Value Stream Mapping to Overcome Obstacles in Adopting Internet of Things in Government Hospital
Suhaili Mohd Hussin1*, Zam Zuriyati Mohamad1, Tengku Rahimah Tengku Arifin1, Azni Suhaily Samsuri1, Siti Subaryani Zainol1
1 Faculty of Business and Finance, Universiti Tunku Abdul Rahman, Perak, Malaysia
*Corresponding Author: [email protected]
Accepted: 1 June 2020 | Published: 15 June 2020
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Abstract: Adoption of internet of things (IOT) is crucial in government hospital to improve the service efficiency especially in reducing the congestion, long waiting time, misplaced records and understaffed. Previous studies concluded that IOT allows faster and safer preventive care, reduce the total cost, upgraded patient unit practice and developed sustainability. However, lack of study related to IOT and health care sector, particularly in Malaysian government hospital. Despites all the government efforts to provide the best medical treatments, little is known on the adoption of IOT in government of hospital. The fundamental issues that need to be addressed is to identify the challenges in adoption of IOT.
In conjunction with that, this study intends to examine the obstacles in adoption of IOT in government hospital. Innovation Resistance Technology will be employed as theoretical model to identify the obstacles. Furthermore, the proposed study also intends to overcome the obstacles by applying value stream mapping. The selection of value stream was due to its ability in identifying the non-value, waste and inefficiency. A Value Stream Mapping is used in the Lean Management approach and helps to create the flow of products for improvements.
Keywords: Service Efficiency, Internet of Things, Government Hospital, Value Stream Performance Measurement, Innovation Resistance Theory
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1. Introduction
Internet of Things (IOT) has progressively applied in many areas of service sectors and widely used in health care industry. In order to keep things running smooth and optimal; IOT offers new possibilities for hospital to improve their service efficiency. In 2015, Ministry of Science, Technology and Innovation (MOSTI) with MIMOS Bhd has initiated National IOT Strategic Roadmap for health care industry. It aims to create continuous diagnostics and precision treatment by using continuous health monitoring application. This application is predictive and actionable models of health and disease. It features with holistic biological data and social information for wellness optimisation and disease management (MIMOS, 2015). The service can be more efficient with this application, as medical staff able to monitor the patients regularly at their desk without need to go to patient’s bed in order to take the data.
The adoption of IOT will contributes to better health services and better social well-being.
This is in line with Sustainable Development Goal (SDG) 9 that build the resilient infrastructure, promote inclusive and sustainable industrialization and foster innovation. The adoption of IOT in the government hospitals is expected to improve the service efficiency.
However, according to the United Nation (UN), the investment in scientific research and innovation is still below the global average despite of the increment in the financing for the economic infrastructure in developing countries (Goal 9: Sustainable Development Knowledge Platform, n.d.). Therefore, more research in the area of promoting a better infrastructure is in need.
In addition, this study is in conjunction with the Sustainable Development Goal (SDG) 11, to make cities and human settlements inclusive, safe, resilient and sustainable. Based on the United Nation (UN) progress goal in 2019, the rate of urban areas expansion is faster than their populations where the areas occupied by cities increased 1.28 faster than their populations between the years of 2000 to 2014. Therefore, the needs for better services in government hospitals are in great importance to ensure public receive enhanced health services (Goal 11: Sustainable Development Knowledge Platform, n.d.). Thus, the use of IOT is hoped to reduce the weaknesses in the government hospitals services such as in the patients’ data registration and management, medicines distribution in the pharmacy department and others.
Shared Prosperity Vision 2030 (SPV 2030), a government blueprint launched by the new government of Malaysia has also reflected the government commitment to implement the agenda for Sustainable Development (SDG 2030). This blueprint aims to build a fair and equitable distribution of economic development at all levels by 2030. In addition, the Malaysian government wants to ensure that no one in any section of society is left behind in achieving the sustainable development as depicted in its Eleventh Malaysia Plan (2016- 2020). Hence, this study was proposed in conjunction with the importance of IOT to improve service efficiency in government hospital. It aims to achieve two objectives. First, to determine the obstacles on the intention to adopt IOT in government hospital. Second, to investigate the application of value stream mapping on the intention to adopt IOT. Third, to examine the potential impact of IOT adoption on service efficiency.
2. Literature Review
Service Efficiency on Government Hospital
Efficiency concept can be seen as an organization uses all available resources or inputs to yield the output. In term of service provider, service efficiency can be determine as reaching maximum productivity with minimum wasted effort. In this context, Palmer and Torgerson (1999) opted that health care as transitional product, which means at the end of results- patients want to improve their health. Therefore, they stated that efficiency is related to the relationship between inputs (costs, in the form of labour, capital contribution or equipment) and either outputs (number of patients treated, or waiting time) or final health result i.e. live saved, life years gained. On the other hand, Hossein, Aljunid, Rahmah, Mazna, and Wan Norlida (2011) tested the efficiency of teaching hospital in Malaysia based on the inputs (bed, doctor, nurse and nonmedical staff) and outputs (number of discharged inpatient and number of visited outpatient by each division). Meanwhile, efficiency in hospital can be drives as control health care cost with simultaneously providing high quality services and better access of care (Shamzaeffa, Ahmad Sobri, Shri Dewi, Jamal and Rahimah, 2016).
Adoption of IOT
The term ‘Internet of Things’ (IOT) is now more extensively used, and there is no common definition or understanding of what the IOT actually comprehends. However, the origin of an Internet of Things (IOT) was found almost 10 years ago and the credit should be given to
Kevin Ashton (2009) refers Internet of Things (IOT) as the network that connecting the objects in the physical world to the Internet. In another definition, it can define as an open and comprehensive network of intelligent objects that have the capacity to auto-organize, share information, data and resources, reacting and acting in the face of situations and changes in the environment (Madakam, Lake, Lake & Lake, 2015). Several past studies conducted the adoption of the IOT in various industries. According to Bi, Da Xu, and Wang (2014) the emerging IOT infrastructure can support information systems of next-generation manufacturing enterprises effectively while many small, medium, and enterprises (SMEs) can improve their business processes by utilizing the digital technology as an effective approach to disseminate the information for their target clients without increasing the cost (Quigley &
Burke, 2013). On the other hand, IOT become more important for the retail industry as it can change the customer shopping behaviour and improve customer interaction when IOT retail technology was implemented. IOT also has key implications for retailers in delivering superior customer experience (Balaji & Roy, 2017).
In the health care industry, the problems are due to the limited accessibility on the patient- related medical information (Turcu & Turcu, 2013). By implementing the IOT specifically for tools or related technologies, it will lead to subsequent dramatic changes in the health care environment. IOT can improves people's access to quality and affordable health care services, to reduce medical errors, to improve patient safety, and to optimize the health care processes.
Moreover, several IOT applications such as Radio Frequency Identification (RFID), and sensors may give significant impact on the health care industry even in an initial stage. In addition, IOT able to monitor the personal care services and maintain an individual digital identity (Kulkarni and Sathe, 2014). Thus, several past studies were conducted on IOT in health care industry in Malaysia. To date, there are studies that explored more on various technologies used in health care services and its security challenges (Bakar, Ramli & Haasan, 2019; Salih, Bakar, Hassan, Yahya, Kama, & Shah, 2019), while other challenges for adopting IOT in the health care industry such as the amount of connected devices and data collection, patient satisfaction also have been discussed (Sivakumar, Jusman, & Mastan, 2017). As a result, most of the past studies conducted in the initial stage explored more on the benefits and challenges of adopting IOT. Lack of studies documented the IOT in government hospital specifically. In order to improve the service efficiency in government hospital, the best option is to adopt IOT.
Expected Impact of IOT in Government Hospitals
The usage of IOT is not only concentrated on having more or better services but commonly performed procedures can be done faster. IOT able to be used in many health applications for instance remote health monitoring, emergency notification systems, wellness activities, chronic diseases and elderly care (Islam, Kwak, Kabir, Hossain & Kwak, 2015). These health applications can form the interactions between different entities involving humans like patients and medical staff, medical devices, smart wheelchairs, wireless sensors, and mobile robots (Mohammed Dauwed & Ahmed Meri, 2019). With many health applications available in the health care industry, the medical staff will put trust on this technology to offer a better quality and affordable health care services, reduce medical inaccuracies when manually record patient’s data, ensure their patients' safety and optimize their health care processes (Turcu & Turcu, 2013).
Other than that, the IOT facilitates the possibility of achieving high exchange of important information between organisations (Mohammed Dauwed & Ahmed Meri, 2019). Therefore, health care in a real-world environment will be able to collect and store data and execute
complex applications with this technology. IOT health care services are also likely to cut costs, rise the quality of life, and improve the user’s experience. According to National Health Expenditure Accounts, United States spend $10,348 per capita on health care services in 2016, which increase 4.3% in 1 year (Hartman, Martin, Espinosa and Catlin, 2018).
Brucher and Moujahid (2017) stated that by monitoring patients in real time based on comprehensive data collection, recording, and analysis of information using sensors, this technology helps to increase quality and eliminate the cost at the same time as a medical staff to be actively engage in data collection by checking the patient’s vital signs at regular intervals. In addition, Brucher and Moujahid, 2017 also indicated that patients will also enhanced their experience, as they are be capable to control their own health by self- monitoring and communicating with the medical staff whenever necessary. This medical staff - patient’s relationship will ensure suitable treatments, increase the accuracy of diagnosis and simplify an intervention time by medical staff.
Feasible Adoption of IOT Value Stream Mapping.
A Value Stream Mapping is one of the tools used in the Lean Management approach (for process improvements) that consists of a sequence of business processes. It helps to create the flow of products and services and demonstrates process improvements (Morlock, & Meier, 2015). Using the Value Stream Mapping method, the wastes, inefficiencies and non-valued added steps can be identified and explored in a single, definable process out of complete product development process (PDP) (Tyagi, Choudhary, Cai, & Yang (2015). According to Bonaccorsi, Carmignani, & Zammori (2011), the Value Stream Map in the services consists of six steps of procedure which are: (1) the organisation has to commit lean, (2) learn about lean, (3) choose the value stream that need improvements, (4) map the current status, (5) identify the waste impact and set the target for improvement and finally, (6) map the future plan.
This Value Stream Mapping approach which is applied for the purpose of Lean Management has been proved successful in manufacturing (Morlock, & Meier, 2015). For instance, it has been applied to the industry that manufactures industrial products such as in Tyagi et al.
(2015) where the unit of their analysis is a branch in energy sector that produced a wide range of gas turbines. In addition, the previous researchers have extended the used of this approach in the services industry such as in Bonaccorsi et al. (2011). They have applied this Service Value Stream Map in the case study of an Italian University. Romero & Arce (2017) stated that the ease of adoption of Value Stream Mapping in various industries has make it a popular approach used in different industries. They have documented the application of this approach as follows:
Table 1: Source: Romero & Arce (2017)
Sector Source
Construction (Matt, et al., 2013)
Health care (Kaale, et al., 2005)
Services: call centre (Piercy & Rich, 2009)
Transport (Villarreal, 2012)
Architecture (Lima, et al., 2010)
Software product lines (Musat & Rodríguez, 2010)
Product development (Tyagi, et al., 2014)
Innovation management (Peek & Chen, 2011)
Services: government (Krings, et al., 2006)
Mining (Kumar, 2014)
Industrial product -service systems (Morlocka & Meier, 2015) Reduction of f ood Looses (Steur, et al., 2016)
Maintenance service (Kasava, et al., 2015)
Innovation Resistance Theory
Innovation Resistance Theory (IRT) was developed by Ram and Sheth (1989) with the intention to examine the incapability of user to adopt technology. Particularly, they argued that people refuse to adopt the technology if they feel that such innovation challenges their satisfactory status quo. The IRT relies on 5 challenges or barriers in adoption of technology which are usage, value, risk, tradition and image. Image is excluded in this study as it is not relevant in determining the adoption of IOT in government hospital. This is because, the image of government hospital is not depending on the adoption of IOT instead the image of government hospital is managing and govern by federal and local authority’s rules and regulation.
Usage barrier
Usage barrier is a situation whereby an innovation is not adaptable with the person’s regular way of working, practices, or habits (Borraz-Mora, Bordonaba-Juste, & Polo-Redondo, 2017). From this study standpoint, it is expected that government hospital will faced difficulties in adoption of IOT due to inconsistency of their existing behaviour. Cant, Wiid, and Hung, (2016) investigated the barriers faced by South Africa Small and Medium Enterprises on the usage of internet based information communication technology (ICT).
They found that lack of knowledge to maintain and use of ICT is the main challenges in adoption of technology. It normally based on the psychological aspect for instance the staff at government hospital may reluctant to adopt IOT due to fear of mistake as it is a new practice for them. The following hypothesis was developed from IRT and past study.
H1: Usage barrier will have negative impact on the intention to adopt IOT.
Value barrier
Value barrier refers to the technology achievement in comparison to the price and existing alternatives. Individual may not adopt the technology if they do not receive any incentive form the adoption. In this study it is necessary to take into consideration from the government hospital on the value from adoption of technology such as the accuracy of the information provided and systematic process using the technology. Thus, if IOT unable to offer more valuable impact to service efficiency, government hospital may not consider to adopt it. The argument is consistent with a study by (Jongbum & Jeonghun, 2017). In their study, they discovered that value barrier is the reason for user resistant to adopt E-books. Consistent with prior literature, the following hypothesis was constructed.
H2: Value barrier will have negative impact on the intention to adopt IOT.
Risk barrier
Risk barrier is defines as the probability that might exist in any innovation and caused individual to delay the adoption. Individual and industry may resistant to adopt the IOT if they foresee the technology will give adverse impact on individual privacy, economic and society. A study conducted by Sivathanu, (2018) empirically evidenced that risk barrier is one of the factors against the intention to adopt of IOT based wearable for health care among
older adults.
H3: Risk barrier will have negative impact on the intention to adopt IOT.
Tradition barrier
Tradition barrier is an obstacle due to the irregularity of innovations from the traditionally perceive concept. Tradition barrier occurs when the changes in adoption of technologies disagrees with their traditions or norms. Users feel uncomfortable to adopt the new technology. In a study by Chen, Tsai, and Hsieh, (2018) found that all the four barriers significantly affect the resistance to adopt the innovation of hydrogen electric motorcycles.
Hence, the following hypothesis has been developed.
H4: Tradition barrier will have negative impact on the intention to adopt IOT.
This study proposed that adoption of IOT will bring benefit to the public and Health Ministry.
Particularly, the implementation of IOT is essential in government hospital. Thus, it is worth to investigate the strategies to overcome the obstacles in adopting IOT. This study propose to use value stream mapping in identifying the non-value, waste and inefficiency in the process of adoption IOT will contribute the intention in IOT adoption. The idea is conceptualise in the proposed framework in Figure 1.
In Figure 1, the obstacles of the proposed study are adopted from Innovation Resistance Theory (IOT). The obstacles will have adverse impact on the intention of IOT adoption. On the hand, it is proposed that value stream mapping concept may able to recommend the strategy to foster the intention of IOT adoption. The actual adoption will not be examined as currently there is limited use in practice. Moreover, IOT in government hospitals in Malaysia are proposed as future services/products. Theoretically, previous researchers have highlighted the gap between intentional behaviour and action (Tudor, Barr, and Gilg, 2007). Thus, this study extends the IRT by including expected value as an impact predicted by behavioural intention.
Figure 1: Proposed Conceptual Framework. H4
H3 H2 H1 Usage
Intention to adopt IOT
Visualisation of complex Value
Quantification of resources
Tradition Risk
Restructuring of workflow
OBSTACLES VALUE STREAM MAPPING
Perceived service efficiency
A quantitative research design will be applied for this study by distributing questionnaires.
The target population is the staff at government hospital who involve with registration, billing, imaging, pathology, emergency, haemodialysis, inpatient, orthopaedic, forensic, physiotherapy and out-patient. They are directly related to the services provided by government hospital. A judgement sampling techniques will be used to select the respondent by considering the years of experience. Data will be collected from the government hospital in Kuala Lumpur (represent capital city of Malaysia), Penang (represent Northern region), Johor (represent Southern region) and Kelantan (represent East Coast Region). The collected data will be analysed using partial least square structural equation modelling.
3. Discussion and Conclusion
The findings for this study will be beneficial to academic research. The combination of technology and accounting research field will give new perspective for multidisciplinary research. The application of value stream performance measurement provide a new research path in determining the service efficiency. Previous studies was focused on either service quality or customer satisfaction. Value stream performance measurement will provide more reliable evaluation as it take into consideration the flow and value in every process. Focusing on government hospital will open an insight new research perspective. The findings will be valuable in improving the service efficiency in government hospital as it will address the issues on how to adopt IOT and the feasibility of adoption IOT in government hospital.
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