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Theory of Constraints (TOC), though a well-established process improvement methodology in manufacturing, is still a novel philosophy for healthcare and an exhaustive review of literature is needed to summarize the key findings of various researchers. Such a review can provide a direction to the researchers and academicians interested in exploring the application of TOC in the healthcare sector. This paper aims to review the existing literature of TOC tools and techniques applied to the healthcare environment, and to investigate motivating factors, benefits and key gaps for identifying directions for future research in the domain of healthcare.

In this paper, different electronic repositories were searched using multiple keywords. The current study identified 36 articles published between January 1999 to mid-2021 to conceptualize and summarize the research questions used in the study. Descriptive analysis along with pictorial representations have been used for better visualization of work.

This paper presents a thorough literature review of TOC in healthcare and identifies the evolution, current trends, tools used, nature of services chosen for application and research gaps and recommends future direction for research. A variety of motivating factors and benefits of TOC in healthcare are identified. Another key finding of this study is that almost all implementations listed in literature reported positive outcomes and substantial improvements in the performance of the healthcare unit chosen for study.

This paper provides valuable insight to researchers, practitioners and policymakers on the potential of TOC to improve quality of services, flow of patients, revenues, process efficiency and cost reduction in different health care settings. A number of findings and suggestions compiled in the paper from literature study can be used for diagnosing, learning and making substantial changes in healthcare. The methodologies used by different researchers were analysed and combined to propose a generic step by step procedure to apply TOC. This methodology will guide the practising managers about the appropriate tools of TOC for their specific need.

Good health is always the first desire of all men and women around the globe. The global aim of healthcare is to quickly cure more patients and ensure healthier population both today and in future. This article will work as a foundation for future applications of TOC in healthcare and guide upcoming applications in the booming healthcare sector. The paper will help the healthcare managers in serving a greater number of patients with limited available resources.

This paper provides original collaborative work compiled by the authors. Since no comprehensive systematic review of TOC in healthcare has been reported earlier, this study would be a valuable asset for researchers in this field. A model has been presented that links various benefits with one another and clarifies the need to focus on process improvement which naturally results in these benefits. Similarly, a model has been presented to guide the users in implementation of TOC in healthcare.

The importance of consumer experience in service industries, particularly healthcare, is widely acknowledged as it captures the intricacies of quality management. In tandem with the emerging research trends that evaluate service excellence through user experience, this study renders a performance analysis of the dimensions of consumer experience that individually or collectively shape healthcare consumers’ perceptions of service quality.

A cross-sectional study was conducted across 13 mid-tier corporate hospitals to collect data from 438 patients. The data was processed through factor analysis in SPSS to confirm sample adequacy and factor extractability. Further, two independent multi-criteria decision-making (MCDM) tools, Fuzzy Technique for Order Performance by Similarity to Ideal Solution (F-TOPSIS) and Grey Relational Analysis (GRA), were executed to render performance analysis of identified factors.

Using F-TOPSIS, factors such as “information” and “hospital environment” received higher performance ratings, while items related to “communication with doctors” and “humanistic care” received lower rankings. Minor yet anticipated deviations were observed while verifying performance scores using GRA. Nonetheless, both outcomes exhibited a strong correlation coefficient of 97.14%, confirming analytical consistency.

Hitherto, such usages of hybrid MCDM techniques have rarely been executed to convey a clear understanding of consumers’ experiences in healthcare services. Moreover, the findings provide a clear insight into consumers’ key response areas, which can further be translated to maximize consumer gratification, thus assisting healthcare managers in improving service performance and clinical decision-making.

This study examines the relationship between economic policy uncertainty (EPU) and managers' ex ante strategic choice on firms’ fixed and variable costs structure, i.e. cost rigidity and the moderating effect of government contracts and political connections.

Using a sample of 4,162 US firms during 2003–2019 and EPU measure from Baker et al. (2016), the authors examine the association between EPU and cost rigidity using multivariate regression analysis. The authors also examine the moderating effects of government customers and political connections using the subsampling method.

This study finds that increases in EPU leads to higher cost rigidity, suggesting that managers tend to look ahead and make an ex ante commitment to invest more in fixed costs to avoid congestion costs in anticipation of future product demand during EPU. The study also finds that the presence of government customers and political connections moderates the need for adopting greater cost rigidity.

This study measures firms' cost rigidity based on archival data. Future studies could utilize managers' cost structure choices using firms' internal management cost structure forecasts data to measure cost rigidity to examine the relationship between cost rigidity and EPU.

This study demonstrates that managers tend to make a proactive commitment to invest in fixed inputs when facing demand uncertainty from EPU to avoid congestion costs. This study also highlights the value of having government contracts and political connections by demonstrating that managers are less concerned about the congestion costs, hence weakening the impact of EPU on cost rigidity when they have government as major customers and/or political connections.

This study extends the management accounting literature by documenting that cost rigidity is related to EPU and that the relationship between cost rigidity and EPU also depends on whether the firm has government as major customers and/or political connections or not.

There is a renewed interest among economists and policymakers in striking a perfect balance between the market, state, and the community for equitable and sustained development. Inclusive development is the need of the hour and healthcare cooperatives provide the perfect means to deliver that. The cooperatives can and should have an important role to play in this scenario. However, there is an important need to provide an enabling environment for the genesis and growth of Healthcare Cooperatives in India and to learn from the best models and practices across the world. The chapter discusses the effectiveness of healthcare cooperatives.

Lean Six Sigma in public and private healthcare organisations has received considerable attention over the last decade. Nevertheless, such process improvement methodologies are not generalizable, and their effective implementation relies on contextual variables. The purpose of this study is to explore the readiness of Italian hospitals for Lean Six Sigma and Quality Performance Improvement (LSS&QPI), with a focus on gender differences.

A survey comprising 441 healthcare professionals from public and private hospitals was conducted. Multivariate analysis of variance was used to determine the mean scores on the LSS&QPI dimensions based on hospital type, gender and their interaction.

The results showed that public healthcare professional are more aware of quality performance improvement initiatives than private healthcare professionals. Moreover, gender differences emerged according to the type of hospital, with higher awareness for men than women in public hospitals, whereas for private hospitals the opposite was true.

This study contributes to the Lean Six Sigma literature by focusing on the holistic assessment of LSS&QPI implementation.

This study informs healthcare managers about the revolution within healthcare organisations, especially public ones. Healthcare managers should spend time understanding Lean Six Sigma as a strategic orientation to promote the “lean hospital”, improving processes and fostering patient-centredness.

This is a preliminary study focussing on analysing inter-relationship between perceived importance of soft readiness factors such as gender dynamics as a missing jigsaw in the current literature. In addition, the research advances a holistic assessment of LSS&QPI, which sets it apart from the studies on single initiatives that have been documented to date.

The study identifies the gap in the understanding of how employee resistance to change (RTC) could impact different stages of the process of innovation. To address this research gap, the paper introduces a new model, which theorizes three moderating effects of RTC on the different elements of absorptive capacity (ACAP).

This study empirically tests the proposed model, using survey data collected from healthcare organizations in the United States of America.

First, the study reveals that RTC could damage the critical “connectedness” between potential absorptive capacity (PACAP) and realized absorptive capacity (RACAP), thus limiting the organization's ability to exploit new knowledge. Second, the findings also reveal that RTC can reduce the positive effect of acquisition (ACQ) on assimilation – the function responsible for decoding the meaning and for assimilating new valuable information incoming from the market.

Research limitations of this study are discussed further.

The paper presents specific practical implications for managers.

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This paper advances past research and practice by revealing two new mechanisms. When employees resist new changes initiated in the organizations, the resistance of employees will hinder the process of innovation in the following ways. (1) At the beginning of the process, employees can oppose and reject new valuable ideas incoming from the market. (2) At the stage of the implementation, such employees can engage in behavior that will weaken the organization's ability to successfully implement new process improvements that could otherwise increase organizational effectiveness.

Higher education institutions (HEIs) are critical in the sustainability agenda, not only as catalysts for promoting sustainability practices but also because their activities have substantial social, economic and environmental impacts. Yet there is limited research that examines their sustainability performance. This paper aims to investigate the factors that are associated with sustainability performance in HEIs. Specifically, drawing from the stakeholder theory and exploiting Ullmann’s (1985) conceptual framework, this study examines the association between sustainability performance and stakeholder power, strategic posture and financial slack resources.

The authors draw the sample from the People & Planet University Green League Table for the period 2011–2019 and use the generalised estimating equations for the modelling approach.

This study finds that stakeholder power, in particular, funding grant income, tuition fee income and student and staff numbers, are positively associated with sustainability performance. In relation to strategic posture, this study finds that sustainability performance is negatively associated with governing body independence and gender diversity, and positively associated with internal structures. Finally, regarding financial slack resources, this study finds that surplus income (staff costs) is positively (negatively) associated with sustainability performance.

To the best of the authors’ knowledge, this research contributes to several existing literature focusing on the not-for-profit sector by documenting, for the first time, the role of stakeholder power, strategic posture and slack financial resources on sustainability performance.

The paper includes relevant implications for HEI managers and regulators for promoting sustainability.

These results contribute to the literature on the factors influencing sustainability performance.

Over the years, despite the best efforts to evaluate service quality through multiple techniques, the connotation between service deliverance and consumer expectation remains sporadic. In the quest to quantify service quality from an innovative perspective, the current study has leveraged consumer-perceived experiences to unveil the novel intricacies of healthcare quality.

Anchoring on the dimensions of patient experience (PX), field data were collected from 244 patients at different private hospitals operating across India. Further, this study incorporated a fuzzy analytic hierarchy process (F-AHP) to evaluate consumer preferences and prioritised the dimensions of PX in three categories of Indian hospitals, namely nursing homes (NHs), mid-tier corporate hospitals (MCHs) and top-tier corporate hospitals (TCHs).

The results establish a performance ranking by demonstrating that MCHs outperform the rest alternatives on the grounds of perceived experiences. Tukey's honestly significance difference (HSD) test was executed to confirm the heterogeneity among the participants' preferences across three different hospital categories. The results reveal that for most of the alternatives, the mean scores of the criterion were statistically significantly different.

In healthcare studies, PX dawned as an entity with an ability to propel healthcare quality in a better way than the classical techniques did. The study's findings present a comprehensive picture of a care delivery system by identifying relatively significant dimensions of PX, hence improving the quality quotients by adjusting healthcare offerings in alignment with consumer expectations and organisational strategies.

High-quality nursing home (NH) care has long been a challenge within the United States. For decades, policymakers at the state and federal levels have adopted and implemented regulations to target critical components of NH care outcomes. Simultaneously, our delivery system continues to change the role of NHs in patient care. For example, more acute patients are cared for in NHs, and the Center for Medicare and Medicaid Services (CMS) has implemented value payment programs targeting NH settings. As a part of these growing pressures from the broader healthcare delivery system, the culture-change movement has emerged among NHs over the past two decades, prompting NHs to embody more person-centered care as well as promote settings which resemble someone's home, as opposed to institutionalized healthcare settings.

Researchers have linked culture change to high-quality outcomes and the ability to adapt and respond to the ever-changing pressures brought on by changes in our regulatory and delivery system. Making enduring culture change within organizations has long been a challenge and focus in NHs. Despite research suggesting that culture-change initiatives that promote greater resident-centered care are associated with several desirable patient outcomes, their adoption and implementation by NHs are resource intensive, and research has shown that NHs with high percentages of low-income residents are especially challenged to adopt these initiatives.

This chapter takes a novel approach to examine factors that impact the adoption of culture-change initiatives by assessing knowledge management and the role of knowledge management activities in promoting the adoption of innovative care delivery models among under-resourced NHs throughout the United States. Using primary data from a survey of NH administrators, we conducted logistic regression models to assess the relationship between knowledge management and the adoption of a culture-change initiative as well as whether these relationships were moderated by leadership and staffing stability. Our study found that NHs were more likely to adopt a culture-change initiative when they had more robust knowledge management activities. Moreover, knowledge management activities were particularly effective at promoting adoption in NHs that struggle with leadership and nursing staff instability. Our findings support the notion that knowledge management activities can help NHs acquire and mobilize informational resources to support the adoption of care delivery innovations, thus highlighting opportunities to more effectively target efforts to stimulate the adoption and spread of these initiatives.

This case study is designed to enable students to analyze the competitive landscape of a business impacted by technological disruption; evaluate the viability of an organic growth strategy using stakeholder analysis; evaluate the revenue and cost structure of Apollo 24/7 and decide on the future investment strategy; and analyze funding strategies of traditional hospitals versus pure digital players.

To extend its reach, Apollo Hospitals Enterprise (Apollo Hospitals), a leading private sector brick-and-mortar hospital chain in India known for using state-of-the-art technology, launched a unified virtual mobile platform Apollo 24/7 in February 2020, 45 days into the COVID-19 pandemic. The management believed that the digital platform had a unique ecosystem that could not be replicated. The analysts were optimistic about the impact of the decision on the future performance of Apollo Hospitals, as it was expected to lead to higher penetration and increased revenue. They also anticipated the unlocking of value, as and when the venture capitalist (VC) would invest in Apollo Hospitals. However, with increasing operating expenses on account of burgeoning technological and marketing expenses, things did not seem to go going as planned. Three years later, in February 2022 after the Q3 of financial year 2023 results. Suneeta Reddy, the company’s managing director found herself pondering whether the digital platform could boost Apollo Hospitals’ profitability in addition to expanding its reach and increasing affordability when the company missed the analyst estimates. In India, which was then the second most populous country, “incremental access” and “affordability” were what mattered to the patients, However, for the investors and analysts, it was quarter-on-quarter performance. The change in the macroeconomic environment stalled the company’s plan of raising money from VCs.

Furthermore, the financing dilemma also plagued Reddy. She knew there was a difference between financing for conventional businesses that for digital businesses. She also had to take decide between short-term profitability with which investors were obsessed versus long-term sustainability, which involved taking care of stakeholders’ interests.

This case study is basically aimed at postgraduate courses and executive management courses.

Teaching notes are available for educators only.

CSS11: Strategy.