(Hammer1990). I used the BPR model to analyze the contributing components of the
revenue cycle during a merger and explore how variations in the contributing components
during the transition might affect business office productivity.
Definition of Terms
Some of the terms in this study have interchangeable meanings. Some of the terms
are unique to the revenue cycle of a hospital business office where leaders measure
business office productivity components. The subsequent terms for the purposes of this
study are as follows:
Back-end (of the Revenue Cycle) - All administrative procedures essential to
correct reimbursement for services. Reimbursement is the method of compensation,
typically by a third-party payer (i.e., insurance companies) for medical treatment
rendered to patient or ancillary hospital costs. The back end of the revenue cycle includes
coding of the medical record and billing, denials management, customer service, and all
bill collection activities to include follow up and cash application (Britt, Adams, & Snow,
2015)
Front-end (of the Revenue Cycle) - All administrative processes essential to
patient throughput, including, scheduling of patients for services, patient registration,
insurance documentation and verification, and coding of the medical record (LaPointe,
2017).
Revenue Cycle - All business processes involved in moving a patient through the
hospital and ensuring payment to the hospital (LaPointe, 2017).
Assumptions, Limitations, and Delimitations
To expose the components that could constrain the research, I have listed
perceived deficiencies that could impact the access to resources or hamper the line of
reasoning that exist in any human inadequacies. In this section are the assumptions,
limitations, and delimitations necessary to further explore the phenomena to be studied.
The subsequent subsections include an explanation of the assumptions, limitations, and
delimitations that may impact this study.
Assumptions
Assumptions are facts considered to be true, but which cannot be verified by the
researcher (Anderson, 2017). All operations considered for this study were assumed
indicative of actions executed with the goal of maintaining productivity during the
merger process. The first assumption was all organizational leadership was acting in the
fiduciary interests of the organization for which they are authorized to make policy
decisions. Furthermore, the second assumption was each leader possessed functional
knowledge and the applicable skillset to critically expound on the processes and
considerations of strategies for maintaining business office productivity during a merger.
The third assumption was that respondents answered honestly, having given appropriate
thought to the subject-matter.
The fourth assumption was that existing processes analyzed available in
written/manual form by operational authorities and department heads are an accurate
depiction of the recorded content. The participants did ethically provide all
documentation considered for informational purposes as a secondary source of
confirmation and validity through access to document archives maintained by the
organization. Regulation constraints made access to some segments of documentation
unavailable due to the presence of Protected Health Information (PHI) as well as the time
involved in mining large quantities of documentation for each episode.
Limitations
Limitations emphasize the threats to validity both internally and externally that
are out of the researcher’s control (Wölfer et al., 2017). The multiple complexities of the
hospital business office prevent the possibility of evaluating the many nuances and
variables that may contribute to increases in business office productivity (Zall, 2016).
The intent of this study was to investigate the strategies related to maintaining
productivity during a merger. While assuming outliers and anomalies, the narrow scope
of this study focused primarily on the measurable components that contribute to business
office productivity of merging midsized urban hospital systems in the south eastern
United States. An example of things beyond the scope of study might include anomalies
such as inclement weather or power outages, which would prevent the otherwise normal
workflow of business due to a fluctuation in the complement of human resources, or the
ability to operate the necessary resources. Participants may feel uncomfortable or anxious
during their interview or exhibit bias in their responses to interview questions (Bourne &
Robson, 2015). Existing internal auditing procedures used during the normal course of
business ensured the data are reliable.
Delimitations
Delimitations are the borders established by the researcher that could introduce
ethical considerations and curtail the scope of the study (Batongbacal, 2015; Rodner,
2015). Location can also be a determinant of the scope of the study (Qiu & Gullett,
2017). The scope of this study was limited to the production key indicator based on
claims billed, followed up, cash posted, appeals executed leading to denials being
overturned, and not clinically specific productivity or a measure of any medical service.
This limit stems from the measurable benchmarks that are engaged to evaluate hospital
revenue cycle as defined by Zall (2016). A midsized urban hospital was the basis for this
analysis of productivity of a hospital business office. The hospital leaders use
standardized productivity practices that are like other midsized, urban healthcare system
hospitals in the southeastern United States.
Significance of the Study
Healthcare leaders going through a merger may be able to use the findings of this
study to maintain business office productivity during the merger. Reviewing the study
findings could assist hospital leaders in establishing a set of protocols for maintaining
business office productivity during a merger. A decrease in business office productivity
during a merger could result in the failure of the merger. If hospital leaders can use the
findings in this study to maintain business office productivity levels, they could avert a
potential merger failure.
Implications for Social Change
The implications for positive social change include effective strategies for
successful mergers that could help maintain business office productivity in hospitals.
Maintaining the business office productivity can lower the risk of hospital closures or
decreased service quality that typically result from failed mergers. Diminishing business
office productivity will cause a decline in the overall financial health of a hospital
(Cascardo, 2018).If business office leaders in hospitals apply effective strategies to
maintain business office productivity during a merger, there was a higher likelihood that
the communities affected by the merger can retain proximate access to quality health care
("Dartmouth Atlas Data", 2019).
A Review of the Professional and Academic Literature
The purpose of the literature review was to investigate hospital considerations for
maintaining business office productivity during a merger. The purpose of the study was
to explore the strategies of hospital leaders who have maintained business office
productivity during the merger of two hospital systems. The existing literature on this
subject was insufficient and researchers have yet to produce a governing theory using
writings on the topic.
The literature review includes the analysis of peer-reviewed articles, dissertations,
and books on mergers and acquisitions (M&As), and revenue cycle management. The
literature review also includes looking at past studies to reveal the substance of the
phenomenon. I searched Walden University’s online resources such as SAGE journals,
EBSCO, and ProQuest. Internet queries also involved Google and Google Scholar online
libraries. The primary electronic database used for the literature review was the
EBSCOhost Discovery Service at Walden University.
Additional relevant sources for the literature review were selected journals and the
ProQuest Dissertations and Theses database, and pertinent books. Ward-Smith (2016)
asserted that a researcher should review the literature to identify best practices and to
regulate how other authors explored the main topics being studied to embrace
evidencebased practices in health care. Neill (2017) posited that a systematic approach to
a literature review begins with using keywords related to a researcher’s topic or research
question.
Literature Review Strategy
The literature review strategy included a search of related studies and searched
terms that included mergers and acquisitions, health care system, revenue cycle, revenue
integrity, patient financial services, financial management, integrated healthcare
organization, billing, coding, follow up, cash application, meaningful use, synergy
management, accounts receivable, reimbursement, productivity, and qualitative case
study research methods and techniques. The review of literature segment includes
literature from seminal books pertinent to the research question: What strategies do
hospital leaders use to maintain hospital business office productivity during a merger?
I have structured the literature review to include five main parts. The objective in
part one, was to gain a holistic understanding of M&A (particularly those relating to
hospitals), including the triggers, strategies, types, and hindrances. In part two, there is an
in-depth analysis of Hammer’s (1990) BPR model. Part three includes a brief background
into various causalities of merger failures. Part four contains an analysis of contributions
to the business office revenue cycle (specifically the Patient Financial Services) that
provided a basis of assessment for maintaining productivity. The final section is a review
of literature pertinent change management.
Context of the Study
The goal of this study was to reveal strategies hospital leaders use to maintain
hospital business office productivity during a merger. As part of medical industry
reforms, healthcare organizations are increasingly employing a self-renewal merger
process, commonly used by organizations around the world to deal with technological
changes, increases in competition, and government regulation (DeHaas et al., 2017).
Every hospital merger is unique with respect to key factors such as business processes,
culture, size, location, and resources (Angwin & Meadows, 2015). When hospitals merge,
there is an integration process of combining the key factors of the acquirer and the
acquired into a single entity, which normally engages both people and processes (DeHaas
et al., 2017). The focus of this study was on strategies used to maintain hospital business
office productivity during a hospital merger, primarily involving the revenue cycle.
Representatives of the Healthcare Financial Management Association (HFMA) defined
revenue cycle as all the administrative, as well as clinical operations that contribute to the
capture, management, and collection of patient services revenue (Mindel & Mathiassen,
2015). The continuously evolving revenue cycle landscape necessitates an increasing
need for more thorough preauthorization and precertification, the ability to respond to
underpayments or variances, and the ability to absorb more frequent delays in payment
(Rauscher & Wheeler, 2008). The inability to maintain these areas during a merger could
result in merger failure.
Mergers often fail because organizations struggle to execute the merger
effectively (Friedman, Carmeli, Tishler, & Shimizu, 2016). Lack of support for any
causality to a merger failure is partly due to the considerable number of variables
involved (Angwin, 2012). Hospital leaders require strategies to address those expected
variables.
Causalities contributing to hindrances to hospital mergers include but are not
limited to the failure of leaders to establish an environment that aids in the transfer of
knowledge and capabilities between entities (Gunkel, Rossteutscher, Schlaegel, & Wolff,
2014; Zhang et al., 2015). Hospital merger failures carry extraordinary risk for vendors,
employees, shareholders, business partners, and ancillary community collaborators
(Eaton & Kilby, 2015; Osarenkhoe & Hyder, 2015). Garzella and Fiorentino (2014)
asserted that there is a risk of diminished value that threatens the expected value creation
that was the basis for the merger. The profitability of a hospital can impact the success or
failure of a merger. Maintaining hospital business office productivity or revenue cycle
productivity as the term is also understood, and therefore, hospital profitability requires
the optimal execution of all contributing components of the revenue cycle, including the
scheduling of the patient through to reimbursement of the final invoice for the medical
service (Anderson, 1988; Krantz, 2006; Ladewig & Hecht 1993). Successful hospital
revenue cycle management processes have increased in significance in the current
hospital business office environment due to changing billing obligations and stricter
guidelines; particularly the management of accounts receivables and patient revenues
(Petaschnick, 2018).
Revenue cycle productivity affects all hospital operations and consequently the
achievement of hospital goals (Petaschnick, 2018). Some challenges in managing the
revenue cycle optimally in an era of reform include (a) compliance reforms, (b) payment
reform, (c) reduced payment, (d) expansion of insurance coverage, and (e) quality
improvement (Boyd, 2017). The management of the revenue cycle also influences other
facets of the hospital, such as the systems, structures, and culture among employees
(Petaschnick, 2018). Hospital leaders are the architects of organizational processes and
structures (LaPointe, 2016). Hospital leaders consider a myriad of factors in facilitating
the process of an organization.
Hospital leaders constantly modify and restructure processes that contribute to the
overall operation of the revenue cycle process to maintain or improve revenue cycle
productivity as desired (Naus, Faint, & Dwyer, 2018). Inconsistencies exist across
hospital systems regarding the details of the revenue cycle process and measurements
(Stockamp, 2003). Some hospital leaders still rely on manual processes to complete
revenue cycle tasks while others have enhanced their capabilities with the adoption of
current technologies; each with varying degrees of success (LaPointe, 2017). Hospitals
leaders have competent revenue cycle management if the accounts receivable average
days are in the 50s, 60s, and even 70s (Beaulieu-volk, 2015). However, leaders cannot
assess overall hospital performance based solely on achieving similar accounts receivable
(AR) days (Stockamp, 2003). Barriers to consistency in assessing revenue cycle
performance exist throughout the cycle (Saharia, 2016). Successful restructuring of
business office processes requires constant modification.
BPR
To meet the objectives of this study, I identified and characterized the interrelated
components of the hospital’s revenue cycle and understand the relationships between
those contributors in the application of BPR theory. The BPR model stems from the
principles of redesigning existing business practices, resulting in dramatic improvements
in productivity (Hammer, 1990). Published academic research concerning BPR has been
limited since the mid-1990s. The research that does exist includes BPR cost-benefit
analysis (Richard & Agwor, 2015), BPR success factors (Guimaraes & Paranjape, 2013),
and the implementation of BPR (Ram, Wu, & Tagg, 2014). Dewi, Anindito, and Suryadi
(2015) studied how BPR could positively affect customer service within an organization.
Chen, Yang, and Tai (2016) explored how BPR impacted of the construction industry.
There was also research conducted about how a hospital used BPR to redesign the patent
system (Kuan-Yu & Chunmin, 2013). Hammer and Stanton (1995) demonstrated the
early applications of the BPR model.
Using the BPR model, I assessed hospital leadership’s ability to start from the
foundation and rethink revenue cycle processes in a way that improves and maintains
productivity as well as delivering value to the patients during the transition of the merger
process. Focusing on the context of hospital mergers, I used business process
reengineering theory to understand the interrelation between the contributing components
of a hospital’s revenue cycle in the considerations of hospital leadership in charge of
managing the combination (Gunkel et al., 2014; Zhang et al., 2015). Understanding the
threats to maintaining adequate productivity within the components of the revenue cycle
and the causality of those threats can enable hospital leadership to respond appropriately
(Vasilaki, Tarba, Ahammad, & Glaister, 2016; Zhang et al., 2015). Exploring the
considerations of leadership in the successful strategies employed to maintain hospital
business office productivity during a merger was the topic and BPR theory served as the
framework.
I used BPR theory as a framework to analyze leadership strategies for maintaining
hospital business office productivity in all phases of a merger. The principles of BPR
emphasize the ability to map the processes of a particular organization and assigned
measurable units to the steps in those processes, monitor those units, diagnose issues and
challenges within those processes, suggest improvements, and continuously monitor
performance based on those processes (Hammer, 1990). BPR is a guide for systemic
approaches to understanding the methods of manipulating business office productivity
(Caffrey, Wolfe, & McKevitt, 2016). BPR theory allows researchers to understand the
optimal level of productivity for each component of a complex system such as a
hospital’s revenue cycle with the implication that hospital leaders may be able to target,
strategize, and manipulate productivity in each area of the revenue cycle (Caffrey et al.,
2016). Hammer (1990) used BPR theory as a framework for understanding and radically
redesigning the processes in organizations to improve specific services, speed and
accuracy, and cost reduction.
Brainard and Hunter (2016) observed that the hospital’s revenue cycle is complex
and contains many variables. Hospital leadership should be able to understand the
complexities involved in the revenue cycle and establish some predictabilities for
influential variables (Cutler, Wilker, & Basch, 2012). Having a better understanding of
the strategies that successfully manipulate the revenue cycle’s components can help
hospital leadership develop and implement processes necessary for the maintenance or
improvement of business office productivity (Cutler et al., 2012). Effective methods for
hospital leadership to collaborate between two merging hospitals and establish processes
that meet regulatory guidelines, ensure accuracy, decrease waste, and reduce cost during
the transition time of the hospital merger is beneficial (Cutler et al., 2012).
Hospital leadership amid a merger should endeavor to effectively combine both
the revenue cycle processes with a model that promotes efficiency and cost-effectiveness
in a hospital (Tucker, 2013). The first principle in BPR is to be clear about the objective
(Cleven, Winter, Wortmann, & Mettler, 2014). Hospital leadership should define and
clearly establish the objective of combining two different processes to create a singular
process to the end that goals for time, quality and accuracy, and cost are met (Brueller,
Carmeli, & Drori, 2014; Jo, Park, & Kang, 2016). BPR may provide a framework to
assess decision making amongst hospital leaders as well as whether strengthened
productivity due to the redesigning the functionality of the organization into cross
functional teams was the outcome. Using the BPR model developed by Hammer (1990)
as a guide to conceptualize radical change, I can gauge whether the implementation
encourages hospital leadership to improve revenue cycle business processes for both the
acquirer and the acquired, rethink the challenges of the people and the organization, and
reorganize business office departments responsible for specific contributions into cross
functional teams that are responsible for the entire process, end to end. To this end, the
second principle of BPR necessitates that I gauge the organizational commitment from all
participants responsible for enacting the change (see Cleven, et al., 2014). According to
the BPR, a successful implementation for reengineering the revenue cycle mechanism of
two converging hospitals would require commitment from top management at both
entities (Al-Ali, Singh, Al-Nahyan, & Sohal, 2017). Mature organizational cultures with
set ideals and beliefs can threaten the commitment to a radical change in processes
(Cleven et al., 2014).
The third principle of BPR can aid in evaluating how hospitals leadership
determines the scope of reengineering (Cleven et al., 2014). Using the BPR model as
applied to assessing the merging of two hospital business offices, I focused on eight key
components of the hospital’s revenue cycle to include (a) scheduling and preregistration,
(b) point of service registration counseling/collections, (c) utilization review and case
management, (d) charge capture encoding, (e) claim submission, (f) third-party followup,
(g) remittance processing and rejections/denials, (h) payment posting/cash application,
appeals, and collections. Since it is unrealistic to change the processes in a complex
organization all at once, usually a subset of prioritized processes are targeted for
development to meet a chosen goal (Al-Ali et al., 2017). To understand the scope, the
hospital leadership should assess the current practices and identify any critical hindrances
that require immediate attention (Mohapatra & Choudhury, 2016).
The eight key components were the focus of the study to explore the
considerations of leadership strategies, the challenges to those strategies, the adaptability
of workers to embrace the change in conjunction with the implementation of the
strategies, and the strategies impact on the process productivity. Hospital leaders can
reduce the organizational layers that result from having duplication in revenue cycle
processes as the two entities merge (Hammer, 1990).The fourth principle of the BPR
model shifted the focus to whether hospital leaders assign process owners to be in charge
of each initiative (Cleven, et al., 2014). Ideally, these process owners would possess the
authority and influence to push through changes in the process (Cleven et al., 2014).
Hospital leaders serve competing interests such as the need to reduce cost,
increase customer responsiveness, and increase service quality for patients, while at the
same time maintaining productivity through a merger (Caffrey et al., 2016). The fifth
principle of BPR can be used to determine how hospital leadership identifies and
develops process improvement initiatives (Cleven et al., 2014). BPR best practice is for
leadership to redesign each selected component of the process targeted for modification
(Hammer, 1990). The changes could be system or procedural changes (De Waal, Maritz,
Scheepers, McLoughlin, & Hempel, 2014).
The BPR model can gauge the successful integration of processes, systems,
people, technology, and environments (Mirzoev & Kane, 2017). Technology and
networking infrastructure, including communications and networks would have to be
flexible to adapt to any radical change (De Waal et al., 2014). BPR requires the
consideration of major infrastructure projects regarding any merger productivity
endeavors (Mohapatra & Choudhury, 2016).
Finally, the sixth principle for BPR focuses on the processes that hospital leaders
establish to monitor the new processes implemented (Cleven et al., 2014). Because
complex organizations are continuously evolving, the need to monitor the processes is
continuous. BPR is about changing an organization to adapt to and reflect new business
realities (Hammer, 1990).
Healthcare Business Considerations
While for-profit hospitals can easily be considered as companies, nonprofit
hospitals also run as companies (Boyd et al., 2017). The bottom line for hospital system
mergers is hospitals must guarantee that activities can be sustained (Angwin & Meadows,
2015). Flexibility and adaptation to changing conditions ensure success for merging
hospital systems (White & Wu, 2014).
How to mitigate the effect of lost income is the task for hospital administrators.
Administrators must consider modifications in a manner that does not negatively
influence the quality of care received by patients (Boyd, 2017). Payment systems for
hospitals affect how hospitals function (Cleverley, 1990). The efficiency of hospitals
correlates with enhanced value (Cleven et al., 2014). When hospital finances are managed
well, patients receive better care (Dobrzykowski et al., 2016).
The factors for maintaining productivity during a merger are (a) clarification of
the particular issues to be solved by the Health Information Technology, (b)
consensusbuilding among stakeholders, (c) consideration of different alternatives, (d)
consideration of costs versus advantages, (e) adequate planning, (f) infrastructure
development, (g) adequate personnel training, (h) ongoing progress assessment, (i)
system maintenance, and (j) long-term maintenance of the undertaking (Yen et al., 2017).
Considering Yen's et al. (2017) 10 points, administrators can help with HIT interventions
planning and execution. Clarifying the issues that technology can fix is critical to
effective intervention
(Richard & Agwor, 2015).
Yen et al. (2017) posited the harmful effect on successful processes that an
assumption of advantages can have. It is essential to indicate objectives because it
improves the probability of sharing the same objectives with all those engaged in the
shift. Indicating objectives also decreases waste (citation). Sometimes it may seem like
HIT is the best way to fix an issue. Using specific issue analysis aids with introducing
other methods of fixing an issue (Edmunds et al., 2016). In addition to clarifying issues,
consensus building, is crucial (Lefroy & Yardley, 2015). Issue analysis procedures are
often complicated and having consensus among all parties can depend on effective
execution.
Yen et al. (2017) determined that whatever the scale of the project, leaders should
reach an agreement. Successful consensus building occurs by creating a strategizing
team. The team should represent all those affected by the change and consider all
elements during planning (Yen et al., 2017). Additionally, the other stages include
considering different alternatives and considering expenses versus advantages as critical
to planning the scope of the intervention (Yen et al., 2017). Leaders need time to consider
alternatives and efficiency depends on applying adequate techniques (Yen et al., 2017).
Increased care helps to avoid unnecessary technological modifications due to the
complexity that often accompanies HIT execution (Yen et al., 2017). Consideration of
expenses versus advantages aids with preserving effectiveness. The choice that yields
optimal advantage is the most inexpensive way to satisfy the requirements of the
organization (Yen et al., 2017). Yen et al. (2017) emphasized that other stages included
the significance of adequate planning and growth of infrastructure. Careful consideration
may guarantee that projects, during execution, do not deviate too far from the initial
scope (Larson, 2015). Proper planning should be flexible, but the issues and needs of the
organization considered.
Proper development of infrastructure improves the probability of proper
functioning of the technology (Yen et al., 2017). Improper operation may result in lower
organizational effectiveness (Koppel, 2016). Yen et al. (2017) determined that inadequate
preparation of employees reduces employee satisfaction. Employee dissatisfaction may
result in decreased effectiveness and clinical outcomes for patients. Training managers
must consider the budgeting operations of individual positions as a priority because
training accounts for a large portion of the budget (Holten & Brenner, 2015).
It is important to improve profitability and healthcare systems in the areas of
services provided, served populations, payer mix, staffing, and financial indicators (Dunn
et al., 2018). Performance criteria will be included with important products from other
sources and the profitability enhancement model. Other performance enhancement
models include plan-do-study-act (PDSA), lean ideas, and Six Sigma (LSS; He & Goh,
2015). Rosemann and Brocke (2015) discovered that organizations could obtain market
share and apply understanding and data using Excel and ongoing process improvements.
Process enhancement teams apply LSS instruments and ideas to important procedures in
organizations to enhance economic efficiency (He & Goh, 2015).
Mergers and Acquisitions
In this subsection, I will elaborate on M&As and their qualities. The term mergers
and acquisitions refer to the act of combining two organizations into one organization
(Jewoo & Tianshu, 2014). Vazirani (2015) added to the definition by saying that a merger
is a situation where a business, including all assets, liabilities, and individual personnel
merges with another business. A frequent occurrence in the marketplace is the formation
of new organizations formed through mergers.
Cording, Harrison, Hoskisson, and Johnson (2014) addressed M&As along with
stakeholder theory and worker satisfaction. What influences one stakeholder will affect
other stakeholders within the stakeholder theory. Over and under-promising patients or
staff during the M&A will have adverse effects (Dewi, Anindito, & Suryadi, 2015). Over
and under-promising patients manifests in lower productivity (Cording, Harrison,
Hoskisson, & Johnson, 2014). The reduced productivity will continue to impact
stakeholders. To study the effects of a hospital merger on revenue cycle productivity,
there have been many theoretical choices. I found BPR was the best fit, since BPR
considers all system involved in an M&A so that the new entity can be faster, more
efficient, and run smoother. Employees are experiencing several modifications within a
M&A. How these changes are brought to their attention and perceived to be conducted
during this moment is a close fit for BPR.
Merger History
In the global economy, mergers are a prevalent occurrence. The waves of merger
activity began at the end of the 19th century (Gaughan, 2010; Varizani, 2015). This wave
of mergers occurred during the post-depression financial development (Vazirani, 2015).
However, Vazirani (2015) and Lipton (2006) discovered the first merger wave between
1893 and 1904. The largest recorded mergers on a global scale were reported in 2015
(Thomson Reuters, 2015). With this short history of mergers, in the rest of this section, I
reviewed why mergers occur, the success rate of mergers, and the impacts of mergers on
organizations and personnel. There are three types of mergers:
1) Horizontal Merger: A type of merger between two organizations in the same
industry. The primary aim of horizontal mergers is to increase revenue by
offering an added range of products to an organization’s existing customers
(Oberg, 2008). Horizontal mergers aid organizations by reducing the threat of
competition in the marketplace. For example, Coca-Cola and Pepsi beverage
division would be a fitting example of a horizontal merger.
2) Vertical Merger: Differs from a horizontal merger in that a vertical merger
signifies the merging of two different organizations that produce different
goods and services resulting in a specific finished product. Improving
efficiency or reducing cost is the main goal of this type of merger (Oberg,
2008). An example would be Nike merging with a leather supplier to reduce
costs.
3) Conglomerate Merger: Conglomerate mergers happen when the merging
organizations are participating in completely unrelated industries. There are
two types of conglomerate mergers: mixed and pure. A mixed conglomerate
merger occurs when organizations are pursuing only market or product
extensions (Oberg, 2008). A pure conglomerate merger happens when the two
companies have nothing in common. An example would be if a soft drink
company merges with a leading athletic-footwear company.
The Merger Process
Complex issues often occur during a M&A (Brueller et al., 2014). Often
organization leaders are not adequately prepared to handle the integration of cultures and
procedures (Rogan & Sorenson, 2014). Organizational structure mixes individuals,
procedures, and all business apps and procedures (Alaranta & Mathiassen, 2014).
Successful mergers can have a beneficial impact. Mergers can have a beneficial impact
on participants (Kandzija, Filipovic, & Kandzija, 2014). Hyder and Osarenkhoe (2015)
stated rising employment rates and job prospects for the population surrounding the
merged entity could be included as a beneficial impact.
Reasons for Mergers
Corporate groups have been merging for centuries, but there may be reasons for
each corporation to address the changes that need to be resolved during the merger phase.
Rodrigues (2014) discovered a multitude of reasons mergers could occur, for example,
the importance of markets, technology, or market size decline. Mergers and acquisitions
are one way for organizations to gain market share, boost efficiency, and remain ahead of
contenders (Brueller et al., 2014; Buiter & Harris, 2013; Rogan & Sorenson, 2014). There
are times that mergers and acquisitions help to decrease the number of rivals (Rogan &
Sorenson, 2014). During the merger and acquisition, organizational leaders can pursue
internal or external development while the two entities are combining (Tijani-Eniola,
2016). Internal development takes longer than external development, as leaders use
resources during the effort (Tijani-Eniola, 2016). M&As are one type of internal
development (Tijani-Eniola, 2016).
Why Mergers Fail
Francis, Hasan, Sun, and Waisman (2014) observed that lack of communication,
broken alliances, and absence of data as the major causes of failed mergers. Van Dyke
(2015) spoke about the need for a governing body to be responsible for all economic
problems during a merger and have someone lead the other components of the newly
merged entity in order for the merger to be a success. May and Noether (2014)
determined that the composition of the market has a significant effect on whether the
merging companies will increase market share, price and production. Mergers, however,
can have both beneficial and negative effects on businesses. Employees must alter and
adapt to the newly created joint venture (Al-Ali, Singh, Al-Nahyan, & Sohal, 2017).
Merger Effects on Personnel
Organizations lose an average of one-quarter of the leadership in the first
postmerger year and 60% in the five postmerger years (Krug, Wright, & Kroll, 2014).
Postmerger there is also increased manager turnover (Krug et al., 2014). A few reasons
for this turnover are to minimize resistance, reduce communication issues, and reduce
uncertainty while creating control (Krug et al. 2014). When someone in organizational
leadership considers the M&A to be detrimental to his career or lower his work status, the
likelihood of leaving the organization rises (Krug et al., 2014). During a M&A, leaders
tend to worry about termination, loss of status, and capacity to make decisions as well as
loss of independence (Krug et al., 2014). Higher postmerger management turnover has an
adverse impact on the postmerger productivity and overall performance (Krug et al.,
2014). Cho, Lee, and Kim (2014) clarified that retaining management and employees
with greater tenure is useful in order to improve the performance during the merger.
Higher turnover during a merger will also consume a significant amount of time
and resources (Krug et al., 2014). The chaos of mergers can cause employees on the staff
level to experience a feeling of loss and neglect (Rogan & Sorenson, 2014). They may
get psychologically distressed, leading to inefficiency in carrying out their tasks as well
as higher staff turnover (Rogan & Sorenson, 2014). The relative deprivation results in
lower organizational engagement and lower worker productivity (Cho et al., 2014).
Lower organizational engagement and lower worker productivity is less likely if
employees identify with the merged organization in terms of culture (Cho et al., 2014).
During a M&A, employees have an increased feeling of vulnerability (Diab,
Safan, & Bakeer, 2018). Workers pay extra attention to the provided indications. Face-
toface communication is the most reliable way to communicate about an upcoming
merger as communicators listen to verbal queues, while also seeing visual indications
(Galpin & Whittington, 2010; Mishra, Boynton, & Mishra, 2014). The responses to these
indications may reduce not only employees’ own satisfaction but may also reduce the
treatment quality and productivity with clients and other stakeholders (Cording et al.,
2014). Employees need ample guidance from leaders in moments of transition and seek
advice from management during the process (Nadim, 2015).
Ethical leadership is essential to gain employee trust and maintain engagement
and confidence in the process (Sharif & Scandura, 2014). Another aspect of employee
engagement is the level of commitment and motivation staff member have toward their
work (Bakker, 2014). When staff members feel their job has significance, they
demonstrate vigor and enthusiastically want to be at work (Bakker, 2014). Engaged
workers will focus on commitments and possess a general good attitude toward fellow
employees (Bakker, 2014). There will be less resistance to change with the M&A when
there is a healthy cultural fit post-merger (Bauer & Matzler, 2014). Zuckerman and
Golden (2015) discovered that their greater productivity occurs within organizations
when leaders concentrate on merging not just the organization but merging the
organizational cultures. Changes in corporate culture, which generally happen on the
acquired entity’s side, are most probable to happen during a merger (Sapkota et al.,
2019).
Engaged staff members are more likely to stay faithful, talk about the organization
in a favorable way, and be high performers (Mishra et al. 2014). Front-line managers
have a significant impact on the commitment of employees during a merger. During a
merger, staff is more involved when front-line managers provide a high level of
assistance (Mishra et al., 2014). Management’s open, coherent communication generates
a greater level of staff commitment (Mishra et al., 2014). Internal communication
improves productivity and employee positivity (Korzynski, 2015). Internal
communication also generates confidence in the merger process and increases
commitment among managers and employees (Mishra et al., 2014). Moreover, internal
communication offers the right data for staff to conduct and fulfill their job
responsibilities (Mishra et al., 2014). Internal communication is a crucial component of
establishing relationships between management and employees, especially in a turbulent
or changing work landscape (Karanges et al., 2014).
Sharing information and radical transparency between management and
subordinates gives the employee a sense of belonging and confidence in the process
(Mishra et al., 2014). Centralization, decentralization, chain of control, chain of
command, and specializations are fields where the focus should be on creating a more
committed workforce in the merger process (Nieberding, 2014). For post-merger
inclusion, organizational authenticity is useful (Cording et al., 2014). Leadership during a
M&A should not over or under promise anything as promises only reduce organizational
authenticity (Cording et al., 2014). During the vulnerable process of the merger, the
confidence of staff members can become impaired. Furthermore, mistrust results in lower
productivity, lower job satisfaction, and higher turnover rates (Cording et al., 2014).
Healthcare Mergers
The dramatic increase in M&As for the healthcare industry began around the time
of the implementation of the Affordable Care Act (Lineen, 2014; McCue, Thompson, &
Tae Hyun, 2015). Some of the rise in M&As in healthcare is due to greater norms of
reimbursement and the need for increased productivity (McCue et al., 2015). TijaniEniola
(2016) posited that healthcare M&As in the United States are in the front of the field.
Leaders of healthcare mergers and acquisitions coordinate care, assume danger, and
implement best practices (Tijani-Eniola, 2016).
According to Korbi (2015), the healthcare institution's environmental situation is
the first component deemed to guarantee advantage. This component represents a wide
array of factors of internal processes that may force the healthcare organization to alter
and these variables are beyond the healthcare organization's control (Korbi, 2015). These
variables include technological development that is possibly outdated compared to
present healthcare technology (Korbi, 2015). Another variable is competition that may
relate to healthcare systems losing, competitive advantage, legal and regulatory factors
that may require a healthcare organization to have additional legal and regulatory
demands (Korbi, 2015). There are numerous other social and economic factors (Korbi,
2015).
Ganta and Manukonda (2017) indicated that another key aspect is organizational
harmony. Organization harmony means that procedures, individuals, and different units
within the organization should work together in harmony to achieve the organization's
goals and objectives (Ganta & Manukonda, 2017). People should have clear knowledge
of the mission and vision of the hospital. The hospital system must also shape the
different procedures and plans implemented to achieve set goals and objectives of the
organization (Klar, 2018). The other aspect of change management to consider is the
energy dynamics or power forces at work that are implementing the change within the
organization. O'Connor and Jackson (2017) argued that energy dynamics relates to an
organization's flow of authority and hierarchy.
Leaders responsible for change need to consider which units’ personnel within the
hospital should focus on as a means of impacting the hospitals choices and outcomes
Arabiat, & Shin, 2015). By determining the hospital’s biggest influencers, it is easier for
leaders to determine the personnel and departments that need change (Ganta &
Manukonda, 2017). Leaders must also consider the hospitals’ capabilities and resources
when implementing change (Klar, 2018).
As the hospital leadership implements new processes, the hospital’s leadership
needs to guarantee that it has the economic, human, and other resources necessary to
execute the change process effectively (Heckmann, Steger, & Dowling, 2016). Hospital
leaders to make sure that the staff involved in the modified process have the required
abilities and expertise to bring about the change (Heckmann et al., 2016). Leaders must
also make sure that the hospital has the funds necessary to execute the process of change
(Cameron et al., 2016). Carnall (2018) indicated that the actual method is to implement
the change process with all resources considered.
Effective execution of the change process is a short process when all stakeholders
within the hospital align with the plan for change prior to execution (Klar, 2018). Paying
attention to resource details may ensure that the new processes will be successful. The
nature of implementing a change in a hospital’s process requires the leadership to
consider the rationale or motivation behind the change (Diab, Safan, & Baker, 2018).
After considering economic and human resources, funding, rationale, and motivation,
healthcare organizations effectively and efficiently implement the change process (Klar,
2018). A successful implementation will lead to an improvement in the quality outcomes
of services provided to patients and the patient’s level of care (Manca, 2015).
Revenue Cycle
The healthcare industry is undergoing extreme changes in which reimbursements
are continuously declining (Yaduvanshi & Sharma, 2017). Management policies for
operations need to guide healthcare professionals to address economic survival issues
(Krzakiewicz & Cyfert, 2017). Earnings management within a healthcare organization
includes cost reduction and increased cash flow (Dong, 2016). Receivable management
accounts should incorporate strategic processes to collect payments for patients and
insurance payers and prevent cost reductions or inadequate care.
Representatives of the Healthcare Financial Management Association (HFMA)
defined revenue cycle as the managerial and medical tasks that aid with the collection,
guidance, and involvement of the funds received from patient assistance (Rauscher, S., &
Wheeler, J. (2012). Furthermore, the term includes the entire life of a patient account
from creation to payment. The revenue cycle process starts when a patient schedules an
initial appointment and concludes when all claims and payments resulting from the
appointment and subsequent settlement of services (Cascardo, 2018). The most important
components of the hospital revenue cycle are front-end core responsibilities that occur
during patient contact and back-end responsibilities that occur after the patient is
discharged (LaPointe, 2016). Organization leadership attempting to merge the business
processes of two different organizations must develop and implement policies and
processes with appropriate performance measures intended to standardize and optimize
the collective processes (Angwin & Meadows, 2015).
Although generally focused on medical billing and revenue collection, hospital
leaders have concentrated consideration on the front end of the revenue cycle (LaPointe,
2016). Beginning with scheduling an appointment, and the pursuant registration, revenue
cycle staff registers the patient and gathers demographic, insurance, and clinical
information (Cleverley & Cameron, 2007). The revenue cycle staff also confirms the
eligibility of the patient for the specific services to be provided, which often requires
obtaining a specialist’ referral, precertification, or preauthorization of services (Cleverley
& Cameron, 2007). Staff computes the expected out of pocket expense for the patient in
terms of copayments and deductibles (LaPointe, 2016). Staff will counsel patients on the
financial considerations of their visit and identify patients who have no or inadequate
health insurance coverage (Cascardo, 2018). Staff is then able to assist those patients
meeting eligibility requirements for public health insurance programs, such as Medicaid,
Medicare, or state sponsored children’s health programs (Hempstead, Sung, Gray, &
Richardson, 2015).
Throughout the value stream of a patient visit, providing healthcare services to
patients is the primary business of a hospital and the phase of the hospital revenue cycle
during the generation of revenue (Cascardo, 2018). Once a patient receives services, it is
important to collect all charges for these services and record the information in the
documentation system of the hospital to prevent diminished reimbursement because a
patient receives a service not entered (Cascardo, 2018). In addition, the length of time
from point of service to charge entry is a critical factor in the efficacy of hospital revenue
cycle management as delays in charge entry lead to delays in billing, cash collection, and
a reduction in revenue collection speed (May, 2004). As a final step, the case receives a
diagnosis and a code for the procedure before a preparing a bill (Cleverley & Cameron,
2007). Accurate and comprehensive clinical data provide the opportunity for medical
coders to qualify to receive the optimum level of reimbursement and thus increase patient
revenue (Berger, 2008).
Back-end functions, such as billing and collections are the areas where revenue
cycle management is readily identified (Goldstein, 2015). Up-to-date, well-functioning
billing practices help prepare prompt and accurate bills (Hackbarth & Gamble, 2017). A
crucial task in the billing system is the editing of claims, which helps to find possible
errors in claims before sending to payers, thus ensuring that the hospital minimizes
rework while collecting the correct fee for services provided and shorten the amount of
time from filing claims for actual payment (Cleverley & Cameron, 2007).
If there is a delay in bill payment, follow-ups and denials management can help
the business office increase the amount of patient reimbursement through the claim
recovery process, which involves correcting and resubmitting previously rejected claims
(Eldenburg, Schafer, & Zulauf, 2004). Furthermore, effective management of denials
may help to reduce the remaining time of receivable accounts. The revenue process of the
hospital ends with the collection and posting of the collected monies. Upon collecting and
recording the fee, the patient’s balance will be reconciled by accepting (additional)
benefits, charity care, and bad debt (Cascardo, 2018).
Successful hospital revenue cycle management processes have increased in
significance due to changing billing obligations and stricter guidelines, particularly the
management of accounts receivables and patient revenues (Beaulieu-volk, 2015). The
revenue cycle process requires a more thorough preauthorization and precertification, the
ability to respond to underpayments or variances, and the ability to absorb more frequent
delays in payment (Rauscher & Wheeler, 2008). Customarily, the hospital revenue cycle
management has concentrated on the reduction of average accounts receivable collection
days (Yin, 2017).
Things that must happen in an efficiently functioning hospital business office
American methods of health information management are outdated (Kiel et al.,
2016). The use of paper and the capacity to access data across platforms devalues the
clinical documentation (Meyers, 2016). Doctors have difficulty offering high-quality care
without a central patient data bank (Kiel et al., 2016). Furthermore, the absence of access
to and sharing of data leads to increased healthcare expenses (Saarnio, Suhonen, & Isola,
2016; Skochelak, et al., 2016). The following data need to be accessible in order to
guarantee adequate patient care: a) clinical, b) financial, c) regulatory, d) demographic
(linked to quality and security), e) government health, and f) epidemiological (Meyers,
2016). Sharing this data with all stakeholders will enhance patient results (Kelsey, Karen,
& Hude, 2017). While considering protecting patients, unless changed, certain
regulations will continue to hurt patients. Sharing data on health enhances the quality of
care (Meyers, 2016). It is necessary to consider core elements when implementing change
(Gurganious, 2016). Of the various systems created to handle change in the healthcare
industry, there are multiple factors that can guarantee a hospital optimizes the multiple
advantages of each model (Holten & Brenner, 2015). Optimizing the multiple advantages
of each change model helps facilitate the application of change management.
Productivity
Productivity is a measure of the efficiency of a person, machine, process, or
system, in converting inputs into useful outputs (Ku, Frogner, Steinmetz, & Pittman,
2015). Leaders determine productivity by dividing average output per period by the total
costs incurred or resources (capital, energy, material, personnel) consumed in that
productivity period (Business Dictionary, 2019).
Accounts Receivables
Accounts receivable (AR) are amounts owed by customers for goods and services
purchased on credit (Aghaei-Hashjin et al., 2014). Instead of immediate payment,
customers might have, for example, a 30 or 60-day period to pay the invoice for those
goods or service (Aghaei-Hashjin et al., 2014). Aghaei-Hashjin et al. (2014) posited that
strategic planning for collecting the outstanding debt is the responsibility of the
management team with account knowledge and those within the financial department
who consult on payment collection (Lai & Gelb, 2015). Health care organizations
manage accounts receivables through income cycles governing insurance companies,
billing processes, and reimbursement protocols (Frandsen, Powell, & Rebitzer, 2015).
The need to manage the income cycles emphasizes the significance of receivable
management accounts, which is essential to organizational economic well-being.
The receivable element of any healthcare organisation is essential to profitability
(Shorr, 2015). Talonpoika, Kärri, Pirttilä, & Monto (2016) assert that operational working
capital is critical to profitability. Before payment, health facilities supply services, and the
supplier depends on the patient for payment (Shorr, 2015). The business model for the
reimbursement of services supplied by healthcare organizations is the intention of paying
for the service (Gurganious, 2016).
Receivable management accounts apply policies to guarantee effective and
efficient payment from patients and insurance payers for services rendered (Foerster et
al., 2017). For sustainability and financial independence, the capacity of hospital system
leaders to obtain compensation from patients and insurance payers is crucial (Shorr,
2015). The collection method enlisted by healthcare organizations seeks to maximize the
medical facility’s income cycle management (Shorr, 2015).
It is not a direct process to collect payment for medical services rendered, but it is
for the practice to flourish (Weinstock, 2015). Collection process barriers include bank
billing errors, unpaid insurance payers, or failure to obtain or misinformation from the
correct patient (Shi, Zurada, Guan, & Goyal, 2015). Consequently, poorly incorporated
strategic planning during the implementation process to avoid patient and insurance
nonpayment becomes a problem during the bill collection process (Shi, Zurada, Guan, &
Goyal, 2015).
Monitoring AR guarantees that payment is timely, and the organization’s
outstanding revenues owed decline over time (Beaulieu-volk, 2015). The traditional type
of compensation is the fee-for-service (FSS) model, as insurance companies pay for each
patient service (Mabotuwana, Hall, Thomas, & Wald, 2017), and collecting payment on
time is a sustainable strategy. Furthermore, collecting payments that affects the hospitals
financial future knowledge of where income comes from and service-related costs are
essential elements the financial manager strategic planning (Sheet, 2017). Healthcare
systems recombination of insurance and payment techniques obtain patients and
insurance payers (Loy et al., 2016).
Ultimately, the organizations economic stability policies and financial
management employees incorporate plans to maximize earnings (Dong, 2015). The
analysis of receivable accounts revolves around the amount of days it takes for payers to
obtain reimbursement, which includes patients, insurance payers, and public institutions
(Dong, 2015). The receivable cycle of accounts breaks down by days, weeks, or months
into time increases; and improvement in the management of receivable accounts will
boost effectiveness and revenues (Foerster et al., 2017). In addition, receivable
management policies within operations management will enhance patient and insurance
payment consistency (Shi, Zurada, Guan, & Goyal, 2015). Financial executives analyze
the patient mix and insurer coverages (Johnson & Garvin, 2017). By selecting patients
and kinds of insurance coverages, manager accounts strategize with activities to identify
methods to enhance profitability and sustainability. The economic and operational
advantage of receivable management reports is to narrow the margin between
profitability and the healthcare entity’s costs (Shi et al., 2015).
Since the early 2000s the healthcare industry has been undergoing extreme
changes resulting in reimbursements for services continuously declining (Yaduvanshi &
Sharma, 2017). Management policies for operations need to guide healthcare
professionals to address economic survival issues (Krzakiewicz & Cyfert, 2017).
Earnings management within a healthcare organization includes cost reduction and
increased cash flow (Dong, 2016). Receivable management accounts must incorporate
strategic processes to collect payments for patients and insurance payers to prevent cost
reductions or inadequate care.
Change Management
Changing a scheme implies that a fresh more appealing state of being has evolved
(Walton, 2016). As a means of creating a complex system model strategy in the public
health sector, an employee requires the ability to adopt a wide strategy for designing,
implementing, and evaluating measures needed to alter a system to accomplish
improvements (Rutter et al., 2017). Therrien, Normandin, and Denis (2017) further
assumed that in the hospital environment, healthcare is complex, but it can change with
the implementation of the theory of complexity.
Workers can merge the distinct stakeholder levels in a healthcare system with
crisis preparedness and leadership when the theory of complexity is implemented
(Therrien et al. 2017). Although at the organizational level change can occur, it can also
occur at the individual level. Interventions in the healthcare sector can affect employees
with regulations in job environment requirements and using resources to change
performance enhancement (Gordon et al., 2018). Individual changes are synonymous
with individual interventions in this example. Han and McKelvey (2016) proposed that
complexity theory is one framework for changing organization’s capacity to network,
gain accountability, trust, legitimacy, and governance to attain economic well-being.
Roberts et al. (2016) claimed that complexity theory poses as an intervention when
applied to health care education and learners may discover new methods. Other forms of
learning can occur with role playing in the healthcare sector. Dunn and Riley-Doucet
(2017) assumed healthcare leaders used complexity theory as a lens to examine clinical
educators to create a simulation of role playing to improve the training of care for
terminally ill patients.
Cruz et al. (2017) proposed that a framework of complexity theory applied to
education might contribute to the learning explanation as well as social transformation
change. Changing within a scheme involves moving from a familiar process to an
unfamiliar process. In the hospital industry, to generate a chance for improvement, the
billing manager can adjust from a familiar method to an unfamiliar method (Shoaib &
Kohli, 2017). Change, however, will occur through conversion, which requires individual
education. Complexity theory tenets portend that feedback loops from all stakeholders
constantly change systems from (Kohli, 2017).
Response to a healthcare system shift needs to generate continuous improvements
in a healthcare facility (Jaworzynska, 2017). Larson (2015) posited that a good reaction to
healthcare change projects requires numerous attempts and relies on a complete system
be effective. Lefroy and Yardley (2015) proposed that the use of the concept of
complexity could enhance the reaction to change by raising the result value. However, the
reaction to change suggested by Nasario de Sousa Filipe Duarte (2016) relies on the
perceived situation of feedback and the workplace. The enhanced value can come from
self-criticizing all changes and understanding the social aspect of company assessment
(Lefroy & Yardley, 2015). Ma, Peng, and Sun (2014) argued that the theory of
complexity has a way to quantify how complex a biological system is and the ability to
adapt and operate in an environment that is constantly changing.
There are similarities that need to be compatible with the capacity to alter the
workplace to include inner and external difficulties relative to the healthcare industry.
Organizations can generate inner complexities such as company growth or new
procedures to react to external complexities to guarantee ongoing adaptability (Schneider,
Wickert, & Marti, 2017). Change adaptability is the capacity to constantly scan the
environment for process improvement possibilities. The capacity to adapt involves the
past and present changes reviewed and adjusted, while considering the complexities of
the company and people’s social component. In the end, the reaction to change includes
the billing manager’s capacity to not only adapt to change within but also to adapt to the
evolving Medicare laws that constantly fluctuate the health care climate (Zhang et al.,
2015).
Willingness to Change
Kirrane, Lennon, O’Connor, and Fu (2017) asserted that organizational changes
are affected by the willingness of individuals to accept or reject the changes proposed.
Kirrane et al. (2017) examined the literature and uncovered how willingness only
improves when normative reductive change approaches are in effect and the perception of
the staff is more learning oriented. The readiness to accept change can also function as a
facilitator or an obstacle to the process of change (Allen, 2016). The willingness to accept
change assists staff in achieving change and project goals (Holten & Brenner, 2015).
Employee readiness demonstrates the cognitive and emotional inclination toward the
change plan versus the status quo (Holten & Brenner, 2015). According to Holten and
Brenner, there are four major variables that influence staff willingness to accept changes:
(a) the process engaged in the operation, (b) the context of a worker, (c) the content of the
change, and (d) the character of the individual implementing the change. Hornstein
(2015) established that changes are related to communications, the level of engagement
of staff to the change, and the possibilities to engage in the change, are beneficial
measures for worker willingness regarding their attitudes of resistance.
The connection between willingness and attitudes of resistance require further
inquiry (Bell, 2015). Using information collected from survey answers of 102 staff level
employees engaged in the change process in New Zealand and Australia, Hornstein
(2015), established a connection between the willingness variables such as empowerment
to engage, change-related communications, and employee engagement. Hornstein also
highlighted the effectiveness of participative, employee-centered implementation of
change initiatives in service industries.
Resistance to Change
Resistance to change is a major obstacle to the change process. Furthermore,
resistance to change can stem from the appearance of a neglected opportunity of leaders
to demonstrate appreciation for something in the organization (Cameron et al., 2016).
Cameron et al. (2016) asserted that resistance to change becomes an issue when not
directly addressed and resolved. Cameron et al. (2016) asserted that resistance to change
includes the natural human inclination as a sort of defense mechanism and argue that
resistance should not become a barrier to the change.
Cameron et al. (2016) posited hospital staff often fear the unknown and therefore
resist the change. This is a natural human response to any type of change (Cameron et al.,
2016). Burnes (2015) asserted that opposition is something strategically resolved.
Accepting the resistance to change is a necessary stage in preparing to tackle new ideas.
The acceptance allows hospital leaders to adequately prepare staff and motivate workers
to accept the change (Allen, 2016).
Trust
The amount of confidence that employees have in any organization’s leadership
as well as their executives has a serious impact on the implementation of change in the
execution of the processes (Diab, Safan, & Bakeer, 2018). Hornstein (2015) stressed the
role confidence plays in an organization by studying the connection between
interpersonal and organizational variables that influence the interactions between
leadership and staff. The dynamic impacts the efficiency of an initiative for change.
Using both qualitative and quantitative research, Hornstein established that the
application of change policies could shape high rates of engagement to change in a
favorable way. According to Hornstein (2015), the outcome of a prominent level of
dyadic confidence is the actual desire to change. Leadership displays of confidence play a
substantial role in the successful execution of change processes (Diab et al., 2018).
Implementing Healthcare Change
While hospitals are always under considerable pressure to improve the quality of
services provided, multiple challenges affect the process (Allen, 2016). The challenges
include a shortage of personnel and a shortage of required financial resources to
guarantee a higher quality of services provided (Allen, 2016). There are usually distinct
circumstances that require the implementation of changes in hospitals to align the
availability of resources and to satisfy distinct stakeholder expectations (Bengat, Odenyo,
& Rotich, 2015).
Hospital leadership experience multiple challenges and increased pressure
attempting to improve quality while facing multiple issues, such as personnel shortages
and absence of funds (Agyeman-Duah, Theurer, Munthali, Alide, & Neuhann, 2014).
Factors that may influence changes in healthcare are like those that hinder changes in
other industries (Allen, 2016). For example, Williams, Perillo, and Brown (2015)
highlighted the situation of nursing instructors toward evidence-based practices could
function as a barrier to successful change projects, such as adopting recent information
technology. Williams et al. (2015) asserted that had there been a favorable attitude
regarding the change among the nursing instructors, there would have been a greater
willingness to use such methods. Negative perceptions of the impacts of IT, however,
could influence nurse instructors causing issues based on their concerns about using new
systems (Pineau Stam et al., 2015). In addition, Bengat et al. (2015) examined the
connection between change-related communication, exchanges between executives and
supporters, and the impact of such expectations on change results.
Bengat et al. (2015) conducted structural equation modeling on 395 randomly
selected nurses using a theoretical model based on a predictive and nonexperimental
design and found that a positive expectation could substantially affect commitment to
change. Bengat et al. (2015) further stated that the chance of exchange and
communication between administrators shapes the choices of nurses to adapt to change or
shape the expectations about possible change. Bengat et al. (2015) found that when
considering the commitment to change, the expectations of nurses about changes are
important.
Larson (2015) claimed that when implementing organizational change, change
management in the healthcare industry faces the same difficulties as other industries.
There are many changes in the healthcare industry in the present setting, both from an
operational point of perspective to a level of government strategy (Edmunds et al., 2016;
Houngbo et al., 2017). Implementation of the Affordable Care Act has changed the
healthcare delivery system in the United States in terms of the organization, finances, and
clinical aspects of medical practice (Birk, 2016). Other government regulations have
moved healthcare from a majority fee-for-service based delivery to a value-based
purchasing model (Cassatly & Cassatly, 2015). Another significant modification in the
U.S. healthcare system was the recent upgrade of diagnosis coding from ICD9 to ICD10
in 2015 (Hellman, Lim, Leung, Blount, & You, 2018). Therefore, change is prevalent in
healthcare organizations and stakeholders need to adapt accordingly so that the method of
change management can be efficient and effective (Al-Ali, Singh, Al-Nahyan, & Sohal,
2017).
Successful application of change management includes taking measures to
overcome difficulties as a means of obtaining the required state (Lewin, 1947). Although
hospital leaders have experienced important pressure to enhance the quality of their
facilities, multiple difficulties impacted the activities (Larson, 2015). These difficulties
include a shortage of nurses and the absence of funds needed to guarantee high-quality
service. There are different circumstances that require hospital adjustments to align the
accessible resources with stakeholder expectations (Bengat et al., 2015).
According to Kogan, Conforti, Yamazaki, Iobst, and Holmboe (2017), the change
management process in the healthcare industry guarantees that different stakeholders in
the sector embrace new methods of changing the organizational culture and recognize
multiple advantages, ensuring sustainability. Several healthcare organizations need to
address the greatest challenge in implementing change management, which is the
confusion that individuals feel during moments of change (Cameron et al., 2016).
The presence of uncertainty enables many people to not respond to change
because of a lack of understanding of the change (Kogan, Conforti, Yamazaki, Iobts, &
Holmboe, 2017). One of the methods that healthcare organizations can use to guarantee
effective change is by applying the 4Rs, reason, result, route, and role (Diab et al., 2018).
The first R is the reason the organization is making the shift to staff by the executive.
According to Kirrane, Lennon, O’Connor, and Fu (2017), understanding the
reason for the shift enables staff to gather responses to the issue of why the change is
essential for the organization, while the staff and other stakeholders support ensuring the
change process. By knowing the reason the change is taking place, the staff and other
stakeholders who may influence the change process can tolerate the multiple changes in
the organization's processes and changing culture (Kirrane et al., 2017). According to
Diab et al. (2018), the focus is on the outcomes on hospital management to achieve a
successful change process.
Results are what the healthcare institutions’ activities and procedures will look
like after the change process (Allen, 2016). Management needs to clarify the new
processes produced as a result of the change process, clarify the new technologies
adopted as a result of the change process, and clarify all stakeholders' future expectations
as a result of the change process (Allen, 2016). The results also include an explanation of
the anticipated benefits of implementing the modifications.
Some of the expectations of applying the change process, according to Saarnio et
al. (2016), include saving expenses, saving time to serve patients, enhancing the quality
of services provided to patients, and enhancing the effectiveness of all hospital
procedures. These expected advantages require an appropriate explanation for all
stakeholders that may affect the process of change. Diab et al. (2018) argued that the
route to change is the method or route followed during the change.
The path indicates how to carry out the change process and how the healthcare
system will shift from the present manner of operations to the required manner of
operating in the future when a healthcare organization implements change. The following
steps involve definition along with an explanation of the actions and the duties performed
at each point of the process of change execution. Timelines aid with completing the
activities to determine and discuss with the stakeholders the general timetable of
implementation of the entire change process (Bengat, Odenyo, & Rotich, 2015). Other
implications need defining for the tasks, including the cost of implementing the change
process (Yen et al., 2017).
The function of the change process is the last thing to establish for stakeholders.
The function comprises of what the change process will mean for staff in terms of their
expectations, advantages, or shortcomings after implementation (Yen et al., 2017). The
function delineates fresh laws and circumstances in which staff are required to work due
to the change process being implemented (Yen et al., 2017).
In the event that the change process involves changing employee roles and
responsibilities, the executive must ensure that there is clear communication about the
new roles with employees so that they can understand the expectation during the change
process (Seamons & Canary, 2017). In the event it is clear what the new role of the
different staff and other stakeholders will be after the modification process, executives
must prepare workers to be flexible and positive while supporting the change process
(Diab et al., 2018).
Change Management Models in the Healthcare Industry
Using Lewin's (1947) change theory and Kanter's (2008) empowerment theory
can guide organizations with implementing multiple organizational modifications to
enhance the quality of care. The development of the organizational model for
transformation in healthcare systems was designed to assist healthcare organizations with
enforcing change at all stages of activities to provide a safer and greater quality
atmosphere and patient care level (Kogan et al., 2017). Kogan et al. (2017) determined
the model directed at ensuring that healthcare organizations can ensure an enhanced
patient care environment by redefining the main elements of the activities. Some of the
main parts implemented are the organization's mission, the vision, and the policies.
The mission, the vision, and the policies are helpful with assisting healthcare
organizations with providing the organization's direction and priorities. Another main
section of the organizational model for change in transformation is the organizational
culture, which describes the values held by the health institution and the behavioral
standards of the staff and other stakeholders (Cameron et al., 2016). The procedures and
operational tasks performed within the healthcare organization are further appropriate
elements of the organizational model for change in transformation (Cameron et al., 2016).
These procedures and features assist with identifying how caregivers do the job in
healthcare facilities to provide patients with the required services.
To promote patient activities and service delivery, healthcare organizations need
different types of infrastructure in place to act as the basis for the different activities
taking place. These foundations include IT systems that support multiple institutional
company activities, human resources allocated to different duties to ensure patient service
delivery, financial services, and facilities management that ensure patient care services
are delivered efficiently to patients (Naus, Faint, & Dwyer, 2018).
Four elements identify the main activities of healthcare institutions, a) supporting
procedures, b) instructions, and c) resources (Thompson, 2017). Successful healthcare
process changes require aspects of transformational change (Thompson, 2017). The main
activities include the incentive to transform, which implies an internal pressure exerted
that forces the healthcare organization to undergo changes to identified parts needed to
enhance service delivery (Thompson, 2017).
While the organization's impetus for transformation relates to external pressure for
change, different inner variables may also force change (Fokkema, 2016). Forces such as
the flow of authority or the hierarchy of the organization can impact change
(O’Connor & Jackson, 2017). Change managers can consider which people, and which
units within the organization have the power and influence to lead a change process
(Hwang, Al-Arabiat, & Shin, 2015). The other vital component for organizational change
in healthcare is the quality commitment of leadership (Fokkema, 2016). Healthcare
institution managers should acknowledge that the level of quality is below par and
therefore aid with the change process to enhance the quality of services (Carnall, 2018).
This shift in change includes identifying the required level of quality that the healthcare
organization should attain (Fokkema, 2016).
Fokkema (2016) stated that staff should be engaged in numerous enhancement
projects directed at improving activities within the organization. The execution of
multiple development projects and employee participation aids with guaranteeing a
significant improvement in the organization's general performance and effectiveness
(Stevens et al., 2017). The primary benefit of involving staff in implementing projects is
employee insight can be helpful in ensuring an effective change process (Carnall, 2018).
Another vital aspect for changing execution in healthcare organizations is the
alignment directed at attaining organizational objectives by allocating resources and
implementing multiple activities at all stages of the activities (Kuipers et al., 2014).
Fokkema (2016) indicated that this allocation alignment happens by involving staff and
other important stakeholders in implementing the multiple change measures aimed at
improving activities.
Finally, organizational leaders should guarantee separate limits within the
organization between different individual parts considered in order to improve the quality
of service (Naus et al., 2018).
Factors Affecting Merger Changes
Various factors impact the execution of the change initiative and changing
variables could function as change facilitators and provide favorable support to the
initiative (Lewis, Passmore, & Cantore, 2016). Some of the primary variables include
work style, communication styles, cultural environment, personnel resistant to change,
personnel willingness and flexibility towards change, and personnel’s confidence in the
hospital’s leadership (By, Armenakis & Burnes, 2015; Seamons & Canary, 2017).
One of the primary factors affecting the execution of changes in processes in any
organization, whether medical or otherwise, is effective communication between
leadership and staff and the organization’s culture (Cameron et al., 2016). It is primarily
the personnel that have to change during the change process, not the hospital (Cameron et
al., 2016). The shift in personnel thinking must be effective to achieve the initial
benchmarks that hospital leaders desire (Cameron et al., 2016). Seamons and Canary
(2017) highlighted the critical success factors that are responsible for effective change
management. These factors include ideas of consciousness, desire, understanding,
capacity, and strength.
Seamons and Canary (2017) conducted a literature review and a pilot study to
develop a survey to investigate the efficacy of organizational change with specific
communication factors. Seamons and Canary surveyed the personnel and divided them
into categories that included personnel who ever experienced change, personnel who
have completed a change process, and personnel who have yet to experience a change
process.
Kuster et al. (2015) found that forces such as frequent interaction with staff, the
centralized leadership structure, employee data accessibility, and the character of the
administrator influenced the communication variables and therefore affect the
achievement of the change process initiative. Employee awareness is a tool for initiating
a change in an organization’s processes. The more employees had a clear understanding
of all implications and requirements of the planned process changes, the easier the change
is for leadership to implement (Kuster et al., 2015).
The main objective of the hospital’s leadership is to allow the recognition of
employees for their contributions and to create favorable attitudes toward the change
initiative (Georgalis, Samaratunge, Kimberley, & Lu, 2015). It is significant to have
mutual comprehension between leadership and frontline staff. In addition, leaders have to
delve deeply into all issues of concern for the hospital by ensuring that both the hospital
as well as the staff do not have unmet requirements (Georgalis et al., 2015). Effective
hospital leaders recognize not only the importance of mutual comprehension, but the
leaders also discern findings that diagnose the change scenarios before executing any
change process (Kogan, Conforti, Yamazaki, Lobst, & Holmboe, 2017).
Hospital leadership should provide employee recognition during change by
educating the personnel of the advantages and benefits of the proposed change and
thereby gain acceptance (Cameron et al., 2016; Shin & Konrad, 2017). Achieving the
level of acceptance by the personnel is a vital step toward the successful implementation
of all organizational process changes (Hwang, Al-Arabiat, & Shin, 2015). The business
office of the acquired hospital should institute changes to processes to align the business
office processes of the acquiring hospital (Klar, 2018). In such an undertaking, it is not
enough to have an understanding that a change is coming; staff need to be aware of using
a methodology to effect the change (Van den Heuvel et al., 2013).
Van den Heuvel et al. (2013) observed that when organization personnel receive
data about a change, they immediately begin to adapt because they can actively
participate in the change and establish links of significance to their own lives. According
to Hornstein (2015), it is obvious that changing the business process results in a structural
change. Hospital changes and innovations require modifications at all levels of the
hospital, including personnel, the organization’s culture, the organization structure,
strategy, performance management, actual procedures, and the technology used, all of
which must be communicated properly (Cameron et al., 2016). Whenever change takes
place that is incompatible with personnel’s learning styles, confusion, and stress can lead
to a decrease in the productivity of the worker or department (Smollan, 2015).
Confusion and stress among employees undermine the ability of an organization to
execute new technology or procedural change in a timely or efficient manner (Smollan,
2015). Considering the strategy of how best to lead staff through change is crucial to
achievement. By et al. (2015) asserted that it is essential that leaders consider cultural
preferences and differences when shaping a significant portion of the businesses culture,
processes, and interactions. Cultural preferences and differences are essential to change
management strategies (By et al., 2015).
The governing structure of the hospital guides leadership, communication, and
business office practices. Other aspects include policies and procedures that determine
organizational goals, planning, task, and direction (By et al., 2015). Since the primary
goal of hospital leadership is to improve general efficiency, leadership should consider
these critical factors (By et al., 2015). As Hornstein (2015) asserted, the pitfalls of
opposition to the change from employees who are reluctant to accept change decreases
when considering the important elements during the process.
Smollan (2015) proposed that if there were a fragile connection between the
actual change process and the significant dimension, it would lead to adverse conditions
and stress of the personnel. Smollan (2015) described the stage of conceptualizing, which
helps employees to connect requirements and expectations with the dimensions of the
change in order to remove any barriers or obstacles to the change. The change
management strategy must include all the required resources and well-established,
communicated goals in this stage. During a crucial change process, Smollan (2015)
pointed out several organizational stress indicators that were present. Those stress
indicators include increased absenteeism, turnover, and poorer productivity (Fugate,
Kinicki, & Scheck, 2002).
When making comprehensive changes such as announcing a new task, when
restructuring takes place, the introduction of new authorities, or if there are any changes
in familiar processes, organizations as well as the employees experience an increase in
anxiety (Smollan, 2015). Smollan (2015) asserted the change often creates considerable
stress for employees. The very nature of technological change can lead to staff
uncertainty and job insecurity (Smollan, 2015). Employees often feel insecure and
pressured about becoming outdated in their current roles (Smollan, 2015).
Employee stress is an obstacle that can alter the actual execution of the change
(Heckmann, Steger, & Dowling, 2016). Hospital leaders may find merger success if they
focus on the stress that employees are feeling and are sensitive to worker job security
issues (Heckmann et al., 2016). Hospital leaders should also be empathetic to the
frustration that staff may feel when spending substantial time implementing change
quickly becomes obsolete (Heckmann et al., 2016). Experienced hospital leaders are
prudent when implementing change so that leadership input is included in the process
(Holten & Brenner, 2015; Smollan, 2015). While hospital leadership is not physically
present the entire time during a change implementation, hospital leadership can direct
new authorities through an efficient method of instituting change (Smollan, 2015).
Holten and Brenner (2015) asserted that delegating responsibilities was significant
because certain change management approaches ensure that the entire workforce is
engaged in the process and more readily executing the organization’s changes. These
assertions also intersect with the teleology model in which respondents moved toward
shared organizational objectives (Tabibi, Nasiripour, Kazemzadeh, & Ebrahimi, 2015).
The inclusion of staff throughout the change process, per Holten and Brenner (2015) and
Tabibi et al. (2015) is another important point for the successful execution of the change.
All the individual stakeholders concerned should be engaged in an efficient
change management process (Tabibi et al., 2015). It is also necessary to understand
individual and group dynamics regarding bias that develops because of mistakes in
critical thinking, bad decision making, group thinking, and failures in recognition
(Cameron et al., 2016). In addition, employees’ refusal to accept the change process
creates a resistance to change scenario (Cameron et al., 2016). Consequently, it is critical
that the directives to the employees should be purposeful, direct, and clear from
leadership implementing the process for the change process to be successful (Cameron et
al., 2016). In addition, key unofficial influencers must be included in the change process
to keep resistance to a minimum (Holten & Brennen, 2015; Cameron et al., 2016).
Key influencers include peer executives, senior executives, and departmental
subordinates at the staff level (Cameron et al., 2016). Leadership develops new policies
and processes when it comes to the level of recognition that employees understand.
Managers set the example; therefore, the level of recognition by leadership of the latest
changes could influence subordinates’ acceptance or rejection (Hwang et al., 2015).
Communication about the change process should be clear and concise.
Communication between hospital leadership and staff during the implementation
of the change can be an efficient incentive and instrument of strength (Cameron et al.,
2016). It is crucial to transmit clear and timely messages to staff during the
implementation of the change to generate appropriate dialogue and reduce resistance and
anxiety (Heckmann et al., 2016). Leadership communicates appropriate dialogue to the
staff when stating their own opposition to change and outcomes during obstacles and
challenges to the change implementation (Heckmann et al., 2016).
Transition and Summary
Through the results of this study, the larger manager community may have greater
knowledge of how to contribute to the success of an organizational merger through
improving employee management. Employees who feel their needs are met may continue
to be loyal to their managers and contribute to the success of the merger. Understanding
the resources available to a manager may allow leaders to manage their employees
successfully through a merger. In this chapter I reviewed the history of mergers,
classifications of mergers, and the successes and risks associated with mergers. I then
discussed the effects of mergers on both organizations and the people. To explore
organizations, I reviewed financial impacts, business development, decision making for
management, meeting production and goal achievement, and technology requirements. I
also discussed the effects of mergers on employees related to training and retention,
systems and processes, employee commitment, trust, communication, attitudes and stress,
engagement and motivation, morale and performance and production.
This chapter also addressed how human resources personnel can assist the
managers with soft skills to manage the employees effectively through a merger. A
leader’s style will make a difference in how an employee can relate to their manager,
especially when a merger is taking place. In Section 2, I outlined the research design and
methodology of the research study. Additionally, in Section 2 is information on the
differences in research design, the rational for the chosen research design, and the role of
the researcher. I also review how the selection of the participants, confidentiality of the
study and interviews, how the interviews were conducted, and the method of analysis. I
end the section with a review of the credibility, transferability, dependability and confirm
ability of the study. Ethics procedures are included in the chapter to ensure the protection
of the participants identified and information collected.
Section 2: The Project
The intent of this qualitative single case study was to explore the strategies of
hospital leaders to maintain business office productivity during a merger. This section
includes a restatement of the purpose statement, the role of the researcher, participants,
method and design, population, and sampling. This section also includes information on
ethical research, data collection instruments, data collection technique, organization, and
analysis. The concluding subsections include reliability and validity of the study and a
proposal summary.
Purpose Statement
The purpose of this qualitative single case study was to explore the strategies of
hospital leadership to maintain productivity during the merger process. The target
population consisted of leadership in a midsized hospital in the southeastern United
States, particularly those connected with hospital business office operations because
business office productivity could decrease during a merger. In addition, direct reporting
vital hospital staff that are responsible for executing the decisions made by the hospital
leadership. The implications for social change include the potential to identify proven
strategies for successful mergers that maintained productivity of a midsized hospital.
Established merger strategies can lower the risk of hospital closures (citation), thereby
ensuring the affected community has proximate access to healthcare.
Role of the Researcher
The role of the researcher was to function as the primary instrument for the data
collection and analyses processes to maintain strict adherence to ethical guidelines
(Morse, 2015). I, as the researcher, developed the interview protocol, conduct interviews,
collects, organizes, analyzes, and interprets the data (see Arriaza, Nedjat-Haiem, Lee, &
Martin, 2015; Cleary, Horsfall, & Hayter, 2014; Hlady-Rispal & Jouison-Laffitte, 2014).
Moreover, I did strive to understand, assess, and determine the value of the participants’
responses (see Bashir, Sirlin, & Reeder, 2014).
For the purposes of this research, I engaged in all aspects of the study, including
data collection, organization, analysis, and interpretation. Berger (2015) posited that a
comprehensive investigation is achieved when a researcher is involved in all facets of the
research. Cleary et al. (2014) contended that the accuracy of collected information must
be assured. Data collection includes gathering information across various sources such as
personal observations and interviews (Cleary et al., 2014). My role was to interview the
participants, organize, and analyze the responses. Throughout this process, I maintained
the privacy of the participants. The member-checking process requires interview
respondents to review and correct the researcher’s interpretation of interview responses to
ensure accuracy (Fusch & Ness, 2015; Noble & Smith, 2015; Yin, 2016). I employed
member checking to ensure an accurate interpretation of participant responses.
The Belmont Report contains fundamental ethical principles a researcher should
abide by when researching human subjects and includes safeguarding the respect of
vulnerable populations, avoiding deceptiveness, and providing uniform handling for all
participants (U.S. Department of Health and Human Services, 1979). To adhere to the
Belmont Report protocol, researchers should abide by ethical standards and guidelines for
the protection of research participants (Honig, Campel, Siegel, & Drnevich, 2014; Zhou
& Nunes, 2013). I adhered to the ethical principles set forth in the Belmont Report and
applied the ethics training I obtained from the National Institutes of Health (NIH) (see
Appendix A).
Researchers should reduce, and if possible, eliminate bias. Bias occurs when a
researcher interprets interview notes through a lens based on preconceived experiences
(Bashir et al., 2014; Malone, Nicholl, & Tracey, 2014). Researchers should demonstrate
active listening, eschew casting judgment, and remain vested in the responses of each
participant (Bashir et al., 2014). I avoided preconceived views from past experiences and
remained vested in the participant’s responses.
My medical industry experience includes 11 years in hospital revenue cycle
management. These duties involved all aspects of the revenue cycle from patient
registration through reimbursement. I avoided bias due to my history within a hospital’s
revenue cycle by maintaining objectivity. I enrolled participants from outside of my
immediate department or sphere of influence to ensure research objectivity (Alimo,
2015). In order to accurately and correctly interpret the information, qualitative
researchers must strive to study the data with limited bias and maintain a neutral and
impartial stance regarding the subject matter (France et al., 2015; Yazdani et al., 2018;
Yin, 2017). I used an interview protocol to uphold consistent and accurate processes
while rejecting bias throughout the research process
To mitigate researcher bias, I did not conduct this study using known participants.
By not using known participants in this study, I avoided involuntarily injecting
considerations based on knowledge that could originate from an established relationship.
I avoided representing my personal beliefs and opinions from experiences of working in
the healthcare industry and use a well-structured interview protocol (see Appendix B) for
maintaining consistency and accuracy while collecting data using interviews. I instituted
a structured interview instrument and enhance the quality of the research study by
aligning interview protocols in accordance with the study, as recommended by Garvare
and Nystrom (2017).
An interview protocol was useful for ensuring impartiality, uniformity, and the
quality of probing interviews and was a useful tool to ensure the quality of research
results (Kono, Izumi, Kanaya, Tsumura, & Rubenstein, 2014; Platt & Skowron, 2013).
Using an interview protocol also allows a researcher to explore unforeseen instinctive
responses that participants may provide (Venkatesh, Brown, & Sullivan, 2016). To ensure
meaning, interview questions should have an open-ended format to allow for maximum
latitude in the response (Venkatesh et al., 2016). The interview structure and open-ended
questions creates an environment for a better flow of communication (Anderson, 2017).
According to Yin (2014), an interview protocol was important to ensure the data
addresses the actual research question. To ensure high quality of research results, I used
an interview protocol (see Appendix B) to conduct the interviews in proper order and
keep the participants’ information confidential.
Participants
The participants for this study consisted of seven hospital leaders (e.g.,
executives, senior managers) of two midsized urban hospitals in the southeastern United
States with experience strategizing approaches to maintain business office productivity
during a merger. The eligibility requirements of participants in this study stemmed from
the following criteria: hospital executives and revenue cycle leaders currently involved in
a hospital merger with decision-making authority for business office processes in the
southeastern United States.
To address the research questions, participants have knowledge and experience
with the research phenomenon (Palinkas et al., 2015; Yin, 2017). Participants are
commonly more inclined to participate when they have experience and knowledge of the
phenomena (Marshall & Rossman, 2015; Pierre-Etienne & Verret Hamelin, 2017).
A working relationship between a researcher and study participants was essential
to the success of the study (Hansson & Polk, 2018; Postma, & Roos, 2016; Yin, 2017). A
working relationship with participants began with an initial email sent, and a follow up
phone call to schedule the interview. Each participant signed a consent form. There was
no compensation for participation.
I used purposive sampling, which was a nonprobabilistic sampling procedure, to
fit the purpose of my study and the criteria that participants be leaders in a midsize
hospital in a southeastern U.S. metropolitan area who were able to maintain business
office productivity during a merger. More specifically, I used the nonprobability method
know as expert sampling (Patton, 1999). This form of purposive sampling seeks the input
of experts in a field to provide data where there is currently a lack of observational
evidence (Patton, 1999). Patton (1999) asserted that convenience sampling is another
nonrandom nonprobability method of sampling but it is less reliable and has the
propensity to be biased. Convenience sampling is used to collect data form participants
who are easily accessible but may not represent the population or be the most informed to
speak about the phenomenon being studied (Patton, 2015). For this reason, I did not
choose convenience sampling. The purposive sampling method was the best technique
for gathering participants needed to collect lived experience data about the research topic
(Palinkas et al., 2015; Yin, 2017). Other types of purposive sampling were not
appropriate for this study. Other types of purposive sampling include homogeneous,
typical case, extreme deviant case, critical case, and maximum variation sampling
(Patton, 1999). Researchers use purposive sampling to include or exclude study
participants (Emmel, 2015; Palinkas et al., 2015; Patton, 2015). According to Zhu et al
(2015), purposive sampling is selective, subjective, and judgmental. Qualitative
researchers use purposive sampling to select participants based on who can answer the
research question most effectively (Benoot et al., 2016).
Researchers should adhere to a protocol requiring study participants to sign
informed consent documents to participate in the study (Broom, Broom, Kirby, & Post,
2018; Chapple & Ziebland, 2018; Levitt et al., 2018). The Walden University
Institutional Review Board (IRB) uses the Belmont Report as a guide in deliberations to
ensure researchers conduct ethical research (see Postma & Roos, 2016). After receiving
approval from the Walden University IRB, I sent study participants a consent form via
email attachment. Walden University’s IRB approval number for this study is 06-03-
200456992 and it expires on June 2, 2021. I ensured research participants signed and
returned consent forms via email before they are enrolled in the study.
I ensured anonymity and confidentiality by using alphanumeric indicators P1
through P7 correspondingly for participant names. Allen and Wiles (2015) asserted that
pseudonyms can aid in organizing study participants and entities during research
examinations. I secured all data collected in a document strong box and on a
passwordprotected computer and will retain it for a minimum of 5-years.
Research Method and Design
Successful completion of a research project depends on selecting the correct
research method and design (Yin, 2017). The three types of research methods are
quantitative, qualitative, and mixed methods. The method for this study was qualitative.
The chosen design for this study was a single case study.
Research Method
The researcher selects the research method centered on the problem statement and
the prospective impact of study results to organizational practices (Kozleski, 2017). I
used a qualitative research method because I sought an in-depth understanding or
explanation of participant’s lived experiences within a context (see Vass, Rigby, &
Payne, 2017). Researchers employ the qualitative method to interpret the significance of
participants’ experiences based on collaboration and personal experience (Patton, Hong,
Patel, & Kral, 2017; Rich, 2017). It is essential that the researcher be involved with the
data when conducting qualitative research. The different patterns or emergent themes
detected in the data depend strongly on the integration of varying perspectives (Fugard &
Potts, 2015; Patton et al., 2017). Researchers can use software such as Atlas.ti 8th edition
to assist with interpreting findings from study interviews (Engle, 2015; Kozleski, 2017).
A qualitative method was an appropriate method for exploring the lived experiences and
unique perspectives of study participants (Yin, 2017). Therefore, I used the qualitative
method to explore leadership considerations for maintaining hospital business office
productivity during a merger. Add summary/synthesis throughout the paragraph to better
connect to your study.
Researchers who use the quantitative research method will conduct statistical tests
to quantify a problem (Counsell & Harlow, 2017). Quantitative research is different from
the qualitative method in that quantitative researchers test and confirm theories, while
qualitative research is exploratory and involves theory building (Dasgupta, 2015).
Quantitative research involves testing hypotheses regarding relationships between
variable (Counsell & Harlow, 2017). Researchers used closed questions and test
hypothesis when conducting a quantitative study (Yin, 2017). Researchers using the
quantitative method can describe and measure participants’ actions; however, they cannot
describe the participants’ lived experiences (Rich, 2017). Quantitative research was not
an appropriate fit for this study since the emphasis of the study was to understand
participants’ lived experiences and explore themes, and not test hypotheses.
Researchers employ mixed methods research whenever they use more than one research
method or whenever they need more time than may be available for a single doctoral
study (citation). Mixed methods researchers use both quantitative and qualitative methods
to examine more than one context or condition of behavior (Brown, SticklandMunro,
Kobryn, & Moore, 2017: Patton et al., 2017). Researchers can use the mixed methods
approach to collect, analyze, and combine quantitative and qualitative data in a single
study (Kachouie & Sedighadeli, 2015; Yin, 2016; Sanchez-Gomez, Pinto-Llorente, &
Garcia-Penalyo, 2017). I did not use any quantitative analysis because the qualitative
method was sufficient to answer the study questions.
Researchers who conduct mixed methods research use a quantitative method to
test a hypothesis. The merits of a researcher employing both quantitative tools and
qualitative tools my yield a richer description of a phenomenon (Counsell & Harlow,
2017). A mixed methods study can present challenges to data validity because of a blend
of both quantitative and qualitative data. (Brown et al., 2017). Mixed methods research
involves measuring the relationships that exist between variables (Sparkes, 2014). A
mixed methods approach was not suitable for this study because the emphasis of this
study was not testing a hypothesis. The emphasis of this study was to explore strategies
and themes. Considering he differences among these three approaches, the most
appropriate method for exploring leadership strategies to maintain hospital business
office productivity during a merger was the qualitative method.
Research Design
If the researcher selects an inappropriate research design then the data collected
during the study may not address the research phenomenon (Yin, 2017). When
conducting a qualitative study, researchers have different research designs to choose from
such as narrative, ethnography, case study, and phenomenology (Levitt, Motulsky, Wertz,
Morrow, & Ponterotto, 2017). Researchers can use a variety of research designs to
collect, organize, and analyze data in different ways.
For an in-depth study that focuses on a circumstance at a set point in time, a
researcher may select the case study research design. The case study research design
allows a researcher to narrow the scope of an expansive research field into one
researchable area and focus on a circumstance, occurrence, or practice at a given point in
time with the intent to capture distinctive perspectives of human experience and behavior
from a social perspective or natural worldview (Yin, 2017). Case study design engages
in-depth topic investigation and analysis to promote the possibility of further research
(Dasgupta, 2015). I selected the single case study research design because this approach
allows the narrowing down of the scope of an expansive research field into one
researchable topic to capture distinctive perspectives of human experience and behavior
with in-depth study.
Researchers should select a research design that effectively addresses the research
question and purpose of the study. Rahi (2017) posited a case study design is the
preferred model whenever the researcher has little to no control over the events studied.
Dasgupta (2015) maintained it is necessary to use the design that is fitting for their
research questions and employ the case study design to answer questions of how or why a
phenomenon occurs (Dumez, 2015; Tetnowski, 2015; Yin, 2017). I used a single case
study design to explore leadership considerations for maintaining hospital business office
productivity during a merger.
Carolan, Forbat, and Smith (2016) contended that using the case study design to
gather data from numerous sources can aid in strengthening the integrity of the research
results. Data collection from multiple sources is a distinctive feature of case study design.
Triangulation means that the researcher is using more than one method to collect data
during a study (Leila, Sangeetha, Jepson, & Donovan, 2019). Data triangulation improves
the integrity and validity of a case study by improving the reliability of the case study
findings through the convergence of information from different sources (Yin, 2017).
Researchers use triangulate evidence derived from observations, interviews, and
reviewing historic documentation to strengthen a case study when examining real-time
events at a set point in time (Creamer & Tendhar, 2016: Yin, 2017). The benefit of
employing multiple sources of evidence is the ability to develop converging lines of
inquiry (Patton, 1999). I collected data using numerous sources to include relevant
hospital business office documents, participant’s verbal and nonverbal responses, and
participant interviews.
When determining the design for this research study, I considered ethnography,
which involves studying people in their cultural context and the ways that culture
influences their behavior as individuals or as a group (see Draper, 2015). Armstrong
(2015) asserted the use of ethnography design can aid in examining the way social
behavior in diverse ethnic groups may differ if observed over a period. Furthermore, Yin
(2017) contended that the use of the ethnographic design can cultivate a single narrative
that pertains to the entire population. The focus was on the strategies used by leadership
to maintain hospital business office productivity during a merger process and not
cultures; and therefore, ethnography was not appropriate for this research.
In addition, I contemplated a phenomenological design. Researchers who use the
phenomenological design use discussions of experiences in a real-life context (Chan &
Walker, 2015). Phenomenological design aids with studying conscious experiences
(Spaulding, 2015). As the emphasis of my study was not on the personal meanings of
individual’s experiencing a phenomenon, but rather on exploring perspectives and
approaches that hospital leaders use to maintain business office productivity during a
merger, the phenomenological design was not suitable in my study.
Raeburn, Schmied, Hungerford, and Cleary (2015) posited that the narrative
design can be used to research a collection of participant’s stories and record the
interpretation of the participant’s experiences. Raeburn et al. (2015) contended that when
using a narrative research design, one communicates facets of a research participant’s life
story. The narrative design was not a fit for this study because capturing each
participant’s detailed life experience stories will not address the research question.
Smith (2015) asserted the use of grounded theory research design is to develop a
theory. Researchers attempt to develop a theory based on a general abstract theory
grounded in the perspectives of the participants (Rohde, Brodner, Stevens, Betz, & Wulf,
2014; Smith, 2015). For that reason, grounded theory research in not applicable because
this research was not about establishing a new theory, and I am using a conceptual
framework. Add a solid conclusion for the section.
Population and Sampling
The population for this study consisted of seven participants who are hospital
leaders (e.g., executives, senior managers) of two midsized urban hospitals in the
southeastern United States who have experience strategizing approaches to maintain
business office productivity during a merger. A researcher’s desired analytic level is a
determinant of the optimal target number of participants in a study (Apostolopoulos &
Liargovas, 2016; Tran, Porcher, Falissard, & Ravaud, 2016). A population of
management-level persons was appropriate for my research because executives, directors,
and managers have a thorough and immediate understanding of business officer merger
challenges (Emmel, 2015; Fugard & Potts, 2015). Population criteria are valuable to
ensure that selected participants have experienced the phenomenon that is the focus of the
research firsthand and can address the research questions (Rahi, 2017). The population
supports the central research question because the selected participants for this research
have experience and comprehensive knowledge strategizing approaches to maintain
business office productivity during a hospital merger.
Emmel (2015) contended that employing a sampling method can aid in ensuring
the appropriate selection of participants. The objective is to select participants who have
knowledge and experience about the research topic (Emmel, 2015; Fugard & Potts, 2015;
Rahi, 2017). Qualitative researchers use purposive sampling to explore and secure the
objectives of a research problem and allow transferability of research findings (Marshall
& Rossman, 2015; Yin, 2017). I used purposive sampling to select the study participants.
I selected hospital leaders (e.g., executives, directors, senior managers) who qualify in
two categories: (a) those who have experience developing strategies for maintaining
business office productivity during a merger that were willing to share their experiences
and (b) those who have experience devising business office procedural strategies.
Sample size indicates the number of participants a researcher will observe for the
study (Marshall, Cardon, Poddar, & Fontenot, 2013). A decision about sample size is
critical for ensuring the integrity of the study, the gravity of the data, and the adequacy of
the data to address the research topic (Roy, Zvonkovic, Goldberg, Sharp, & LaRossa,
2015). A small sample size is acceptable for qualitative studies (Palikas et al., 2015) and
for purposive sampling (Yin, 2017). Use of a small sample size can be warranted for a
researcher to realize quality and to gain a full understanding of a study phenomenon
(Marshall & Rossman, 2016). Qualitative researchers can accomplish data saturation
using a sample size in a range of five to fifty participants (Emmel, 2015). I selected at
least seven hospital leaders who meet the requisite experience and knowledge among the
total conceivable population of this single case study.
Fusch and Ness (2015) contended that data saturation is achieved when one can
no longer uncover new information or new themes, and there is commonality in
responses from participants (Fusch & Ness, 2015). Morse (2015) posited that achieving
data saturation can aid in strengthening the integrity of qualitative research. Marshall et
al. (2015) posited that the composition of sample size, rather than the size of the sample,
facilitates data saturation. Saturation is the point in the interview process where the
researcher ceases to identify new themes (Morse, 2015). Data saturation occurs when no
new themes, concepts, or findings are evident during the data analysis process (Roy et al.,
2015). I gathered data by interviewing seven or more participants and reviewing relevant
organization documents. The interviews continued until there was no new information
obtained and therefore ensure data saturation.
Qualitative researchers may justify their understanding of the data collected from
interview responses with participants (Palinkas et al., 2015). Qualified participants can
offer data substantial enough to achieve saturation and to address the requisites of the
study (Palinkas et al., 2015). Member-checking is beneficial for achieving data saturation
(Fusch & Ness, 2015). Data saturation happens when interview responses begin to be
replicated (Elsawah, Guillaume, Filatova, Rook, & Jakeman, 2015). Member-checking is
a process by which a researcher follows up with participants to confirm the researcher’s
interpretations of the participants original responses in order to strengthen the validity
and reliability of the study (Noble & Smith, 2015). Consequently, I used
memberchecking to validate the interpretation of interview responses to ensure no new
themes.
Qualitative researchers use interviews to gather data from qualified participants
with varying perspectives of the phenomenon being studied (Yin, 2017). I allocated 45
minutes to one hour for facilitating interviews giving reverence to the accessibility of the
participants. Researchers use consent forms to safeguard confidentiality and assure
participants’ rights during the data collection process (Koonrungsesomboon, Laothavorn,
& Karbwang, 2015). Participants in this study signed and returned the consent form
found in Appendix C. I gathered data from interviews and relevant organization
documents that included the hospital’s website, the 5 year plan, and the master plan of the
respective operating unit.
Ethical Research
The informed consent process requires explaining to all participants (a) the
rationale of the research study, (b) how the research study might be useful to their
organization, (c) the process for conducting the study, and (d) the voluntary nature of the
planned study (Honig et al., 2014). I gave the potential participants verbal and written
information about the purpose and proposed advancement of the research. At that time, I
gave potential participants the opportunity to pose clarifying questions or raise any
concerns prior to giving their permission.
Obtaining the participant’s consent was necessary to be compliant with
informedconsent protocols (Bromley, Mikesell, Jones, & Khodyakov, 2015; Honig et al.,
2014). Participants should understand that they can withdraw at any time with no risk of
penalty regarding their participation (Honig et al., 2014). I notified study participants of
their ability to withdraw their participation at any time. Making direct contact should be
done to inform participants of any compensation methods that are applicable to the study
(Bromley et al., 2015). There was no compensation for participating in this research.
It was vital that the ethical protection of participants be ensured as ethical
challenges are encountered at all stages of research, (Honig et al., 2014). Ethical
challenges that some researchers face during a study include confidentiality, anonymity,
designing and reporting, and informed consent as well as the researcher’s potential bias
toward the participants (Bromley et al., 2015; Honig et al., 2014). The three primary areas
of ethical concern in a research study where human subjects are involved include (a)
justice, (b) autonomy, and (c) beneficence (U.S. Department of Health and Human
Services, 1979). Giving ethical protection to participants can be achieved by employing
three primary ethics principles stated in the Belmont Report (a) justice, which contains
conceivable benefits for research participants, (b) autonomy, which establishes the
participant’s right to participate or not participate in the study, and (c) beneficence,
efforts to minimize risk of harm to participants (Honig, et al., 2014; Zhou & Nunes,
2013). I observed Belmont Report principles to ensure the ethical protection of study
participants. Bias is a significant risk that can distort study results or outcomes (Whiting
et al., 2016). Making a conscious effort can aid in eschew biasing the participants
(Gittelman et al., 2015). Excluding individual beliefs and opinions based on experience
could aid in mitigating bias (Yin, 2017). I excluded my personal beliefs and opinions
acquired from working in a hospital business office and evaluated the interview questions
with a neutral third party that does not have a stake in the research study to ensure no
bias.
It was necessary to consider ethical issues when conducting interviews (Gelling,
2016). Privacy and rights of participants should be protected while gathering data, storing
data, and analyzing data (Levitt et al., 2017). At times, participants share concerns
regarding confidentiality during the data collection process (Bromley et al., 2015;
Marshall & Rossman, 2016). Consequently, I stored all electronic data on a
passwordprotected computer and a strong box for a minimum of 5-years to ensure the
confidentiality of study participants. Using electronic and digital formats can aid in
preserving the security of research data (Alimo, 2015; Trace & Karadkar, 2017).
During the research process, I converted paper documents to a digital format via
scanner as well as store the digital files on a secure external hard drive and shred all paper
documents to protect the confidentiality of study participants. Research projects with
inadequate quality research designs, weak data analysis, and deficient reporting of the
research findings lack ethical backing (Brzezinski, 2016). The Belmont Report was a
standard for IRB deliberations to ensure researchers conduct ethical research (Honig et
al., 2014). I conducted this study after requesting and receiving IRB approval from
Walden University.
Confidentially preserving the identities of study participants can aid in sustaining
anonymity and safeguard the integrity of research (Marshall & Rossman, 2016). Using
pseudonyms to distinguish participants and organizations during research helps to
maintain privacy, confidence, trust, and anonymity (Zhou & Nunes, 2013). Using
alphanumeric categorizations such as P1 and P7 to signify the participants,
correspondingly, and BUS1 or BUS2 to reference the hospitals correspondingly, should
aid with anonymity and confidentially during the research process of this single case
study design.
Data Collection
I was the primary data collection instrument in this research study. The researcher
is the primary data collection instrument in qualitative research (Noble & Smith, 2015)
because the researcher is directly involved with the research participants by observing the
responses and interpreting the data (Marshall & Rossman, 2016; Yin, 2017). Interviews
are effective to gather data for study participants with differing perspectives on similar
topics (Marshall & Rossman, 2016; Yin, 2017).
A data gathering tool in this research was interviews consisting of asking the same
set of open-ended questions to each study participant as recommended by Wilson et al.,
(2016). Interviews allow the effective collection of data from participants with differing
perspectives on a similar subject (Wilson et al., 2016). Participants typically give detailed
explanations when answering open-ended questions (Kornbluh, 2015; Yin, 2017). I asked
open-ended questions (see Appendix D) while conducting the interviews to explore
leadership strategies for maintaining hospital business office productivity during a
merger.
The interview protocol for this study consists of identifying study participants,
establishing the length of the interview, and concentrating on the participants’ experience
(Castillo-Montoya, 2016). Due to the COVID-19 pandemic, I did not use face-to-face
interviews since this type of research was not considered an essential activity. Instead, I
ethically employed video conferencing and phone interviews.
The participants e-mailed a signed copy of the informed consent form confirming
their informed consent to participate as an unpaid volunteer. The interview protocol
assisted in collecting data for this study and included (a) a reminder to give the
participants a consent form if they volunteer to participate, (b) a script of what I said
before the interview, (c) a list of interview questions, (d) a script of what I said at the end
of the interview, and (e) a reminder to ask the participants if they would like any
information pertaining to the interview as recommended by Jacob and Furgerson (2012).
The final step of the interview process was data analysis, which involves identifying the
themes and codes related to the transcripts from the interview (Castillo-Montoya, 2016).
Using documents can be a tool for collecting data (Marshall & Rossman, 2016;
Smith, 2016). In addition, conducting a single case study using organization
documentation can provide evidentiary support to the interviews (Kornbluh, 2015; Yin,
2017). I used organization documents such as monthly accounts receivable reports and
five year strategic plan documentation as additional data collection instruments. Archival
documents offer historical information and can strengthen the value of a case study (El
Haddad, 2015). Gathering data from varied sources can aid in achieving triangulation
(Baskarada, 2014; Santiago-Delfosse, Gavin, Bruchez, Rous, & Stephen, 2016). Using
triangulation while interpreting research data diminishes the threat to validity (Marshall
& Rossman, 2015; Noble & Smith, 2015; Yin, 2017). I accomplished triangulation by
using data triangulation.
The combination of member-checking and triangulation increases the reliability
and validity of a case study (Baskarada, 2014; Santiago et al., 2016; Yin, 2017).
Additionally, data saturation has been achieved when themes become recurrent or have
excessive similarity (Kornbluh, 2015; Yin, 2017). I gave study participants a chance to
review and modify responses at the conclusion of each interview. Member-checking
consists of follow-up discussions that benefit researchers by strengthening the reliability
and validity of the study (Noble & Smith, 2015; Yin, 2017). To ensure reliability and
validity in the data collection phase, I asked open-ended questions (see Appendix: B) and
use member-checking, triangulation, and I monitor themes for data saturation.
Data Collection Technique
After obtaining IRB approval from Walden University, I initiated the process of
confirming study participants. Due to the COVID-19 pandemic in 2020 data collection
techniques were modified. Interviews were conducted virtually via video conference and
phone interview platforms that provide video and audio output, as well as recording
functionality and/or transcript generation. These virtual meeting platforms are secure, and
I can digitally record each session. I conducted video conference or phone interviews
with the participants at a time and location where confidentiality can be protected. The
data collection process involved making initial contact with the study participants by both
phone and email, planning and conducting the video conference or phone interviews, and
recording and documenting exhaustive notes throughout the interview process. These
steps are in accordance with suggestions made by Gergen, Josselson, and Freeman
(2015). After the consent forms were signed, I conducted virtual interviews. Participants
chose a designated location where they were assured privacy and confidentiality was
protected.
Methodological triangulation merges various types of data collection (Ruiz,
Martinez, & Bravo, 2016). Qualitative research involves an assortment of data collection
methods such as face-to-face discussions, reviews of archived and current documentation,
questionnaires, observation, and focus groups (Pasila, Elo, & Kääriäinen, 2017). Using
the within-method can assist in achieving triangulation by exercising at least two data
collection methods and the same design (Hussein, 2015). I used methodological
triangulation to include multiple methods of data collection.
Detailed data collection in a qualitative study includes various research tactics
such as survey, document and artifact review, observation, and interviews (Gergen et al.,
2015). There are many ways of conducting investigational research when using the
qualitative method, but the common types are observations, review of documents, and
interviews (Marshall & Rossman, 2016; Yin, 2017). One of the popular forms of data
collection for reaching data saturation for qualitative research was interviewing (Cairney
& St Denny, 2015; Fusch & Ness, 2015). Using interviews was a primary method of data
collection during a qualitative study (Marshall & Rossman, 2015). Face-to-face
interviews are the favored qualitative data collection method (Kornbluh, 2015).
Consequently, I used face-to-face or virtual interviews to explore leaderships’ strategies
for maintaining hospital business office productivity during a merger.
With the respondent’s permission, I conducted interviews virtually via video
conference or phone interview that provide video and audio output. These virtual meeting
platforms are secure, and I can digitally record each session. I used the recorded content
of those interviews to enable automated cataloging and analysis (Fredrick, 2015; Patton,
2015). Digital recording and documenting respondent’s body language are effectual
methods for qualitative data collection (Rosenblum & Hughes, 2017). These virtual
platforms can generate transcripts of each session. Transcribing was comprised of
interpersonal (the relationship between researcher and participants), experiential (action
or event), and interpreting text data (transcribed data) components (Yin, 2017).
Some of the benefits of qualitative researchers using interviews include (a)
obtaining in-depth responses from participants, (b) obtaining exhaustive data about the
study participant, (c) asking questions in detail (Yin, 2017). Some disadvantages to using
interviews could be (a) answers may not accurately reflect the participant’s genuine
perspectives or opinions and (b) respondents may sense discomfort answering questions
in a formal location (Yin, 2017).
Accumulating and assessing organizational documents is included in qualitative
studies (Kornbluh, 2015; Marshall & Rossman, 2016; Yin, 2016). Gathering data from
documentation can enhance interviews (Kornbluh, 2015; Yin, 2017). I used archival
documentation such as a five year strategic plan to strengthen study findings.
The benefits of using organization documentation include: (a) the researcher can
access information that is not available to the public on a hospital’s website or CMS.gov,
and (b) the researcher has the ability to review information numerous times to ensure
accuracy (Kornbluh, 2015; Yin, 2017). Some of the disadvantages of reviewing
documentation during a study are: (a) participants may not want to divulge
documentation they feel may be confidential, and (b) the documentation could be
outdated concerning the topic of study (Kornbluh, 2015; Yin, 2017). Using archival
records, physical artifacts, and documentation could aid in triangulating the available
data, but the data may be redundant (Yin, 2017). Using organization documents,
interview data, and observations are essential to achieving triangulation (Marshall &
Rossman, 2016; Yin, 2016). I used methodological triangulation by observing and
documenting participant’s body language, review company documents, and recording
participant’s responses to interview questions,
Member-checking refers to the research practice of securing feedback from study
participants to strengthen the accuracy, validity, applicability, and credibility of
interpreted responses (Emrich, 2015; Nyhan, 2015). Recording interviews can aid in
ensuring study participants’ responses are accurately captured and described (Yin, 2017).
Using a member-checking process, I provided participants the occasion to review and edit
my written version of their responses to guarantee accuracy.
Data Organization Techniques
I organized recordings derived from video conference or phone interviews to
identify recurring themes. Trace and Karadkar (2017) posited the significance of data
organization because researchers may benefit from stored data when they analyze the
data to understand developing themes. New themes can become apparent during the
coding process (Chowdhury, 2015; Pasila et al., 2017; Yin, 2017). I categorized themes
using a coding process. Using digital formats and electronic files can aid in keeping the
information safe (Alimo, 2015). Converting paper documents via scanner into electronic
files in order can aid in organizing the data (Trace & Karadkar, 2017). I scanned paper
records in digital files then safeguard the digital files in a password-protected electronic
folder and after 5-years, I shredded the paper files after conversion to preserve
confidentiality of data and participants.
Thomas (2015) posited that qualitative researchers exercise a filing method to
preserve confidentiality and strengthen integrity. Multiple copies of the data into different
formats and locations such as pen drives, cloud drives, and hard drives may help to
recover data should a disaster occur (Madu, 2016; Trace & Karadkar, 2017). Study
participants frequently share a concern for anonymity and confidentiality during the data
collection phase of a study (Bromley et al., 2015; Marshall & Rossman, 2016). I
preserved all electronic data in a password-protected external hard drive and secure the
hard drive containing all digital data in a combination strong box for a minimum of
5-years, before deletion.
It is important that qualitative researchers classify stored data (Alimo, 2015; Yin,
2017). Using a coding system can aid in maintaining the integrity, validity, and quality of
research (Ingham-Broomfield, 2015; Thomas, 2015; Yin, 2017). I used a coding system
to categorize and organize the text into small groups of content, find evidence of the
code, and assign the code to a tag. For example, I used specific labels such as P1 to
categorize study participants to refer to participant 1 or P7 to correspondingly categorize
participant 7. I would label the hospitals as Bus1 and Bus2 respectively.
I arranged the information to ensure that I preserve the confidentiality of the data.
I organized data properly when recording the research process, create checklists, and use
computer software to store the data (Alimo, 2015). I coordinated research data using
Atlas ti 8th edition (Nassaji, 2015; Stuckey, 2015). I used Atlas ti 8th edition for Windows
to store the data for the study and use Atlas ti 8th edition’s qualitative data organization
software to upload and analyze data from Atlas ti 8th edition. Using Atlas ti 8th edition
could aid in storing and organizing data within a study (Sarma, 2015; Woods, Paulus,
Atkins, & Macklin, 2015). Using password-protected digital files with unique
identification numbers could preserve data privacy and confidentiality (Alimo, 2015). To
maintain security and confidentiality, I arranged the information in password-protected
digital files.
Data Analysis Technique
For data collected from study participants, I performed data analysis using the
four stages of the constant comparative method to include: (a) comparing the incident’s
applicable to each category, (b) integrating categories and their properties, (c) delimiting
the theory, and (d) writing the theory (Vaughn & Turner, 2016). Organizing the data and
applying meaning to the data is the beginning of the systematic process when analyzing
qualitative data (Vaughn & Turner, 2016). The four triangulation types are (a) data
triangulation, (b) investigator triangulations, (c) triangulation of theory, (d) method
triangulation, and (e) environmental triangulation (Yin, 2017). Using triangulation could
aid in collecting and analyzing data from numerous sources such as interviews and
documents (Joslin & Müller, 2016; Spadafino et al., 2016, Yin, 2017). Conducting a case
study should include using multiple sources of evidence (Yazan, 2015). I used
methodological triangulation to analyze data from each interview and company
documents such as annual reports and a 5-year strategic plan. To protect the identities of
study participants, qualitative researchers use pseudo coding designations (Cleary et al.,
2014; Emmel, 2015). Qualitative researchers use coding to strengthen data analysis,
reliability, and validity (Stuckey, 2015; Yin, 2017). I used pseudo coding designations
made of alphanumeric categorizations such as P1 and P7 to signify the participants,
correspondingly, and BUS1 or BUS2 to reference the hospitals correspondingly to protect
the identity of the study participants as well as identify key themes that emerge from the
interview process.
Transcribing the data collected and member-checking during the data analysis are
essential activities. Employing video conference and phone interview platforms provides
automatic transcriptions of each session. Transcribing data is an act of data
representation, analysis, and interpretation in such a way that it has a significant influence
on the conceptualization of the data (Emmel, 2015). Using a member-checking process, I
used transcribed responses to the interview questions and send to the study participants to
ensure that my interpretation was correct. Using member-checking could improve the
credibility, validity, accuracy, and applicability of qualitative research by giving
participants an opportunity to verify the accuracy of the data collected (Yin, 2017). I
started the data analysis process once study participants approve that my interpretation
was accurate.
I used Yin’s (2017) five phases to analyze the data. These include: (a)
compilation, (b) disassembly, (c) reassembly, (d) interpretation, and (e) closure.
Qualitative researchers can analyze and transcribe research data using Atlas.ti 8th edition
for date storage and organization (Nassaji, 2015; Plamondon, Bottorff, & Cole, 2015;
Stuckey, 2015). I entered interview recordings into Atlas.ti 8th edition. Using qualitative
software like Atlas.ti 8th edition could aid in sorting, categorizing, and arranging data
during data analysis (Stevens, Moser, Köke, van der Weijden, & Beurskens, 2017;
Thiem, 2015; Wood, Gnonhosou, & Bowling, 2015; Woods et al., 2015; Zamawe, 2015).
I used Atlas.ti 8th edition during the data analysis process to assemble data into a
coherent order.
I disassembled the data into smaller sets after compiling the data. Disassembling
data means making practical groupings after separating the data (Castleberry & Nolen,
2018). Using coding could protect the data of participants and establish the relationships
between the coded information and the phenomenon (Emmel, 2015; Kelsey, Karen, &
Hude, 2017). Coding is often used by researchers to disassemble and reassemble data
(Castleberry & Nolen, 2018). After disassembling, I had smaller data sets to create
meaningful groupings.
After disassembling the data, I reassembled the information into groups for coding
(Castleberry & Nolen, 2018). In a qualitative study, the identification of themes is an
important phase (Kelsey et al., 2017). Using coding could establish the relationship
between the coded information and the phenomenon being studied (Emmel, 2015). Using
thematic analysis, which requires an interpretation and integration of themes, I analyzed
the data after reassembly. Interpreting data could aid in identifying themes using thematic
analysis involving the abstraction and synthesis of themes (Castleberry & Nolen, 2018;
Padilla-Diaz, 2015). Castleberry and Nolen (2018) noted that using the experience of
participants could aid identifying the themes and relate themes to phenomena.
Upon arranging the data, analyzing the data broadly, and discovering regularities,
I confirmed the conclusions and determine what trends stand out in the data between the
responses of the participants. Using quotes from respondents could aid in obtaining
credibility (Madu, 2016). Using member-checking could aid in enhancing the validity of
research findings (Emrich, 2015; Nyhan, 2015). Oghuma, Libaque-Saenz, Wong, and
Chang (2016) referenced correlating the concepts associated with the literature and the
theoretical context. Eventually, with the accompanying literature and the analytical
context, I compared relevant topics from interviews and relevant company reports. The
data analysis results can provide successful strategies for innovation used by hospital
leaders to maintain business office productivity during a merger. After concluding the
tutorials for NVivo and Atlas.ti software, I decided to use Atlas.ti 8th edition software to
aid in sorting, organizing, and arranging data collected during the study. I based my
selection on Atlas.ti 8th edition being a more user-friendly software for coding data
analysis to establish themes, and to sort, manage, and analyze the data I collected during
interviews, direct observation, and review of documents.
Yin (2018) suggested employing flowcharts to categorize the association between
themes. I followed Yin’s suggestion. I used reflexivity to evaluate themes I identified in
the interview, through direct observation, and other documents. I continued to analyze the
data for emerging themes until data saturation was achieved. Where applicable, I used
verbatim quotes of participants to support data analyses. The research question is
congruent with the aim of the research. The style of the research question is different than
the style of the interview questions; as the research questions formulates what I want to
understand; whereas, the interview questions are what I ask participants to gain that
understanding (Brinkmann and Kvale, 2015). Patton (2015) posited that the hope of the
interviewer is to elicit relevant answers that are meaningful and useful in understanding
the interviewee’s perspective. Inquiry-based questions were used to gain specific
information related to the aims of the study (Patton, 2015).
To determine the desired goal for the business office productivity strategies used
during the merger, I asked the question most connected to the study’s research question,
for example: “What strategies did you implement to maintain business office productivity
during the merger at the operating unit for which you are responsible?”. This question
was asked in the middle of the interview after building a rapport with the participant as
recommended by Yin (2018).
To determine what the expected outcome of combining the two business offices,
I asked: “What was the primary expected benefit of the merger within the business
office?” To establish a frame of reference for what would be considered a successful
merger of the two business offices, I posed the question: “How did you safeguard against
overestimating the expected benefit of streamlining redundant processes that result from
combining two business offices?”
By requesting the participant to explain any restructuring of organizational
processes to improve service, speed, accuracy, and/or cost performance, I began to
establish the procedures employed to maintain business office productivity during and
merger, and the reasoning behind them. I attempted to understand the method of
evaluating each business offices practices existing prior to the merger by asking “What
types of measurement was used to understand the existing practices prior to the merger?”.
By asking “How would you describe the personnel interaction or cooperation between the
two merging entities during the merger process?”, I gained an understanding of the
working culture between the combining offices.
I determined the three challenges to maintaining business office productivity
during a merger by exploring the perspectives of participants regarding their respective
responsibilities for both the acquiring and acquired business office by inquiring “What
strategies did the organization for which you are responsible address the top three
challenges to maintaining business office productivity during the merger?”. I
established the units of measurement for successfully maintaining business office
productivity during a merger by asking “How did you measure business office
productivity success at the completion of the merger?” By asking “What else would
you like to add that we have not yet discussed regarding the strategies used to maintain
business office productivity during a merger?”, I captured data not specifically
requested in previous interview questions. The key focus of this study was exploring
strategic knowledge considered by hospital leaders to develop strategies for
maintaining business office productivity during a merger based on BPR.
Reliability and Validity
During data collection, ensuring the accuracy and validity of data are equally
important (Noble & Smith, 2015). Validity refers to the extent in which the results
accurately reflect the data and reliability refers to the validity of the analytical
procedures, including differences in personal and analysis methods that may have
affected the findings (Noble & Smith, 2015). Reliability, credibility, transferability, and
confirmability are the basic criteria for achieving quality and rigor in a qualitative study
(Marshall & Rossman, 2016). Such parameters must be established using subjective
approaches such as member-checking and triangulation (Noble & Smith, 2015).
Member-checking is the process of reviewing study participant’s ideas of
confirmation and collecting materials to develop categories (Emrich, 2015; Nyhan, 2015).
Reliability and validity were typically characteristic of quantitative researcher studies
(Kasim & Al-Gahuri, 2015), but contemplating dependability, credibility, transferability,
and confirmability reliability and validity are reconsidered qualitative research criteria
(Avenier & Thomas, 2015; El Hussein, Jakubec, & Osuji, 2015). I used reliability and
validity criteria to strengthen this study.
A clear reflection of the collection, sampling, and analysis of data can increase
validity and reliability (Kasim & Al-Gahuri, 2015). The strategies used to maintain
validity and reliability include (a) recognition of personal biases, (b) audio and video
recordings of video conference or phone interviews with participants, (c) use of peer
reviews for questions or debriefing, (d) use of member checking, and (e) data
triangulation (Morse, 2015; Noble & Smith, 2015). Additional strategies such as
prolonged engagement, rich description, negative case analysis and external audits aid
with conducting proper research (Morse, 2015).
Reliability
It is important to collect data of high quality. Reliability refers to the accuracy of
the analytical methods, including personal and analysis process biases that may affect the
findings (Morse, 2015; Noble & Smith, 2015). Using objective research information can
aid in achieving precision in qualitative studies (Yin, 2017), and if the study data is not
biased, achieve reliability (Morse, 2015). Research results that can be repeated have
achieved reliability (Noble & Smith, 2015). Case study research is reliable if a future
researcher or auditor can draw similar conclusions after repeating the procedures (Yin,
2017). Focusing on achieving reliability could aid in the repetition of the results by future
studies ((Noble & Smith, 2015).
Dependability is a concept that means the demonstration of reliability in a
qualitative study (Connelly, 2016; Yin, 2017). Dependability refers to the reproducibility
of study findings through a transparent process containing limitations and the study’s
anticipated contribution (Connelly, 2016; Yin, 2017). Ways to improve a study’s
reliability include data interpretation, member-checking, transcript review, pilot testing,
interview question validations by experts, interview protocol, focus group protocol, and
participant observation protocol (Marshall & Rossman, 2016; Yin, 2017). A qualitative
analysis allows a researcher to ensure reliability and continuity throughout the research
process (Connelly, 2016). Reliability guarantees that the findings of a qualitative study
are dependable (Yin, 2017). The use of member-checking in a qualitative study
demonstrates the accuracy and quality of the information provided by the participants
(Emrich, 2015; Nyhan, 2015).
Using an audit trail process, I can ensure reliability (Connelly, 2016). Marshall
and Rossman (2016) determined member-checking as suitable for enhancing academic
accuracy. By checking, creating, and maintaining an audit trail of the research process, I
ensured reliability. I used an interview protocol (see Appendix B) to create and maintain
research notes and adhere to the order of the study. Dependability can be accomplished
through a step-by-step process from the collection of data to the final study decision
(Connelly, 2016). I used the interview protocol to ensure dependability (see Appendix B).
I used consistent data methods to ensure the reliability of this study. Using the same
open-ended interview questions and asking questions with each participant in the same
order, enhances reliability (Yin, 2017). For each interview, with a least seven
respondents, I used the same interview questions before achieving data saturation. By
following the interview protocol (see Appendix B), I collected interview data with a set
of interview questions and ensure reliability.
Encoding, audio recording, and note taking enhance reliability (Yin, 2017). It was
imperative that participants consented to the audio and video recording of the interviews
in order to ensure validity and reliability of research (Mitchell et al., 2018; Wright et al.,
2018; Yin, 2017). I obtained permission from the participants to audio and video record
the interviews to ensure reliability and validity of the study. Member checking is a
process involving participants in a review of the interview summary, verifying the
emerging themes, and inferences by asking participants to offer reasons denoted in
patterns (Birt, Scott, Cavers, Campbell, & Walter, 2016; Nyhan, 2015; Smith &
McGannon, 2018; Yin, 2016). Member checking improves validation because it
decreased the chance of misinterpreting the data (Carlson, 2010). Employing member
checking establishes credibility and reduces internal threats to the study (Bygstad &
Munkvold, 2007). I received input from the respondents on my interpretation of the
interviews and was assured that there were no misrepresentations
Saturation of data helps ensure the dependability of the findings of the study
(Yazan, 2015). Methodological triangulation enhances the results of qualitative research
because the data collected comes from different sources (Marshall & Rossman, 2016;
Yin, 2017). In a study, triangulation is the way to achieve dependability (Yin, 2017). I
achieved methodological triangulation by analyzing relevant company documents, body
language of the participants, and connected these to the answers to the interview
questions.
Validity
Validity is a measure of truth and honestly when the research results are used to
accurately represent the data (Bengtsson, 2016; Noble & Smith, 2015). Qualitative study
validity refers to the credibility, transferability, and validity of the findings (Brown et al.,
2017). In qualitative research, credibility and transferability are associated with validity,
while confirmability is a theoretical viewpoint of objectivity (Kornbluh, 2015; Yin,
2017).
As a follow up to the interview process, I used member checking to enhance
reliability and validity of the data instruments in the study. Member checking involves
study participants reviewing the researcher’s interpretation of data and validation of
emerging themes (MacPhail, Khoza, Abler, & Ranganathan, 2016). Member-checking
and consistent participant analysis during interviews improve the credibility of research
results (Marshall & Rossman, 2016).
Triangulation enhances the reliability and integrity of a case study by improving
the research findings’ credibility (Kornbluh, 2015; Yin, 2017). There are a wide range of
triangulation types, such as information triangulation, investigator triangulation,
theoretical triangulation, and methodological (Marshall & Rossman, 2015; Noble &
Smith, 2015; Yin, 2017). Methodological triangulation increases credibility (Fusch &
Ness, 2015) and supports qualitative researchers in gaining different participant’s
perspectives during the study.
Data triangulation is a way to explore different levels and viewpoints of the same
phenomenon and a way of ensuring the validity of the results of the study (Fusch & Ness,
2015). Wilson et al. (2016) determined researchers use methodological triangulation to
explain data and improve the quality of research findings. Theoretical triangulation is
beneficial for capturing the shifting role of expertise (Burau & Andersen, 2014). All types
of triangulation are useful for the consistency of qualitative data analysis if a researcher is
aware of the applicability of the research design to the type of triangulation chosen (Yin,
2017). Methodological triangulation can improve the validity and credibility of a research
study because the process includes cross-checking information using two or more
methods can give greater credibility (Lodhi, 2016). Therefore, to maintain validity and
credibility, I used methodological triangulation. In general, I cross-checked the responses
to interview questions, and information from organization documents such as annual
reports and a 5-year strategic plan.
Transferability occurs if study readers can agree on the applicability of research
findings in other settings (Bellemare et al., 2018; Bryman & Bell, 2015; Korstjens &
Moser, 2018; Sinclair et al., 2018). Transferability depends on the decision-makers’
judgment (Bærøe, 2018).
I used the same interview protocol for each participant. Transferability can be
accomplished by data saturation (Yin, 2017). Failure to achieve data saturation affects the
quality of the research carried out and hinders the validity of the content (Fusch & Ness,
2015). Data saturation evidence is important to improve the validity of a qualitative study
(Morse, 2015; Noble & Smith, 2015). Data saturations is achieved once no new data is
found, no new themes arise, no new coding is necessary and other researchers can
replicate the study (Fusch & Ness, 2015). I must ensure the achievement of data
saturation to assist prospective readers and researchers in making decisions about the
transferability of the research results.
There is a direct link between triangulation of data and data saturation. Data
triangulation is a method of data saturation (Fusch & Ness, 2015). Data saturation occurs
when the information gathered for an analysis exceeds a breadth and depth point (Morse,
2015; Noble & Smith, 2015). Saturation of data occurs when the information collected is
redundant or repetitive (Fusch & Ness, 2015) and the quality of the interview questions,
the extent of the research experience in qualitative research, the methodological
understanding of the process, and the use of a guiding conceptual framework are also
important aspects of achieving data saturation (Aldiabat & Navenec, 2018).
I used different steps to achieve data saturation, including (a) reading and
analyzing interview transcripts and/or recordings, (b) writing each question and
synthesizing interview data in one sentence, (c) providing each participant with a copy of
the synthesis, (d) requesting input from participants as to whether the synthesis reflects
the answers correctly or whether there was additional information, (e) verification and
correction of data definitions based on participant responses, and (f) member checking
until there was no new data to collect.
Confirmability can be accomplished when the same information can be used by
other researchers to collaborate the results (Marshall & Rossman, 2016). Data neutrality
and accuracy ensure objectivity and confirmability (Houghton et al., 2013). Achieving
neutrality and precision through their theoretical documentation, could aid in reaching a
decision (Houghton et al., 2013). In order to achieve confirmability, Bekhet and
Zuszniewski (2012) maintained neutrality and objectivity. Research data should
accurately reflect the responses of the participants (Yin, 2017). Researchers can provide
quotes from participants to enhance authenticity (Cope, 2014). I must ensure
confirmability by being neutral and objective throughout the research process, provide an
audit trail, and use quotes. Identifying the conclusions and interpretations of the
responses could aid in achieving confirmability (Cope, 2014). I must adhere to the
study’s purpose of ensuring data confirmability by pursuing the study’s goals, using
interviews, recording audio and video from video conference or phone interviews, using
member checking, and sharing some direct quotations from participants to improve
confirmability.
Sample size does not guarantee data saturation (Fusch & Ness, 2015). Even with a
limited but sufficient sample, a researcher can achieve data saturation if the sample
includes experts in the field of interest (Morse, 2015). Through maintaining a small
sample size of seven participants, I can ensure that I achieve data saturation and ensure
that all participants have expertise in maintaining business office productivity during a
merger. To increase reliability, researchers must prevent bias in their study (Morse,
2015). Researchers must ensure validity of the analysis and the conclusions demonstrated
using a qualitative method (Hammarberg, Kirkman, & de Lacey, 2016). To increase the
likelihood of accuracy, this study involved verifying the data with participants.
Transition and Summary
In Section 2, I discussed the (a) role of the researcher; (b) participants; (c) research
method and design; (d) population and sampling; (e) data collection instruments; (f) data
analysis; and (g) credibility, transferability, dependability, and confirmability. Section 3
contains (a) an overview of the study, (b) the presentation of findings from the research,
(c) the professional application of the findings, (d) implications for social change, (e)
recommendations for action and future research, (f) personal reflections, and (g)
conclusions.
Section 3: Application to Professional Practice and Implications for Change
Introduction
The purpose of this qualitative single case study was to explore leadership
considerations for maintaining hospital business office productivity during a merger.
Using Hammer’s (1990) BPR theory as the conceptual framework, I explored the
considerations of leaders from the business offices of two merging hospital systems in the
southeastern section of the United States who were successful maintaining business office
productivity as they facilitated a merger of the two hospitals. Study participants indicated
several considerations that contributed to maintaining the business office productivity,
including delivering unified and consistent messaging during the merger. Section 3
includes the presentation of the findings, application to professional practice, and
implications for social change. Also included in Section 3 are recommendations for
action and additional research, personal reflections, and the conclusion of the study.
Presentation of the Findings
The intent of this qualitative single case study was to answer the central research
question: What strategies do hospital leaders use to maintain hospital business office
productivity during a hospital merger? To answer the question, I conducted virtual
interviews, in compliance with COVID-19 pandemic protocols, with seven hospital
business office leaders, comprised of the acquiring hospital referred to as Business 1
(B1), and the acquired hospital referred to a Business 2 (B2), which are both
headquartered in the southeastern section of the United States. I also reviewed relevant
current and archival documentation. B1 is a midsized urban hospital system with 12
operating units and 25,000 employees. This hospital is a recognized medical industry
leader in the southeastern United States and globally. B1 has merged with or acquired
several hospital systems between 1995 and 2020. B2 is a smaller 600 bed, three operating
unit hospital system with 4,000 employees.
Seven leaders comprised of leaders from B1 and B2 received invitations to
participate in the study. The criteria for selecting participants included hospital leaders
who worked for both the acquiring hospital’s business office and the acquired hospital’s
business office and were successful in maintaining business office productivity during a
merger. Of the seven hospital leaders who received invitations to participate, all seven
were available to participate. Of the seven participants, four worked in the business office
of the acquired hospital, and three worked in the business office of the acquiring hospital.
Study participants positions ranged from manager to vice president, to chief financial
officer (CFO). I achieved data saturation and no new themes emerged (see Marshall et al.,
2013).
I conducted and recorded the interviews via virtual electronic communication
platforms including Microsoft Teams and Zoom. The seven participants responded to
nine open-ended interview questions listed in an interview protocol (see Appendix A).
Interviews lasted no longer than 45 minutes. Throughout the interviews, each contributor
shared personal experiences, perspectives, and anecdotes from their respective positions
within the business office regarding the strategies they used to maintain business office
productivity during the merger. During this process, I referred to all participants using
coded names, such as Participant 1 (P1), Participant 2 (P2), and so forth.
After the interviews, I thanked the participants for their contributions to the study.
I then transcribed the recorded interviews and e-mailed the transcripts to the participants
with an appeal that they assess the transcripts for accuracy within a week. Next, I
conducted member-checking interviews using a virtual electronic communication
platform. The member-checking process involved giving the participants one-paragraph
interpretations that I created for each of their responses to the open-ended interview
questions. The purpose was to confirm my interpretations conveyed what they intended.
This process also gave the participants an opportunity to contribute additional material
about the research topic, which further assisted me in achieving data saturation.
Case study research includes the use of data triangulation, which involves
gathering data from numerous sources (Krichanchai & MacCarthy, 2017). Examples
include interviews, participant observations, archival records, and documentation (Yin,
2018). I substantiated the data I collected throughout the virtual interviews by reviewing
hospital documents. The documents included the hospital’s website, CMS reports on the
hospital’s performance.
After completing the data collection process, I followed Yin’s (2018) five-step
process for qualitative data analysis that involved compiling, disassembling,
reassembling, interpreting, and concluding. I began this process by transferring all
interview data into Microsoft Word where I manually coding and analyzing the data to
identify key themes. I then transferred the data into the Atlas ti 8th edition qualitative
analysis software program for computer-aided coding, interpretation, and theme
development.
I evaluated the themes that developed from my computer-aided and manual data
analysis processes. Four themes emerged related to the research topic: (a) leadership
presented unified and consistent messaging, (b) leadership shared outsourcing
advantages, (c) leadership was purposeful in alleviating staff’s fear of the unknown, and
(d) leaders were proactive in addressing even potential challenges. Each of the four
themes validated common themes from the literature review for this study. Several
participant’s responses reinforced Cameron et al’s. (2016) change management theory,
which suggests that resistance to change can stem from the appearance of a neglectful
opportunity of leadership to demonstrate an appreciation for the efforts of staff during the
transition. Participant 4 reinforced this idea by suggesting that leadership who ignore the
efforts of staff to achieve the goals for the business office find a waning enthusiasm for
the change and often an overt rebellion toward the change. Most participants reinforced
change management theory by emphasizing the need for leadership to deliver consistent
messaging about how to view the upcoming changes that will arise because of the
merger. All participants suggested that employs who understand their responsibilities,
who feel valued, tend to commit to the change and apply themselves to o maintaining
business office productivity with a positive attitude. Those employees can serve as
personal ambassadors for the merger when speaking with coworkers, and other
stakeholders.
Theme 1: Leadership Presented Unified and Consistent Messaging
All participants remarked that the unified and consistent messaging provided by
hospital leadership enabled the employees to maintain focus on achieving the
productivity goals established throughout the merger (see Table 1). Hospital leadership
must establish unified and consistent messaging when communicating with employees
about processes, goals, expectations, and appreciation related to business office
productivity. The best way for hospital leadership to develop unified and consistent
messaging to employees is to prioritize employee comprehension (Al-Ali et al., 2017).
The study outcomes indicated that hospital leadership who adhered to a unified and
consistent messaging during the merger, inspired staff to maintain focus on productivity
to the hospital’s benefit.
Table 1
Coding of Participants’ Responses Related to Themes
Themes Participantsa Responsesb
1. Unified and Consistent Messaging 7 7
2. Openly Shared Outsourcing Advantages 7 8
3. Alleviating fear of the unknown 7 9
4. Proactively address potential challenges 7 9
Total (duplicated) 28 33
Note, a Number of hospital leaders who contributed responses linked to the themes. b
Number of interview questions for which participant responses linked to the themes.
Participant 1, Participant 3, Participant 4, and Participant 6 suggested that a unified and
consistently delivered message established by hospital leadership reinforced the notion
that the business office of the acquiring hospital and the business office of the acquired
hospital should begin to see themselves as one combined entity. For example, Participant
4 emphasized that a mantra of “no separation” was repeatedly vocalized by hospital
leadership during collaborative meetings of both entities business office personnel from
the initial stages of the merger. Participant 3 added that even lower level staff would
begin to volunteer the “no separation” messaging on their own during the meetings.
Although there was still uncertainty surrounding the future state of the combined business
offices, Participant 3 said staff appreciated the reassurance that the combined entity was
view as one team. Participant 3 also explained that many employees at both B1 (the
acquiring hospital), and B2 (the acquired) hospital business offices were initially
uncertain as to whether they would be view differently than their counterparts on staff
with the other operating unit’s business office. Participant 3 said the reassurance allowed
staff to maintain focus on achieving productivity standards. Participant 1 described how
the removal of ambiguity in expectations bolstered employee retention during the
transition because the consistent messaging increased the staff’s comfort level with the
merger process. Hospital documentation confirmed participant’s assertions regarding a
unified and consistent messaging.
The findings of this study support the peer-reviewed sources in the literature
review. Hospital leaders who provide a unified and consistent messaging can augment the
employee’s morale, and productivity (Al-Ali et al., 2017). As staff labor to maintain
business office productivity during the merger, they appreciate hospital leadership
removing uncertainty by being unified and consistent in the messaging regarding the
merger (Tabibi et al., 2015). Unified and consistent messaging such as “no separation”
and “address the issue before it becomes a problem” can fortify employee’s commitment
to the organization’s goals (see Tabibi et al., 2015). The findings of this study also bolster
the conceptual framework, BPR theory, as consistent messaging regarding the processes
set forth, leads to employee’s ability to adapt to change and focus on priorities (see
Hammer, 1990). Being deliberate about messaging is one strategy that leadership can use
to maintain hospital business office productivity during a merger.
In addition to repeating consistent messaging in a unified manner, hospital leaders
have identified the significance of delivering on the promise of those messages.
Participant 7 offered that treating staff as one unit after proclaiming there was “no
separation” between the two combining business offices, created buy-in to the culture
change and process modifications during the transition. Participant 5 and Participant 4
both identified key components of the messaging to be developed during the merger,
including positive affirmations, admonishments, and process descriptions.
Participant 2 also cited the importance of habitual messages of employee appreciation as
a priority for hospital leadership. For example, during daily huddles, business office
leaders were tasked with finding someone to celebrate in front of their peers; thereby
reinforcing the message that effort will be recognized and rewarded. Equally important to
habitually appreciating employees in front of their peers is having the messaging to show
appreciation to employees individually. Participant 2 indicated that if an employee
consistently met their productivity goals, they as a leader was diligent to send a message
of appreciation for the effort.
These findings corroborate the literature on resistance to change. Hospital leaders
who deliver unified and consistent messaging can assuage resistance to change that is a
characteristic recognized in employees during mergers (Hornstein, 2015). Hornstein
(2015) posited that consistency is a significant component of effective messaging because
employees who receive repeated unified and consistent messaging from leaders are more
likely to remain engaged and focused. In addition, hospital leaders acknowledge the
benefit of a consistent message of appreciation, admonishment, or direction (Hornstein,
2015). Unambiguous messaging benefits the organization by enhancing employee’s
ability to withstand the uncertainty of the future state of an organization experienced by
employees during a merger (Hornstein, 2015). Employees who can defy that uncertainty
can focus on maintaining productivity standards (Al-Ali et al., 2017). Add summary and
synthesis throughout the paragraph.
Another aspect of unified and consistent messaging involves hospital leadership
being transparent in their messaging. Participant 4 said that consistently vocalizing
appreciation for employees’ efforts has been a great way for leaders to incentivize
employees to not only achieve their productivity goals, but to exceed them. Employees
who feel appreciated by their leaders are more likely to buy-in to the changes being made
during the merger and apply maximum effort for the duration of the transition (Kirrane et
al., 2017). Even seemingly trivial messaging, such as a “good job” in passing has
improved employee’s determination to achieve productivity standards during the business
office merger.
Theme 2: Leadership Openly Shared Outsourcing Advantages
Participants noted the willingness to share information typically not shared
regarding outsourcing and leveraging established relationships with respective outsource
vendors alleviated burdensome processes and released employee capacity to engage other
areas of responsibility that contributed to business office productivity. Employees who
were able to transfer time consuming or tedious responsibilities to vendors who already
managed those responsibilities for their counterparts, were able to address other areas of
productivity (Eaton & Kilby, 2015; Osarenkhoe & Hyder, 2015). All seven participants
mentioned how instrumental the application of outsourcing was to the success of the
merger, and how it was leveraged was in maintaining business office productivity during
the merger.
Hospital leaders created capacity for employees to focus on the task of revenue
collection which was measured using productivity standards. Six of the 7 participants
explained how employees were able to concentrate of working high dollar accounts and
collecting high balances when the lower balance accounts, that require excessive effort
and produce little revenue, were outsourced to vendors. Participants 3 noted that when an
employee had the newly added capacity to work higher dollar accounts, they were able to
meet their collections productivity standards more easily.
Participant 3 added that employees often can own management of their own areas
of business when they have the capacity to devote the necessary time to achieving their
productivity expectations. Employees feel a greater ability to focus when they know they
will not be inundated with low dollar, high effort accounts for which they are responsible
for collecting balances. Both Participant 3 and Participant 4 agreed that employees
generally appreciated not being overwhelmed with high effort-low yield productivity
responsibilities and appreciated that hospital leaders were actively looking for ways to
remove barriers to their achieving productivity standards. These findings are consistent
with the literature, noting that employees perform worse when saddled with mundane or
unrewarding repetitive tasks (Eaton & Kilby, 2015; Osarenkhoe & Hyder, 2015). The
findings of the study also support the conceptual framework, as redistributing capacity
can give employees the ability to efficiently learn and execute new processes (Hammer,
1990).
Hospital leaders also enabled the business office employees to maintain
productivity standards by using outsourced vendors to continue business office operations
while employees were unable to work accounts due to the process of physically
relocating their respective offices to a new shared location. Participant 3 said that the
physical office move resulting from the merger neutralized employees for nearly a month.
The dismantling of one office, the physical move, and the reassembly of the offices in the
new shared space prevented employees from optimal contribution to business office
productivity for nearly a month. This supports the notion that outsourcing certain
business functions can lessen the operational risks resulting from outside factors
preventing employees from executing their responsibilities (Anderson, 1988; Krantz,
2006; Ladewig & Hecht 1993). Hospital leaders who employ the services of outsource
vendors to perform a portion of productivity-based responsibilities, while employees are
busy with the logistics of moving their offices, aid the business office in maintaining the
productivity standard set by the organization (Anderson, 1988; Krantz, 2006; Ladewig &
Hecht 1993).
Hospital leaders also leveraged the establish relationships that already existed
with one operating unit’s business office to generate similar advantages for the joining
business office. Because of the ability to offer outsourced vendors increased volume due
to the addition of the new business resulting a merger with a new business office, hospital
leaders were able to negotiate more favorable rates in the outsource contracts. That
financial savings allowed hospital leaders to redirect funds toward resources to enable
employees to do their work. Participant 4 stated this availability of funds helped procure
resources like software and equipment that helped employees do their work more
efficiently and maintain business office productivity during the merger. This sentiment
supports the literature such as Cameron et al. (2016) that leaders can leverage existing
resources to remove barriers to employees executing the change that results from a
merger.
Theme 3: A Concerted Effort to Alleviate Fear of the Unknown
Employees have a greater aspiration to achieve productivity standards when they
are not preoccupied with the fear and uncertainty that can accompany mergers (Holten &
Brenner, 2015). Leaders who are purposeful about alleviating the uncertainty that
accompanies mergers increase the likelihood of employee retention during a merger
(Diab, Safan, & Bakeer, 2018). Approximately 77% of study participants acknowledged
that employee anxiety about pending merger changes would have disrupted operations.
Participant 7 conceded that hospital leadership and employees benefitted from a
concerted effort and comprehensive strategies to not add to the uncertainty. Participant 7,
along with Participants 1, 2 and 4, cited the hospital business office’s daily meetings,
huddles, and briefings as one strategy for fostering improved morale and predictability
among employees.
Participant 1 noted that the daily meetings, huddles, and briefings typically
covered productivity related topics such as problem accounts, collection projections, and
contractual procedures. Although some external speakers contributed to these meetings,
employees were given opportunities to develop their own leadership skills by facilitating
portions of the meetings. Hospital leaders acknowledge that direct participation in the
facilitation of the meeting increased employee’s confidence and fostered a sense of trust
and inclusion in the newly combined business office entity. The inclusivity bolstered
employee retention which helps to maintain business office productivity during the
merger. Hospital leaders also encouraged employees with previously underutilized
competencies to take a greater role and increased responsibilities in the pursuit of the
business office goals. Participant 1 indicated that in many cases, leaders needed to
increase their own comfort level with relinquishing control to subordinates.
Hospital leaders also challenged employees to expand their skillset. Participant 2
expressed that employees who were continually challenged were less likely to become
complacent in their roles and more likely to remain engaged. Occupational challenges
also positioned employees for advancement opportunities within the business office that
had not previously been afforded to them. The confidence gained from addressing those
challenges gave employees a comfort level with the pending changes of the merger.
Participant 3 indicated that hospital leaders were continually thinking about succession
planning to backfill positions of employees who were advanced because of improved
skillset. Participants 1 and 2 corroborated this perception, adding that hospital leaders
typically aim to promote from within before seeking talent outside of the organization.
Participant 3 expressed that employees appreciated having greater opportunities within
the hospital’s business office to advance from their existing roles to roles that have more
impact on the combined organization’s productivity. Participant 4 said that employees
with the most seniority especially appreciated having advancement opportunities because
of the merger after having been stagnant in their career trajectory for a time. Participants
noted that employees felt accomplished when they were continually learning and not
stagnant in their current position. Hospital documents supported the focus on profession
development. For example, the hospital’s website continually indicated that because
business office employees continually participated in professional development courses,
they were more likely to grow within the business office and not leave the hospital for
more fulfilling employment. The hospital’s organization development website also
highlighted the business office leadership team’s focus on coaching employees to
acclimate them to their new responsibilities.
These findings confirmed the research from the literature review. Diab et al.
(2018) posited employees feel more engaged and willing to work harder when they are
provided opportunities for career development. Zuckerman and Golden (2015) also
suggested that employees feel more connected to their work when they receive
appropriate mentorship. Hospital business office leaders who offer growth opportunities
show that they appreciate their employees having the knowledge, skills, and abilities
required to succeed for the duration of their careers (Shah & Gupta, 2018). This strategy
for leveraging the offer of professional develop opportunities to strengthen the resolve of
employees to maintain or exceed acceptable productivity standards during a business
office merger aligns with the conceptual framework, BPR theory, as investing in
employee’s professional development was one way to foster a favorable outlook in how
employees view the hospital business office’s productivity goals.
Theme 4: Leadership Was Proactive in Addressing Potential Challenges Study
participants indicated that employees were better positioned to maintain business office
productivity during the merger because of a concerted effort to address obstacles before
they disrupted operations. A proactive approach to addressing challenges was vital to
identifying and addressing obstacles before they can disrupt productivity (Cameron et al.,
2016). Study participants explained that hospital leadership fostered an attitude of
continuous improvement in operations during the business office merger.
Hospital documents, specifically the hospital’s website, reinforced that promoting
continuous improvement motivated employees to surface productivity obstacles and
address them immediately.
Participant 4 identified the adoption of continuous improvement as a high priority
concept defined by Lean Six Sigma (He & Goh, 2015). From a perspective of standard
work for all employees, leaders were able to leverage the concept of continuous
improvement business office- wide. For example, Participant 1 and Participant 3 noted
that business office leaders establish, encouraged, and rewarded employees across the
business office to compel them to seek out and surface obstacle to maintaining
productivity so the obstacles could be resolved. Four participants also cited the business
office daily dashboard reports as a valuable tool for keeping the workforce informed and
on the lookout for obstacles and challenges. The dashboard highlights key information
such as issues with safety, methods, equipment, supplies, or staffing. These participants
also alluded to the importance of communicating the accepted resolution to the raised
obstacles that were surfaced by the employees. Participant 1 noted that as the employee’s
confidence grew that their perceived obstacles would receive the appropriate attention
and were resolve in an expedient manner, the employees were more proactive in
identifying obstacles. This focus on proactively addressing obstacles to productivity
supports the literature review. Multiple researchers have explored the importance of
leveraging internal communication means to update and level set employees (Karanges et
al., 2014; Korzynski, 2015; Nadim, 2015)
From an oral communication perspective, hospital leaders leveraged in-person
meetings to foster open dialogue and increase opportunities to detect obstacles to inherent
in processes or barriers hindering the employee’s workflow. All the study participants
noted that each department within the business office conducted weekly meetings focused
on removing barriers and resolving issues that were obstacles to achieving the
productivity goal set for that department. Among the meeting discussions were current
workloads, opportunities for improvement, problem-solving, and the sharing of best
practices. Although some employees were unable to attend meetings due to being at a
different physical location, Participant 4 described how employees could attend via Zoom
to be connected. This team meeting strategy supports the literature, as Seymour and
Geldenhuys (2018) posited that team dialogue can have a positive effect on employee
engagement with organizations. In addition to facilitating team meetings, leaders
regularly engaged in weekly one-on-one meeting with employees. Participant 3 said that
while weekly team meetings were beneficial, one-on-one meetings enhanced the
opportunity to identify issues that may have been missed in group discussions. Participant
3 noted that these encounters allowed employees to drive the agenda and share more
detailed descriptions of challenges and needs. Participant 2 also developed the routine of
spontaneously rounding on employees to observe and confer about their activities and
concerns. Participant 2 added that leaders efforted to foster an atmosphere of open
communication to optimize the opportunity to surface issues. Contributors expressed that
each of these interactions furthered collaboration, which heightened the opportunities to
both surface challenge to productivity and resolve those obstacles.
Regarding day-to-day communication, about 71% of respondents said that they
consistently engaged employees in person versus relying on email. This outlook aligns
with research conducted by Men and Hung-Baesecke (2015) and O’Neill et al. (2015),
who discovered that employees feel most unified when leaders communicated with them
face-to-face. Participant 6 remarked that employees tended to feel a personal connection
when communication was more intimate. Conversely, Participant 6 noted that employees
could easily misconstrue impersonal communication from leadership as being
uninterested in their perspectives on issues. Participant 1 and Participant 6 also
emphasized the need for employees to be able to speak openly with each other to resolve
challenges and remove barriers to workflow.
Some notable outliers developed from the research data regarding hospital
leadership communication practices and tools. After emphasizing some of the business
office’s strengths, Participant 4 acknowledged that the merged business office still has
openings to be even more efficient. For example, Participant 4 noted that business office
leaders might benefit from establishing a self-service instant message network that allows
customers of the hospital to communicate instantly with the business office employees
via a virtual chat feature. Participant 4 added that customers could use this technology to
inquire about billing, pay their bills online, and request records. Participant 4
acknowledged that utilizing this type of technology could free up significant capacity,
enabling employees to exceed productivity standards. Participant 4 expressed there are
still opportunities because of the newly combined business office still working on
separate computer platforms. Participant 4 noted that the dual computer platforms being
used has led to some communication-related inefficiencies.
Participant 1 and Participant 4 noted that business office leaders must model the
behavior that they seek from their employees. Participant 1 and Participant 2 stated that
they continually worked accounts just as their employees. This meant business officer
leaders were also responsible for meeting productivity requirements. Because they were
doing the same work they could empathize with employee’s concerns. Participant 4 noted
that business office leaders did not place blame on others when a mistake occurred, and
they did not demand employees maintain a productivity standard that they themselves
were not willing to accomplish. Leaders doing the day-to-day work lead to employees
feeling inspired, unified, and valued. The literature corroborates this concept, as Ong and
Yaqiong (2018) stressed that leader’s behaviors directly influence staff’s satisfaction,
attitudes, and commitment to the organization.
Participant 1 and Participant 4 noted that leaders found it beneficial to contour
messaging to specific tasks that contributed to overall productivity. Participant 1
explained that they developed separate specific strategies for maintaining productivity in
billing, and follow up, and Denials. This meant that the strategy to maintain productivity
for billing was different than the strategy to ensure follow up productivity was
maintained. The strategies for each respective area were developed with consideration of
the process necessary to carry out a complete cycle of each. Once the process was
mapped and measured, business office leaders would consider each contributing
component of that process and a strategy to optimize those components individually. The
theory was that if incremental improvements to the contributing factors were made, the
improvements would result in an improved overall process. Participant 5 expressed
appreciation for an approached that allowed leaders to focus on smaller issue rather than
the nebulous concept of productivity. The literature supports this notion. Hammer (1990)
posited that the whole could be improved by improving each of its individual parts.
Findings Related to the Conceptual Framework
I used Hammer’s (1990) BPR theory to explore the leadership considerations for
maintaining hospital business office productivity during a merger. The core principle of
BPR is systems thinking and an emphasis on removing all processes that do not create
value for the organization. The theory is based on leadership’s ability to map the
processes of a particular organization and assign measurable units to the steps in those
processes, monitor those units, diagnose issues and challenges within those processes,
suggest improvements, and continuously monitor performance based on those redesigned
processes (Hammer, 1990).. This theory is consistent with the research included in this
study. For example, when leadership redesigned existing hospital business office
practices to better align the processes of the two combining business offices, productivity
was maintained during the merger. Understanding the threats to maintaining suitable
productivity within the components of the revenue cycle and the connection between
those contributing components can enable hospital leadership to respond appropriately
(Vasilaki, Tarba, Ahammad, & Glaister, 2016; Zhang et al., 2015).
Study participants substantiated BPR theory. Participant 3 and Participant 4 noted
that when leaders were able to consider incremental improvements to the components
contributing to overall productivity, employees were able to focus on delivering better
performance in their specific area of responsibility; which resulted in optimal overall
productivity. Participant 1 noted that rearranging how work queues were organized
allowed employees to focus more on high dollar accounts and thereby achieve the cash
collection productivity goal more easily. All four themes delineated in this study
exemplify strategies used by hospital leaders used to maintain business office
productivity during a merger: (a) leadership presented unified and consistent messaging;
(b) leadership openly shared outsourcing advantages; (c) a concerted effort to alleviate
fear of the unknown; (d) leadership was proactive in addressing potential challenges.
Hospital leaders employed these tactics and were successful in maintaining the
productivity of the business office during the merger. Participant 7 and Participant 4
added that the implementation of these strategies have been integral in fostering a desire
amongst employees to dedicate the appropriate effort to maintain productivity.
Applications to Professional Practice
The specific business problem for this study was that some hospital leaders lack
strategies for maintaining business office productivity during a merger. The results of this
study reveal the strategies that hospital leaders at midsize urban hospitals in the
southeastern U.S. use to realize this aim. The findings are applicable to maintaining
business office productivity during a merger because they include specific suggestions for
using the principles of BPR to improve the processes of two combining business offices
in order to maintain productivity as they merge into one newly formed business office.
The results of this study incorporated the resulting suggestions for hospital leaders
to improve business office practices where achieving a required productivity was the
focus: establish a unified and consistent messaging for processes and expectations, and
convey those messages at every opportunity. Other suggestions included exploring ways
outsourcing and existing outsourcing relationships can benefit each business office during
a merger, and how combined business office volume can command better rates than
either entity experienced individually. Other significant recommendations involved
frequent team meetings and huddles consisting of leadership transparency in
communication and both routine group and routine individual daily engagements to foster
robust communication. Additional proposals included adopting and developing an
atmosphere of continuous improvement among all personnel, promoting the practice of
anticipating obstacles and aggressively confronting those obstacles before they can
disrupt productivity.
These findings are pertinent to improved business processes as they exemplify
strategies that other researchers, in Hammer (1990), Karanges et al. (2014), and Yin
(2018) have expressed are important to maintaining business office productivity during a
merger. Various researchers acknowledge a connection between how organizational
leaders strategically develop processes and improve effect on productivity (Cameron et
al., 2016; Al-Ali et al., 2017). Employees who feel valued tend to perform better which
contributes to higher productivity (Seymour & Geldenhuys, 2018; Karanges et al., 2014).
The findings of this study can guide hospital leaders who struggle to maintain business
office productivity during a merger. Following the suggested approaches can aid hospital
business office leaders experience a success merger by improving processes that lead to a
sustained productivity (Angwin & Meadows, 2015; Georgalis et al., 2015).
Implications for Social Change
Using the findings from this study to maintain hospital business office
productivity during a merger could lead to positive social change by helping hospitals,
individuals, and communities succeed. From a hospital perspective, combining business
offices that can maintain productivity will experience successful mergers (Al-Ali et al.,
2017). Hospital leaders with merging business offices that can deliver unified and
consistent messaging experienced a more focused employee outlook and stronger
commitment to achieving established goal (Tabibi et al., 2015). Enhancing employee
focus during a hospital merger can influence the ultimate success of the merger. From
an individual standpoint, effort to enhance leadership engagement with employees
through transparency, better communication, assembling frequently proliferates
opportunities for employee professional development (Eaton & Kilby, 2015;
Osarenkhoe & Hyder, 2015). Employees who have an opportunity to sharpen skills and
add competencies can solidify commit to the organization and improve retention during
a merger (Diab, Safan, & Bakeer, 2018). Employee retention during a merger fosters
stability which enables an organization to focus on productivity (Garmon, 2017).
Merging hospitals with successfully integrating business offices will be able to continue
to provide proximate healthcare to surrounding communities (Cascardo, 2018).
Hospital with efficiently functioning business offices secure adequate operating
revenue and are more likely to have the resources to benefit society through delivering
patient care (Angwin & Meadows, 2015). More hospital leaders are acknowledging the
importance of efficient processes regarding their business practices (Boyd, 2017;
Cleven et al., 2014). Hospitals that experience successful mergers can maintain
profitability and therefore can provide stable healthcare to communities that would be
deprived if diminished productivity during the merger, caused the merger to fail or even
hospital closure ((Dobrzykowski, McFadden, & Vonderembse, 2016).
Recommendations for Action
In this qualitative single case study, I explored leadership considerations for
maintaining hospital business office productivity during a merger. The findings can
benefit hospital leaders who wish to compel employees to appreciate that it was essential
to focus on performance in every area that was measured in efficiency and yield (Ku,
Frogner, Steinmetz, & Pittman, 2015). The recommendations from this research study
may benefit (a) hospital leaders who are in the midst of a merger with another hospital
that may be experiencing a decline in business office productivity, (b) business office
leaders who are having issue with consistent communication with their employees, and
(c) leaders and employees who lack the competency, information, or determination, to
accomplish the organizations productivity goals.
Four recommended steps for action include the following: (a) identify effective
unified and consistent messaging that appeals to employees, (b) establish practices to
evaluate outsourcing opportunities that will compare and contrast the costs and benefit,
(c) develop and identify initiatives that will confront and alleviate fears inherent in the
uncertainty of mergers, (d) seek methodology that operationalizes an aggressive proactive
approach to confronting potential issues. Hospital leaders would benefit from pursuing
these incremental advances by setting attainable goals with a realistic timeframe for
accomplishing them. Continuous monitoring, reassessment, and adjustment will
determine if the initiatives are producing the desired result.
The first recommendation is to identify effective unified and consistent messaging
that appeals to employees. Hospital leaders could initiate this by educating and
reinforcing the goal and “what right looks like” with all stakeholders. Once the direction
is made clear, hospital leaders can find consensus on the exact wording of effective
messaging that will be uniformly adopted by all. Examples range from how messaging
was conveyed in group meetings, to one-on-one scripting for individual encounters, to
written messaging disseminated for instruction, education, encouragement, or
admonishment. Hospital leaders could request input from employees to ascertain what
kinds of messaging and communication methods are effective to them and then create the
messaging in conjunction with their feedback.
The second recommendation is to establish practices to evaluate outsourcing
opportunities that will compare the costs and benefit. A feasible way to establish this
practice is to develop a standard tool that measures outsourcing opportunities based on
agreed upon fixed criteria with which all opportunities will be evaluated. Hospital leaders
can empower employees to evaluate the effectiveness of outsourcing on a business office
responsibility; as the employee, who is the authority closest to the task, plausibly has the
best understanding of what the task requires. From a cost standpoint, hospital leaders can
evaluate if the, in a merger situation, the return on investment is worth increasing the
business given to an outsource vendor to drive down rates, to maintain current levels, or
discontinue use of a vendor altogether.
The third recommendation involves developing and identifying initiatives that
will confront and alleviate fears inherent in the uncertainty of mergers. Hospital leaders
can anticipate employees having fears inherent in any merger processes and be
purposeful in doing what is necessary to alleviate the fears that are within their control.
During a merger, hospital leaders can alleviate merger fears by ensuring employees feel
they are valued by organization. Hospital leaders can be transparent about future-state
plans regarding locations, positions, and responsibilities expected post-merger. Hospital
leaders would benefit from creating opportunities to listen to and respond promptly to the
concerns of employees. This transparency and responsiveness during the merger process
can soothe anxieties of employees which can become disruptive to productivity if not
addressed properly.
The fourth recommendation involves seeking methodology that operationalizes an
aggressive proactive approach to confronting potential issues. For hospital leaders to
realize this recommendation, a culture change must occur. Hospital leaders must create
an atmosphere where all stakeholders have a consistent desire for continuous
improvement. Hospital leadership would benefit from demonstrating, modeling, and
encouraging a relentless pursuit of improvement to each component of a total process. In
addition, hospital leaders could develop a practice of spontaneously inspecting processes
and questioning what have employees noticed that could improve the steps of a process.
Equally as important, leadership can inquire what both leaders and employees are doing
to improve a process at any given time.
Participants in this study will be given a two-page synopsis of the study’s findings
via email. Plans also include publishing this study in the ProQuest Dissertations and
Theses Database. I will also identify opportunities to present the research finding in
industry meetings and other applicable forums.
Recommendations for Further Research
I conducted this qualitative single case study was to explore leadership
considerations for maintaining hospital business office productivity during a merger.
Researchers should conduct further studies to address a couple of key limitations of this
study: geographic location and sample size. The study participants I interviewed worked
with hospital business office operations from both an acquiring hospital and the acquired
hospital in a merger headquartered in the southeastern portion of the United States.
Future researchers could extend the geographical location to other hospital systems
merging in other areas of the United States, as hospital leaders in other areas may have
unique merger characteristics worth investigating. In addition, the findings of this study
might not apply to all hospitals, business offices, or business office employees. Future
researchers could conduct case studies using other departments within medical facilities
that is productivity based.
I suggest that future researchers adhere to some of the delimitations of this study.
For example, they could continue exploring leadership’s considerations for maintaining
hospital business office productivity during a merger, as opportunities continuously
present themselves to gain new knowledge on this phenomenon. Researchers could also
employ purposeful sampling to identify hospital leaders who can effectively address the
topic. However, future researchers might contemplate using mixed-methods or a
quantitative approach to incorporate empirical data on the topic. They could also collect
data from a hospital’s personnel via focus groups or surveys to ascertain employees’
perspectives on strategies to maintain productivity during a merger. Gathering data from
employees can help validate or refute perspectives from hospital leaders.
Reflections
When I embarked on this journey, I was excited to increase my understanding and
knowledge of doctoral-level research. I aggressively studied topics related to research
designs, research methodologies, qualitative validity and reliability approaches, and data
collection techniques. Although the entire process was educational, I found the most
fulfillment by undergoing the process firsthand and experiencing the challenges,
frustrations, and successes that accompanied each phase of the journey. Achieving
milestones such as arriving at a research topic, refining a problem statement and research
questions, finding the case study organization, and collecting and analyzing data required
comprehensive preparation and perseverance. I have greater appreciation and respect for
the strategic and critical thinking and attention to detail required to design, conduct, and
present sound research.
All researchers have preconceived ideas, values, and personal biases that could
sway their data collection and analysis. I abated my own biases by using strategies such
as conducting interviews in neutral environments. In addition, I used an interview
protocol (see Appendix A) to preserve consistency during my dialogue with study
participants. I also conducted member-checking interviews with participants to
corroborate my interpretations of the data I collected.
The interview activity was particularly fulfilling for me, as leaders appeared to be
humbled by the opportunity to discuss their strategies for maintaining business office
productivity during the merger. I was equally humbled after seeing how much the
hospital leadership respected their employees and the challenges they faced during the
course of executing day-to-day responsibilities during the uncertainty of a merger. The
strategies I learned are worth sharing with colleagues and applying throughout my career.
Conclusions
Maintaining business office productivity during a hospital merger is vital to the
success of the merger (Al-Ali et al., 2017). However, some hospital leaders lack
strategies to effectively maintain business office productivity during a merger (Sapkota,
Ivanov, Bachman, Vermillion, & Goyal, 2019). The purpose of the qualitative single case
study was to answer the research question “What strategies do hospital leaders use to
maintain hospital business office productivity during a hospital merger?” Seven leaders
at a recently merged hospital business office in the southeastern section of the United
States participated in interviews to address this question. I complemented the interviews
by examining hospital documents, including the hospital’s social media data, and
website. Four themes emerged following data collection and analysis: (a) leadership
presented unified and consistent messaging; (b) leadership openly shared outsourcing
advantages; (c) a concerted effort to alleviate fear of the unknown; (d) leadership was
proactive in addressing potential challenges. The findings indicated that hospital leaders
who leverage these strategies can maintain business office productivity during a merger.
