Measurement of Facilities Management Performance in Ghana's Public Hospitals [1st ed.] 9789813343313, 9789813343320

Citation preview

Management in the Built Environment Series Editor: Low Sui Pheng

Daniel Amos Cheong Peng Au-Yong Zairul Nisham Musa

Measurement of Facilities Management Performance in Ghana's Public Hospitals

Management in the Built Environment Series Editor Low Sui Pheng, National University of Singapore, Singapore, Singapore Editorial Board Abdul Rashid Bin Abdul Aziz, University Science Malaysia, Penang, Malaysia An Min, Salford University, Salford, UK Azlan Shah Ali, Faculty of Built Environment, University of Malaya, Department of Building Surveying, Kuala Lumpur, Malaysia Faisal M. Arain, Niagara College, Makkah Campus, Welland, ON, Canada Fang Dongping, Tsinghua University, Beijing, China Gao Shang, University of Melbourne, Parkville, VIC, Australia George Ofori, London South Bank University, London, UK Hamzah A. Rahman, University of Malaya, Kuala Lumpur, Malaysia Javier Cuervo, Department of Management and Marketing, University of Macau, Taipa, Macau, Guangdong, China Liu Junying, Department of Construction Management, Tianjin University, Nankai, Tianjin, China Oluwayomi K. Babatunde, Construction Economics & Management, University of the Witwatersrand, Johannesburg, Gauteng, South Africa Oswald Chong, School of Sustainable Engineering and the Built Environment, Arizona State University, Tempe, AZ, USA

The aim of this book series is to provide a platform to build and consolidate a rigorous and significant repository of academic, practice and research publications that contribute to further knowledge relating to management in the built environment. Its objectives are to: 1. Disseminate new and contemporary knowledge relating to research and practice in the built environment 2. Promote synergy across different research and practice domains in the built environment and 3. Advance cutting-edge research and best practice in the built environment The scope of this book series is not limited to “management” issues per se because this then begs the question of what exactly are we managing in the built environment. While the primary focus is on management issues in the building and construction industry, its scope has been extended upstream to the design management phase and downstream to the post-occupancy facilities management phase. Management in the built environment also involves other closely allied disciplines in the areas of economics, environment, legal and technology. Hence, the starting point of this book series lies with project management, extends into construction and ends with facilities management. In between this spectrum, there are also other management-related issues that are allied with or relevant to the built environment. These can include, for example cost management, disaster management, contract management and management of technology. This book series serves to engage and encourage the generation of new knowledge in these areas and to offer a publishing platform within which different strands of management in the built environment can be positioned to promote synergistic collaboration at their interfaces. This book series also provides a platform for other authors to benchmark their thoughts to identify innovative ideas that they can further build on to further advance cutting-edge research and best practice in the built environment. If you are interested in submitting a proposal for this series, please kindly contact the Series Editor or the Publishing Editor at Springer: Low Sui Pheng ([email protected]) or Ramesh Premnath ([email protected])

More information about this series at http://www.springer.com/series/15765

Daniel Amos Cheong Peng Au-Yong Zairul Nisham Musa •

•

Measurement of Facilities Management Performance in Ghana’s Public Hospitals

123

Daniel Amos Kumasi Technical University Kumasi, Ghana

Cheong Peng Au-Yong University of Malaya Kuala Lumpur, Malaysia

Zairul Nisham Musa University of Malaya Kuala Lumpur, Malaysia

ISSN 2522-0047 ISSN 2522-0055 (electronic) Management in the Built Environment ISBN 978-981-33-4331-3 ISBN 978-981-33-4332-0 (eBook) https://doi.org/10.1007/978-981-33-4332-0 © The Editor(s) (if applicable) and The Author(s), under exclusive license to Springer Nature Singapore Pte Ltd. 2021 This work is subject to copyright. All rights are solely and exclusively licensed by the Publisher, whether the whole or part of the material is concerned, specifically the rights of translation, reprinting, reuse of illustrations, recitation, broadcasting, reproduction on microfilms or in any other physical way, and transmission or information storage and retrieval, electronic adaptation, computer software, or by similar or dissimilar methodology now known or hereafter developed. The use of general descriptive names, registered names, trademarks, service marks, etc. in this publication does not imply, even in the absence of a specific statement, that such names are exempt from the relevant protective laws and regulations and therefore free for general use. The publisher, the authors and the editors are safe to assume that the advice and information in this book are believed to be true and accurate at the date of publication. Neither the publisher nor the authors or the editors give a warranty, expressed or implied, with respect to the material contained herein or for any errors or omissions that may have been made. The publisher remains neutral with regard to jurisdictional claims in published maps and institutional affiliations. This Springer imprint is published by the registered company Springer Nature Singapore Pte Ltd. The registered company address is: 152 Beach Road, #21-01/04 Gateway East, Singapore 189721, Singapore

Preface

Performance measurement (PM) has become an important element of strategic planning and quality improvement programmes towards service excellence in today’s competitive and dynamic business environment. Necessitated by the quest to improve healthcare delivery in Ghana, performance has become an issue of discussion among healthcare managers, politicians and the citizenry. Regrettably, most performance measurement interventions have focused on core healthcare delivery rather than facilities management (FM) that provides the enabling environment to facilitate the core healthcare delivery. This therefore raises the question of what performance measurement techniques and tools are applicable for measuring FM performance in public hospitals and how performance as well as performance measurement could be improved. The book presents the results of a novel investigation into facilities management performance measurement in Ghana’s public hospitals. It set fought an in-depth theoretical and empirical underpinnings of performance measurement for hospital facilities management services, with the view to demonstrate critical performance dimensions to improve FM contributions and added value to support healthcare delivery. The research approach adopted is mixed methods encompassing qualitative interviews in case study setting and questionnaire survey of sampled hospitals in Ghana. Accordingly, qualitative interviews were first conducted in selected case study hospitals to familiarize and establish key performance concepts. In line with the standard procedure of an exploratory sequential mixed methods, two strands of questionnaire surveys were conducted for the research population: firstly, to confirm the established performance measures in the qualitative interviews, whereas the second strand of the questionnaire survey was specifically targeted towards assessing the performance of FM. The investigations highlighted the need to improve performance measurement of FM since most of the existing techniques had lapses in measuring FM performance. In relation to key performance indicators (KPIs), 17 KPIs were confirmed and categorized following an expanded balanced scorecard (BSC) typology. In order to ascertain key performance dimensions that need to be improved, a structural model was developed to investigate the interaction between KPIs and performance of FM. The results of the structural equation model (SEM) suggest that strategic v

vi

Preface

commitment should be strengthened. It further affirms FM’s contributions and added value to hospitals. This should motivate public hospital managers to acknowledge FM’s role in healthcare delivery. The book establishes key performance measurement concepts which is of relevance to healthcare managers, facilities management practitioners and academics towards measuring and improving FM performance in hospitals. Although the data used in the analysis is based on the case study country Ghana, the result is by extension useful to several developing countries faced with the challenge to improve FM services delivery in public hospitals as well as other facilities management service sectors. Kumasi, Ghana Kuala Lumpur, Malaysia Kuala Lumpur, Malaysia

Daniel Amos Cheong Peng Au-Yong Zairul Nisham Musa

Contents

1 Introduction . . . . . . . . . . . . . . . . . . . . . 1.1 Background . . . . . . . . . . . . . . . . . 1.2 Problem Statement . . . . . . . . . . . . 1.3 Research Questions . . . . . . . . . . . . 1.4 Research Aims and Objectives . . . 1.5 Significance of the Research . . . . . 1.6 Scope and Limitations of the Study 1.7 Organization of Chapters . . . . . . . . References . . . . . . . . . . . . . . . . . . . . . . .

. . . . . . . . .

. . . . . . . . .

. . . . . . . . .

. . . . . . . . .

. . . . . . . . .

. . . . . . . . .

. . . . . . . . .

. . . . . . . . .

. . . . . . . . .

. . . . . . . . .

. . . . . . . . .

. . . . . . . . .

. . . . . . . . .

. . . . . . . . .

. . . . . . . . .

. . . . . . . . .

. . . . . . . . .

. . . . . . . . .

. . . . . . . . .

. . . . . . . . .

. . . . . . . . .

. . . . . . . . .

1 1 2 3 3 4 5 5 6

2 Overview of Facilities Management and the Public Healthcare System in Ghana . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 2.1 Development and Definitions of Facilities Management . . . 2.2 Facilities Management Functions and Services . . . . . . . . . . 2.3 Healthcare Facilities Management (Review of the Service Scope for the Study) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 2.4 Healthcare Development in Ghana . . . . . . . . . . . . . . . . . . . 2.5 The Ministry of Health and Ghana Health Service . . . . . . . 2.6 Summary . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . References . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

.... .... ....

9 9 11

. . . . .

. . . . .

. . . . .

. . . . .

13 14 16 17 17

3 A Literature Review on Performance Measurement . . . . 3.1 The Concept of Performance Measurement . . . . . . . 3.2 Performance Measurement of Facilities Management 3.3 Key Performance Indicators (KPIs) . . . . . . . . . . . . . 3.3.1 Construction Management KPIs . . . . . . . . . 3.3.2 Supply Chain Management KPIs . . . . . . . . . 3.3.3 Facilities Management KPIs . . . . . . . . . . . . 3.4 Key Performance Indicators for the Study . . . . . . . .

. . . . . . . .

. . . . . . . .

. . . . . . . .

. . . . . . . .

21 21 23 25 25 26 27 28

. . . . . . . .

. . . . . . . .

. . . . . . . .

. . . . . . . .

. . . . . . . .

vii

viii

Contents

3.5 Summary . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . References . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

31 32

. . . . . . . . . . . . . . .

. . . . . . . . . . . . . . .

. . . . . . . . . . . . . . .

. . . . . . . . . . . . . . .

. . . . . . . . . . . . . . .

35 35 36 37 39 39 40 41 41 42 43 43 44 45 46

5 Findings and Discussions . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 5.1 Case Study Findings and Discussions . . . . . . . . . . . . . . . . 5.2 Selection and Presentation of Cases . . . . . . . . . . . . . . . . . . 5.3 Performance Measurement Techniques . . . . . . . . . . . . . . . . 5.3.1 Peer Review Program . . . . . . . . . . . . . . . . . . . . . . 5.3.2 User Satisfaction Surveys . . . . . . . . . . . . . . . . . . . 5.3.3 Inspections with Standard Checklist . . . . . . . . . . . 5.3.4 Quality Assurance Program . . . . . . . . . . . . . . . . . . 5.3.5 Performance Appraisal for FM Staff . . . . . . . . . . . 5.4 Conclusive Remarks on Performance Measurement Techniques for FM Services . . . . . . . . . . . . . . . . . . . . . . . 5.5 Key Performance Indicators . . . . . . . . . . . . . . . . . . . . . . . . 5.6 Performance Outcomes . . . . . . . . . . . . . . . . . . . . . . . . . . . 5.6.1 Peer Review Scores . . . . . . . . . . . . . . . . . . . . . . . 5.6.2 Complaints and Feedback Received . . . . . . . . . . . . 5.6.3 Impact of FM on Core Healthcare Delivery . . . . . . 5.6.4 Budget Variance . . . . . . . . . . . . . . . . . . . . . . . . . 5.6.5 Infections Prevention and Control . . . . . . . . . . . . . 5.7 Conclusive Remarks on Performance Outcomes . . . . . . . . . 5.8 Questionnaire Survey Findings and Discussions . . . . . . . . . 5.9 Scale Development, Reliability and Validity . . . . . . . . . . . . 5.10 Sample Demographics (General Questionnaire Survey) . . . . 5.11 Investigations into Existing Performance Measurement Techniques . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 5.12 Frequency of Use of Performance Measurement Techniques

. . . . . . . . .

. . . . . . . . .

. . . . . . . . .

. . . . . . . . .

47 47 47 48 49 49 50 50 51

. . . . . . . . . . . .

. . . . . . . . . . . .

. . . . . . . . . . . .

. . . . . . . . . . . .

51 52 55 55 56 56 57 57 58 59 59 59

.... ....

62 62

4 Research Methodology . . . . . . . . . . . . . . . 4.1 Research Approach . . . . . . . . . . . . . . 4.2 The Research Process . . . . . . . . . . . . 4.3 Research Strategy . . . . . . . . . . . . . . . 4.4 Case Study . . . . . . . . . . . . . . . . . . . . 4.5 Data Collection in the Case Studies . . 4.6 Survey . . . . . . . . . . . . . . . . . . . . . . . 4.7 Population and Sample . . . . . . . . . . . 4.8 Sample Size . . . . . . . . . . . . . . . . . . . 4.9 Sampling Techniques . . . . . . . . . . . . 4.10 Qualitative Data Analysis . . . . . . . . . 4.11 Quantitative Data Analysis . . . . . . . . 4.12 Conceptual Framework for the Study . 4.13 Summary . . . . . . . . . . . . . . . . . . . . . References . . . . . . . . . . . . . . . . . . . . . . . . .

. . . . . . . . . . . . . . .

. . . . . . . . . . . . . . .

. . . . . . . . . . . . . . .

. . . . . . . . . . . . . . .

. . . . . . . . . . . . . . .

. . . . . . . . . . . . . . .

. . . . . . . . . . . . . . .

. . . . . . . . . . . . . . .

. . . . . . . . . . . . . . .

. . . . . . . . . . . . . . .

. . . . . . . . . . . . . . .

. . . . . . . . . . . . . . .

. . . . . . . . . . . . . . .

. . . . . . . . . . . . . . .

. . . . . . . . . . . . . . .

Contents

5.13 Effectiveness of Existing Performance Measurement Techniques . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 5.14 Determining Key Performance Indicators (KPIs) for PM of FM Services . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 5.15 Exploratory Factor Analysis (Principal Components) of KPIs . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 5.15.1 Bartlett’s Test of Sphericity and the Kaiser Meyer-Olkin (KMO) Test . . . . . . . . . . . . . . . . . . . . . 5.15.2 Determining Communalities . . . . . . . . . . . . . . . . . . . 5.15.3 Factor Specifications and Variable Selection . . . . . . . 5.16 Discussion of Results . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 5.17 The Relationship Between KPIs and Performance of FM Services . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 5.18 Descriptive Statistics for KPIs and Performance Outcome Measures of FM Services . . . . . . . . . . . . . . . . . . . . . . . . . . . 5.19 Development of a Hypothetical Model (KPIs Versus Performance) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 5.20 Application of Partial Least Squares Structural Equation Modelling (PLS-SEM) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 5.21 Assessment of the Measurement Model . . . . . . . . . . . . . . . . . 5.21.1 Assessment of the Reflective Constructs . . . . . . . . . . 5.21.2 Assessment of the Formative Construct (Performance of FM Services) . . . . . . . . . . . . . . . . . . . . . . . . . . . . 5.22 Assessment of the FM Performance Structural Model . . . . . . . 5.23 Coefficient of Determination (R2) . . . . . . . . . . . . . . . . . . . . . 5.24 Statistical Power of the Structural Model . . . . . . . . . . . . . . . . 5.25 Evaluating Significance and Relevance of the FM Structural Model . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 5.26 Discussion of Results . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 5.27 Summary . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . References . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 6 Conclusions and Recommendations . . . . . . . . . . . . . . . . . . . . . . . 6.1 Conclusions of the Study . . . . . . . . . . . . . . . . . . . . . . . . . . . 6.1.1 Research Question 1: What are the Performance Measurement Techniques Used for Evaluating FM Services? . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 6.1.2 Research Question 2: What are the Key Performance Indicators for Performance Measurement of FM Services? . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 6.1.3 Research Question 3: How Do the Key Performance Indicators Influence Performance of FM? . . . . . . . . . . 6.2 Contributions to Knowledge . . . . . . . . . . . . . . . . . . . . . . . . . 6.3 Implications for Practice . . . . . . . . . . . . . . . . . . . . . . . . . . . .

ix

..

64

..

67

..

68

. . . .

. . . .

68 69 70 72

..

75

..

75

..

78

.. .. ..

79 81 81

. . . .

. . . .

83 84 85 85

. . . .

. . . .

87 89 92 93

.. ..

97 97

..

98

..

98

.. 99 . . 100 . . 101

x

Contents

6.4 6.5

Recommendations for Public Hospital Managers . . . . . . . . . . . . 101 Suggestions for Future Research . . . . . . . . . . . . . . . . . . . . . . . . 102

Appendix A: Protocol for Case Study Interviews . . . . . . . . . . . . . . . . . . . 103 Appendix B: Questionnaire Survey on KPIs for FM . . . . . . . . . . . . . . . . 107 Appendix C: General Questionnaire Survey . . . . . . . . . . . . . . . . . . . . . . . 111 Appendix D: PLS-SEM Evaluation . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 117

Abbreviations

AVE BSC CR CSFs CV EFA FM GHS HAIs HTMT ICT IFMA IPC KMO KPI MOH NHIA NHS PCA PLS-SEM PMS QA SCOR SEM SLA VIF WHO

Average variance extracted Balanced scorecard Composite reliability Critical successful factors Convergent validity Exploratory factor analysis Facilities management Ghana Health Service Hospital acquired infections Heterotrait–monotrait ratio of correlations Information communication technology International Facilities Management Association Infection prevention and control Kaiser–Meyer–Olkin Key performance indicator Ministry of Health National Health Insurance Authority National Health Service Principal component analysis Partial least squares structural equation modelling Performance measurement system Quality assurance Supply chain operational reference Structural equation modelling Service-level agreements Variance inflation factor World Health Organization

xi

List of Figures

Fig. Fig. Fig. Fig. Fig. Fig. Fig.

2.1 4.1 4.2 5.1 5.2 5.3 5.4

Hospital FM services, NHS . . . . . . . . . . . . . . Research process . . . . . . . . . . . . . . . . . . . . . . . Conceptual framework of the study . . . . . . . . Hypothetical model for the structural equation PLS-SEM Evaluation (Adopted from [63]) . . . Coefficient of determination . . . . . . . . . . . . . . FM structural equation model with t values in

.......... .......... .......... modelling . . .......... .......... parenthesis .

. . . . . . .

. . . . . . .

. . . . . . .

. . . . . . .

. . . . . . .

14 38 45 76 80 86 88

xiii

List of Tables

Table Table Table Table Table Table Table Table Table Table Table Table

2.1 2.2 3.1 3.2 4.1 5.1 5.2 5.3 5.4 5.5 5.6 5.7

Table 5.8 Table 5.9 Table 5.10 Table Table Table Table Table Table Table Table Table Table Table

5.11 5.12 5.13 5.14 5.15 5.16 5.17 5.18 5.19 5.20 5.21

Categorization of FM services . . . . . . . . . . . . . . . . . . . . . . . Health facilities by type . . . . . . . . . . . . . . . . . . . . . . . . . . . . Rationale for measuring performance . . . . . . . . . . . . . . . . . . Summary of key performance indicators from literature . . . . Sample distribution by region. . . . . . . . . . . . . . . . . . . . . . . . Case studies profile . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Rankings of KPIs . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Performance measurement techniques and outcomes . . . . . . Sample demographics . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . PM approaches in-use for FM services . . . . . . . . . . . . . . . . PM techniques according to the type of FM service . . . . . . Level of effectiveness of performance measurement techniques . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Group difference test using Kruskal–Wallis . . . . . . . . . . . . . Pairwise comparison of the level of effectiveness of PM techniques . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Bartlett’s Test of Sphericity and the Kaiser Meyer-Olkin (KMO) Test . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Communalities for KPIs . . . . . . . . . . . . . . . . . . . . . . . . . . . . Principal component analysis results for KPIs . . . . . . . . . . . Descriptive statistics for KPIs (Performance scores) . . . . . . . Descriptive statistics for performance measures . . . . . . . . . . Convergent validity (2nd trial after deleting IB6) . . . . . . . . . Fornell-Larcker criterion . . . . . . . . . . . . . . . . . . . . . . . . . . . . Cross loadings . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . HTMT . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Measurement properties for formative constructs . . . . . . . . . Lateral collinearity (Inner VIF) . . . . . . . . . . . . . . . . . . . . . . Result of the path coefficient (hypothesis testing). . . . . . . . .

. . . . . . . . . . .

12 15 22 30 42 48 53 55 60 63 64

.. ..

65 66

..

67

. . . . . . . . . . . .

69 70 71 77 78 81 82 83 83 84 85 87

. . . . . . . . . . .

. . . . . . . . . . . .

xv

Chapter 1

Introduction

Abstract The introductory chapter presents the background of the study and the research problem. Based on the research problem, the chapter then defines the research questions, aim and objectives of the study. The chapter briefly highlight the significance of the research as well as the scope and limitations of the study. The chapter concludes with an outline of the book.

1.1 Background Global competition and the dynamic business environment of today’s knowledge economy have placed Performance Measurement (PM) on the agenda on many organizations [1]. Consequently, there are much concerns in finding the best ways to measure and report many types of activities that could improve performance with more emphasis on non-financial measures [2]. Performance measurement is the language of process for many organization in today’s information driven decision making environment as it gives direction to an organization in achieving its goals [3]. In the health sector, performance measurement has equally become a potent part of strategic and service quality decisions leading to several international projects initiated by the World Health Organization (WHO) [4]. Although the primary objective of hospital is on clinical care, there are other support services without which modern day hospitals cannot effectively deliver their core tasks. Within the context of hospital management, the largest component of nonclinical services falls within the ambit of Facilities Management (FM). Ikediashi [5] observed that FM have continued to live by it definition of creating the right enabling environment that supports the core mandate of rendering clinical and medical diagnostic services, while [6] asserts that FM is one of the key elements for successful delivery of healthcare services. It is an established fact that clinical tasks such as safety, patient centered care, minimizing medical errors are key factors for hospital performance [7], nonetheless an important primary factor usually overlooked is the facilities management services which provides the enabling environment for healthcare delivery. Given that poor FM practices can significantly hinder the delivery of © The Author(s), under exclusive license to Springer Nature Singapore Pte Ltd. 2021 D. Amos et al., Measurement of Facilities Management Performance in Ghana’s Public Hospitals, Management in the Built Environment, https://doi.org/10.1007/978-981-33-4332-0_1

1

2

1 Introduction

the hospital’s core services [8], measuring performance is a key step towards ensuring optimal service delivery and equally an essential tool for effective implementation of a facilities management strategy in hospitals [9, 10]. Yet most of the international and local performance measurement interventions in healthcare have focused on clinical performance of hospitals rather than FM [11]. Amaratunga [12] noted that performance measurement for healthcare FM provides the primary evaluation, planning tools and it identifies the performance indicators that are meaningful to FM and the core business. Put succinctly by Buttigieg et al. [13], performance measurement provides hard evidence about existing practices, values, and enables the administration to develop a systematic means of identifying shortfalls and improve its future performance. Against this backdrop, this study seeks to contribute to public healthcare delivery in Ghana by developing a performance measurement model to acknowledge as well as enhance FM’s contribution to healthcare to ensure that appropriate added value is achieved [14].

1.2 Problem Statement Hospital managers around the world are faced with tight decisions with regard to cost reduction, service efficiency and equity, responsiveness to users and communities as well as service quality [15]. At the same time patients are becoming more knowledgeable than ever amidst increasing levels of competition, patient service alternatives, medical and technological advances [16]. In Africa and for that Ghana where quality healthcare is seen as a poverty reduction strategy, the problem is further exacerbated by shortage of appropriately trained and motivated health workers, limited use of ICT, increase utilization without any significant improvements in equipment and infrastructure as well as challenges with quality of service provision [17]. In pursuance of the agenda of creating a healthy human capital support for national development, Ghana’s healthcare sector has been subjected to several reforms in recent years. This includes the National Health Policy, Ghana Shared Growth and Development Agenda I &II, Ghana National Healthcare Quality Strategy and more remarkably the National Health Insurance Scheme (NHIS) which has resulted in an increased access to public healthcare [18, 19]. Notwithstanding these interventions, the quality of healthcare in public hospitals in Ghana has remain a significant challenge and has been under constant pressure from the public and governments to improve. Inappropriate FM practices resulting in the prevalence of Hospital Acquired Infections (HAIs), substandard healthcare healing environment coupled with the general lackadaisical attitude of staff have continued to be a challenge in most public hospitals in Ghana [20, 21]. The problem is further exacerbated by the dwindling financial fortunes of the National Health Insurance Authority (NHIA) which is one of the main financier of public healthcare in Ghana, thus leading to a deliberate and constant challenge in competing needs between core healthcare and non-core FM of scare resources in public hospitals [22].

1.2 Problem Statement

3

As a result of these challenges, performance has become an issue of discussion among healthcare managers, politicians and the citizenry. The recently updated policy on infection prevention and control by the Ministry of Health placed an enormous responsibility on the FM departments [23], nonetheless the policy framework equally lacked a systematic means through which FM performance can be assessed. Yet there is very little if any comprehensive empirically based research reported in the literature which is directed towards performance measurement of FM services in public hospitals in Ghana, notwithstanding the significance of performance measurement as a critical tool that can ensure optimal performance by monitoring FM progress, identifying weak areas in performance, opportunities for improvement and enhanced motivation leading to improved healthcare delivery [24, 25]. This is quite disturbing given that public hospitals forms the largest public sector agency under the Ministry of Health (MOH) and account for a substantial portion of government budget [19]. Again considering the fact that FM is at an embryonic stage in public hospitals in Ghana, which is more operational and less strategic and usually placed on a lower position in the healthcare hierarchy, FM departments may not be well equipped with the necessary best practice mechanisms to develop performance measurement systems which underscores the need for this research to develop a model for performance measurement as a point of reference to evaluate FM performance to make resources more sustainable in Ghana’s public hospitals. From the abovementioned problem, the study seeks to answer three research questions which are presented in the next section.

1.3 Research Questions The major question for the study is “How do public hospital in Ghana measure the performance of facilities management services”? To answer the above question, the research would seek to address the following sub questions; 1. What are the performance measurement techniques used for evaluating FM services? 2. What are the key performance indicators for performance measurement of FM services? 3. How do the key performance indicators influence performance of FM services?

1.4 Research Aims and Objectives The aim of this study is to examine performance measurement of FM services by drawing on knowledge on existing performance measurement practices and literature to identify critical performance dimensions with the view to develop a mechanism that would improve performance measurement of FM. In order to achieve this aim, the research objectives are:

4

1 Introduction

1. To identify existing performance measurement techniques used in evaluating FM performance. 2. To determine key performance indicators for performance measurement of FM services. 3. Develop a structural model to investigate the relationships between key performance indicators and performance of FM.

1.5 Significance of the Research Despite the numerous performance measurement initiatives in healthcare organizations, most of these performance interventions have centered on clinical performance rather than the non-clinical FM performance. Performance measurement is a strategic function that has the ability to link the facilities management department to organizational performance via its corporate objectives. Thus a study on FM performance measurement is worthy to facilitate quality healthcare delivery in the context of public hospital management. Theoretically, the research contributes to FM literature by exploring performance measurement in the context of a developing country like Ghana. Generally, research on performance measurement for FM services in public hospitals are limited, while a few studies are centered mostly in developed countries [26–28]. The study thus provides a theoretical foundation that can be used in an academic capacity to study FM performance in public hospitals in most developing countries where FM is emerging. This study adds to the FM body of knowledge a performance measurement structural model which is useful to improve FM services in public hospitals taking cognisance of the poor state of quality of healthcare delivery in Ghana. As there are limited studies that examine the role of FM to healthcare delivery more especially in developing countries, this study is one of the few that has attempted to measure FM in hospitals which should motivate healthcare managers to acknowledge FM’s role in healthcare delivery. In practice, by examining performance measurement techniques, KPIs and performance outcomes, public hospitals FM managers’ can evaluate their level of performance and institute appropriate strategies to improve performance. By extension, the developed model of the study is of invaluable use to many developing countries who share similar socio economic characteristics and are equally faced with the challenge to improve FM services delivery in public hospitals. Recommendations from the study are also expected to guide the key regulators of public hospitals in Ghana (Ministry of Health and Ghana Health Service) in their policy planning, monitoring and evaluation. Other state and parastatal organizations can also benefit from recommendations from the study to improve upon their FM practices. Methodologically, the study also makes an important contribution. The study employs an exploratory sequential mixed methods approach to develop performance scales and applies Partial Least Squares Structural Equation Modelling (PLS-SEM) to successfully verify and validate the research model, thus increasing the attention

1.5 Significance of the Research

5

of FM researchers towards the use of PLS-SEM since it is yet to gain grounds in FM research despite its appreciation in other academic disciplines [29].

1.6 Scope and Limitations of the Study This study was limited to public hospitals under the management of the Ghana Health Service (GHS) within South Western Ghana. Specifically defined in the context of this study to include Ashanti, Western, Central and Brong Ahafo regions.1 These four regions together account for about 55% of public hospitals in Ghana and are among the most economic vibrant regions in Ghana. Further, the four regions in total account for about 48% of Ghana’s population with substantial healthcare needs. Unarguably, there are numerous services in public hospitals which each play a complimentary role in the healthcare delivery, however the service scope of this study was limited to general hospitals cleaning, waste and estate management services. These services have been carefully selected because they sit contiguous to each other and are well established in Ghana’s public hospitals. Moreover they are linked to causing Hospital Acquired Infections (HAIs) which is prevalent in Ghana [26, 30]. Besides studying all services would be unrealistic and can result in poor understanding of the concepts being investigated. Finally, typical of most public institutions in developing countries, there were instances of under staffed FM departments, long leave of absence and vacant positions which in some instances affected the number of participants in both the interviews and the questionnaire survey that the researcher expected. Nevertheless, the researchers remained determined not to compromise the standard of the research in the midst of these challenges.

1.7 Organization of Chapters This book is structured into 6 chapters. This chapter; set forth the background of the research, statement of the research problem, research questions, aims and objectives, scope and limitations of the study. Chapter 2; presents an introduction to the definitions and development of facilities management. An overview of FM function and services is presented, based on which the service for the study are selected. The chapter also presents an overview of public healthcare delivery in Ghana and the key stakeholders (MOH/GHS) to inform readers on how the public health care system works in Ghana. Chapter 3; provides a review of extant literature on performance measurement. First an overview of the theoretical concepts on performance measurement is presented, followed by a review of literature on performance measurement within

1 Based

on the map of Ghana as at August, 2017 before creation of new regions.

6

1 Introduction

the context of FM. The chapter also presents a review of key performance indicators to extract performance scales that are useful to the study. Consistent with any scientific investigation, the chapter further reviewed literature on key performance indicators in supply chain and construction management to argument the existing indicators in FM. Chapter 4; is devoted to the research methodology. The chapter begins with an elucidation of the research approach of the study. A concise but brief description of the research strategies, design, data collection and analytical procedures is presented. The chapter also presents the conceptual framework of the study. Chapter 5; combines the findings and discussions from the multiple case studies interviews and the questionnaire survey. Chapter 6; presents the conclusions and recommendations of the study. Suggestions for future research are outline as part of the concluding remarks.

References 1. C. Yang, S. Modell, Power and performance: institutional embeddedness and performance management in a Chinese local government organization. Acc. Auditing Accountability J. 26(1), 101–132 (2012) 2. K.K. Choong, Has this large number of performance measurement publications contributed to its better understanding? A systematic review for research and applications. Int. J. Prod. Res. 52(14), 4174–4197 (2014) 3. M. Pitt, M. Tucker, Performance measurement in facilities management: driving innovation? Property Manag. 26(4), 241–254 (2008) 4. H.-C. Liu, A theoretical framework for holistic hospital management in the Japanese healthcare context. Health Policy 113(1), 160–169 (2013) 5. D.I. Ikediashi, A Framework for Outsourcing Facilities Management Services in Nigeria’s Public Hospitals (Doctoral Dissertation) (Heriot-Watt University: Edinburgh, Scotland, 2014) 6. L. Rodríguez-Labajos, C. Thomson, G. O’Brien, Performance measurement for the strategic management of health-care estates. J. Facil. Manag. 16(2), 217–232 (2018) 7. V. Nieva, J. Sorra, Safety culture assessment: a tool for improving patient safety in healthcare organizations. Qual. Saf. Health Care. 12(suppl 2), ii17-ii23 (2003) 8. P. Featherstone, D. Baldry, The value of the facilities management function in the UK NHS community health-care sector. J. Manag. Med. 14(5/6), 326–338 (2000) 9. K. Alexander, The emergence of facilities management in the United Kingdom National Health Service. Property Manag. 11(1), 31–41 (1993) 10. N.E. Myeda, S.N. Kamaruzzaman, M. Pitt, Measuring the performance of office buildings maintenance management in Malaysia. J. Facil. Manag. 9(3), 181–199 (2011) 11. D. Amos, Z.N. Musa, C.P. Au-Yong, Performance measurement of facilities management services in Ghana’s public hospitals. Build. Res. Inf. 48(2), 218–238 (2020) 12. D. Amaratunga, D. Baldry, M. Sarshar, Assessment of facilities management performance— what next? Facilities 18(1/2), 66–75 (2000) 13. S.C. Buttigieg, A. Pace, C. Rathert, Hospital performance dashboards: a literature review. J. Health Organ. Manag. 31(3), 385–406 (2017) 14. P.A. Jensen, T. van der Voordt, Towards an integrated value adding management model for FM and CREM, in 20th CIB World Building Congress 2016 (2016) 15. M. Mesabbah, A. Arisha, Performance management of the public healthcare services in Ireland: a review. Int. J. Health Care Qual. Assur. 29(2), 209–235 (2016)

References

7

16. M. Elg et al., Swedish healthcare management practices and quality improvement work: development trends. Int. J. Health Care Qual. Assur. 24(2), 101–123 (2011) 17. M. Akosua Akortsu, P. Aseweh Abor, Financing public healthcare institutions in Ghana. J. Health Organ. Manag. 25(2), 128–141 (2011) 18. B. Ekman, Community-based health insurance in low-income countries: a systematic review of the evidence. Health Policy Plann. 19(5), 249–270 (2004) 19. Ministry of Health, Ghana National Healthcare Quality Strategy (2017) 20. F. Owusu, Differences in the performance of public organisations in Ghana: implications for public-sector reform policy. Dev. Policy Rev. 24(6), 693–705 (2006) 21. World Health Organization (WHO), 2016 Annual Report. 2016 10/12/2018, Available from: https://www.afro.who.int/publications/ghana-annual-report-2016 22. R.K. Alhassan, E. Nketiah-Amponsah, D.K. Arhinful, A review of the National Health Insurance Scheme in Ghana: what are the sustainability threats and prospects? PLoS ONE 11(11), e0165151 (2016) 23. Ministry of Health (MOH), National Policy and Guidelines for Infection Prevention and Control in Health Care Settings 2015 10/0/2017. Available from: https://www.ghanahealths ervice.org/downloads/National_Policy_and_Guidelines%20_for_Infection_Prevention_and_ Control_in_Health_Care_Settings_2015.pdf 24. Myeda, N.E., Enhancing the Facilities Management (FM) Service Delivery in Malaysia: The Development of Performance Measurement Framework (PERFM) (Doctoral Dissertation), UCL (University College London, 2013) 25. M. Støre-Valen, A. Kathrine Larssen, S. Bjørberg, Buildings’ impact on effective hospital services: the means of the property management role in Norwegian hospitals. J. Health Organ. Manag. 28(3), 386–404 (2014) 26. C. Liyanage, C. Egbu, A performance management framework for healthcare facilities management. J. Facil. Manag. 6(1), 23–36 (2008) 27. S. Njuangang, C. Lasanthi Liyanage, A. Akintoye, Performance measurement tool (PMT) to control maintenance-associated infections. Facilities. 34(13/14), 766–787 (2016) 28. I.M. Shohet, L. Nobili, Application of key performance indicators for maintenance management of clinics facilities. Int. J. Strateg. Property Manag. 21(1), 58–71 (2017) 29. D.I. Ikediashi, S.O. Ogunlana, I.A. Odesola, Service quality and user satisfaction of outsourced facilities management (FM) services in Nigeria’s public hospitals. Built Environ. Project Asset Manag. 5(4), 363–379 (2015) 30. World Health Organization (WHO), Report on the Burden of Endemic Health Care-Associated Infection Worldwide. 2011 20/08/2017. Available from: https://www.who.int/gpsc/country_w ork/burden_hcai/en/

Chapter 2

Overview of Facilities Management and the Public Healthcare System in Ghana

Abstract This chapter set forth the general background of facilities management and facilities management within the context of healthcare. The chapter also provides information on the FM functions and services to define the FM services scope of study. Finally, literature on public healthcare system in Ghana, specifically on healthcare development as well as the role of key stakeholders such as the Ministry of Health and the Ghana Health Service are also presented.

2.1 Development and Definitions of Facilities Management According to [1], the evolution of FM dates back to 1950s residential and commercial development in the then America which was powered by Dwight D. Eisenhower federal interstate highway system. Contrary to this, [2] maintain that the term FM originated during the late 1960s and describes the practice of banks increasingly outsourcing the processing of credit card transactions to specialist providers while [3] attributes the origin of FM to the Herman Miller Corporation, the world’s leading furniture manufacturer staged conference on “Facilities Impact on Productivity” in 1978. Against this diverse background on the evolution of FM, [4] postulate that FM has existed as long as buildings and its recorded history is a nanosecond in time. In its modern form made up of institutes, academic programs and professionals, FM has only existed since the 80s [5]. In the latter part of the 1990s several scholars and FM professional bodies have defined FM in various ways. There is a widespread variance in understanding of what FM is, how it operates and to what extent it offers sustainable opportunities for businesses [6]. Ikediashi [7] noted that there is a lack of consensus on an appropriate definition for FM. Hinks and McNay [8] have attributed the lack of a universally accepted definition for facilities management (FM) to the evolving nature of the discipline. In extant literature, the most frequently cited definition is from the International Facility Management Association (IFMA), [9] which defined FM as “a profession

© The Author(s), under exclusive license to Springer Nature Singapore Pte Ltd. 2021 D. Amos et al., Measurement of Facilities Management Performance in Ghana’s Public Hospitals, Management in the Built Environment, https://doi.org/10.1007/978-981-33-4332-0_2

9

10

2 Overview of Facilities Management and the Public Healthcare …

that encompasses multiple disciplines to ensure functionality of the built environment by integrating people, places, processes and technology”. Another often-cited definition comes from [10] which defined FM as “an integrated approach to operating, maintaining, improving and adapting the buildings and infrastructure of an organization in order to create an environment that strongly supports the primary objectives”, whereas the international organization for standardization (ISO) defines FM as “organizational function which integrates people, place and process within the built environment with the purpose of improving the quality of life of people and the productivity of the core business” [11]. The focus of these two definitions is on FM meeting organization objectives. IFMA’s definition stresses on the interdependences of multi disciplines, however it failed to link it in meeting the organizations objectives as such [12] describes IFMA’s definitions as a basic framework for FM. Atkin and Brooks [10] postulate that whatever form FM is defined, the focus should be on integrative, interdependent disciplines whose overall purpose is to support an organization in the pursuit of its business objectives. According to [10], FM can thus be said to: • • • • • • •

Support people in their work and in other activities. Enhance individual well-being. Enable the organization to deliver effective and responsive services. Sweat the physical assets, that is, make them highly cost-effective. Allow for future change in the use of space. Provide competitive advantage to the organization’s core business. Enhance the organization’s culture and image.

This book entirely agrees from the foregoing arguments and accordingly defines FM as; The management of infrastructure and support services to provide added value to support the achievement of an organization objectives at best cost.

Although FM is relatively young in comparison to other management disciplines, it has developed recognition as a profession in a number of regions across the world. According to [13], between 1980 and 1990s was a transformational period for FM in Europe and that by mid-1980 FM had entered United Kingdom and Netherlands in 1986. In the 1990s FM made it way to northern Europe, entering Germany in 1995 and Scandinavia in 1992. Within the period 1993-1995 most countries in Europe had established various FM professional bodies. In Asia, FM has seen development in Japan, Australia, New Zealand, Hong Kong, Singapore and more recently in Malaysia. Globalization, ICT, rising cost of space and labour, coupled with the dynamics of the Asian economy have driven the development of FM in the region [14]. In Africa, FM is evolving and hardly exist as an explicit profession in most countries, however most organizations do adopt procedures mimicking that of a facilities manager’s role [15]. The review of literature reveals a severe deficiency of FM research in Africa, plausibly due to its embryonic stage and informal recognition as a profession. Empirical evidence suggests that, FM has grown largely in Nigeria, Ghana and South Africa. South Africa has a registered body with which

2.1 Development and Definitions of Facilities Management

11

FM is regulated; the South African Facilities Management Association while Ghana and Nigeria have local chapters of IFMA [16]. Opaluwa [17] asserts that facilities management practice in Nigeria has seen a steady growth in recent years with a wide range of applications. According to [18] FM in Nigeria presents diverse activities with janitorial services topping the list of the facilities services. Nigeria’s growth of FM is partly attributed to the rigors activities of multinational companies operating in its rich oil fields. In addition, FM has also seen applications in several areas of the private and public sectors such as banking and hospitals in Nigeria [19]. In Ghana, the development of FM can be tracked to the last two decades due to the springing up of commercial banks amidst outsourcing of non-core banking services. Anecdotal evidence suggests that concentrating on core business and cost reduction were the primary drivers. Outsourcing of services such as cleaning, security, reception, cashier services and catering became rampant in the private sector. In the public sector, FM was exhibited in local governments through the use of Private Finance Initiate (PFI) due to budgetary constraints and the need to exploit potentials in privatization of public infrastructure to allow for private capital inflow in the development and operations of public facilities [20]. In the health sector, the introduction of the National Health Insurance Act (NHIA) in 2003 brought on board numerous healthcare service providers to offer various facets of services to public and private healthcare institutions, mostly procurement of medicines and medical equipment, infrastructure development and services [21]. In the early part of 2013, the commercialization of Ghana’s nascent oil and gas industry stimulated FM in the energy sector due to the influx of multi-national oil and gas companies [22]. Notwithstanding the growth and contribution of FM in various sectors, the practice is bedevilled with numerous challenges. Prominent among them are reactive FM practices, lack of policy guidelines for FM, complete absence of building maintenance manuals, lack of funds, lack of strategic direction and socio cultural issues [23]. These challenges deserve the urgent attention of FM researchers and practitioners.

2.2 Facilities Management Functions and Services Regarded as a form of traditional maintenance and real estate management practices where friends and family were a necessary form of cheap labour for FM functions, FM has grown to become a defined sector accounting for the greatest component of operational expenditure for many organizations [24, 25]. According to [26], FM has undergone a significant shift over the past decade and has developed an increasingly sophisticated understanding of its role within the organization. The growth in the complexity of buildings and the cost significance of their operation has led to the need to introduce tactical and strategic management functions, thus raising the profile of the discipline alongside other support functions such as the management of human resources and information technology. FM’s primary function is to handle and manage support services to meet the needs of the organization, its core operations and employees [27]. According to [10], FM is responsible for managing infrastructure

12

2 Overview of Facilities Management and the Public Healthcare …

and services in order to achieve optimum productivity, constant quality improvement, cost reduction and risk minimization and ultimately improved value for money. The typical FM function ranges from strategic which is more confined to senior management level, middle level or tactical to the operational level who are usually the task masters. Strategic FM concerns planning for the future facility and service provision and extends beyond operational matters requiring the facility manager to be well versed in the organization’s quantitative and qualitative objectives, economic considerations, and the qualities of an effective, comfortable work environment [28]. Tactical FM manages the operational tasks by ensuring best practices that meet organizations goals and objectives [27]. The objective of tactical FM is to add value to the organizational planning, support services, and management of processes [29]. Operational FM are the real task masters offering the variety of FM tasks such as maintenance, security, janitorial services among others. To date the scope of FM is not clearly defined and numerous authors have generically synchronized facilities management services into various forms of hard and soft FM. Hard FM relates to management and maintenance of property which is engineering based while soft FM basically involves the management of support services. Table 2.1 depicts the various categorizations of the FM services as presented in literature. Careful examination of Table 2.1 shows that most of the services identified are homogenous. Chitopanich [27] noted that the range of facilities management services is widely accepted as being broad and highly inclusive of a number of functions and roles played out by practitioners. Some schools of taught like [30] and [31] have also argued that FM is evolving and constantly changing, as such adopting a rigid scope could be relevant Table 2.1 Categorization of FM services Author/Year FM services [27]

Real estate and property management, maintenance and repairs, office services, space planning and management and employee support services

[17]

Personnel, information services, premises and support services

[34]

Property management, property operations and maintenance and office administration

[9]

Communication, quality, technology, operations and maintenance, human factors, finance and business, emergency planning and business continuity, leadership and strategy, real estate and property, project management, and environmental stewardship and sustainability

[10]

Real estate management, financial management, change management, human resources management, health & safety and contract management, building management, domestic services (such as cleaning and security) and utilities supplies

[35]

Estate management, environmental management support services, hotel support services, site support services, business support services and space management support services

[36]

Reception, health, safety, mail room, security, helpdesk, catering, grounds and gardens, cleaning, mechanical and electrical engineering, and waste management

2.2 Facilities Management Functions and Services

13

only in the short term. This study agrees entirely with these taught as harmonizing a uniform scope will prove to be difficult due to the variance in context of the competencies developed by various FM professional bodies and scholars. On that account, [32] advocate that FM researchers have to develop a robust knowledge base to ensure longevity. A recent research by Bröchner et al. [33] makes several propositions towards shaping the future of FM. Bröchner et al. [33] recommend inter alia the need for digitization and sustainable FM as well as strengthening and consolidating FM education, research and practice.

2.3 Healthcare Facilities Management (Review of the Service Scope for the Study) The National Health Service of the United Kingdom (NHS) defines healthcare facilities management as “the process by which an NHS trust creates and sustains a caring environment and delivers quality hotel services to meet clinical needs at best cost” [37]. Healthcare facilities management is one of the complex and challenging task to manage. This is attributed to the need for facilities to be working perfectly at all time. The least and any deficiency or failure has the possibility to cause dead. [38] asserts that the provision of FM and other non-core activities to healthcare organizations have been growing gradually, as its impact on the quality and effectiveness of healthcare services and that the current state of the art in both academic and professional communities consist of six key domains; maintenance management, performance management, risk management, supply services management, development and ICT. From the perspective of FM as a support service to healthcare delivery, [35] presents an outline of the FM services in the Nation Health Service (NHS) UK, grouped under six distinct categorizes of estate management support services, environmental management support services, hotel support services, site support services, business support services and space management support service. Figure 2.1 shows the categorization and the respective services. In a recent study and from the perspective of a developing country, [7] conducted a study on outsourcing of FM services in public hospital in Nigeria. The study identified estate management, maintenance and repairs, administrative management as well as employee support services. This study acknowledges that all these FM services for hospital are vital for healthcare delivery and patient satisfaction; however the scope of this study will be limited to cleaning, waste management and estate management services. These three services are deemed quite critical to public hospitals in Ghana and affect user satisfaction directly. Moreover, it is established that poor management of these services can cause Hospitals Acquired Infections (HAIs) which is prevalent in Ghana [39– 41]. HAIs is a major problem for patient safety and its impact can result in prolonged

14

2 Overview of Facilities Management and the Public Healthcare …

FACILITIES MANAGEMENT

Hotel support services

Catering Reception Residence House keeping

Environmental support services

Health & safety Pollution control Incineration Waste mgt.

Estate Mgt. Services

Grounds and gardens Energy & utilities Property mgt. Property maintenance Design Building services

Site support services

Pottering Security Car parking Telecommun ication Accommoda tion& Cleaning Hygiene

Business support services

Leisure Recreation Strategic maintenance Transportation Occupation health Reprographic Procurement IT Transportation Purchasing Marketing Complaints management

Space Mgt. support services

Space utilization Space allocation Space Audit

Fig. 2.1 Hospital FM services, NHS

hospital stay, long-term disability, increased resistance of micro-organisms to antimicrobial agents, a massive additional financial burden for the health system, high costs for patients and their families, and excess deaths [42]. HAIs have been a challenge to healthcare globally. According to estimates by the World Health Organization (WHO), 15 per 100 patients in developing countries attract HAIs with a prevalence rate of about 15% [42].

2.4 Healthcare Development in Ghana Ghana’s healthcare has a long history of development. Following the colonization by Britain in the 1870s, formal healthcare was run by the British missionaries. According to [43], in 1878 there were four colonial army medical hospitals in the southern Ghana (situated in Keta, Accra, Cape Coast and Elimina) and a collection of missionary operated hospitals, aid post and clinics. Records has it that they were established to serve the British colonial officials and not the ordinary citizenry [44]. The political instability between 1970 and 1980 thwarted any efforts to make health reforms. Within

2.4 Healthcare Development in Ghana

15

that period there were six different military regimes. According to [43] the then military regime in 1978 was forced to sign up the “Alma-Ata Declaration” to improve healthcare equity and access following global discussions. The plan aimed to build primary healthcare centres to make accessibility more easily for the citizenry. This bold initiate however failed due to lack of resources and the will to implement. Subsequently there was the Bamako initiative by United Nations International Children’s Emergency Fund (UNICEF) signed by African health ministers which equally failed in 1987 [44]. In modern day Ghana’s democratic dispensation since 1992 upon establishing the national constitution, superior reforms and investment have been made in the health sector. More recently the national health policy of 2007, Ghana shared growth and development agenda I and II, and the Ghana national healthcare quality strategy [41]. Principally public healthcare delivery comprises of primary healthcare institutions made of district, municipal and metropolitan hospitals; secondary healthcare which are regional hospitals and also serves as emergency centres and tertiary which are teaching hospitals run by public universities. In addition, there are polyclinics, clinics, community health improvement compounds (CHIPS) and traditional birth attendants (TBAs). In terms of ownership, government owned hospitals under the management of the Ghana health services account for about 55% while the private sector makes up about 40% of the hospitals mostly dominated by mission based healthcare service providers such as the Christian health service hospitals and the Islamic missionary hospitals [45]. There are however a few quasi government health institutions. Table 2.2 provides the summary statistics of healthcare by the various regions as well as the type of facility. Despite the significant investment and expansion in healthcare facilities over the last two decades, Ghana now faces a high threat of infectious and chronic non-communicable diseases (NCDs), such as hypertension, Table 2.2 Health facilities by type Region

CHIPS

Clinic

Ashanti

1041

130

135

96

1

0

Brong Ahafo

458

102

90

12

4

0

Central

235

67

61

16

2

1

Eastern

611

116

99

14

2

0

Greater Accra

201

283

28

76

13

2

Northern

386

56

96

13

4

0

Upper East

225

50

53

1

0

0

Upper West

208

14

68

8

5

0

Volta

350

40

161

11

3

0

Western

470

145

64

20

0

0

National

4185

1003

855

267

34

3

Source GHS 2017 Annual report

Health centres

Hospital

Polyclinic

Psychiatric hospital

16

2 Overview of Facilities Management and the Public Healthcare …

stroke, diabetes and cancers [46]. In fact Schieber, Cashin [47] attributed the possible rise in non-communicable diseases to the populations’ structure, lifestyles and the tendency of an increases number in the over 64 years age bracket. Life expectancy estimates by the World Health Organization is fairly low around 62 years for male and 64 for female. Possibility of dying between 15 and 60 years per 1000 Ghanaians stands at 262 and 222 for men and women respectively. Although some progress have been made in healthcare delivery, there are challenges such as morbidity and mortality caused by malaria and drug resistance tuberculosis among others [48].

2.5 The Ministry of Health and Ghana Health Service The Ministry of Health and the Ghana Health Service are primarily responsible for public healthcare delivery in Ghana. As a critical sector of the Ghanaian economy, the Ministry of Health is mandated to develop policies and see to the implementation of programs that will improve the health of the citizenry. It has the sole mandate of regulating all forms of healthcare delivery in Ghana through its policy planning, monitory and evaluation under the leadership of the health minister [49]. The ministry works in collaboration with its sector agencies and collaborates both locally and internationally with sector agencies and departments to improve the human capital support of the nation through the deployment and implementation of polices to ensure improved healthcare and universal coverage for all Ghanaians. The Ghana health service is an autonomous public sector agency responsible for implementing programs by the ministry of health and has the largest staff numbers of the ministry. Established in 1996 under Act 525, the GHS has the mandate to provide quality healthcare delivery to the public through implementation of policies rolled out by the ministry. The GHS has the responsibility to provide equitable, efficient, accessible and responsive health services to all Ghanaians. It also has the authority to implement national policies with the council of the Ministry of Health. The principal functions of the Ghana Health Service include; • “Develop appropriate strategies and set technical guidelines to achieve national policy goals/objectives”. • “Undertake management and administration of the overall health resources • “Promote healthy mode of living and good health habits by people”. • “Establish effective mechanism for disease surveillance, prevention and control”. • “Determine charges for health services with the approval of the Minister of Health”. • “Provide in-service training and continuing education”.

2.6 Summary

17

2.6 Summary This chapter focused on the concept of facilities management as well as public sector healthcare delivery in Ghana which forms the basis of this study. With the desire to reduce operational expenditure of the built environment, coupled with the persistent change in requirements of buildings and health systems, facilities management has become an important discipline for both academics and practitioners. The review shows that FM has evolved to become a defined discipline and organizations have acknowledged it role in supporting core business. In most developing countries and for that matter Ghana, FM is emerging and there is paucity of research in FM which underscores the need for more research interest. The chapter discusses the evolution, definitions and functions of FM. In particular it links the concept of FM with healthcare and review key facilities management services in healthcare delivery. Based on the review, the FM service for the study are selected. The second part of this chapter highlighted the background of healthcare in Ghana, more importantly this was aimed at informing readers about the health characteristics of Ghana to be understood in its right context rather than being judged as a universal phenomenon.

References 1. R. Starner, The Legacy of one Man Site Selection. publication of January. (Conway Data Incorporated, 2004) 2. Lord, A., et al., Emergent behaviour in a new market: facilities management in the UK. in Proceedings of the 2002 Conference of the Manufacturing Complexity Network:“Tackling Industrial Complexity: The Ideas that Make a Difference.” University of Cambridge (2002) 3. M. Pitt, M. Tucker, Performance measurement in facilities management: driving innovation? Property Manag. 26(4), 241–254 (2008) 4. F. Becker, The Total Workplace: Facilities Management and Elastic (Praeger, New York, 1990) 5. A. Junghans, N. OE Olsson, Discussion of facilities management as an academic discipline. Facilities, 32(1/2), 67–79 (2014) 6. L. Tay, Strategic facilities management of Suntec Singapore International Convention and Exhibition Centre: a case study. Facilities 24(3/4), 120–131 (2006) 7. D.I. Ikediashi, A framework for outsourcing facilities management services in Nigeria’s public hospitals (Doctoral Dissertation) (Heriot-Watt University, Edinburgh, Scotland, 2014) 8. J. Hinks, P. McNay, The creation of a management-by-variance tool for facilities management performance assessment. Facilities 17(1/2), 31–53 (1999) 9. International Facilities Management Association(IFMA), What is Facility Management? 2006 10/9/2016. Available from: https://www.ifma.org/about/what-is-facility-management 10. B. Atkin, A. Brooks, Total Facilities Management. 4th edition ed. 2015 (Wiley-Blackwell Publishers, New York, 2015) 11. International Organization for Standardization(ISO), Facility Management—Scope, Key Concepts and Benefits (2018). [cited 2018 1/5/2018]. Available from: https://www.iso.org/ standard/71235.html 12. L.S. Pheng, Z. Rui, Service quality for facilities management in hospitals (Springer, Singapore, 2016) 13. K.I. Levainen, Building Sites as a City Facility (Facilities management: European Practice, Arko publishers, Netherlands, 1997), pp 44–47

18

2 Overview of Facilities Management and the Public Healthcare …

14. M. Moore, E. Finch, Facilities management in South East Asia. Facilities (2004) 15. C.M. Natukunda, M. Pitt, A. Nabil, Understanding the outsourcing of facilities management services in Uganda. J. Corporate Real Estate 15(2), 150–158 (2013) 16. Y. Adewunmi, C. Ajayi, O. Ogunba, Facilities management: factors influencing the role of Nigerian estate surveyors. J. Facil. Manag. 7(3), 246–258 (2009) 17. S. Opaluwa, Principles and Practice of Facilities Management in Nigeria (Still Waters Publications, Abuja, 2005) 18. V. Alaofin, Overcoming the challenges facing FM operators in Nigeria to profit from hidden opportunities. Facil. Manag. World 4(1), 42–48 (2003) 19. D.I. Ikediashi, A.M. Ekanem, Outsourcing of facilities management (FM) services in public hospitals: a study on Nigeria’s perspective. J. Facil. Manag. 13(1), 85–102 (2015) 20. S. Olusola Babatunde, A. Opawole, O. Emmanuel Akinsiku, Critical success factors in publicprivate partnership (PPP) on infrastructure delivery in Nigeria. J. Facil. Manag. 10(3), 212–225 (2012) 21. NHIA, NHIS Review (2014) 22. F. Obeng-Odoom, Oiling the Urban Economy: Land, Labour, Capital, and the State in SekondiTakoradi, Ghana. (Routledge, 2014) 23. H.A. Koleoso, M.M. Omirin, Y.A. Adewunmi, Performance measurement scale for facilities management service in Lagos-Nigeria. J. Facil Manag. 15, 128–152 (2017). https://doi.org/10. 1108/jfm-04-2016-0015 24. B. Atkin, L. Bildsten, A future for facility management. Constr. Innovation. 17, 116–124 (2017). https://doi.org/10.1108/ci-11-2016-0059 25. N. Brackertz, R. Kenley, A service delivery approach to measuring facility performance in local government. Facilities 20(3/4), 127–135 (2002) 26. N. Brackertz, Relating physical and service performance in local government community facilities. Facilities 24(7/8), 280–291 (2006) 27. S. Chotipanich, Positioning facility management. Facilities 22(13/14), 364–372 (2004) 28. F. Waardhuizen, The two facets of facility management. Eur. Facil. Manag. 1, 12–17 (1999) 29. C. Langston, R. Lauge-Kristensen, Strategic management of built facilities (Routledge, London, 2013) 30. L. Tay, T.L. Ooi Joseph, Facilities management: a “Jack of all trades”? Facilities. 19(10), 357–363 (2001) 31. Z. Waheed, S. Fernie, Knowledge based facilities management. Facilities 27(7/8), 258–266 (2009) 32. S. Nenonen, A.-L. Sarasoja, Facilities management research in Finland–state-of-art about current Finnish PhD-projects. Facilities 32(1/2), 58–66 (2014) 33. J. Bröchner, T. Haugen, C. Lindkvist, Shaping tomorrow’s facilities management. Facilities 37(7/8), 366–380 (2019) 34. D.G. Kincaid, Measuring performance in facility management. Facilities. 12(6), 17–20 (1994) 35. M.I. Okoroh et al., Adding value to the healthcare sector—a facilities management partnering arrangement case study. Facilities 19(3/4), 157–164 (2001) 36. M. Tucker, M. Pitt, Customer performance measurement in facilities management: a strategic approach. Int. J. Prod. Performance Manag. 58(5), 407–422 (2009) 37. E. NHS, Health Facilities Note (HFN) 17—A Business Approach to Facilities Management (HMSO Publications London, 1998) 38. I.M. Shohet, S. Lavy, Healthcare facilities management: state of the art review. Facilities 22(7/8), 210–220 (2004) 39. C. Liyanage, C. Egbu, A performance management framework for healthcare facilities management. J. Facil. Manag. 6(1), 23–36 (2008) 40. S. Njuangang, C. Liyanage, A. Akintoye, Key performance measures to control maintenanceassociated HAIs. Int. J. Health Care Qual. Assur. 28(7), 690–708 (2015) 41. Ministry of Health (MOH), National Policy and Guidelines for Infection Prevention and Control in Health Care Settings 2015 10/0/2017. Available from: https://www.ghanahealths ervice.org/downloads/National_Policy_and_Guidelines%20_for_Infection_Prevention_and_ Control_in_Health_Care_Settings_2015.pdf

References

19

42. World Health Organization (WHO), Report on the Burden of Endemic Health Care-Associated Infection Worldwide. 2011 20/08/2017. Available from: https://www.who.int/gpsc/country_w ork/burden_hcai/en/ 43. A.D.-G. Aikins, K. Koram, Health and Healthcare In Ghana, 1957–2017. (The Economy of Ghana Sixty Years after Independence, 2017), p 365 44. D.K. Arhinful, The solidarity of self-interest: social and cultural feasibility of rural health insurance in Ghana (Afr. Stud. Centre, Leiden, 2003) 45. G. Abekah-Nkrumah, T. Dinklo, J. Abor, Financing the health sector in Ghana: a review of the budgetary process. Eur. J. Econ. Finance Adm. Sci. 2009(17), 45–59 (2009) 46. Agyei-Mensah, S., A.D.-G. Aikins, Epidemiological transition and the double burden of disease in Accra, Ghana. J. Urban Health. 87(5), 879–897 (2010) 47. G. Schieber et al., Health Financing in Ghana (World Bank Publication, Washington, 2012) 48. World Health Organization (WHO), 2016 Annual Report. 2016 10/12/2018. Available from: https://www.afro.who.int/publications/ghana-annual-report-2016 49. Ministry of Health (MOH), Role and Function of MOH. 2018 10/01/2018. Available from: https://www.moh.gov.gh/the-ministry/

Chapter 3

A Literature Review on Performance Measurement

Abstract This chapter explores and reviews performance measurement literature to understand the theoretical concepts and in particular identify the gaps in performance measurement literature. The chapter is presented in three parts. The first sections examines the concept of performance measurement generally and subsequently within the context of facilities management. The second part of the chapter deals with key performance indicators. In order to gain a broader knowledge of KPIs, a review of KPIs in construction and supply chains disciplines is conducted alongside KPIs in FM. Based on the integration of KPIs from the three disciplines, KPIs for the study are selected and presented.

3.1 The Concept of Performance Measurement The concept of performance measurement is multi-dimensional, complex, and sometimes ambiguous while the development of a universal theory of performance measurement has eluded scholars amidst a high degree of fragmentation [1]. Choong [2] observed that despite the high level of academic and practical interests in Performance Measurement Systems (PMS), there is little to no agreement on such simple and obvious areas such as terms and descriptions. According to [3] attempts to define PM is frustrating since the word “performance means so many different things. In management terms, it can mean anything from efficiency, to robustness or resistance or return on investment, or plenty of other definitions never fully specified”. In management literature, one of the most often cited definitions is by Neely et al. [4]. The authors defines performance measurement as the” process of quantifying the effectiveness and efficiency of an action. Whereas the term effectiveness refers to the extent to which a particular requirement or goal is achieved, efficiency indicates the speed of performing an action that by standards has to be both quantifiable and verifiable [5]. By contrast, [6] opined that performance measurement should be actions geared towards meeting the strategic objectives of an organization. According to [3],

© The Author(s), under exclusive license to Springer Nature Singapore Pte Ltd. 2021 D. Amos et al., Measurement of Facilities Management Performance in Ghana’s Public Hospitals, Management in the Built Environment, https://doi.org/10.1007/978-981-33-4332-0_3

21

22

3 A Literature Review on Performance Measurement

PM is a system by which a company monitors its daily operations and evaluates whether it is attaining its objectives. This study agrees entirely with these definitions and accordingly view PM as activities centred on the assessment of task in an organization to ensure superior performance. According to [7], PM evolved around the 1860s and 1870s and developed with a straight-forward objectives to monitor and maintain organizational processes. The aim was to achieve the goals and objectives and compare results against expectations with the implied objective of learning to do better [8]. In the 1960s, it became a key topic amongst accounting researchers with traditional management accounting system focused on financial measures such as traditional budgeting, costing, variances analysis and cost volume profit [9]. The main objectives of the traditional PM was on maximizing the wealth of stakeholders. In the 1990s, the constantly changing business environment amidst globalization and competition changed the direction of PM [10]. Traditional performance measurement tools designed for the industrial-age economy, which emphasize financial measures and tangible assets, were no longer able to capture the changing nature of today’s business environment [11]. Consequently, scholars from several disciplines for the last two decades have directed significant effort in the development of multidimensional performance measurement systems comprising financial and non-financial measures [12]. PM is now recognized as a continuous improvement tool based on critical element of strategic planning, quality improvement programs, service excellence and results based budgeting systems. According to [13] public managers can use performance measurement to achieve eight managerial purposes. As part of their overall management strategy, public managers can use PM to evaluate, control, budget, motivate, promote, celebrate, learn and improve as illustrated in Table 3.1. Behn [13] further postulate that without at least a tentative theory of how performance measures can Table 3.1 Rationale for measuring performance Purpose

Questions for managers of public organizations

Evaluate

How well is my public agency performing?

Control

How can I ensure that my subordinates are doing the right thing?

Budget

On what programs, people, or projects should my agency spend the public’s money?

Motivate

How can I motivate line staff, middle managers, non-profit and for-profit collaborators, stakeholders, and citizens to do the things necessary to improve performance?

Promote

How can I convince political superiors, legislators, stakeholders, journalists, and citizens that my agency is doing a good job?

Celebrate

What accomplishments are worthy of the important organizational ritual of celebrating success?

Learn

Why is something working or not working?

Improve

What exactly should be done differently to improve performance?

Source Adopted from [13]

3.1 The Concept of Performance Measurement

23

be employed to foster improvement, public managers will be unable to decide what should be measured. Sharma [14] noted that PM is a crucial element to improve business performance and it is believed that organizations that effectively implement performance measurement systems are likely to perform better than those that do not. Harbour [15] describe performance measurement as a necessity to achieve organizational goals. According to [15], PM helps an organization to establish performance goals and track progress of base lines and achieved performance. By analysing the variance between targeted and achieved performance, organization can determine their position and develop strategies to improve future performance. From the foregoing arguments, PM is an important tool for organizational improvement, however performance measurement outcomes can be useful when management integrate performance measurement with performance management. Amaratunga and Baldry [16] however postulate that measurement is not an end to itself, but a tool for more effective management. Performance management involves systematic utilization of performance information to improve organizational outcomes [17]. Positioning performance measurement within the context of this research, it has the greatest influence on FM, since the largest operational expenditure is on the functional operations of facilities, as such facilities managers are gradually embracing PM who increasingly use it as a benchmark against which effectiveness can be measured and as a basis for which improvement can be determined. The next section reviews PM in the context of facilities management.

3.2 Performance Measurement of Facilities Management FM performance measurement could be viewed as a measure of how adequate FM is at identifying the needs of the users and its ability to put in place proper provisions to satisfy such needs and enhance their productivity [18]. Congruent to this, [19] describe performance measurement as a process of assessing progress towards achieving pre-determined goals, including information on the efficiency by which resources are transformed into goods and services, the quality of these outputs and outcomes, and the effectiveness of organizational objectives. By this definition, it is expected to have an established goals vis-a-vis stated objectives to be met. The question then is how is FM performance assessed or measured? [20] postulate that the process of measuring performance should be operational, inventive, performancebased and comparative both within and between organizations. According to [21], the starting point of PM is an understanding of the organization’s objectives which forms the basis of FM operational measures. Another school of taught by Duffy [22] is that Key Performance Indicators (KPIs) are the first step towards improvement and knowledge on performance measurement and their interrelationship with organizations goals, processes and roles should be made visible via a modern framework for organization modelling. Choosing the right KPIs is however reliant upon having a good understanding of what is important to the organization. Atkin and Brooks [23] refers to such factors as Critical Success Factors (CSFs) and describe

24

3 A Literature Review on Performance Measurement

them as those actions that must be performed well in order for the goals or objectives established by an organization to be met satisfactorily. CSFs are paramount to performance measures of any organization and without well-established CSFs, performance measurement systems are likely to fail. Thus the development of KPIs and Performance Measurement Systems (PMS) requires a thorough understanding of the CSFs which are aligned to the strategic objectives of the organization. Measuring FM performance presents enormous benefits to the organization. According to [24] performance measurement in FM is important for reviewing past and present functioning of a facility and for making decisions regarding future strategies. Koleoso et al. [25] views PM as ways to improve effectiveness of facilities by providing simple ways of achieving user requirements with minimal efforts and costs as well as assists the process of resource allocation while [26] posit that performance measurement and management in FM is an effective tool to detect pros and cons of the domestic service, support strategic decision-making, serve as a point of reference to compare past performance levels with the present and utilized to identify mistakes and assist with appropriate remedies to be taken. The conclusion to be made from these discussions is that there is growing importance of the need to measure FM performance. This is of particular interest to healthcare facilities which remains amongst one of the complex, costly and challenging to manage. Performance measurement for healthcare facilities is complex due to the need to balance efficiency and cost against access, with quality and consumer outcomes [27]. The constant changes and advancement in healthcare, further makes performance measurement important to healthcare since informed decisions about aspects of facilities services that needs to be improved, retain or dispose to a large extent leads to effective clinical strategy and performance [28]. Regrettably, PM has not been given the needed attention in FM and that models for FM performance have been limited [29]. Meng and Minogue [30], Amos et al. [31], observed however that there is a lack of systematic investigations of performance measurement systems in the context of FM, as most studies in FM have largely relied on PM models in other management discipline. Notably, models such as the Balanced Scorecard, Performance Prism, and the European Foundation for Quality Management. Nevertheless, in the quest of raising facilities management role towards to the organization, FM researchers have equally developed PM frameworks. Brackertz and Kenley [32] developed the Service Balanced Scorecard (SBSC) specifically for the management of public buildings in Victoria Melbourne, Australia as part of the Logometrix project. Tucker and Pitt [33] developed the Customer Performance Measurement System (CPMS) to improve FM service delivery to customers. Liyanage and Egbu [26], Njuangang et al. [34] also developed FM performance measurement frameworks specifically to control Hospital Acquired Infections (HAIs). Using the basis of the BSC [35], developed the Facilities Management Balanced Scorecard (FMBSC) for Italian hospitals. On the basis of the plan-do-check and act cycle, [36] developed a four step framework for FM performance measurement and value adding. Koleoso et al. [18], observed that most of the performance measurement frameworks in extant literature reflect peculiar issues within an organization and do not lend themselves for comparison across firms, practices and situations. Considering

3.2 Performance Measurement of Facilities Management

25

hospital FM services in Ghana as under developed discipline with its own peculiar characteristics, a great deal of modification will be needed in the application of these frameworks in extant literature. As such a context specific FM performance measurement framework tailored to improve the quality of FM services in public hospitals in Ghana is required.

3.3 Key Performance Indicators (KPIs) Performance measurement systems will make no meaning unless key performance indicators are developed to monitor and measure the progress. Toor et al. [37] posited that performance measurement can be carried out by establishing KPIs which offer objective criteria to measure the success of a project. KPIs represent a set of measures focusing on those aspects of organizational performance that are the most critical for the current and future success of the organization [38]. Maté [39] adds further that such measures are relative to organizational objectives thereby enabling corrective action where there are deviations. In fact the BSC institute advocates that the KPIs should determine the gap between actual and targeted performance and determine organization effectiveness and operational efficiency. KPIs should be manually integrated within dashboards and scorecards used by decision makers and should be capable of generating a quantified value to indicate the level of performance taking into account single or multiple aspects [40]. This study note that the application of KPIs in FM is not rigors as compared to other management disciplines. Consistent with any scientific investigation, a brief review of KPIs in construction management and supply chain where KPIs have been rigorously explored is first presented. Thereafter studies on KPIs in FM is also presented. The rationale is to generate a broader list of KPIs to build a robust knowledge for FM performance measurement.

3.3.1 Construction Management KPIs In the quest of improving construction performance, KPIs have been very popular tool for researchers and practitioners in the construction industry. In one of the studies in UK, [6] identified seven project performance indicators for a conceptual performance management framework. The framework adapted the balanced scorecard (BSC) with the addition of a number of elements and perspectives. On the basis of subjective and objective measures, [41] developed 9 KPIs for the success of construction performance in Hong Kong. According to [41] whereas the objective measures uses mathematical formulae to calculate the respective values, subjective measures uses opinions and personal judgment of the stakeholders. A study by Luu et al. [42] on project management performance of large contractors in Vietnam using benchmarking approach identified 9 KPIs mostly subjective. The findings by Luu

26

3 A Literature Review on Performance Measurement

et al.[42] corroborate [41]. In yet another study congruent to [42, 37] noted exceptionally that the traditional measures of the iron triangle (on-time, under-budget and according to specifications) have long been applied to measure the performance of large public sector development projects. Nonetheless, performance indicators such as safety, efficient use of resources, effectiveness, satisfaction of stakeholders, and reduced conflicts and disputes are increasingly becoming important. The authors developed and analysed the perceptions of three different stakeholders involved in an airport project in Thailand. In a more rigorous attempt to develop indicators for performance measurement for construction projects in Saudi Arabia, [43] extended the BSC’s four perspective of finance, internal business process, customer satisfaction, learning and growth and added environmental performance as a fifth perspective to developed 47 indicators. Although the study acknowledged the need for a minimal number of KPIs, it failed to apply appropriate method to reduce the KPIs to a meaningful number. Data reduction techniques such as factor analysis might probably have re-grouped and reduced the indicators. Recent studies by Che Ibrahim et al. [44] on construction team integration based on the mean ranking identified free flowing communications as the highest factor for effective team integration while client care team was the least factor. The study was geared towards developing KPIs to mitigate problems of integration, coordination and communication between projects.

3.3.2 Supply Chain Management KPIs According [45] performance measures in supply chain can generally be classified as qualitative and quantitative in nature. Qualitative measures involve no direct measurement although some aspect may be quantifiable and include indicators such as customer satisfaction, flexibility, information and material flow, integration and effective risk management whereas the quantitative measures are segmented into cost, customer response and productivity measures. Cho et al. [46] identified cost, time, quality, flexibility, innovativeness and resource utilization as key performance indicators for supply chain performance. These KPIs falls into the collective group of qualitative and quantitative described by Chan and Qi [45]. The Supply Chain Operation Reference (SCOR) has also been used as basis for the development of KPIs. According to [47], KPIs should be developed using the SCOR as a basics and that potential KPIs should be developed for each of the SCOR’s four meta-processes operations reference of plan, source, make, and deliver. Arif-Uz-Zaman and Nazmul Ahsan [48] also advocate that supply chain performance indicators should be a combination of reliability measures, cost measures, responsiveness measures and asset management efficiency. In a recent study and based on studies of several authors, [49] used a qualitative approach to the identify transport optimization, inventory optimization, information technology optimization and resource optimization as KPIs to enhance performance

3.3 Key Performance Indicators (KPIs)

27

and return on assets of supply chain management. The study is however deficient as it lacked empirical basis.

3.3.3 Facilities Management KPIs In the context of FM, KPIs are financial and non-financial measures of a service performance relative to the critical success factors (CSFs). According to [50], the use of KPIs in FM setting helps to focus managerial efforts on relatively important areas of performance, selection of FM service providers, communicating clear description of desired outcomes and how they will be monitored and controlled. The work of [51] is seen as seminal work in FM. Hinks and McNay [51] developed the management by variance tool to supports a structured creation of a custom list of KPIs of mutual interests to FM providers and customer. The management by variance tool identified a total of 23 performance indicators through a Delphi approach. In yet another study on major performance measurement models, [30] based on expert interviews and a questionnaire survey in the UK and Ireland identified the ten most important performance indicators. This study partly corroborate the management by variance indicators since about half of the KPIs identified in this study were captured. By contrast [52] advocate that KPIs for facilities management should be developed along the four perspective of the Balanced Scorecard (BSC); internal business process, learning and growth, finance and customer. They argue that the BSC fits the strategic requirement of PM to provide an organization efficient and effective strategy to measure performance by putting value on results. From a theoretical points of view [53] developed and categorized KPIs for facilities performance assessment under four main headings of physical, functional, financial and customer satisfaction. KPIs for FM maintenance have also been on the research agenda quite recently. Au-Yong Cheong [54] through a combination of literature and interviews identified downtime, cost variance, system breakdown rate and number of complaints received to measure maintenance performance. Zulkarnain et al. [55] analysed KPIs for building management practices for university sector in Malaysia from the four perspectives of the BSC. Yahya and Ibrahim [56] found safety, time, cost, functionality and environmental friendliness to benchmark the performance of building maintenance for high-rise office buildings in Klang Valley, Malaysia. Within the same Malaysian context and from the perspective of public hospital buildings, [57] outline ten key performance indicators to measure the effectiveness of maintenance management in the public hospital buildings. Results of the correlation analysis showed that monitoring and supervision, task planning and scheduling and computerized maintenance management system are strong factors to ensure that maintenance services operate with optimum performances. Research by Shohet [58], Shohet and Nobili [59] developed quantitative KPIs for maintenance performance measurement. The list of KPIs included Managerial Span of Control (MSC), Maintenance Efficiency Indicator (MEI), Building Performance Indicator(BPI); Replacement Efficiency Indicator(REI), Functional

28

3 A Literature Review on Performance Measurement

Index(FI), and Indoor/outdoor environmental quality (IOEQ) indicator; Annual Maintenance Expenditure(AME) and Maintenance Sources ratio (MSR). A similar group of unquantified indicators was also developed by Talib et al. [60], Myeda et al. [61]. The indicators centred on building function, building impact/physical, building quality and user satisfaction, financial and image. Koleoso et al. [18] within the context of Nigeria’s FM developed a total of 41 scales for building performance in Lagos along the lines of financial, quality and disaster response. Studies by Enoma and Allen [62] on the role of FM in airport identified breach of security, evacuation in emergency cases, hysteria control, attack on airport facilities, and criminal behaviour. Lai and Choi [63] from the point of view of FM and hospitatity found education support, brand enhancement, financial performance and facilities performance KPIs. Loosemore and Hsin [50] developed indicators for benchmarking service sectors such as health, education, post, navy and hotel.

3.4 Key Performance Indicators for the Study The review of literature covers an exhaustive review of KPIs in supply chain management, construction management and facilities management which is the focus of this study. Noticeably, the various works on KPIs involves a mixture of quantitative and qualitative KPIs using the BSC and Supply Chain Operation Reference (SCOR) as the underlying principles. Studies in construction have centred on the iron triangle of time, quality and budget. Interestingly, other KPIs such as resource management, quality management systems, safety and disputes and stakeholders satisfaction are increasingly gaining attention. The review noted that non-financial measures are increasingly gaining attention on the PM agenda due to concerns for customer satisfaction and service quality which is of relevance to FM. Generally most of the non-financial measures are subjective measures. Non-financial measures are judgmental and establishing benchmarks is complex and often difficult [64]. That notwithstanding [18] argues that such measures have the essential ability to practically demonstrate how FM meets the needs of the users of facilities and how much value it adds to the activities that takes place within these facilities. Financial measures are easily quantifiable and establishing benchmarks is straight forward, nonetheless, it is always not possible to gather accurate, standard and objective performance data. This study adapt both financial and non-financial indicators for FM performance and employs the BSC typology as the basis for KPIs categorization since that give a complete picture of the FM performance [52]. Nonetheless, the application of the BSC mechanism is not without limitations. Amaratunga et al. [65] stresses on the need to construct a reasonable framework highlighting the perspectives of the BSC and also how it should be tested against the validity of cause-and-effect relationships. Till date what constitutes the four perspectives of the BSC is undefined in FM. In order to have a minimal and meaningful list of indicators for the study and avoid duplication which is a common problem with KPIs development, a concise effort is made to

3.4 Key Performance Indicators for the Study

29

synthesize the KPIs in extant literature. Accordingly the KPIs have been categorized along the four perspectives of the BSC finance, learning and growth, internal business and quality. This study uses quality instead of customer since quality is the overriding interest for FM services. The summary of KPIs in extant literature is presented in Table 3.2. The quality indicators were mostly drawn from the three disciplines. According to [66], service quality indicators are very necessary for the performance of a facilities function. This indicators basically assess the extent to which services delivery meet the expectation of consumers of healthcare. From the point of view of FM as a service, it is intangible thus the process involved in the service delivery to satisfy users is of paramount interest. According, [10], the financial performance measures define the long-run objectives of the business unit and measure strategy implementations that are contributing to bottom-line improvement. Most of the financial metrics are centred on cost, for instance cost of construction, cost in supply chains and FM. As healthcare delivery revolutionizes, the need for learning, growth, and innovation becomes crucial. Okoroh et al. [67] found that facilities managers in hospitals have to ensure that healthcare facilities do not only support current healthcare needs but can also adapt to continual changes in the healthcare environment. These include: respond to epidemic crisis, moves and expansions, introduction of new services, and re-structuring of the hospital which requires hospitals FM to embark on continuous improvement through learning and growth. Thus having the support from an able and adaptable FM become paramount. In this context, some indicators are directed towards the learning and growth functions of FM. Finally, the internal business processes perspective reports on the efficiency of the internal processes and procedures. The premise behind this perspective is that customer-based measures are important, but they must be translated into measures of what the organization must do internally to meet its customers’ expectations [10]. These measures are centred on work ethics and cooperation to deliver efficient services to support the core clinical tasks. The measures are centred on activities through which the facilities management objectives could be achieved. Indisputably, these works make important contribution to FM literature that notwithstanding the known problem of a lack of uniform KPIs for FM performance assessment is evident although some of the indicators are common among the various research works. FM Performance measurement is complex and where inadequate and inappropriate measures are used can result in dysfunctional behaviour. In FM, most of the studies requires the development of specific measures since there is no one size fit all solution [31]. Moreoever, the selection of KPIs should consider the audience involved in the development, audience/stakeholders for the KPIs and the level of performance to be measured [36]. The study is mindful of fact that FM in Ghana’s pubic hospitals is evolving as such selection of complex quantifiable indicators might be difficult to comprehend by respondents. The peculiarity of this research (performance measurement of critical hospital FM services in a developing country’s context) demands tailored indicators based on an understanding of the relationship between FM and hospital performance. Accordingly, an exploratory investigation will be launched to confirm the KPIs for the study.

30

3 A Literature Review on Performance Measurement

Table 3.2 Summary of key performance indicators from literature Performance dimension

KPI

Reference(s)

Service response time

[6, 30, 42, 46]

Quality Service reliability

[47, 51]

Professional approach

[51]

Responsiveness to problems

[18, 30, 45]

Deadline met

[51]

Effectiveness of help desk

[18, 19]

Appearance of equipment and staff

[51, 68]

Cash flow

[43]

Finance Financial management

[55, 57]

Cost effectiveness/ Value for money

[30]

Cost

[41, 47]

Financial stability

[19, 43]

Net Present values(NPV)

[41]

Learning and Growth Change management

[42]

Innovation and improvement

[44, 46]

Employee turnover

[24]

Staff development programs

[55]

Promotions made

[19]

Competence of staff

[55]

Number of courses completed

[57]

Effectiveness of task planning

[23, 57]

Internal business ICT application

[30, 49]

Resources optimization/utilization

[46, 49]

Free flow communication

[44]

Safety and accident management

[37, 69]

Team focus on goals and objectives

[24, 44]

Commitment from top management

[44]

No blame culture

[37, 44]

Team flexibility

[42, 46]

Internal business

Conflicts and disputes

[37]

Environmental impact assessment scores

[41] (continued)

3.5 Summary

31

Table 3.2 (continued) Performance dimension

KPI

Reference(s)

Outsourcing contractors performance

[23, 57]

Risk management

[45]

Resources optimization

[45, 49]

3.5 Summary This chapter presented a review of the concept of Performance Measurement (PM) with the aim to identify gaps in relation to facilities management. The chapter commenced with an overview of the general theoretical concepts of PM. The chapter also reviewed performance measurement within the context of facilities management. Given that key performance indicators are an essential aspect of performance measurement systems, the second part of the literature review was centred on KPIs. In line with any scientific investigation, further review of KPIs in related literature in construction management and supply chain were conducted. The discussions from the literature review chapter can be summarized as; 1. The review shows that PM has evolved substantially driven by the paradigm shift from the traditional financial centred metrics to non-financial performance measures such as service quality and customer satisfaction. There appears to be a lack of universally accepted definition of performance and performance measurement. 2. Facilities management has acknowledge PM as a tool against which effectiveness can be measured and for further improvement in the facilities management function. Nevertheless the growing interest to measure FM performance is not matched by research in FM performance measurement. 3. In relation to KPIs, the review shows that FM lacked comprehensive KPIs. Subsequently, a review of KPIs in construction management and supply chain was conducted to generate a broader knowledge of possible KPIs that could be considered for this study. To this end a total of 35 KPIs were extracted from FM, construction management and supply chain literature. The indicators were pre-categorized following an adapted balanced scorecard typology of quality, finance, learning and growth and internal business indicators. Evidently, there are fundamental gaps in FM performance measurement, especially within the context of developing countries. This study seeks to fill these gaps by exploring performance measurement techniques, KPIs and performance dimension that needs to be improved.

32

3 A Literature Review on Performance Measurement

References 1. G. Bouckaert, J. Halligan, Comparing performance across public sectors. Performance Information in the Public Sector. (Palgrave Macmillan, London, 2008), pp. 72–93 2. K.K. Choong, Has this large number of performance measurement publications contributed to its better understanding? a systematic review for research and applications. International Journal of Production Research 52(14), 4174–4197 (2014) 3. M.J. Lebas, Performance measurement and performance management. International Journal of Production Economics 41(1–3), 23–35 (1995) 4. A. Neely, C. Adams, M. Kennerley, The Performance Prism: The Scorecard for Measuring and Managing Stakeholder Relationship (Financial Times Prentice Hall, London, 2002) 5. M. Striteska, M. Spickova, Review and comparison of performance measurement systems. J. Organ. Manag. Stud. 2012, 1 (2012) 6. M. Kagioglou, R. Cooper, G. Aouad, Performance management in construction: a conceptual framework. Constr. Manag. Econ. 19(1), 85–95 (2001) 7. A. Neely, M. Gregory, K. Platts, Performance measurement system design: a literature review and research agenda. Int. J. Oper. Prod. Manag. 15(4), 80–116 (1995) 8. P. Rouse, M. Putterill, An integral framework for performance measurement. Management Decision 41(8), 791–805 (2003) 9. S. Nudurupati, T. Arshad, T. Turner, Performance measurement in the construction industry: an action case investigating manufacturing methodologies. Comput. Ind. 58, 667–676, (2007). https://doi.org/10.1016/j.compind.2007.05.005 10. R.S. Kaplan, D.P. Norton, The Balanced Scorecard: measures that drive performance. Harvard Business Review 1(70), 71–79 (1992) 11. R. Jusoh, D.N. Ibrahim, Y. Zainuddin, Assessing the alignment between business strategy and use of multiple performance measures using interaction approach. Bus. Rev. 5(1), 51–60 (2006) 12. A. Neely, C. Adams, M. Kennerley, The Performance Prism: The Scorecard for Measuring and Managing Business Success. (Prentice Hall Financial Times London, 2002) 13. R.D. Behn, Why measure performance? Different purposes require different measures. Public Administration Review 63(5), 586–606 (2003) 14. M.K. Sharma, R. Bhagwat, G.S. Dangayach, Practice of performance measurement: experience from Indian SMEs. Int. J. Globalisation Small Bus. 1(2), 183–213 (2005) 15. Harbour, J.L., The basics of performance measurement. 2nd Edition ed. 2009, Madison Avenue, New York: Routledge 16. D. Amaratunga, D. Baldry, Moving from performance measurement to performance management. Facilities 20(5/6), 217–223 (2002) 17. V. Martinez et al., Historical analysis of performance measurement and management in operations management. Int. J. Prod. Perform. Manag. 56(5/6), 384–396 (2007) 18. H.A. Koleoso, M.M. Omirin, Y.A. Adewunmi, Performance measurement scale for facilities management service in Lagos-Nigeria. J. Facil. Manag. 15, 128–152 (2017). https://doi.org/ 10.1108/jfm-04-2016-0015 19. D. Amaratunga, D. Baldry, A conceptual framework to measure facilities management performance. Property Manag. 21(2), 171–189 (2003) 20. F. Duffy, Measuring building performance. Facilities 8(5), 17–20 (1990) 21. B.J. Varcoe, Facilities performance measurement. Facilities 14(10/11), 46–51 (1996) 22. V. Popova, A. Sharpanskykh, Modeling organizational performance indicators. Inf. Syst. 35(4), 505–527 (2010) 23. B. Atkin, A. Brooks, Total Facilities Management. 4th edition ed. 2015 (Wiley-Blackwell Publishers, New York, 2015) 24. S. Lavy, J.A. Garcia, M.K. Dixit, KPIs for facility’s performance assessment, Part I: identification and categorization of core indicators. Facilities 32(5/6), 256–274 (2014) 25. H. Koleoso et al., Applicability of existing performance evaluation tools and concepts to the Nigerian facilities management practice. Int. J. Strateg. Property Manag. 17(4), 361–376 (2013)

References

33

26. C. Liyanage, C. Egbu, A performance management framework for healthcare facilities management. J. Facil. Manag. 6(1), 23–36 (2008) 27. N. Inamdar, R.S. Kaplan, K. Reynolds, Applying the balanced scorecard in healthcare provider organizations/Practitioner’s Response. Journal of Healthcare Management 47(3), 179 (2002) 28. L. Rodríguez-Labajos, C. Thomson, G. O’Brien, Performance measurement for the strategic management of health-care estates. J. Facil. Manag. 16(2), 217–232 (2018) 29. N. Brackertz, Relating physical and service performance in local government community facilities. Facilities 24(7/8), 280–291 (2006) 30. X. Meng, M. Minogue, Performance measurement models in facility management: a comparative study. Facilities 29(11/12), 472–484 (2011) 31. D. Amos, N. Musa Zairul, P. Au-Yong Cheong, A review of facilities management performance measurement. Property Manag. 37(4), 490–511 (2019) 32. N. Brackertz, R. Kenley, A service delivery approach to measuring facility performance in local government. Facilities 20(3/4), 127–135 (2002) 33. M. Tucker, M. Pitt, Improving service provision through better management and measurement of customer satisfaction in facilities management. J. Corp. Real Estate 12(4), 220–233 (2010) 34. S. Njuangang, C. Lasanthi Liyanage, A. Akintoye, Performance measurement tool (PMT) to control maintenance-associated infections. Facilities. 34(13/14), 766–787 (2016) 35. A.F. De Toni et al., A performance measurement system for facility management: the case study of a medical service authority. Int. J. Prod. Perform. Manag. 56(5/6), 417–435 (2007) 36. T. van der Voordt et al., Value Adding Management (VAM) of buildings and facility services in four steps. Corp. Real Estate J. 6(1), 42–56 (2016) 37. S.-U.-R. Toor, S.O. Ogunlana, Beyond the ‘iron triangle’: Stakeholder perception of key performance indicators (KPIs) for large-scale public sector development projects. Int. J. Project Manag. 28(3), 228–236 (2010) 38. Parmenter, D., Key performance indicators: developing, implementing, and using winning KPIs. Wiley, Hoboken (2015) 39. A. Maté, J. Trujillo, J. Mylopoulos, Specification and derivation of key performance indicators for business analytics: a semantic approach. Data Knowl. Eng. (2017) 40. A. Parida, U. Kumar, Maintenance performance measurement (MPM): issues and challenges. J. Qual. Maintenance Eng. 12(3), 239–251 (2006) 41. A.P.C. Chan, A.P.L. Chan, Key performance indicators for measuring construction success. Benchmarking Int. J. 11(2), 203–221 (2004) 42. V.T. Luu, S.-Y. Kim, T.-A. Huynh, Improving project management performance of large contractors using benchmarking approach. International Journal of Project Management 26(7), 758–769 (2008) 43. H.A.E.M. Ali, I.A. Al-Sulaihi, K.S. Al-Gahtani, Indicators for measuring performance of building construction companies in Kingdom of Saudi Arabia. J. King Saud Univ. Eng. Sci. 25(2), 125–134 (2013) 44. C.K.I. Che Ibrahim, S.B. Costello, S. Wilkinson, Key indicators influencing the management of team integration in construction projects. Int. J. Managing Projects Bus. 8(2), 300–323 (2015) 45. F.T. Chan, H.J. Qi, An innovative performance measurement method for supply chain management. Supply Chain Manag. Int. J. 8(3), 209–223 (2003) 46. D.W. Cho et al., A framework for measuring the performance of service supply chain management. Computer and Industrial Engineering 62(3), 801–818 (2012) 47. B. Chae, Developing key performance indicators for supply chain: an industry perspective. Supply Chain Manag. Int. J. 14(6), 422–428 (2009) 48. K. Arif-Uz-Zaman, A. Nazmul Ahsan, Lean supply chain performance measurement. Int. J. Prod. Perform. Manag. 63(5), 588–612 (2014) 49. N. Anand, N. Grover, Measuring retail supply chain performance: Theoretical model using key performance indicators (KPIs). Benchmarking Int. J. 22(1), 135–166 (2015) 50. M. Loosemore, Y.Y. Hsin, Customer-focused benchmarking for facilities management. Facilities 19(13/14), 464–476 (2001)

34

3 A Literature Review on Performance Measurement

51. J. Hinks, P. McNay, The creation of a management-by-variance tool for facilities management performance assessment. Facilities 17(1/2), 31–53 (1999) 52. D. Amaratunga et al., Application of the balanced score-card concept to develop a conceptual framework to measure facilities management performance within NHS facilities. Int. J. Health Care Qual. Assur. 15(4), 141–151 (2002) 53. S. Lavy, J.A. Garcia, M.K. Dixit, KPIs for facility’s performance assessment, Part II: identification of variables and deriving expressions for core indicators. Facilities 32(5/6), 275–294 (2014) 54. P. Au-Yong Cheong, S. Ali Azlan, F. Ahmad, Participative mechanisms to improve office maintenance performance and customer satisfaction. J. Perform. Constructed Facil. 29(4), 04014103 (2015) 55. S. Zulkarnain et al., A review of critical success factor in building maintenance management practice for university sector. World Acad. Sci. Eng. Technol. 5(3), 195–199 (2011) 56. M. Yahya, M. Ibrahim, Building maintenance achievement in high rise commercial building: a study in Klang Valley, Malaysia. OIDA Int. J. Sustain. Dev. 4(06), 39–46 (2012) 57. M.F. Omar, F.A. Ibrahim, W.M.S.W. Omar, An assessment of the maintenance management effectiveness of public hospital building through key performance indicators. Sains Humanika. 8(4–2) (2016) 58. I.M. Shohet, Key performance indicators for strategic healthcare facilities maintenance. J. Constr. Eng. Manag. 132(4), 345–352 (2006) 59. I.M. Shohet, L. Nobili, Application of key performance indicators for maintenance management of clinics facilities. Int. J. Strateg. Property Manag. 21(1), 58–71 (2017) 60. Y. Talib, R.J. Yang, P. Rajagopalan, Evaluation of building performance for strategic facilities management in healthcare: A case study of a public hospital in Australia. Facilities 31, 681–701 (2013). https://doi.org/10.1108/f-06-2012-0042 61. N.E. Myeda, S.N. Kamaruzzaman, M. Pitt, Measuring the performance of office buildings maintenance management in Malaysia. J. Facil. Manag. 9(3), 181–199 (2011) 62. A. Enoma, S. Allen, Developing key performance indicators for airport safety and security. Facilities 25(7/8), 296–315 (2007) 63. J.H.K. Lai, E.C.K. Choi, Performance measurement for teaching hotels: a hierarchical system incorporating facilities management. J. Hospitality, Leisure, Sport Tourism Educ. 16, 48–58 (2015) 64. S.S. Nudurupati et al., State of the art literature review on performance measurement. Computer and Industrial Engineering 60(2), 279–290 (2011) 65. D. Amaratunga, D. Baldry, M. Sarshar, Assessment of facilities management performance— what next? Facilities 18(1/2), 66–75 (2000) 66. D.I. Ikediashi, S.O. Ogunlana, I.A. Odesola, Service quality and user satisfaction of outsourced facilities management (FM) services in Nigeria’s public hospitals. Built Environ. Project Asset Manag. 5(4), 363–379 (2015) 67. M.I. Okoroh et al., Adding value to the healthcare sector—a facilities management partnering arrangement case study. Facilities 19(3/4), 157–164 (2001) 68. A. Parasuraman, V.A. Zeithaml, L.L. Berry, A conceptual model of service quality and its implications for future research. J. Mark. 49(4), 41–50 (1985) 69. M.R. Yahya, M.N. Ibrahim, Building maintenance achievement in high rise commercial building: a study in Klang Valley, Malaysia (2012)

Chapter 4

Research Methodology

Abstract This chapter presents the research methods used in attaining the set objectives of the study. The chapter explains the research approach, process and strategies. In addition, the data collection and analytical techniques are also discussed. The conclusions of the chapter is preceded by the conceptual framework that set forth the researcher’s assumed intentions and directions of the research parameters tailored to meet the objectives of the study.

4.1 Research Approach The choice of a research approach is guided by the research problem, the personal experiences of the researcher, and the audience for whom the report will be written [1]. Two main approaches within the research paradigms are; quantitative and qualitative research. According to Creswell [1], qualitative research is based on an interpretivist epistemology and capitalizes on the relationship developed between researchers and their subjects of study to understand the meaning individuals and groups ascribe to social phenomenon and social problems [2]. By contrast quantitative research method involved testing theories through an empirical examination of the interactions among a set of variables and making inferences from extant literature [3]. Proponents of qualitative methods argue that it provides rich information about a phenomena under study while supporters of quantitative research relents on its strengths of being unimaginative but well suited to providing hard evidence and factual information [4]. Mixed method research resides in the middle of the field because it incorporates elements of both qualitative and quantitative approach where the researcher draws inferences from both sides. This study adopt a pragmatic philosophical orientation of a mixed methods approach. It is generally agreed that qualitative researcher’s tend to be overly dependent on impressionistic data that can neither produce objective nor reliable knowledge, however quantitative research can also lead to overreliance on statistical data that will not explore the fundamentals of the subject under study. This stands to

© The Author(s), under exclusive license to Springer Nature Singapore Pte Ltd. 2021 D. Amos et al., Measurement of Facilities Management Performance in Ghana’s Public Hospitals, Management in the Built Environment, https://doi.org/10.1007/978-981-33-4332-0_4

35

36

4 Research Methodology

prove that both a purely qualitative or quantitative approach may either have its own drawbacks, as such combining the two together can be complementary. Amaratunga and Baldry [5] postulate that the success of healthcare FM services research lies in the joint application of both qualitative and quantitative methodologies. This study support such stands of a mixed approach.

4.2 The Research Process Having justified the selection of the research approach, this section presents a highlights of the steps to be followed in the mixed method approach adopted. Yin [6] describes mixed methods as a combination of research methods to answer research questions or objectives. Creswell [7] presents three clear approaches of going about mixed methods in social sciences and these include; Convergent parallel mixed methods; a form of mixed methods design in which the researcher converges or merges quantitative and qualitative data in order to provide a comprehensive analysis of the research problem. In this design, the investigator typically collects both forms of data at roughly the same time and then integrates the information in the interpretation of the overall results. Explanatory sequential mixed methods: one in which the researcher first conducts quantitative research, analyses the results and then builds on the results to explain them in more detail with qualitative research. It is considered explanatory because the initial quantitative data results are explained further with the qualitative data. Exploratory sequential mixed methods; in an exploratory sequential approach, the researcher first begins with a qualitative research phase and explores the views of participants. The data are then analysed, and the information used to build into a second quantitative phase that best fits the sample under study or to specify variables that need to go into a follow-up quantitative study. Particular challenges however resides in the appropriate qualitative findings and analysis as well as the sample selection for both phases of the research. Having carefully considered the three options available, the study adopted an exploratory sequential mixed methods approach. This is attributed to; • The amount of literature on performance measurement for FM services is not enough to generate a comprehensive list of variables for an explanatory sequential or convergent parallel mixed methods. • FM is emerging in the case study country, as such the approach will illuminate the fundamentals in understanding the issues of FM performance measurement. • Most of the well-known performance measurement models and frameworks are not applicable to the case of a developing country’s FM, as such an exploratory approach will give the chance to unearth the PM techniques in use.

4.2 The Research Process

37

• The approach is expected to build research variables together with available literature for the follow up questionnaire survey to enable the objectives of the study to be met. Amaratunga et al. [8] points out that there is lack of a systematic process for determining appropriate performance measures in facilities management and advocate for an exploratory approach. The well-known problem of a lack of standard constructs for FM performance measurement is still relevant, despite the available literature on FM performance measurement. Measuring FM performance is complex and could be misleading where inappropriate measures are used. Consequently a number of studies in FM performance measurement research have adopted an exploratory approach to investigate performance [9–11]. Figure 4.1 depicts the research process of the study. The research process outline in Fig. 4.1 involves four stages. This begins with literature review and informal interviews as to way of scoping early information on the research problem. As recommended by [12] the questions of the informal interviews were straight forward open ended and centered on FM and key performance measurement techniques that are used in hospitals in a semi structured manner. Convenience sampling was employed since it was the very onset of the research to select a variety of interviewees including hospital administrator, estate and environmental officers. The informal interviews reinforced the need for the exploratory approach adopted and also highlighted first-hand information on performance measurement for FM in hospitals. The inputs in stages 2, 3, and 4 culminates into the final structural model which is based on performance parameters established. Two main research strategies were however employed for the exploratory sequential mixed methods approach. These involves multiple case studies interviews for the qualitative enquiry and a broader questionnaire survey.

4.3 Research Strategy According to [13] a research strategy is a set of actions designed to achieve a specific research goal and that consideration should be given to three key issues; suitability, feasibility and ethics. With the regard to suitability, [13] stresses that particular attention should be paid to the usefulness and appropriateness of the strategy, while time constrains and access to data should also be practically feasible for the study. Ethical consideration should also be made for the participants to ensure anonymity, confidence and voluntary participation. Since the study involves a qualitative and quantitative approaches, it is worthwhile considering holistically the research strategies available and justify the rationale for the research strategy chosen that best answers the research questions. Denscombe [13] outline key strategies to include phenomenology, ethnography, grounded theory, action research, case study, experiment and surveys. Although phenomenology, ethnography, action research and grounded theory are very good qualitative approaches, they hold peculiar features that makes their application difficult in this study. A modified Delphi approach using

38

4 Research Methodology Literature Review/informal interviews (1)

Gaps in literature Identify the problem Formulate research question and objectives STAGE ONE

Pilot case study (2)

Refinement of research questions, interview questions /refine case study protocol mechanism

Validate the results of (1) and (2) through multiple case studies (3) STAGE TWO

Generalize results of (3) by conduct a questionnaire survey (4) STAGE THREE

Develop and validate a structural model for performance measurement using data from (4) STAGE FOUR

Findings, conclusions and Recommendations

Fig. 4.1 Research process

focus groups discussions was planned for the study. However, due to shortage of staff at the Ghana Health Service (GHS), coupled with the difficulty of having participants for the Delphi discussions thwarted the approach after the first two attempts. As a result, case study approach was the most feasible and economical to use considering the circumstances of this study. Generally, case study allows for empirical investigation into contemporary phenomena operating in a real-life context and allows the researcher to deal with the subtleties and intricacies of complex social situations. In relation to the quantitative approach, a survey was employed.

4.4 Case Study

39

4.4 Case Study Case study research is more often recommended as part of a mixed methods approach in which the same dependent variable is investigated using multiple additional procedures, e.g. survey research, ethnography among others [6]. Denscombe [13] postulate that case study allows a researcher to deal with the subtleties and intricacies of social situations by grappling with the relationships, social process and multiple sources of data. This study lends itself on the strength of case study to examine the critical underpinnings of the issues of PM to be able to establish sound constructs for the study. Among the four types of case study, multiple case study embedded design is used. Evidence from multiple case studies is regarded as more compelling and the overall study is therefore regarded as more robust as compared to single, holistic design and single case embedded designs case studies. This study employs multiple cases with FM and performance measurement as embedded units of analysis in Ghana’s public hospitals. Using multiple case studies embedded gives the leverage to establish generalize theoretical propositions that emanate from the cases. This is of peculiar interest to this study considering the fact that public hospitals under the GHS have common managerial traits and policy guidelines which gives a high level of credence that most issues on performance are common to support generalization of the case study findings. Further, although the use of an exploratory sequential approach is not to triangulate the results, the approach test the wider applicability of the case study findings to the study population which invariably addresses the drawbacks of case study such as bias, self-delusion and objectivity of the study [14].

4.5 Data Collection in the Case Studies The choice of the qualitative data collection tool was of greater importance in this study as the approach aimed to build a deeper insight into the research problem and generate key variables for the general questionnaire survey. Semi structured interview was chosen since that allows for some degree of flexibility on interviewees opinions while at the same time the interviewer keeps the direction of the research [13]. The interviews were conducted with staff at the strategic (top management) and tactical (middle level management) positions in the hospitals. Flynn et al. [15] argues that the combine use of interviewees from different categories of the organization may be the best way of overcoming potential bias in interviews. The interviewees principally comprised of heads of estates management and environmental units that superintends over general hospital cleaning, waste management and estate management services which basically are middle level managers. The top level management interviewees were directors of hospital administration and deputies. Due to the complexity of performance measurement, choosing participants from such groups was expected to provide useful and reliable information. The interview protocol (See Appendix A) was developed on four key themes; general hospital information, characteristics of

40

4 Research Methodology

the services, information on performance measurement techniques, key performance indicators and performance outcomes. Focus of the interview therefore centred on activities, process and outcomes. Denscombe [13] emphasis on the importance of planning and preparations prior to interviews especially on the choice of informants, authorization and venue. Bearing in mind the busy schedule of staff at public hospitals in Ghana, the researcher had in advanced written officially to the case study hospitals. To make known to the participants the knowledge of the content of the interview, copies of the interview protocol was attached to the official letters. In addition, ethical clearance was sought from Ghana Health Service (GHS) and the case study hospitals prior to the interviews.1 With regard to venue, interviews were conducted at the offices of the interviewees at an agreed date and time at the participants’ convenience within the planned period of the second phase of this research. The Participant Inform Sheet (PIS) and consent form which set out the research aims, conditions of participant involvement regarding cost, benefits, confidentiality, outcome and feedback was made available for participants’ perusal. An important piece of information that gave confidence to the interviewees was on the confidentiality as no names were to be mentioned in the report neither the hospitals they represent. Per the participant consent form, respondents were made to understand that the conversation would be tape-recorded which most interviewees gladly accepted. This was however augmented with field notes taken by the researcher during the interviews. To most of the interviewees, the interview presented the first opportunity for them to discuss issues of performance of non-core hospital services, something they found very interesting as most activities in the GHS are centred on issues of core healthcare delivery. To the researcher, this opportunity was a first-hand experience to know the issues of performance measurement of FM services in public hospitals in Ghana.

4.6 Survey Surveys are widely used in social science research, however the distinguishing features of surveys are the form of the data and the method of analysis [16]. As such it is seen by many as not just a technique for collecting data and may include multiple data collection techniques such as questionnaires, structured and in-depth interviews, observation, content analysis and so forth. According to [13], surveys are used to the best effect when the researcher want factual information relating to groups of people, what they do, what they think, and who they are [7] postulate that surveys are economical for collection of large data from a given population and also allow generalization from a sample to a population. The common types of surveys are postal, telephone and interview surveys. Others are internet surveys, questionnaires and observational surveys. This study however make use of a questionnaire 1 Ghana

Health Service ethical clearance number GHS-ERC:009/09/17.

4.6 Survey

41

survey. Considering the fact that, most academic research are constrained by time and finance, adopting a questionnaire survey was the most economical. Notwithstanding, the researchers was cautious to ensure richness of the information and also take the appropriate steps to achieve a reasonable response rate that would improve the findings of the study. Due advantage was also taken of the statistical validity and reliability techniques to also improve the result of the survey.

4.7 Population and Sample Population refers to the entire group of people, events, or things of interest that the researcher wishes to investigate [17]. The population for the questionnaire survey component comprises all public hospitals within the south western portion of Ghana, defined within the context of this study to include western, Ashanti, Brong Ahafo and Central regions of Ghana. Public hospitals within the context of this study is made of all governments district, teaching and regional hospitals under the management of the Ghana Health Service (GHS). Specifically these hospitals offer tertiary to primary health services and represent the very core fabric of healthcare delivery in Ghana and have the attributes of a well-established in-house FM services to meet the objectives of the study. A sample is a subset of the population. It comprises some members selected from it while the sample frame on other hand is the listing of all the elements in the population from which the sample is drawn. Saunders et al. [14] suggest that for a population to be scientifically sampled, the population frame must be first defined as that gives a complete list of all the cases in the target population from which the sample will be drawn. The sample frame for this study based on GHS/MOH database is 50 hospitals comprising of 2 teaching hospitals, 4 regional hospitals and 44 district hospitals. The target respondents were all staff at the strategic and tactical level positions in the sampled hospitals. Per the GHS organogram strategic level respondents comprised of medical superintended, directors of hospital administration and deputies. Tactical Level on the other hand included heads of hospital environmental and estate management units and deputies. The study excluded respondents at the operational level because of the technical nature of the issues on performance measurement that the questionnaire sought to achieve. Arguably most staff at the operational level have low levels of educations and might make it difficult for them to comprehend the terms in the questionnaire.

4.8 Sample Size The approach to determine the sample size is of importance since it has an influence on the reliability and validity which enables researchers’ to generalize the findings from the sample to the population under investigation. Saunders et al. [14] argues that the larger the sample size, the lower the likely error in generalizing to the target

42 Table 4.1 Sample distribution by region

4 Research Methodology Region

Total number of hospitals

Sample

Ashanti

19

17

9

8

Brong Ahafo Central

8

7

Western

14

13

Total

50

45

population. Two key issues are considered in generating the required sample; precision and confidence level. Precision is a function of the range of variability in the sampling distribution of the sample mean while confidence denotes how certain we are that our estimates will really hold true for the population. Other important factors to be considered are the size of the target population and the type of analyses that data will be subjected [14]. The total number of public hospitals in the population stands at 50. Using a precision level of 0.05 and 95% confidence level, the sample required for the study is 45. To ensure a representative sample for the respective regions, the corresponding percentage based on the total number of hospitals within each region was computed and accordingly used to estimate the required corresponding sample. Table 4.1 shows the distribution of the sample for the respective regions.

4.9 Sampling Techniques There are two approaches to the selection of samples. These are probability sampling and non-probability sampling. In probability sampling, the elements in the population have some known chance or probability of being selected as sample subjects. Examples include simple random sampling, systematic sampling, stratified random sampling and cluster sampling. In non-probability sampling, the elements do not have a known or predetermined chance of being selected as subjects. Examples are convenience sampling, purposive sampling and snow ball sampling. A multi stage sampling procedure encompassing stratified random sampling and purposive sampling techniques were used for the study. Stratified random sampling subdivides a population into different subgroups/strata and then chooses the number required within the strata using simple random sampling. In this way, each of the strata is represented proportionally within the sample. This technique was used for the first stage of the study to divide the hospitals in south western Ghana using their regional boundaries as strata. Thereafter, simple random sampling was applied to select the hospitals from within each strata or region. In this regard, the random number generator was used to generate the sampled hospitals until the required sample was achieved. Purposive sampling is a best way of getting information by selecting respondents most likely to have the experience or expertise to provide quality information and valuable insights on the research topic [13]. Bearing in mind the technicalities involved in the performance measurement of FM and the fact that the researcher had no knowledge about

4.9 Sampling Techniques

43

the number of respondents qualified or best suited to answer the questionnaire in the sampled hospitals, the approach was considered appropriate to select staff at the strategic and tactical levels in public hospitals. These sampling techniques were deployed for the first and second strands of the questionnaire survey. Using purposive sampling to identify the relevant respondents, the study achieved a valid response of 116 and 205 sample for the first and second strand of questionnaire survey respectively. It is worth emphasizing that the first strand of the questionnaire centred on the development of key performance indicators while the second strand was the general questionnaire survey which involved the assessment of the various performance dimensions identified from the multiple case study and the first strand of the questionnaire survey. The sample of 116 from the first survey meet the minimum recommended sample for exploratory factor analysis of 100 as suggested by [18]. Equally the 205 valid samples exceeds the minimum sample required for the PLSSEM analysis as recommend by [19].

4.10 Qualitative Data Analysis The qualitative data analysis followed the procedure for thematic driven content analysis as suggested by [20]. Generally, the intent of qualitative data analysis is to aggregate data into smaller number of themes. The procedure however involves the following steps; • Preparing the raw data which involves cleaning, transcription, typing of field notes. • Familiarization with the data to generate a general view of the themes and the direction of the data. This is more important especially where the researcher want to establish a common logic to affirm the literal replication for the selection of the multiple cases. • Data coding and categorization which involves a selective reduction of the text based on the main themes captured across the three services as suggested by [7]. • Using narrative analysis to understand the meaning of the themes, sub themes and interconnect similar themes, especially those that related to measuring the same constructs to avoid duplication. • Interpretation of the meaning of themes with comparisons of findings from literature to identify any divergence of theory from practices.

4.11 Quantitative Data Analysis The choice of quantitative method for data analysis is greatly influenced by the nature of the research question, type of data and nature of variables (exogenous/endogenous) of the study. Following the research objectives and the questionnaire design, two main types of data that was expected were ordinal and nominal data. To achieve the

44

4 Research Methodology

objectives of the study, two key statistical tools were employed. These were Statistical Package for the Social Sciences (SPPSS) version 24 and PLS-SEM version 3.2.7. SPSS was principally used for descriptive statistics (mean value comparison, mode and cross tabulation) and non-paramedic statistics (Kruskal Wallis) for objective 1 (performance measurement techniques). SPSS factor analysis (principal components extraction) was also applied to answer objective 2 (KPIs). PLS-SEM was employed to investigate the relationship between KPIs and performance outcomes.

4.12 Conceptual Framework for the Study Without a research framework, researchers are at risk of describing the phenomenon under study without bringing out its deeper meaning [21]. The framework relates specific research questions to literature and establish empirical evidence to support its importance to the study. Amaratunga and Baldry [22] postulate that the framework must benefit from previous studies, identify gaps in extant literature and critically examine lessons that the current state of knowledge offers for further advancement by the present study. The lack of systematic procedure for determining set of measures for FM performance coupled with the weak theoretical basis for FM performance measurement necessitate the need to bridge the gap between theory and practice [23]. In this study, the conceptual framework draws on knowledge on both literature and practice to develop a tailored structural equation model for FM performance measurement. To this end, the conceptual framework of the study drawing on the set objectives, explores the existing performance measurement techniques for FM to familiarize with FM performance measurement in Ghana’s public hospitals since the concept of FM is emerging and little is known about the PM practices in literature. Moreover investigating existing PM techniques gives the leverage for a fair idea of possible performance outcomes (Research objective 1). Given that key performance indicators are important in achieving performance outcomes and demonstrate structures and activities of the FM organization, research objective (2) was directed towards determining KPIs for FM. The study then investigate the relationships between KPIs and performance outcomes (Research objective 3). In this context, KPIs constitute the independent variables given their influence on performance which is the main dependent variable in this study. A structural model is developed and tested with the performance data to highlight FM contributions as well as significant performance dimensions useful to improve service delivery. Figure 4.2 depicts the conceptual framework for the study.

4.13 Summary

Investigate how public hospitals measure FM

PM TECHNIQUES

45

Explore and establish KPIs. Incorporate literature and FM teams KPIs

KPIs FOR FM PM

Develop and validate a PM structural model

FM PERFORMANCE

Interaction between KPIs and FM performance

Research objectives to be considered

Significant areas to be explored Fig. 4.2 Conceptual framework of the study

4.13 Summary In order to achieve the objectives of the study, a combination of qualitative and quantitative research approaches were adopted. Unarguably, combination both methods enriches findings of the study since the weakness of one method is augmented by the other. This chapter presented the research approach and strategies for both the case study interviews and the questionnaire surveys. Preceding the conceptual framework of the study is discussions on the analytical tools for both the qualitative and quantitative data analysis. The conceptual framework of the study which highlighted the research areas to be discovered vis-a-vis the research objectives concluded the chapter. The overall research process was however mapped on a four stage research plan as illustrated in Fig. 4.1. The process commenced with a review of extant literature to garner knowledge on the problem under investigation. This lead to the identification of research gaps and subsequent development of the research questions. Thereafter a pilot case study was conducted to refine the research questions of the study. Stage 2 advances the study by conducting interviews in multiple case study hospitals. In line with the pragmatic stands of the study, specifically the exploratory sequential mixed methods approach that was adopted by the study, stage 3 extended the findings in the exploratory qualitative case study through a questionnaire survey. Finally stage 4 develop and validate a performance measurement structural model by using data from stage 4 which integrates the outcomes of stages 1, 2 and 3.

46

4 Research Methodology

References 1. Creswell, Research Design: Qualitative, Quantitative and Mixed Methods approaches. 4th edition ed. (Sage Publications, Thousand Oaks, London, 2014) 2. K. Punch, Survey Research: The basics. first edition ed. 2003 (Sage publications, Thousands Oaks, Carlifonia, 2003) 3. R. Fellows, A.M.M. Liu, J. Stepaniak, Research Methods for Construction. (Blackwell publishing Limited, West Sussex, UK, 2003) 4. D. Silverman, Interpreting Qualitative Data. 4th edition ed. 2011 (Sage publication, New Delhi, India, 2011) 5. D. Amaratunga, D. Baldry, Case study methodology as a means of theory building: performance measurement in facilities management organisations. Work Study 50(3), 95–105 (2001) 6. R. Yin, Case Study research: Design and Methods, 3rd edn. (Sage Publications, Beverly Hills CA, 2003) 7. J.W. Creswell, Research Design: Qualitative, Quantitative and Mixed Methods Approaches. 2nd edition ed. 2003 (Sage Publications, Thousand Oaks, London, 2003) 8. D. Amaratunga, D. Baldry, M. Sarshar, Assessment of facilities management performance— what next? Facilities 18(1/2), 66–75 (2000) 9. M. Pitt, M. Tucker, Performance measurement in facilities management: driving innovation? Property Manage. 26(4), 241–254 (2008) 10. N.E. Myeda, Enhancing the Facilities Management (FM) Service Delivery in Malaysia: The Development of Performance Measurement Framework (PERFM)(Doctoral Dissertation). UCL (University College London, 2013) 11. H.A. Koleoso, M.M. Omirin, Y.A. Adewunmi, performance measurement scale for facilities management service in Lagos-Nigeria. J. Facil. Manage. 15, 128–152 (2017). https://doi.org/ 10.1108/jfm-04-2016-0015 12. J.L. Welch, Researching marketing problems and opportunities with focus groups. Ind. Mark. Manage. 14(4), 245–253 (1985) 13. M. Denscombe, The Good Research Guide: for Small-Scale Social Research Projects. 4th edition ed. 2010 (McGraw-Hill Education (UK), Berkshire, England, 2010) 14. M. Saunders, P. Lewis, A. Thornhill, Research Methods for Business Students 5th edition. 5th edition, ed. (Pearson Education Limited, Essex, UK, 2009) 15. B.B. Flynn, R.G. Schroeder, S. Sakakibara, A framework for quality management research and an associated measurement instrument. J. Oper. Manag. 11(4), 339–366 (1994) 16. D. De Vaus, Surveys in Social Research; Social Research Today. 6th edition ed. (Routledge, London, 2014) 17. U. Sekaran, R. Bougie, Research Methods for Business: A Skill Building Approach. 5th edition ed. (Wiley, New York, USA, 2010) 18. R.L. Gorsuch, Common factor analysis versus component analysis: some well and little known facts. Multivar. Behav. Res. 25(1), 33–39 (1990) 19. J. Cohen, A power primer. Psychol. Bull. 112(1), 155 (1992) 20. V. Braun, V. Clarke, Using thematic analysis in psychology. Qual. Res. Psychol. 3(2), 77–101 (2006) 21. D.M. Mertens, Research and Evaluation in Education and Psychology: Integrating Diversity with Quantitative, Qualitative, and Mixed Methods. (Sage publications, 2014) 22. D. Amaratunga, D. Baldry, A conceptual framework to measure facilities management performance. Property Manag. 21(2), 171–189 (2003) 23. M. Loosemore, Y.Y. Hsin, Customer-focused benchmarking for facilities management. Facilities 19(13/14), 464–476 (2001)

Chapter 5

Findings and Discussions

Abstract This chapter presents the findings and discussions from the case studies interviews and the questionnaire survey. In line with the procedure of an exploratory sequential mixed methods adopted by the study, the results from the qualitative case study enquiries forms the basis for the questionnaire instrument of the second stage. The chapter is presented in two parts. Part I presents the findings and discussions from the case studies interviews. Part II presents the results of two strands of questionnaire survey (see Appendix B and C). Specifically part II presents the quantitative analysis on the investigations into performance measurement techniques, the result from the exploratory factor analysis and the proposed structural equation modelling to investigate the interactions between the performance dimensions established.

5.1 Case Study Findings and Discussions This section presents discussion of findings from the content analysis of interviews textual materials. The discussion of the interviews is centred on three themes for the respective facilities management services that was captured by the study (i.e. hospital cleaning, waste and estate management services). These includes an investigation into the existing performance measurement techniques, identification of key performance indicators and performance outcomes.

5.2 Selection and Presentation of Cases Four case study hospitals were selected in the study population including a teaching, regional, municipal and district hospital numbered case 1 to 4. A total of 12 different interview sessions with 6 experts in the various professional categories was conducted. It is worthwhile emphasizing that due to the shortage of staff at the

© The Author(s), under exclusive license to Springer Nature Singapore Pte Ltd. 2021 D. Amos et al., Measurement of Facilities Management Performance in Ghana’s Public Hospitals, Management in the Built Environment, https://doi.org/10.1007/978-981-33-4332-0_5

47

48

5 Findings and Discussions

Table 5.1 Case studies profile Case

Interviewee

Profession

1

Deputy director of administration

1

Years of experience with GHS

Number of interviews conducted

Service scope covered

Health services 10 administrator

2

Hospital cleaning and waste management services

Head of estate management

Estate manager 15

1

Estate management services

2

Head of environment and house keeping

Public health services administrator

29

2

Hospital cleaning and waste management services

2

Head of estate management

Estate manager 24

1

Estate management services

3

Director of hospital administration

Health services 17 administrator

3

Hospital cleaning waste, and estate management services

4

Head of estate/acting environmental officer

Estate Manager

3

Hospital cleaning waste, and estate management services

10

Ghana Health Services (GHS), some of the participant’s representing the cases had to be interviewed three consecutive times for each service in turn. For instance in case 1, deputy head of administration was interviewed for two services specifically cleaning and waste management whereas in case 3 and 4, the director of hospital administration and head of estate respectively were interviewed on the three services. This resulted in a total of 6 participants being involved in the four cross-case studies. Table 5.1 illustrates details of the case study participants’ profile.

5.3 Performance Measurement Techniques In line with the first research objective of the study which seeks to investigate FM performance measurement techniques used in public hospitals, a question was posed to the interviewees to describe how they evaluated the performance of the FM

5.3 Performance Measurement Techniques

49

services. This was followed by a discussion on the frequency of use as well as the level of effectiveness of the PM techniques identified in the discussion. There were mix reactions towards the question posed to interviewees on how they evaluated the performance of the respective FM services captured for the study. The responses reveals that FM teams in the case studies measure FM performance in diverse ways. Based on the textual analysis and pattern matching of the interviews transcripts, five distinct performance measurement techniques for FM services could be deduced. These include; inspections with standard check list, the peer review program, quality assurance technique, user satisfaction surveys and performance appraisal for FM staff. Highlights of the interview findings on the respective techniques is presented hereafter.

5.3.1 Peer Review Program This involves healthcare institutions constituting their management members together every year to assess their performance on various aspects of healthcare delivery. The peer review uses a standardized check list to inter peer health facilities within the region. The peer review program instituted by the Ghana health service, is currently the most active performance measurement technique. Under the institutional care division of the Ghana health service, the peer review is expected to duplicate best practices in all aspects of healthcare delivery, imbibe the culture of responsibility and accountability and encourage facilities to build own grown innovative solutions to their challenges. With the exception of teaching hospitals that inter peer wards bi-annually, all other public hospitals under the management of the GHS are involved in the annual peer review exercise. The peer review however puts undue financial pressure on the health facilities. Head of administration at case 3 asserts that “typical of Ghanaians we usually put in more when the exercise is being conducted and this put undue pressure on us, We have not progress much and we scored 13th in the last time.” The three service scope for this study are captured in the peer review and is conducted on an annual basis for cases 1, 3 and 4.

5.3.2 User Satisfaction Surveys Satisfaction surveys are conducted in the hospitals for in-patients and outpatients as well as staff. Focus of the survey is however on the core healthcare delivery. The investigations revealed that out of the 22 key areas of assessment, only one item is devoted to the environment. This clearly shows the significant need for an improvement in the current user satisfaction performance assessment tool. Generally, most hospital satisfaction surveys focus on core health care delivery. Considering the fact that patients may find it difficult to question the expertise of medical diagnosis and that the environment influences patients overall satisfaction of healthcare facility,

50

5 Findings and Discussions

it is imperative to have more variables on FM in patient satisfaction survey. Case 1 and 2 conduct surveys every quarter, whereas in case 3 and 4 the tool is often used bi-annually for all the FM services. The user satisfaction survey has not been an effective tool in measuring performance of FM services since it focus on FM is limited. Participants for case studies however mentioned that they seeks client view on hospital cleanliness and waste management through other mediums such as discussions and complaints received/feedback.

5.3.3 Inspections with Standard Checklist This involves heads of department and team conducting ward rounds with a standard checklist. Based on the inspections, assessment is done and periodic feedback is given to supervisors of the staff at the operational level. Across the four cases, the tool was applied on weekly basis for cleaning and waste management task, whereas the frequency of inspections for estate management team varies across the cases. For instance in case 2 and 4 monthly inspections were held for the hospital estate while Case 1 and 3 follows it Planned Preventive Maintenance (PPM) schedule which usually involves quarterly inspections. The tool works more effectively for cleaning and waste management services in the case study hospitals than for estate management services. Head of environmental unit for case 2 asserts that “we use the checklist for inspections to assess if the cleanliness is satisfactory or not. The checklist works like where there is no fault and meet the checklist assessment partly, we can measure it say 50%, but in a situation where we found that the cleaning meet all the checklist assessment criteria, we score it as very good (100%.)”.

5.3.4 Quality Assurance Program The case study hospitals have instituted quality assurance teams of which the environment and estate department are core members due to their role in infection prevention and control. Quality Assurance (QA) applies through all activities and units of the Ghana health service facilities. Under the directorate of the institutional care division of the GHS, the quality assurance unit is primarily responsible for the development and implementation of quality assurance in areas of clinical governance and infection control systems in all health facilities consistent with national, bilateral and international expectations [1]. An important role of the QA team is on Infection Prevention and Control (IPC). The development of standards and protocols to ensure quality, effectiveness and efficient service delivery is the vision of the quality assurance program. The case studies interviews revealed that the areas of assessment for QA performance for FM include;

5.3 Performance Measurement Techniques

51

• The application and institution of technical guidelines (standard precaution, hand hygiene and Personal Protective Equipment (PPE)/clothing). • Environmental management and controls (cleaning, laundry and linen guidelines). • Standard operating procedures for healthcare waste management (segregation into coloured containers, transport to temporal storage site, treatment and final disposal.). • Occupational health and safety. QA evaluations are carried out every quarter of the year in case 1, 2 and 4, whereas case 3 conduct its QA bi-annually. The QA exercise is equally applicable to all the three services. Quality assurance has not been an effective tool for FM performance assessment, due to fact that the policy guidelines provides procedure for quality assurance measures in hospitals FM but lack a systematic set of performance measures to assess FM performance.

5.3.5 Performance Appraisal for FM Staff The civil service codes of the GHS makes performance appraisal mandatory for all staff. The tool is used on quarterly basis for all 3 services in case, 2 and 4, whereas case 1 and 3 conduct appraisals for its staff bi-annually. The case study interviews shows that the major problem for performance appraisal is the low level of education among FM staff at the operational level making it difficult for objectives to be set as benchmarks to be appraised. The interviews also revealed that the appraisal is used as tool for promotion rather than to assess performance of FM staff to address weakness, and strengths. The findings confirm earlier research by Bawole et al. [2] in performance measurement of local government that appraisal is used when staff are going for promotion. The tool is not effective for cleaning and waste management staff in all the four cases, whereas, the estate management department of case 1 and 4 to some extent make valuable use of the appraisal. Most of the estate technicians in these two cases are fairly educated.

5.4 Conclusive Remarks on Performance Measurement Techniques for FM Services The results from the interviews on the performance measurement techniques used in the hospitals shows the lack of a comprehensive performance measurement tools for FM performance assessment. The annual peer review exercise by the Ghana health services is an audit tool and put undue pressure on hospitals. Besides, the peer review is focused on just the availability and existing state of FM and infrastructure without recourse to the process and outcome of FM service delivery. Noticeably, with the exception of inspections with standard checklist which is partly effective for cleaning

52

5 Findings and Discussions

and waste management services, quality assurance, performance appraisals and user satisfaction surveys generally have some challenges as tools for FM performance assessment. This raises doubt about their effectiveness in measuring FM performance. Interestingly, the findings is replicated in all the cases, thus supporting the literal replication logic for the selected cases. The variance however is with the frequency of the performance measurement technique, which plausibly is due to resource base of the case hospital in question. The interviews also indicate evidence of a lack of common understanding of how performance could be measured in practice for facilities management. Research by Liyanage and Egbu [3] on the role of FM in hospital acquired infections in the NHS in the UK equally made similar observation. The study admit that the existing performance measurement techniques offers some level of performance information however it is worthwhile having a uniform and tailored PM framework which integrates these outcomes to measure the performance of FM.

5.5 Key Performance Indicators This section investigates key performance indicators for facilities management services. KPIs are important for the performance measurement systems to work effectively and also determine the extent that FM services are being delivered. Although the informal interviews hitherto the case studies indicated that public hospitals had no clear KPIs for facilities management services, the researcher took advantage of the case study interviews to investigate further. Interviewees were asked the question; “Do you have key performance indicators for FM/hospitals support services? If yes, could you please provide me details of the KPIs in use for FM/hospital support services”? Regrettably, participant’s responses to the questions revealed that current KPIs are limited and not exhaustive enough to meet the research objective of this study. For instance the use of metrics like available, not available, good, fair, poor, satisfactory which lacked clarity and conflicts with existing performance measurement techniques as KPIs. Research by Liyanage and Egbu [3] found that the absence of a robust PM approach could be the main reason for the lack of a comprehensive set of performance indicators and measures in domestic FM services in the NHS in the UK, this result is no different from this study context. To probe further to meet the research objectives of the study, respondents were asked to consider some KPIs generated from literature for the study. A question was posed “If no, could you please consider the following KPIs generated from the literature? (see Sect. 5.3 of the interview protocol). The interviewees were also asked to rate the level of importance of the KPIs to the performance of FM services using a scale of 1 = not important 5 = very important. Interviewees were asked to comments on their answers where possible. Although the participants, were given copies of the interview protocol well in advanced, the researcher still took time to explain the categorization of the KPIs in the protocol as well the variables constituting each category. Table 5.2 presents

5.5 Key Performance Indicators

53

Table 5.2 Rankings of KPIs KPIs

Average case study ranking

Average score

Case 1

Case 2

Case 3

Case 4

Service response time

5

5

5

5

5

Reliability of service

4

5

5

4

5

Professional approach

4

5

5

5

5

Responsiveness to problems

5

5

5

5

5

Appearance of equipment and staff

4

5

4

4

4

Effectiveness of help desk

3

4

3

3

3

Prompt release of cash for FM activities

5

5

5

5

5

Proportion of FM budget approved by management

4

5

4

5

5

Cost effectiveness in delivery FM

3

4

3

4

4

Staff development programs

4

4

4

5

4

Employee turnover

4

4

3

5

4

Competence of staff

4

4

3

5

4

Promotions made

2

4

3

2

3

Change management

3

3

2

4

3

Stakeholders communication

5

5

4

4

5

Achievement of set goal and objectives

4

4

4

4

4

Commitment from top management

5

5

4

5

5

Safety and accident managements

5

5

4

5

5

Effectiveness of planning/FM strategy

4

5

5

5

5

Fulfilment of SLAs/performance of FM contractors

5

5

4

5

5

Use of ICT

2

5

3

4

4

Quality indicators

Financial indicators

Learning and growth indicators

Internal business process

54

5 Findings and Discussions

the rankings and average scores of 21 KPIs computed for the three service across the four cases. The results from Table 5.2 shows that out of the 21 KPIs suggested to the participants, none of the KPIs had an average score of 1 (not important) or 2 (slightly important) for the four cases. Following the logic of the strategic requirement of the Balanced Scorecard (BSC), the KPIs were categorized under FM service quality indicators, FM financial indicators, FM learning and growth indicators, and FM internal business indicators. Conspicuously, most of the indicators were ranked as either important or very important. Service quality determinants identified six dimensions of performance including service response time, reliability, professional approach and responsiveness to problems, help desk and appearance of staff and equipment. Traditionally, financial measures of FM have mostly been centred on cost driven by profit maximization. However the case study revealed that the financial objective of public hospitals is not profit maximization but rather concerns issues of timely release of cash for FM services, proportion of budget approved and cost effectiveness in the delivery of FM task. Research by Pitt and Tucker [4] have expressed the need for FM to improve performance through learning, growth and innovation. In this regard, the interview discussions identified five key facets that will measure the learning and growth perspective of performance. These include FM staff training and development, competence, employee turnover, change management and promotions. The internal business processes perspective reports on the efficiency of internal processes and procedures that will improve the FM processes. These include top management commitment, achievement of set goals and objectives and stakeholders communication. Others were safety and accident management, effectiveness of planning the FM task, performance of outsourced contractors and use of Information Communication Technology (ICT). Compared with the KPIs identified from the literature review, one improvement of this study is synthesizing the KPIs to produce a minimal number of indicators. It is advised that having a limited and manageable number of KPIs is maintainable for regular use since too many and complex KPIs can be time and resource consuming. A conspicuous observation from the case study interviews was that most quantitative hard KPIs were found to be inappropriate to the case of Ghana’s hospital FM services, plausibly due to the embryonic stage of FM development. Again, the study highlights the importance of timely release of cash, proportion of budget approved and cost effectiveness as new financial dimensions which is an innovation of this study. Overall 11 KPIs had an average score of 5 (very important) while 7 had an average of 4 (important). Three indicators (ICT, change management and promotions) however had an average score of 3 (somewhat important). Discussions on the KPIs with participants also buttressed the fact that majority of the variables were of relevance to hospitals FM services.

5.6 Performance Outcomes

55

5.6 Performance Outcomes Literature have established that there is neglects for real estate and facilities in organization as their contribution is not readily acknowledged by senior management [5]. The low level of priority accorded FM in public hospitals and the concomitant lack of clear procedures and methodologies in assessing FM performance in organizations are potential reasons [6]. Traditional measures of facilities performance have centered on finance, most commonly the cost of the individual facilities function. There is however the inherent desire to incorporate non-financial measures such as service quality and customer satisfaction which is of paramount interest to FM [7]. Based on the discussions with the case study participants on the existing performance measurement techniques and key performance indicators, five performance scales which are outcome measures were deduced. These include the peer review scores, FM contribution towards core healthcare, FM contribution to infection prevention and control, budget variance and complaints and feedback received [8] asserts that performance outcomes represent final results of service process whereas [9] observed the FM process must lead to outcome measures which have significant impact and add value to the organization. Table 5.3 provides a summary of the existing PM techniques and outcomes as emanated from the case studies interviews. Elaborations on the findings of the respective performance outcomes is presented hereafter.

5.6.1 Peer Review Scores The annual peer review exercise conducted by the Ghana health service is seen to be one of the core performance assessment within the year. The peer review score is a performance outcome geared towards identifying shortfalls and offers critical suggestions for future improvement. This view by participants is supported by [18] who postulated that peer review is an essential process for reviewing ideas and Table 5.3 Performance measurement techniques and outcomes Performance measurement technique

Performance outcome

References in extant literature

Ghana health service peer Peer review scores review

[10]

Quality assurance

Infection prevention and control

[3, 11]

Performance appraisal

Support for core healthcare

[12–14]

Budget management committee appraisal

Budget variance

[15]

Users satisfaction survey

Complaints/feedback received [16, 17]

56

5 Findings and Discussions

grasping mistakes with the ultimate objective to ensure compliance to standards and best practices. Notwithstanding these perceived benefits, [19] raises concerns of its effectiveness in detecting gross defects and fraud, highly subjective, time wasting and in some instance tends to be costly. In the case of public hospitals in Ghana, the challenge however is the financial burden involved in the preparation hitherto the exercise.

5.6.2 Complaints and Feedback Received Complaints and feedback have become one of the mediums that offers first-hand information on client dissatisfaction with services for prompt response. The measure is partly hinged on the outcome of the satisfaction survey conducted in hospitals for patients, staff and visitors [17] have pointed out that one of the important ways of getting information on customer satisfaction is through informal discussion, complaints and feedback received from customers for further action to improve performance. User satisfaction and feedback have become necessary because of the constantly changing customer expectation, competition in the health sector and the need to maintain patient’s loyalty [20]. The environment influence patients overall level of satisfaction about hospital and it is equally important for hospitals to assess client view on the performance on the environment and infrastructure. Participants to the case study interviews were of the view that feedbacks or complaints received from users of facilities is an important indication of how one is performing. Feedback is generally positively associated with performance of a service and focuses on the extent to which employees have achieved expected levels of work during a specified time period. In fact head of environment and housekeeping of case 2 pointed out that “despite the fact the our survey is not centred on environment, the report of the survey always point to us to keep our surrounding clean, I think management have to carter for the environment in the survey”.

5.6.3 Impact of FM on Core Healthcare Delivery The linkage between FM and core healthcare delivery is well established as FM adds value to core healthcare. Without a well-functioning facilities management team, the core business of rendering clinical services could be jeopardize. According to [12], the supportive role of FM lies in the ability to effectively manage facilities resources, support services and the working environment to enhance the core business of the organization in both the long and short term. This stands were reaffirmed in the interviews as participants expressed FM support for core healthcare delivery. One of the participants of the case study echoed that.

5.6 Performance Outcomes

57

I believe strongly that the in the absence of cleaning service, clinical care cannot have any quality that can be guaranteed, our hospital orderlies have contributed greatly towards our vision of becoming a number 1 healthcare provider in the region.

While another participants also expressed that. In my own view it is about time, we equally pay attention to the hospital support services because without the support services, the hospital cannot operate effectively. The Health Administration and Support Services division (HASS) of the GHS is supposed to spearhead our initiatives yet, the clinical issues always dominate the non-clinical. I am particularly happy about your research and I hope it will bring to the limelight our contribution to core healthcare.

5.6.4 Budget Variance Until the latter part of the year 2000, health financing in Ghana was largely private, based on the “cash and carry” system. The introduction of the National Health Insurance Scheme (NHIS) was a way to reduce the burden of health finance on the citizenry and to pave way for more access to public healthcare in Ghana. Despite the remarkable progress made by the NHIS, there are challenges confronting it operations. Prominent amongst them is finance. This to a greater extent has affected the management of public hospitals, including the operations of support services. Consequently, budget variance has increasingly become an important performance appraisal tool to assist in the management of cash inflows and outflows and provide mechanism for effective planning, control and forms the basis for benchmarking. It must be emphasized that public hospitals FM departments are Budget Management Centres (BMC) and do not have direct control over the planning, use and execution of financial activities in the hospitals. This apparently makes the use of rigid financial ratios/indicators difficult. In addition there are practical difficulties with accuracy and neutrality of financial data. To the participants of the interviews, the degree of variance between estimated and actual expenditure of the FM department is measured as the financial performance. In facilities management [21] have postulate that FM can add value to the core business through cost reduction which hinges on efficient utilization of FM budget. The need for FM department to contribute towards cost savings is of great importance to the GHS facilities. Taking cognizance of the current financial challenges facing public hospitals in Ghana, financial efficiency and solvency is thus expected of the FM department in the quest of rendering services.

5.6.5 Infections Prevention and Control This measure is an output of the quality assurance program by the Ghana health services institutional care division. It is very critical issue in healthcare FM due to the updated policy and guidelines on Infections Prevention and Control (IPC) by

58

5 Findings and Discussions

the Ministry of Health in 2015. The new policy seeks to address the inappropriate IPC practices in public hospitals. A growing body of knowledge now exist which suggests that Healthcare Associated Infections (HAIs) are major causes of morbidity and mortality. Since non-clinical causes of HAIs are mostly the result of poor facilities management practices, FM’s contribution to infections prevention and control is of paramount interest to healthcare managers. The recently updated national quality assurance policy on infection prevention and control is driven by the mission that an IPC programme is fundamental to the quality of health care because it carries the potential benefit of reducing the disease burden on patients, health institutions, and the nation as a whole [22]. The policy guidelines is expected to ensure excellence in client-centred care and maximize protection against infections for all categories of health staff, patients/clients, and communities. Key members in the IPC team per the GHS policy are the FM staff. The policy documents among others specify FM teams to; • Ensure a clean healthcare environment with minimal threat of infections. • Seek effective work practices and procedures concerning clinical waste, support services such as cleaning and linen and catering and use of therapeutic devices. • Need for Personal Protective Equipment/clothing (PPE), or barrier-protection items in the course of work to prevent spread of infections.

5.7 Conclusive Remarks on Performance Outcomes Measuring FM performance is complex and where inappropriate scales are used can result in dysfunctional behaviour. Most studies in FM have used an exploratory approach to investigate performance scales that best suit the case context. In FM performance measurement, it is important to acknowledge target areas of performance and performance priorities which are aligned to the goals of the organization in question [23]. The peculiarity of this study (FM performance of a developing country’s hospitals) demanded appropriate scales tailored to measure service delivery. FM’s contribution to the core healthcare success is usually submerged in that of the entire hospital. The GHS like in many other organizations can provide readily or updated information on core issues like mobility ratios, maternal death, among others. Regrettably management of public hospitals cannot provide useful information on FM’s contribution and success, more especially in the case of a developing country like Ghana where FM existence is questionable. This fundamentally underscore the need for performance measurement of FM not only to give progressive report on FM performance but also to address weakness in the facilities functions. Without a systematic assessment of FM performance, FM contributions to healthcare delivery would be submerged and persistently be refereed as cost centres.

5.8 Questionnaire Survey Findings and Discussions

59

5.8 Questionnaire Survey Findings and Discussions In line with the procedures of an exploratory sequential mixed methods adopted by this study, findings from the qualitative enquiry were extended to the research population. This section presents the results of two strands of questionnaire survey from the study. Specifically it presents quantitative data analysis, results and discussions in meeting the three objectives of the study.

5.9 Scale Development, Reliability and Validity Nominal scale was used to measure the frequency of use of performance measurement techniques for objective 1 while the level of effectives of PM techniques was put on Likert scale. All performance dimensions were also anchored on a five point Likert scale. A five point scale is more accurate to capture extreme ends of participant’s opinions on performance. In terms of reliability, the internal consistency was applied on objective 2 which dealt with participant’s perception on the level of importance of the KPIs. The Cronbach’s alpha for the KPIs was 0.866, which shows a high degree of consistency among respondents on the level of importance attached to the indicators. In terms of construct validity, an exploratory factor analysis was performed on the 21 performance scales to establish the validity of the constructs [24]. This study also make use of the quality assessment criteria of the measurement model of PLS-SEM to establish the psychometric soundness of the variables for the structural model of the study. Details of the evaluation criteria and test are presented in Appendix D.

5.10 Sample Demographics (General Questionnaire Survey) Table 5.4 depicts the sample characteristics of the study based on the 205 observations from the second strand of the questionnaire survey. The highest responses received was from waste management services with 73 responses while estate management recorded the least with 60 valid responses. An examination of Table 5.4 shows that the respondents represents diverse set of job descriptions. The highest recorded was hospital administrators and deputies who represent the strategic management level positions in the hospital. For instance, about half of the usable responses came from the hospital administrators and deputies in the sample hospitals. It must be emphasized that the GHS has no official position for facilities managers and in most of the facilities, the hospital administrators or deputies are the shadow FM officers. Representing the middle management level are estate managers, environmental and housekeeping officers and their assistants. Together accounted for 43% of the respondents. As mentioned earlier, the study excluded operational staff due to the issues on

60

5 Findings and Discussions

Table 5.4 Sample demographics Item

Frequency

%

FM services Cleaning service

72

35.1

Waste management services

73

35.6

Estate management services

60

29.3

205

100

Health Administrator

86

41.5

Deputy health administrator

23

11.2

Medical superintended

6

2.9

Head of environmental services and housekeeping

32

15.6

Position

Head of estate management

35

17.1

Assistant environmental officer

12

5.9

Assistant estate officer

9

4.4

205

100

14

6.8

Academic qualification Higher National Diploma(HND) BSc/BA/Btech

83

40.5

MSc/MBA/MA/MPhil

89

43.5

MBBS/MBChB

6

2.9

others

13

6.3

205

100

Less than 1 year

41

20

1–5 years

93

45.4

6–10 years

52

25.4

11–20 years

16

7.8

Above 20 years

3

1.5

205

100

Less than 1 year

9

4.4

1–5 years

17

8.3

6–10 years

42

20.5

11–20 years

76

37.1

Above 20 years

61

29.8

205

100

Years of experience at present hospital

Total years of experience with GHS/MOE

Hospital type (continued)

5.10 Sample Demographics (General Questionnaire Survey)

61

Table 5.4 (continued) Item

Frequency

%

Teaching

20

9.8

Regional

11

5.4

Municipal/district/metropolitan

174

84.9

205

100

51–100

19

9.3

101–500

82

40.0

501–1000

84

41.0

Above 1000

20

9.8

205

100

20,000–40,000

25

12.2

40,001–60,000

11

5.4

Approximate number of staff

Approximate patient attendance per year (inpatient/outpatients)

60,001–80,000

38

18.5

80,001–100,000

24

11.7

Above 100,000

107

52.2

205

100

50–100

102

49.8

101–200

71

34.6

201–300

6

2.9

Above 300

26

12.7

205

100

Number of beds/capacity

performance measurement that required great extent of knowledge on FM in hospitals. Medical superintendent/directors, although are top level managers of public hospitals, do not play much role in FM as such there were only 6 observations from that category. Overall the results indicate that all major professionals involved with management of the three services were captured. In terms of academic qualification, almost 84% had a combination of a Bachelor’s degree and Master’s degree. HND constituted less than 10% specifically 6.8% while MBBS/MBChB was 2.9%. Others which were mostly Middle School Leaving Certificates (MSLC) represented 6.3%. Two types of experience were sought from respondents; years of experience at present hospital and total years of experience. The first category is important, since most of the answers to be provided in the questionnaire were based on the experience in the current hospital where the respondent’s work, whereas the second is important to get their overall experience in performance measurement issues in public hospitals. The decision to split the experience was informed by the case study interviews given that most staff in the GHS by the civil service codes supposedly spend less than 5 years

62

5 Findings and Discussions

at a hospital and less than ten years in a region. The result from the questionnaire survey affirms this trends given that almost half (45.4%) of the responses had 1– 5 years of working experience at the present hospital. That notwithstanding generally more than half of the respondents had total work experience with the GHS/MOE of 20 years or more. The high competency of these mixed respondents, who are qualified academically, technically and professionally, emphasizes the legitimacy of the collected responses for conducting rigorous analysis. The sample hospitals were classified according to type. Despite the investment in the health sector, there are not much teaching hospitals in Ghana. In total there are three teaching hospitals across the 10 political regions. Coincidentally, one teaching hospital was captured in the study population and was represented by a total of 20 observations. More than 80% are either municipal, metropolitan and district hospitals. There is not much significant differences between these sub categories since the GHS classify them as primary healthcare institutions. About 41% of the facilities recorded a staff strength of 101–500 or 501–1000, while the 20 observation mostly from the teaching hospital reported a staff strength of over 1000. In terms of patient turnover, about 50% reported an annual turnover of over 100,000 while 11.7% had turnover from 80,0001 to 100,000. All together 36% had patient’s attendance of less 100,000 a year. The bed statistics or referral capacity was 50–100 for 50% of hospitals while 34.6% had capacity of 101–200. About 15% however had a capacity of 200 or more.

5.11 Investigations into Existing Performance Measurement Techniques The results of the multiple case study revealed five performance measurement techniques that are currently being used for FM. The questionnaire survey by extension sought to investigate how the PM techniques identified through the case study interviews holds for the entire study population. This section addresses the first research objectives of the study by assessing the frequency of use and the level of effectiveness of the existing performance measurement techniques.

5.12 Frequency of Use of Performance Measurement Techniques Table 5.5 presents the overall mean scores and mode for the five PM techniques outlined for the study. A closer look at the means put inspections with standard checklist as the frequently used PM technique, evidenced by a mean score of 1.82. It is further affirmed by its mode being in the scale of 1. Interestingly, four PM techniques specifically peer review, quality assurance, performance appraisal for FM staff and user satisfaction survey are within the mean grouping of 3, representing

5.12 Frequency of Use of Performance Measurement Techniques

63

Table 5.5 PM approaches in-use for FM services PM technique

Mode

Overall mean(OVM) score

Rank

Remarks

Peer review

4

3.80

5

Fairly frequent

Inspections with standard checklist

1

1.82

1

Very frequent

Quality assurance

3

3.00

2

Fairly frequent

Performance appraisal for FM staff

3

3.22

4

Fairly frequent

User satisfaction survey

3

3.09

3

Fairly frequent

Meaning of scale (frequency of use of PM approach); 1–very frequent, 2–frequent, 3–fairly frequent, 4–not frequent and 5–not applicable. [Scale adapted from the work of [6]

fairly frequent in use. There is however discrepancies observed in the modal values. While quality assurance, performance appraisal and satisfaction survey have a mode of 3 which is at par with the mean, peer review had a mode of 4 which by rank is classified as not frequent. Nonetheless by mean rank analysis, peer review is the least frequently used tool. The results of the questionnaire survey further validate the findings from the case study which revealed that inspections is the very frequently used technique for FM performance assessment. It emerged during the case study interviews that inspections are usually conducted on a weekly basis with native scores while quality assurance, performance appraisal and satisfaction surveys are usually conducted on quarterly and bi annual basis depending on the health facility. Research on performance management in the National Health Service in the United Kingdom by [6] put institutional audit by domestic team, Infection Control Committee (ICC), national audit office and patient satisfaction surveys as the most common and frequently used performance management approaches in control of hospital acquired infections. An equivalent of the audit for public hospitals in Ghana is the peer review by the GHS. The contrast however is that the peer review is not frequently used in Ghana and usually conducted on an annual basis. Further examination of the means shows that they are fairly similar even when compared across the three service for the study. Table 5.6 presents the mean scores and ranks for the three FM services; cleaning services, waste management services and estate management services. A close observation of Table 5.6 shows that inspections with standard checklist is the most frequently used, followed by quality assurance, patient satisfaction survey and performance appraisals. Conspicuously, peer review still remains the least in the rank. Further the kruskal–wallis test, (the non-parametric equivalent of ANOVA for K–independent samples) shows no significant differences in the frequency of use with the exception of inspections (Specifically p = 0.000, at 5% significance). This is possibly due to the fact that the frequency of inspections for cleaning service is held weekly while in most of the hospitals waste management inspections are monthly as emanated in the case studies interviews. Inspections for estate management are

64

5 Findings and Discussions

Table 5.6 PM techniques according to the type of FM service PM technique Cleaning services (CS)

Rank

Waste Mgt. services (WMS)

Rank

Estate Mgt. services (EMS)

Rank

KW

Peer review

3.81

5

3.81

5

3.80

5

0.997

Inspections with standard checklist

1.13

1

2.53

1

2.78

1

0.000*

Quality assurance

3.00

2

3.00

2

3.00

2

1.000

Performance appraisal for FM staff

3.22

4

3.19

4

3.25

4

0.721

Users satisfaction survey

3.10

3

3.08

3

3.10

3

0.927

The mean difference is Significant at 0.05 level, KW-Kruskal–Wallis Meaning of scale (frequency of use of PM approach); 1–very frequent, 2–frequent, 3–fairly frequent, 4–not frequent and 5–not applicable

usually conducted on quarterly basis usually based on the planned preventive maintenance plan for the facility. The frequency of use basically connotes the number of times the PM technique is applied within a particular time. Whereas generally there is no significant differences in the frequency of use, possibility of effectiveness of the PM techniques may differ across the three FM services. Again, the effectiveness of the existing PM techniques have also been questionable due to the drawbacks observed in the case studies interviews. As a result, an investigation into the level effectiveness was conducted to ascertain whether the use of the existing performance measurement techniques facilitate improvement in performance to achieve the desired goals of FM department and the hospital at large.

5.13 Effectiveness of Existing Performance Measurement Techniques According to [25] an effective performance measurement system enables an organization to assess whether goals are being achieved and facilitates performance of the organization by identifying their position, clarifying goals and highlighting areas that requires improvement. To ascertain the level of effectiveness of the existing PM techniques, respondents were asked to rate the level of effectiveness of the existing PM techniques based on a five point scale from 1 not effective to 5 very effective. Table 5.7, shows some interesting results on the level of effectiveness. The overall

5.13 Effectiveness of Existing Performance Measurement Techniques

65

Table 5.7 Level of effectiveness of performance measurement techniques PM TECHNIQUES

CS

WMS

EMS

OVM

Rank

Remarks

Peer review

3.24

3.23

3.28

3.25

2

Somewhat effective

Inspections with standard checklist

4.03

3.18

3.02

3.45

1

Somewhat effective

Quality assurance

3.04

3.29

3.22

3.18

3

Somewhat effective

Performance appraisal

2.18

2.29

2.63

2.35

4

Slightly effective

Users Satisfaction surveys

2.36

2.12

2.22

2.23

5

Slightly effective

mean scores for peer review, inspections, and quality assurance is somewhat effective with means ranging from 3.18 to 3.25, while performance appraisal for FM staff and users satisfaction survey are slightly effective with means of 2.35 and 2.23 respectively. Inspections with standard checklist had the highest mean score, closely followed by peer review and quality assurance. The peer review is an institutional annual excercise by the Ghana health service. The tool however is not without challenges, [26] raises concerns for exploitation due to the complete subjective nature of such committees, costly and resources needed for the exercise and challenges for standardization which this study equally view as potential challenges in the Ghana health service peer review. A recent study by [27] observed that most hospital peer reviews are for external audit purposes and not to improve internal performance. With regard to performance appraisal, the results of the questionnaire survey on performance appraisal corroborates similar research in Ghana’s decentralized local government by [2] where performance appraisal was identified as a weak tool and generally used when promotions are due. Other potential challenges are rater’s problems like leniency or harshness error, central tendency error and personal bias [28]. On the contrary, the results contradict [29] assessment that performance appraisal is effective in improving performance of employees and motivating them. The plausible varaince in the findings however could be attributed to culture, inaccuracies, politics, management and workers attitudes towards performance appraisal [29]. A findings of perculiar interest in context of FM in Ghana’s public hospitals is the low level of education among operational staff. In relation to users satisfaction survey, the potential drawback is that the current patient satisfaction survey carries limited information on FM, thus affecting its ability to convey performance information. Interestingly, satisfaction surveys have been widely used in the healthcare to determine service quality [30, 31]. A close examination of the mean scores for the respective services, shows some slight differences. For instance peer review is somewhat effective across the three service with no major differences in the mean scores. Cleaning services however tops the group for inspections with standard checklist. This is due to the fact that the current standard checklist is well developed for cleaning services than for estate and waste management services. With regard to quality assurance, waste management had the highest mean score and this re-emphasizes the significance of quality assurance issues attached to healthcare waste management. The study found that

66

5 Findings and Discussions

quality assurance program for waste management is reinforced quite recently by the Standard Operating Procedure (SOP) developed by the government of Ghana and supported by United States Agency for International Development (USAID). The SOP set fourth standard guidelines regarding waste segregation, treatment and disposal for the health facilities. That notwithstanding, it effectiveness in terms of performance measurement is average. Estate management tops the mean for performance appraisal plausibly due to the fact that estate staff are fairly educated and will invaluably affect appraisal of estate staff while cleaning services equally seems to be more favoured for user satisfaction survey. The result shows that none of the PM techniques is either effective or very effective apart from inspections for cleaning services. This fundamentally underscores the need for a more tailored performance measurement framework for FM in public hospitals in Ghana. The study do not necessarily suspects differences in the level of effectiveness of the PM techniques due to the proximities in the means. However in order to empirically assess whether there are significant differences in the level of effectiveness of the performance measurement techniques across cleaning, waste management and estate management services, the study employed the Kruskal–Wallis test. Table 5.8 displays the results of the Kruskal Wallis test for the level of effectiveness of the PM techniques across the three FM services. It is obvious that, there is some differences in the level of effectiveness across inspections, quality assurance and performance appraisal for the three FM services at 5% significance. A possible explanation holds in the frequency of use of inspection which is explained in Sect. 5.12. This study is of the view that the slow pace of use of inspections for waste management and estate management obviously could have an effect on the level of effectiveness which could be a potential subject for further investigation. Quality assurance and performance appraisal for FM staff equally varies possibly due to the potential reasons noted earlier. Table 5.9 presents the results of the pairwise comparison to investigate the significant differences. The results of the pairwise comparisons for the Kruskal Wallis test however shows that about half of the observations are statistically significant. For instance, there were statistically significant differences for the level of effectiveness for inspections between estate management and cleaning; as well as waste management and cleaning service. This is quite obvious since inspections for estate management may not be effective like cleaning services which generally have routine daily inspection. With Table 5.8 Group difference test using Kruskal–Wallis

PM TECHNIQUES

Sig ( P. Value)

Remarks

Peer review

0.960

NS

Inspection with standard checklist

0.000**

SS

Quality assurance

0.009**

SS

Performance appraisal of FM staff

0.026**

SS

Users satisfaction survey

0.133

NS

The significance level is 0.05, SS(**) = significant, NS = not Significant

5.13 Effectiveness of Existing Performance Measurement Techniques

67

Table 5.9 Pairwise comparison of the level of effectiveness of PM techniques PM TECHNIQUES

FM SERVICES

T statistic

Inspections

EMS-WMS

13.612

9.739

EMS-CS

62.671

9.769

WM-CS

49.059

EMS-CS

Quality assurance

EMS-WMS Performance appraisal

Standard error

Std. test statistic

Sig

Ad. sig

RM

1.398

0.162

0.487

NS

6.415

0.000*

0.000

SS

9.263

5.285

0.000*

0.000

SS

10.904

9.600

1.136

0.256

0.768

NS

28.701

9.570

2.999

0.003*

0.008

SS

CS-WMS

−17.797

9.122

−1.951

0.051

0.153

NS

CS-WMS

−3.936

8.763

−0.449

0.653

1.00

NS

CS-EMS

−23.613

9.222

−2.560

0.10

0.031

SS

WMS-EMS

−19.677

9.194

−2.140

0.032*

0.097

NS

P is Significant at 0.05. CS = cleaning Services, WMS = waste Management Services, EMS = estate Management Services, RM = Remarks SS = significant, nS = not Significant

regard to quality assurance technique, significant difference was found between estate management and waste management. Again, the weak policy document on quality assurance for estate management as compared to waste management services could plausibly explain the differences. The national policy on Infection Prevention and Control (IPC) gives greater responsibilities on the environmental units which handles hospital waste and cleaning services than estate management department. There were also significant differences for performance appraisal between waste management and estate management services. It will be recall in the case study interviews that most of the hospital orderlies have low level of education, which hampers the use of performance appraisal generally as compared to estate management technicians who are by all standards fairly educated. The findings corroborate recent research on waste management in public hospitals in Ghana by [32] which observed the adverse effect of education on waste management performance.

5.14 Determining Key Performance Indicators (KPIs) for PM of FM Services This section presents the results of the investigations of the first strand of questionnaire survey on the KPIs.1 A major outcome of the case study interviews was the identification of 21 key performance indicators. In order to select the most important indicators among the groupings and as a form of confirmation of the practical significance of the indicators, exploratory factor analysis (principal component extraction) 1 The

sample is based on 116 valid observations from the first strand of the questionnaire survey.

68

5 Findings and Discussions

was performed. The next section presents the procedure for the exploratory factor analysis.

5.15 Exploratory Factor Analysis (Principal Components) of KPIs This study admits that although the use of factor analysis to determine the required number of factors to retain may be statistically relevant, notwithstanding this study finds challenges to such patterns as logical inferences about such patterns may not necessarily follow the theoretical conceptions of this research. As a results, the use of exploratory factor analysis (principal component extraction) in this research as data reduction technique, is not primarily to investigate the relationships in the original sets of data but to select the most important factors in each of the four categories of key performance indicators and as a form of confirmation of the practical significance to the performance of FM. Recent research by Refs. [33–35] have equally adopted this approach to factor analysis. The procedure followed Kaiser’s approach to factor analysis [36]. The analysis and results are presented hereafter:

5.15.1 Bartlett’s Test of Sphericity and the Kaiser Meyer-Olkin (KMO) Test Bartlett’s test of sphericity and the Kaiser Meyer-Olkin (KMO) are test statistics used to examine the hypothesis that the variables are uncorrelated in the population and that the correlation matrix formed is an identity matrix. This is useful to examine the appropriateness of factor analysis. The KMO value ranges from 0 to 1. High value (between 0.5 and 1.0) indicates that factor analysis is appropriate. Small values of KMO statistics indicates that the correlations between pair of variables cannot be explained by other variables and hence factor analysis is not suitable [37]. The results on the 21 indicators for the four performance dimensions is presented in Table 5.10. A close examination shows that the Bartlett test of sphericity generally ranged from 220 to 450 whereas the associated significance is 0.000 meaning that the population correlation matrix is an identity matrix. Also, the value of Kaiser-MayerOlkin measure of sampling adequacy ranges from 0.651 to 0.790, which is above the 0.5 threshold. The results thus indicates that the samples for the four components of the study meets the criteria for factor analysis.

5.15 Exploratory Factor Analysis (Principal Components) of KPIs

69

Table 5.10 Bartlett’s Test of Sphericity and the Kaiser Meyer-Olkin (KMO) Test Performance dimension

Test/evaluation

Test Results

Quality indicators

Kaiser–Meyer–Olkin measure of sampling adequacy

0.752

Bartlett’s test of sphericity Approximate Chi-Square

469.974

Df

15

Sig

0.000

Kaiser–Meyer–Olkin measure of sampling adequacy

0.651

Bartlett’s test of sphericity Approximate Chi-Square

332.737

Df

3

Financial indicators

Learning and growth indicators

Internal business indicators

Sig

0.000

Kaiser–Meyer–Olkin measure of sampling adequacy

0.790

Bartlett’s test of sphericity Approximate Chi-Square

221.876

Df

10

Sig

0.000

Kaiser–Meyer–Olkin measure of sampling adequacy

0.740

Bartlett’s test of sphericity Approximate Chi-Square

567.638

Df

21

Sig

0.000

5.15.2 Determining Communalities Communality is the variance in the observed variables which are accounted for by a common factor or common variance [38]. Communalities for each factor should be 0.5 for the factor solution to account for half of the factors each original variable’s variance [39]. Accordingly an indicator with communality of less than less 0.5 is discarded as it is statistically independent and cannot be combined with other variables [40]. The general results for the four component of indicators is presented in Table 5.11. In this study, two (2) quality indicators (appearance of staff and equipment (Q5) and effectiveness of help desk (Q6) and two (2) learning and growth indicators (Promotions (LG3) and change management (LG5) had communalities less than 0.5 and were subsequently discarded before performing a second test as illustrated in Table 5.11.

70

5 Findings and Discussions

Table 5.11 Communalities for KPIs Performance dimension

Indicators

Initial

Extraction (1st trail)

Extraction (2nd trail)

Quality

Q1

1.000

0.711

0.732

Q2

1.000

0.797

0.846

Q3

1.000

0.847

0.882

Q4

1.000

0.818

0.808

Q5

1.000

0.186* (1st trail)

Deleted

Q6

1.000

0.182* (1st trail)

Deleted

FI

1.000

0.765

F2

1.000

0.887

F3

1.000

0.945

LG1

1.000

0.767

0.839

LG2

1.000

0.662

0.761

LG3

1.000

0.272*

Deleted

LG4

1.000

0.772

0.787 Deleted

Finance

Learning and growth

Internal business

LG5

1.000

0.406*

IBI

1.000

0.809

IB2

1.000

0.850

IB3

1.000

0.669

IB4

1.000

0.729

IB5

1.000

0.720

IB6

1.000

0.697

IB7

1.000

0.788

5.15.3 Factor Specifications and Variable Selection Eigen value represents the total variance explained by each factor. The threshold is to extract factors with Eigen values greater than 1 [36], with cumulative variance of more than 50% [41]. The rotated matrix is subsequently examined to select indicators that have significant loadings on the principal components. A threshold of 0.50 was used to select the factors to confirm their practical significance. The summary results for the respective categories of indicators is presented in Table 5.12. For quality indicators, one component was extracted which had Eigen values greater than 1 while the total variance explained was 81.706%. Also the component matrix indicates that the four indicators included in the single component have loading of more than 0.50 with values ranging from 0.856 to 0.939. Thus a model formed with the four indicators specifically “service response time, reliability of service, professional approach and responsiveness to problems to represent the service quality construct is deemed valid. Although finance had the smallest number of factors, the result of the factor analysis affirm all the three financial indicators under one single components. In relation to learning and growth, one components was extracted with Eigen values greater

5.15 Exploratory Factor Analysis (Principal Components) of KPIs

71

Table 5.12 Principal component analysis results for KPIs Performance dimension

KPIs included

Indicator load

Provision of prompt service/service Response time(Q1)

0.3268

Reliability of service (Q2)

0.856

Professional approach (attitude and courtesy of FM staff) (Q3)

0.899

Responsiveness to problems (Q4)

0.939

Quality indicators

Financial indicators

Learning and growth

Internal business strategic (Component 1)

Internal business operations (Component 2)

Eigen value

% of variance explained

Cum. %

3.268

81.706

81.706

2.597

86.552

86.552

2.387

79.560

79.560

3.950

56.429

56.429

1.313

18.759

Timely/prompt release 0.972 of cash for FM task (FI) Proportion of FM budget approved by management (F2)

0.942

Cost effectiveness in delivery FM(F3)

0.875

FM staff training/development (LG1)

0.916

Employee turnover (LG2)

0.887

Competence (LG4)

0.873

Stakeholders communication (IB1

0.879

Goals and objectives achievement (IB2)

0.882

Top management commitment (IB3)

0.806

Use of ICT(IB4)

0.848

75.188 (continued)

72

5 Findings and Discussions

Table 5.12 (continued) Performance dimension

KPIs included

Indicator load

Outsourcing performance (SLAs) for FM contractors (IB5)

0.800

Safety and accidents management (IB6)

0.757

Effectiveness of FM planning (IB7)

0.771

Eigen value

% of variance explained

Cum. %

than 1 while the cumulative variance explained was 79.560%. Interestingly again, all three indicators under the component matrix (FM staff training/staff development programs, employee’s turnover and competence) had significant loadings above the 0.50 threshold thus affirming their relevance as key indicators to measure the learning and growth perspective of FM service performance. Seven indicators represented significant loadings for internal business category and two components were extracted. Stakeholders communication, senior management commitment and goals and objectives achievement loaded significantly on component one, whereas four other indicators; use of ICT, performance of outsourced contractors, safety and accident management and effectiveness of FM planning equally load well on component two. There were cross loading on two factors (use of ICT and effectiveness of FM planning). Nonetheless, there is a gap of at least 0.2 between the primary and cross-loadings in all the two cases and hence it is understood that the cross-loading does not affect the interpretation of the identified factors [38].

5.16 Discussion of Results In order to select the most significant indicators representing the four component, Kaiser’s exploratory factor analysis/principal component was conducted. Service quality indicators category originally comprised of 6 indicators, however appearance of FM staff and equipment and effectiveness of help desk failed to achieve the recommend threshold and were subsequently dropped leaving service response time, professional approach, reliability and responsiveness to problems. The results of this investigation reinforced the relevant attached to service quality in FM delivery and by extension consistent with previous literature on FM service quality [35, 42].[43] list of customized KPIs for FM ranks service reliability, responsiveness to problems and professional approach as top KPIs for facilities management services. Similarly, timely delivery of services is well established KPIs in construction and supply chain disciplines [44, 45]. It was however surprising that appearance of FM staff and

5.16 Discussion of Results

73

equipment as well as the effectiveness of help desk received comparatively lower communalities in the service quality categories and were subsequently dropped. From the point of view of FM as a service, it is generally intangible as a result service providers try to put in effort to make them tangible [46]. The result thus contradicts [47] stands on tangibility as a critical service quality dimension to improve performance. Equally research by Koleoso et al. [35] ranked the effectivness of help desk among the least of 42 indicators developed for measuring building performance in Nigeria. The finance category had the least number of indicators. Although, initially the idea was not to subject them to factor analysis, [48] recommend that a factor needs a minimum of three indicators and hence the constructs met the threshold. The factor analysis was performed to ascertain the construct validity for the financial indicator which is very important to FM performance measurement, more especially when there is the need for a balanced view of FM performance incorporating financial and non-financial measures. Interestingly, all factors received satisfactory loadings to measure the financial construct of the study. This reinforces the attention paid to financial issues in the quest of service delivery pertaining to budget approvals, timeliness of cash release and more especially cost effectiveness in times when the National Health Insurance Scheme (NHIS) is under financial constraints. As mentioned earlier, the financial motive of public hospitals is for public good and value for money which is cost effectiveness for their constituents rather than for profit making which invalidate the use of core profit centred financial metrics. Research by Refs. [49, 50] have emphasized FM cost effectiveness as a means of adding value to the organization. According to [51] hospitals revolutionizes due to changes in technology, demographic changes, changes resulting in new modes of treatment, political changes and public expectations. This also necessitates the need for learning, growth, and innovation of FM to deliver quality services. Learning and growth had five indicators, however promotions and change management failed to meet the threshold and had to be dropped. It is worthy to note that with poor service quality of healthcare currently being faced by the hospitals, training programs and competence are inevitable prerequisite for FM performance [52] recommended regular training for staff members in charge of healthcare waste management in public hospitals in Ghana to improve waste management performance while [53] stresses on the qualifications and competence of waste management staff for succesful waste managemen in hospitals. Low remuneration, lack of incentives, attitudes, high workload and pressure alongside ageing orderlies frustrate the task of domestic staff which has the potential to cause high turnover rate and absenteeism [3]. Thus it is imperative to have turnover as an indicator of growth in the FM organization. This study agrees with [54] assertion on turnover rate as a key physical indicator for facilities performance. Despite the quest for innovation, two key facets “promotions and change management processes” failed to meet the expected threshold and were subsequently removed. Interestingly, promotion are often are done enmasse, thus making it a weak tool for performance in most civil services. With regard to change management, inadequate mechanisms and resources to manage the expected change presents a potential challenge for FM

74

5 Findings and Discussions

departments [55] postulate that organizations need to adopt an intelligent approach to planning, coordinating and controlling a process of change that ensures continuity of operations, whilst injecting new energy and impetus into the business and its social infrastructure. The results thus contradicts [56] findings which argues that change management is very important for an organization performance more particularly in pursuit of meeting shortfall in expected performance, unexpected moves by competitors, shifts in technology and new customer demand which triggers change. The last category comprised of internal business indicators which had 7 factors. A close inspection of Table 5.12 shows that there first three indicators; stakeholder’s communication, achievement of goals and objectives and top management commitment loaded quite well on component 1 while 4 other indicators; use of ICT, achievement of SLA for FM contractors, accident and safety management and effectiveness of FM planning equally loaded well on component 2. This however calls for name tagging of the two components. A careful interpretation and taught into the first three indicators demonstrate that their connection with FM performance mostly requires strategic initiatives, while the latter are internal business measures concerned primarily with FM operations. On this score, this study tagged component 1 as internal business strategic and component 2 as internal business operations. The high loads of all the seven factors affirms the importance attached to internal business issues in public hospitals since the indicators reports on the efficiency of internal processes and procedures that will improved FM performance. It is however interesting that use of ICT had the highest communality and subsequently loaded high on the factor. This however underscore the need to develop the information communication technology in FM, more especially for the infection prevention and control task. Safety and accidents management has been similarly rated among the top ten important measures in past researches by Refs. [43] and [50] in FM whereas related studies in construction by Toor and Ogunlana [57] have rated safety and accident management among the top 6 indicators in construction management since that affects productivity. With regard to outsourcing, although, outsourcing is currently on a limited scale in public hospitals in Ghana, the results suggest that performance based outsourcing is vital for the nascent FM in public hospitals. The results affirms similar studies by Kremic et al. [58] which rated performance improvement in service delivery as the top rational for outsourcing, while effectiveness of planning recognizes the need for a tactical FM plan. The internal business strategic indicators confirms the relevance of FM strategic directions and commitment to performance. Based on the result of the factor analysis, principal component extraction, 17 out of 21 indicators met the threshold under the five categories namely quality, finance learning and growth, internal business strategic and internal business operations. The study developed an adaptable scale of 17 indicators which serves as fundamental basis for performance measurement of FM which are largely consistent with previous studies. The indicators however are largely subjective which suits more of the operational based FM in Ghana. An innovation of this study is the confirmation of two non-conventional financial measures based on time and size of FM budget approved.

5.17 The Relationship Between KPIs and Performance of FM Services

75

5.17 The Relationship Between KPIs and Performance of FM Services An important element of performance improvement is knowledge on the relationship between the KPIs and the performance outcomes. As a result, PLS-SEM was employed to investigate the interactions of the performance dimensions established to assess their relative and absolute statistical strengths and contribution to FM performance. This would alert facilities managers of public hospital on key performance dimensions that needs to be improved. The lack of appropriate performance measures for facilities management services necessitated the need to for the exploratory approach to develop performance scales for FM assessment. From the case study interviews, five distinct performance measures were deduced as performance outcomes to (As described in Sect. 5.6 of the case study analysis). The results of the EFA also presented 17 KPIs. This section investigate the interaction between KPIs and performance outcome through the use of PLS-SEM. The hypothetical model that guided the study is presented in Fig. 5.1 to establish the causal links among the variables. It must be emphasis again that this study is not primarily focused on assessing service quality and customer satisfaction from clients, but to capture a holistic view of FM performance from the perspective of hospital facilities managers with focus on three FM services that are well established in public hospitals in Ghana. These services have been carefully selected because they sit contiguous to each other in the public hospitals and also are currently the most actively managed services by the in house team. Again, the recent national Infection Prevention Policy (IPC) gives a greater responsibility for the FM departments concerned with these three services. The section begins with the descriptive statistics into rankings of key performance indicators based on achievement levels of the KPIs and performance outcomes by the hospitals.

5.18 Descriptive Statistics for KPIs and Performance Outcome Measures of FM Services In line with the third objectives of this study, respondents (health administrators, estate and environmental officers in the sampled hospitals) were asked to rate the performance level of the indicators and the resultant performance outcomes. The results of analysis shown in Table 5.13 presents the means for the respective services, overall mean, Kruskal–Wallis test as well as the group means for the five dimensions of indicators. The results shows a fair level of achievement using the individual means for the three services. With regard to quality indicators, provision of prompt service topped the group with professional approach being the least. Attesting to the desire by health care managers to deliver FM services on time, more especially when hospitals are is lifesaving entities. With regard to finance, out of the three indicators, cost effectiveness topped the group pointing the acute shortage of funds

76

5 Findings and Discussions

Fig. 5.1 Hypothetical model for the structural equation modelling

and the need for FM department to make judicious use of the existing scare resources. As mentioned earlier finance has remained a challenge for public hospitals and this has necessitated cost effectiveness in all aspects of healthcare delivery. Regrettably, timely release of funds is the least and this has the adverse effect of delaying the execution of FM task. Competence and top management commitment came top for learning & growth and internal business strategic indicators respectively, while safety and accident management topped internal business operations. Carefully examining the group means shows that internal business strategic factors was rated 1st, closely followed by quality indicators as 2nd. Learning and growth and internal business operations were close as the group mean differences was just about 0.05. The least ranked in terms of achievement was finance. The test result of the Kruskal Wallis also shows that with the exception of three indicators specifically; competence levels, percentage of budget approved and timely release of funds, generally level of achievement was fair across the three FM services. The main endogenous variable for the study was performance of FM, which is defined as the extent to which FM services and staff support the aim and strategic objectives of public

5.18 Descriptive Statistics for KPIs and Performance Outcome …

77

Table 5.13 Descriptive statistics for KPIs (Performance scores) KPIs

Cleaning Waste Estate OVM KW

G/mean

Provision of prompt service/service response time (Q1)

4.49

4.63

4.63

4.53

0.82

4.37

Reliability of service (dependable and accurate service delivery) (Q2)

4.39

4.58

4.43

4.47

0.66

Professional approach (attitude and courtesy of FM staff) (Q3)

4.08

4.34

4.17

4.20

0.159

Responsiveness to problems (Q4)

4.21

4.38

4.20

4.27

0.066

Timely/prompt release of cash for FM task (FI)

2.57

2.97

2.63

2.73

0.001* 3.37

Proportion of FM budget approved by management (F2)

3.08

3.60

3.13

3.28

0.000*

Cost effectiveness in delivery FM (F3)

3.93

4.22

4.12

4.09

0.073

FM staff training/development (LG1)

3.68

3.95

3.83

3.82

0.107

Employee turnover (LG2)

3.67

3.93

3.88

3.82

0.088

Competence (possession of required skills) (LG3)

4.07

4.52

4.33

4.31

0.000*

Stakeholders communication (IB1)

4.43

4.48

4.42

4.44

0.740

Achievement of goals and objectives/mission and vision achievement (IB2)

4.26

4.27

4.15

4.23

0.511

Top management commitment (IB3)

4.72

4.70

4.67

4.70

0.788

2.40

2.79

2.50

2.57

0.192

Achievement of Service Level Agreement 4.08 (SLAs) for FM contractors (IB5)

3.92

3.95

3.99

0.401

Safety and accidents management (IB6)

4.71

4.60

4.63

4.65

0.396

Effectiveness of FM planning (IB7)

4.51

4.45

4.48

4.48

0.759

Quality

Finance

Learning and growth 3.98

Internal business (strategic) 4.46

Internal business (operations) Use of ICT (IB4)

3.93

P is significant at 0.05 OVM-overall mean score, KW-Kruskal Wallis, G/mean-group mean

hospitals to meet the demands of patients, staff and visitors. It is also a measure of FM’s contribution and added value to the hospital. Table 5.14 presents the means for the respective services, overall mean, rank and the Kruskal–Wallis test result for the five performance outcomes. The results in Table 5.14 on the performance of FM services shows that performance in peer review and support for core healthcare delivery was above average whilst complaints and feedback received, Infection Prevention and Control (IPC) and

78

5 Findings and Discussions

Table 5.14 Descriptive statistics for performance measures Performance outcomes

CS

WMS

EMS

OVM

KW

Rank

Peer review scores (PMPR)

3.99

4.05

3.97

4.00

0.725

2

Feedback/complaints received (PMCOMP)

3.03

3.05

3.05

3.04

0.972

5

Support for core healthcare delivery (PMCH)

4.03

4.11

4.00

4.05

0.639

1

Infection prevention and control (PMIPC)

3.79

3.89

4.03

3.90

0.126

3

Budget variance/financial performance (PMBV)

3.18

3.23

3.17

3.20

0.780

4

CS-cleaning service, WMS–waste management service and EMS–estate management, KWKruskal–Wallis

budget variance were average for the three services combined. Despite the neglect of FM in most public hospitals in Ghana, coupled with competing needs for scarce resources between core and non-core services, the results indicate that FM have lived to support the hospitals core business. A more thorough investigation of the interaction between KPIs and performance is conducted with the use of partial least square structural equation modelling. It is worthwhile mentioning that the Kruskal–Wallis test (As presented Tables 5.13 and 5.14) shows no significant differences with the exception of three instances. As a result looping the data from the three FM services will not affect the overall reliability and validity of the findings. The next section presents the hypothetical model for the structural equation modelling.

5.19 Development of a Hypothetical Model (KPIs Versus Performance) Given that performance is a concept of theoretical interest which is difficult to observe directly, the best logic to measure is inference based on a set of ranked indicators. Following the KPI categorization based on the BSC strategic map from the exploratory factor analysis, the five dimensions of KPIs were modelled as first-order exogenous construct, and they consist of quality (4 indicator); finance (3 indicators); learning and growth (3 indicators); internal business strategic (3 indicators) and internal business operations (4 indicators) (see Table 5.13), whereas performance of FM was operationalized as the main endogenous construct measured by the five scales presented in Table 5.14. The study hypothesized that the level of achievement of the KPI index in the quest of FM service delivery contributes to the overall performance which is operationalized as a five dimensional constructs of scores in peer review(PMPR), infection prevention and control (PMIPC), FM support for core healthcare(PMCH), budget variance(PMBV) and complaints/feedback received (PMCOMP). The arrows between the first and second order constructs represent their inclusive relationships and illustrate the direction of hypothesized influences in the structural model as depicted in Fig. 5.1.

5.19 Development of a Hypothetical Model (KPIs Versus Performance)

79

In this model, two types of structural measurement are used. First, the direction of the relationship is from the five exogenous construct (quality, finance, learning and growth, internal business strategic and operations) to the 17 KPIs which is a reflective measurement model and also from the performance outcomes (peer review, infection prevention and control, support for core healthcare, budget variance and complaints/feedback received) to the main endogenous construct (performance of FM services) which is formative measurement model. Generally reflective measurement are related to the construct domain and are highly correlated and interchangeable. Conversely, formative measurement model is a linear combination of a set of indicators, in which variations in the indicator precedes variations in the latent constructs [59]. Specifically, the study uses SEM to test the hypothesis that a high score in a KPIs index is directly associated with performance of FM services. As part of the investigation of the relationships between KPIs and performance, five hypothesis are postulated for the PLS-SEM analysis. H1 Quality of FM services is positively related to performance. H2 Financial support for FM services is positively related to performance. H3 Learning and growth mechanisms of FM services is positively related to performance. H4 Internal business (strategic) support for FM services is positively related to performance. H5 Internal business (operations) support for FM services is positively related to performance.

5.20 Application of Partial Least Squares Structural Equation Modelling (PLS-SEM) The principal aim of PLS-SEM is to model the relationship between KPIs and performance to avail to hospitals managers an aggregate insight of key performance dimensions. PLS-SEM was selected among other modelling techniques because of its ability to handle multiple observed and unobserved variables which cannot be modelled by other multivariate analysis methods. According to [60] SEM is an advanced statistical software which has the capability to handle both direct and indirect effects of multiple inter related variables and estimate their combined effects as compared to multiple regression which deals with a one sided effect. PLS-SEM has become a popular tool to efficiently deal with errors in variables and is increasing widely gaining attention in social science research where methods for testing theories are not well developed and largely non-experimental [61]. Particularly this study lends on the ability of SEM to handle multiple complex variables while its control extreme autocorrelations, endogeneity of explanatory variables and other violations which is likely to exist among the predictors variables because of plausible inter correlations [62]. Further, as mentioned earlier, performance is a construct of theoretical interest and that the best logic to measure is inference through unobserved and observed indicators which SEM is best positioned to handle. The application

80

5 Findings and Discussions

of SEM however involves the assessment of the measurement model to determine the psychometric soundness of the variables and subsequent assessment of the FM structural model. Figure 5.2 depicts the various stages involved in SEM application while the full evaluation criteria is summarized in appendix D. Stage 1 involves the evaluation for the measurement model (outer model) while stage 2 is the structural model evaluation (inner model) where hypothesis of the study are examined.

Does the model include reflectively measured construct?

Stage 1.1 evaluation criteria (reflective model Indicator reliability Internal consistency Convergent validity Discriminant validity

Does the model include formatively measured construct?

Stage 1.2 evaluation criteria (formative model) Convergent validity Collinearity Significance and relevance of indicator weights Stage 2. Evaluation criteria (structural model) Collinearity R2 explanation of the endogenous latent variables Predictive relevance Q2 Significance and relevance of path coefficient F2 and q2 effects size of path coefficient

Fig. 5.2 PLS-SEM Evaluation (Adopted from [63])

5.21 Assessment of the Measurement Model

81

5.21 Assessment of the Measurement Model The examination of the measurement model is to determine the psychometric soundness of the constructs used for the analysis. This involves establishing convergent and discriminant validity for the reflective exogenous constructs and subsequent assessment of the multi collinearity and significance of the formative endogenous measures.

5.21.1 Assessment of the Reflective Constructs Convergent validity is assessed with the Average Variance Extracted (AVE) and composite reliability (CR). AVE is the degree of common variance shared by the exogenous construct’s indicators and the recommended threshold is 0.50 whereas composite reliability which measures the construct’s internal consistency reliability generally uses a threshold of 0.60–0.95 [63]. A close observation of Table 5.15, shows that all four constructs (quality, finance, internal business strategic and learning and growth) have the desired AVE value of 0.5, with indicators loading significantly well on the construct. The construct “internal business operations”, however failed to achieve the desired AVE value after the first trail. The construct had an AVE value of 0.485. As recommended, the indicator with the lowest loading is first deleted in Table 5.15 Convergent validity (2nd trial after deleting IB6) Construct

Items

Loadings

AVE

CR

Quality

Q1

0.853

0.744

0.920

Q2

0.885

Q3

0.914 0.732

0.891

0.664

0.855

0.574

0.794

0.569

0.786

Finance

Learning and growth

cInternal business(strategic)

Internal business(operations)

Q4

0.792

FI

0.914

F2

0.863

F3

0.785

LG1

0.888

LG2

0.755

LG3

0.796

IB1

0.547

IB2

0.724

IB3

0.947

IB4

0.923

IB5

0.811

IB7

0.444

82

5 Findings and Discussions

Table 5.16 Fornell-Larcker criterion Finance Finance

Internal business (ops)

Internal business Learning and (strat) growth

0.856

Internal business 0.138 (ops)

0.755

Internal business 0.112 (strat)

0.477

0.757

Learning and growth

0.776

0.115

0.032

0.815

Quality indicators

0.734

0.077

0.168

0.623

* (ops)–operations;

Quality indicators

0.862

(strat)–strategic

an effort to achieve the desired AVE value. Subsequently, IB6 (safety and accident management) was deleted to run a second test to achieve the AVE of 0.569. For composite reliability, all five constructs exhibited satisfactorily values thus meeting the 0.70 criteria. It can thus be concluded that convergent validity for the reflective constructs is established. Next, the discriminant validity of the reflective exogenous construct is examined. PLS-SEM version 3. 2.7 gives three approaches for examining discriminant validity. These include cross loading criterion by Chin [64], Fornell and Larcker criterion [65] and the Heterotrait–Monotrait ratio of correlations (HTMT) [66]. Using the Fornell and Larcker [65] criteria, it is suggest that indicators should load more strongly on their own construct that on other constructs in the model and that the average variance shared between each construct and its measures should be greater than the variance shared between the construct and other constructs. The results in Table 5.16 indicates that all constructs meet satisfactoryc discriminant validity by the Fornell and Larcker [65] criteria, where the square roots of the AVE diagonal is larger than the correlations (off diagonal) for the reflective constructs. Assessing the discriminant validity using the cross loadings also shows that each indicator loaded high on its own construct but low on other constructs as shown in Table 5.17. It can thus be concluded that discriminant validity using the cross loading is also meet. Equally the reflective constructs also meet the discriminant validity assessment by the HTMT as neither the lower nor upper confidence interval included a value of 1 [67]. (see Table 5.18).

5.21 Assessment of the Measurement Model

83

Table 5.17 Cross loadings Finance

Internal business (ops)

Internal business (strat)

Learning and growth

Quality

Q1

0.686

−0.001

0.038

0.608

0.853

Q2

0.708

0.034

0.086

0.603

0.885

Q3

0.636

0.132

0.220

0.526

0.914

Q4

0.541

0.044

0.162

0.460

0.792

FI

0.914

0.140

0.103

0.681

0.704

F2

0.863

0.071

0.132

0.680

0.592

F3

0.785

0.134

0.056

0.633

0.575

LG1

0.725

0.106

0.013

0.888

0.529

LG2

0.588

0.174

0.084

0.755

0.478

LG4

0.572

0.023

0.001

0.796

0.519

IB1

0.048

0.235

0.547

−0.003

0.092

IB2

0.143

0.415

0.724

0.021

0.198

IB3

0.084

0.427

0.947

0.034

0.129

IB4

0.145

0.923

0.359

0.116

0.093

IB5

0.089

0.811

0.391

0.120

0.010

IB7

0.041

0.444

0.527

−0.051

0.071

Table 5.18 HTMT Finance

Internal bus (ops)

Internal bus (strat)

Learning and growth

Quality

Finance Internal bus (ops)

0.164

Internal bus (strat)

0.150

0.862

Learning and growth

0.987

0.206

0.069

Quality

0.867

0.093

0.194

0.779

5.21.2 Assessment of the Formative Construct (Performance of FM Services) This study has one main formative construct which is measured by five distinct outcome measures. (Peer review scores, infection prevention and control, budget variance, complaints and feedback received and support for core healthcare). This study report on collinearity issues and the significance and relevance of the formative indicators. Multi collinearity is assessed with the Variance Inflation Factor (VIF).

84

5 Findings and Discussions

Table 5.19 Measurement properties for formative constructs Construct

Items

VIF

Weight

t-value weight

Sig

Load

t-value load

Sig

Performance of FM

PMPR (peer review)

2.051

0.359

1.370

0.171

0.778

5.989

0.000

PMIPC (infection prevention and control)

1.164

0.304

2.651

0.008

0.459

3.657

0.000

PMBV (budget variance)

2.808

0.355

1.955

0.051

0.868

11.049

0.000

PMCOMP (complaints and feedback)

1.689

0.222

0.975

0.330

0.712

4.296

0.000

PMCH (core healthcare)

3.103

0.134

0.651

0.515

0.855

10.124

0.000

The highest VIF values (core health = 3.103) is not at critical level thus satisfying Diamantopoulos and Siguaw [68] threshold. Subsequently we examined the significance and relevance of the outer weights for the formative measures which draws on a bootstrapping of 500 samples (more than twice the sample of the study),2 no sign changes, bias corrected and accelerated and accelerated confidence interval in a two tail testing at 0.05% significance level. The test results shows that infection prevention and control is the only indicator that has relative contribution measured by its outer weights specifically β = 0.304, and significant at 5% [69]. For the core healthcare, budget variance, complaints and feedback and peer review, consideration is given to their outer loads to establish the significance of the formative indicators. By the outer loads, it can inferred that these four formative indicators have β > 0.50 and are significant at 5% (p < 0.05). On the basis of their absolute contribution in terms of loads, the four indicators are considered in the model for further analysis [70]. Table 5.19 summarizes the result for the VIF, weights, loads and their respective P values.

5.22 Assessment of the FM Performance Structural Model Having met the reliability and validity for the measurement model (both reflective and formative), this section presents the results of the assessment of the structural model. The section begins with investigation into the lateral collinearity. Congruent with vertical collinearity that uses a threshold of 3.3 [63] or 5 [68] same criteria also 2 Bootstrapping

with larger samples increases reliability and validity of the statistical results.

5.22 Assessment of the FM Performance Structural Model Table 5.20 Lateral collinearity (Inner VIF)

Construct

85 VIF

Finance indicators

3.411

Internal business indicators (strat)

1.356

Internal business indicators (ops)

1.330

Quality indicators

2.279

Leaning and growth

2.596

holds for lateral collinearity. The highest inner VIF value according to the test result in Table 5.20 is finance indicator (3.411) suggesting that lateral collinearity is not a problem. Thus the results of the predictor constructs has no possibility of misleading findings of the structural model [71].

5.23 Coefficient of Determination (R2 ) This study relies on the R2 as the models predictive abilitys calculated as the squared correlation amongst all exogenous constructs. There are some controversies surrounding what constitute an acceptable R2 descipline wise [69]. suggest that reseachers should interpretate the R2 in the context of the study at hand and by related studies. On the contary [72] also recommeded that the R2 should be equal to or greater than 0.10 in order for the varaince explained by a particular exogenous construct to be deemed adequate. The result of the R2 is 0.387 as shown is Fig. 5.3. This is considered substantial by [73] criteria, since we fail to find any acceptable values of R2 in similar studies in related literature. This is an indication of the strength of the exploratory variables used in the study.

5.24 Statistical Power of the Structural Model One of the main advantages of PLS-SEM is its high statistical power ability, more especially for exploratory research. Based on the total number of variables in the measurement model which stands at 22 (see Fig. 5.1), the minimum sample size required is 220 [74]. Using the 205 observations and the coeffiecient of determination of the model (R2 = 0.387) produces an effect size of 0.631. The corresponding statistical power is 99%. According to [75], PLS-SEM requires a sample of 147 to attain a power of 80% (that is given that an estimated R2 of 0.10 at 5% significance for 5 exogenous constructs).

86

5 Findings and Discussions

Fig. 5.3 Coefficient of determination

Power Calculation: F tests - Linear multiple regression: Fixed model, R² deviation from zero Analysis: Compromise: Compute implied α & power Input: Effect size f² = 0.6313214 β/α ratio = 1 Total sample size = 205 Number of predictors = 5 Output: Noncentrality parameter λ = 129.4209 Critical F = 8.2568607 Numerator df = 5 Denominator df = 199 α err prob = 4.153071e-007 β err prob = 4.153071e-007 Power (1-β err prob) = 0.9999996

5.24 Statistical Power of the Structural Model

87

The statistical power of the study with 205 sample is 99.9%, thus proving that the sample is adequate to validate the results of the PLS-SEM based on the power estimates by the G*power software.

5.25 Evaluating Significance and Relevance of the FM Structural Model This section examines the hypothesis of the study which draws on bootstrapping of 500 samples, no sign changes, bias corrected and accelerated and accelerated confidence interval in a one tail testing at 0.05% significance level. First, the study examine if the result is valid by analysing the confidence interval bias corrected (BCa) result. This is paramount to confirm the validity of the results of the PLS-SEM bootstrapping. The results presented in Table 5.21 shows that the upper and lower bound of the confidence interval bias does not capture any value of ‘0 implying the result is valid [63]. Further the results of the path coefficient shows that four constructs have t values ≥ 1.645, thus significant at 0.05% level. Specifically predictor’s quality, finance, learning & growth and internal business operations. While the predictor internal business strategic has a weak path coefficient (β = 0.154, t value = 1.466) and is not significant at 5%. Interestingly, the relationship between quality indicator and performance has a strong path value (β = 0.516), however it effect on performance is moderate (f2 = 0.19). Again despite finance, learning & growth and internal business operations having significant relationships with performance, their effect is however small, specifically effect size less than 0.15 [73]. Internal business strategic the only construct which had no positive relationship with performance of FM equally has a Table 5.21 Result of the path coefficient (hypothesis testing) H

Rel

H1 Quality → Perf

Confidence Std Beta Std interval bias Error corrected 5% 95% [0.377, 0.659]

t-value P f2 values

Decision

0.516

0.093 5.573

0.000

0.191 Supported

−0.289

0.143 2.026

0.019

0.040 Supported

0.218

0.106 2.049

0.020

0.030 Supported

H4 Internal bus(strat) [−0.031, → perf 0.346]

0.154

0.116 1.330

0.092

0.029 Not Supported

H5 Internal bus(ops) → perf

0.267

0.128 2.081

0.019

0.087 Supported

H2 Financial → Perf [−0.513, 0.059] H3 Leaning and growth → perf

[0.039, 0.395]

[0.020, 0.451]

** Perf–performance of FM services; Internal bus (strat) –internal business strategic; Internal bus (ops) –internal business operations, H-hypothesis, Rel.–Relationships

88

5 Findings and Discussions

small effect in predicting performance. Figure 5.3 depicts the FM structural model with t values in parenthesis. Although the results indicate that four path model are significant, P value or statistical significance does not measure the importance of a construct. A path coefficient may be significant but their size maybe so small that they do not justify scholarly or managerial attention. Thus it is important to assess the relevance of the significance of the relationships. This would inform us about the level of importance amongst the four constructs. Carefully examining the result in Table 5.21 put quality as the most important predictor followed by finance respectively β = 0.516 and β = -0.289. This is followed by internal business operations (β = 0.267) and learning and growth (β = 0.218). The least important predictor was internal business strategic (β = 0.154) (Fig. 5.4).

Fig. 5.4 FM structural equation model with t values in parenthesis

5.26 Discussion of Results

89

5.26 Discussion of Results The structural equation model confirm the existence of a statistically significant relationships between four key performance indicators (quality of service delivery, finance, learning and growth and internal business operations) and FM performance. The investigation found no significant relationship between internal business strategic and performance of FM. The observations drawn from the interpretations of the FM performance measurement structural model reveals a higher preference on quality of service delivery than finance, learning & growth and internal business operations. This finding is consistent with [35, 76] which found quality to be the hallmark of FM service delivery. Beyond FM, service quality has been a strong indicator of performance in service management literature. Research in service management by [77] have established positive relationship between quality and organization performance. It is generally acknowledged that user’s perception of service quality such as tangibles, reliability, responsiveness, and professionalism affects organization’s performance and offers sustainable competitive advantage [78]. Finance in terms of significance and relevance is ranked second to FM performance but negative effect. The finding however has some profound practical implications. The financing of healthcare services has been a major issue to governments in the face of rising healthcare costs. Studies by [79] have identified late subvention payment by government, control over use of donor funds and interference in setting user fees as major challenges confronting the financial management of public hospitals in Ghana. Contrary to finance in the private sector which has profit maximization as the main objective, in the public settings like public hospitals in Ghana, the overriding objectives is value for money. As such profit centred measures were less realistic and unimportant in this study. The National Health Insurance Scheme (NHIS) is currently indebted in arrears making cost effectiveness a necessary evil in the FM task [50] have equally referred to it as value for money and argued that the evaluation of FM performance depends on the impact, efficiency, and cost effectiveness. This study agrees with this assertion but adds that leveraging on the cost effectiveness should be based on value engineering. This however necessitate the need for the development of more appropriate tools to evaluate cost effectiveness, especially where there are no benchmark data in Ghana for value engineering. The findings also established a positive relationship between internal business operations and performance. Internal business operations mechanism are fundamentally the primary processes involved in the FM delivery processes geared towards improving the quality of FM services. Critically examining the three indicators that represented the construct points to some interesting issues. A critical component of the internal business operations is effectiveness of FM planning which is fundamental to successful service delivery. According to [55], FM requires strategic planning in order to deliver to the client organization. Again, performance of service outsourced contractors (achievement of service levels agreements) equally has been given the needed attention, although outsourcing is currently limited in public hospitals in Ghana.

90

5 Findings and Discussions

The least in terms of relevance to performance though statistically significance is learning and growth. Through learning, growth and innovation, FM department will improve business processes, achieve for value for money and above all satisfy client’s needs. The learning and growth perspective was represented by three indicators; staff training and development, turnover and competence levels which make up the human capital base of the FM departments. Human capital includes the skills, knowledge, expertise and the extent of training given to employees. The challenge for the FM departments remains that, while the process of medical diagnostics revolutionizes and advances over time, the need for learning, growth, and innovation becomes vital. In FM, studies by [4, 21] equally have established innovation, learning and growth as key ingredient for FM added value to the organization. The result of the SEM thus confirm these previous studies. Commendably, several facets of service delivery have been advanced while generally employee turnover is low in public hospital due to high unemployment in Ghana. That notwithstanding, there are practical challenges with training and staff development as well as requisite competence more especially for estate management staff. Undoubtedly, the public hospitals will not attract the best competencies due to low remuneration and poor working conditions in the public sector in Ghana. The result however found no statistically significant relationship between internal business strategic and performance of FM hence nullifying hypothesis 4. The construct is termed “strategic” because communication, achievement of goals and objectives and top management commitment are all facets of performance that requires the drive and initiative of strategic level or senior management support. The results of the structural model however is in contrast with the findings of [80] which emphasized managerial commitment as an important factor that affects organizational performance [81] advanced that strategic initiatives and commitment are vital for service quality and fosters the development of customer orientation to enhance performance. From a practical point of view, the results however makes sense in the Ghanaian context because most of the management initiatives are focused on core healthcare delivery at the expense of support services. This however demands a change in orientation of FM practices since failure to view FM as a strategic resource limits its potential value adding capabilities which has consequences of affecting the core business in the future [27]. Given the critical influence of the five performance outcomes measures (peer review scores, infection prevention and control, support for core healthcare, complaints and feedback received, budget variance) to FM performance, it would be beneficial to examine the strengths of their influence and their statistical significance. Based on the results of the bootstrapping as presented in Table 5.19, infection prevention and control was the only measure that has relative contribution measured by the outer weights whereas consideration was given to the absolute contribution measured by the outer loads for four formative indicators. Infection Prevention and Control (IPC) is a critical measure for this study due to the updated policy and guidelines of the Ministry of Health in 2015 which seeks to address the inappropriate IPC practices in public hospitals. A growing body of knowledge now exist which suggests that healthcare associated infections are major causes of morbidity and mortality. In

5.26 Discussion of Results

91

the context of FM, research by Njuangang et al. [82] have expressed the significant role FM plays in the control of HAIs which is driven by infection prevention and control practices. Thus the relative contribution of the measure in the structural model further support these studies since poor performance on the part of healthcare facilities management services are the main non-clinical causes of HAIs [11]. On the basis of the absolute contribution to performance, the result of the structural model put budget variance as top to FM performance. In facilities management, most studies have relied on the cost of operating the facility for financial assessment, this study however uses non-conventional measure of variance in budget as its main financial performance. Budget variance has been used as a core financial performance tool in many organization and the confirmation in the structural model highlights it relevance to FM performance. According to [83], budget variance is important and that performance appraisal based on budget achievement helps in the management of cash inflows and outflows, provides mechanism for effective planning and control and forms the basis for benchmarking. As FM is emerging in public hospitals in Ghana, the result re-emphasize the importance for financial management, more especially as funding remains a major challenge. Facilities management have lived to provide continual support for core healthcare delivery and by absolute contribution ranks 2nd. According to [14] the supportive role of FM lies in the ability to effectively manage facilities resources, support services and the working environment to enhance the core business of the organization in both the long and short term. The role of FM to public hospitals is well-established and the results of the absolute contribution to performance further buttress this stands in literature. The peer review comes third. The Ghana health service introduced the peer review program with the objective to improve the quality and standards of service delivery. Although the peer review is more of institutional audit, it relevance to performance necessitated by the need to ensure best practices in all spheres of healthcare delivery is established in this study. The least in terms of absolute contribution was complaints and feedback received which is an indication of client satisfaction of FM services. Recent studies by [16] have found significant correlations between user satisfaction, feedback and maintenance performance, more especially informal discussions with clients. Taking cognizance of the fact that complaints and feedbacks offers first-hand information that should be considered for further improvement, it would have been interesting to be the most important. The interpretations of the FM structural model demonstrate that largely the results of the study is consistent with previous studies. This study however makes an important contribution to the existing body of knowledge on FM. Most studies on facilities management services have focused on service quality and customer satisfaction dimensions at the neglect of aggregate performance. This study explored and confirmed key performance measures and indicators from the perspective of healthcare facilities managers. The five formative indicators and the non-conventional financial indicators are innovations of the study. Its use of structural equation modelling also lends strength to the findings, which identifies the critical indicators that influence performance by assessing the relative contributions, thus providing useful techniques to improve the performance of FM services and that this study

92

5 Findings and Discussions

is one of the few studies that have investigated such relationships using structural equation modelling. Moreover, the developed structural model can also serve as a motivation tool for acknowledging FM’s role in healthcare delivery. Findings of the study should motivate hospital managers to place more priority on FM services as the SEM suggest that strategic directions and commitment should be strengthened. This study admits that the underlying constraints in the provision of quality health care are efficiency and financing gaps, which has the potential of affecting performance, this however places performance measurement central to the scarce resource management in our hospitals.

5.27 Summary This chapter presented the results of an in-depth investigations on hospital FM performance measurement of the case study interviews and general questionnaire survey. In sum, the result of the exploratory case study interviews highlighted; 1. Five performance measurement techniques for measuring FM performance, specifically, the peer review by the Ghana health service, inspections with standard check list, performance appraisal, quality assurance and user satisfaction survey. 2. Majority of the existing techniques are not tailored for FM performance assessment. The peer review and inspections with standard checklist appears to the most effective tool at present. 3. FM departments lacked KPIs, however KPIs adopted from FM literature were largely found to be relevant to the performance of FM services. A total of 21 KPIs were identified through discussions with participants of the case study interviews. 4. Discussions on the existing performance techniques and KPIs yielded five (5) performance outcomes which include the peer review scores, support for core healthcare, infection prevention and control, budget variance as well as complaints and feedback received. The analysis of the quantitative data from the questionnaire survey lead to the following findings; 1. The questionnaire survey further confirmed the five techniques identified through the case study interviews. Following a descriptive analysis of the relevance and frequency of utilization of the performance measurement techniques, inspections with standard checklist appears to be the most frequently used whereas in terms of effectiveness, the peer review and inspections are very effective. This support the earlier qualitative findings. 2. The result of the questionnaire survey confirmed 17 KPIs out of the initial 21 KPIs with the exploratory factor analysis/principal components extraction. This is in line with the second research objective of the study.

5.27 Summary

93

3. The investigations into the relationship between the KPIs and performance with PLS-SEM (Research objective 3) was to avail to public hospitals manager’s key performance dimensions that needs to be improved. In total five hypothesis were proposed for the structural model. Four performance indicators (quality, finance, learning and growth and internal business operations), were however supported while one hypothesis (internal business strategic) was rejected.

References 1. Ghana Health Service (GHS), Objcetives and Fucntional Responsibilities of the Unit. (2016) 2. J.N. Bawole et al., Performance appraisal or praising performance? The culture of rhetoric in performance management in Ghana civil service. Int. J. Public Adm. 36(13), 953–962 (2013) 3. C. Liyanage, C. Egbu, A performance management framework for healthcare facilities management. J. Facil. Manage. 6(1), 23–36 (2008) 4. M. Pitt, M. Tucker, Performance measurement in facilities management: driving innovation? Property Manage. 26(4), 241–254 (2008) 5. A.L. Lindholm, K.I. Leväinen, A framework for identifying and measuring value added by corporate real estate. J. Corp Real Estate 8(1), 38–46 (2006) 6. Liyanage, C.L.: The role of facilities management in the control of healthcare associated infections (HAI) (Doctoral Dissertation). Glasgow Caledonian University. (2006) 7. S.S. Nudurupati et al., State of the art literature review on performance measurement. Comput. Ind. Eng. 60(2), 279–290 (2011) 8. J.L. Harbour, The Basics of Performance Measurement. 2nd edn ed. (Madison Avenue, New York, Routledge, 2009) 9. T. van der Voordt et al., Value Adding Management (VAM) of buildings and facility services in four steps. Corp. Real Estate J. 6(1), 42–56 (2016) 10. C. Mangan, M. Pietroni, D. Porter, “Being brave”: A case study of how an innovative peer review approach led to service improvement. J. Integr. Care 24(4), 201–213 (2016) 11. S. Njuangang, C. Liyanage, A. Akintoye, Key performance measures to control maintenanceassociated HAIs. Int. J. Health Care Qual. Assur. 28(7), 690–708 (2015) 12. S. Chitopanich, Positioning facilities management. Facilities 22(13/14), 364–372 (2004) 13. I.M. Shohet, S. Lavy, Healthcare facilities management: state of the art review. Facilities 22(7/8), 210–220 (2004) 14. O. Amankwah, C. Weng-Wai, A.H. Mohammed, Modelling the mediating effect of health care healing environment on core health care delivery and patient satisfaction in Ghana. Environ. Health Insights 13, 1178630219852115 (2019) 15. A.S. Reddy, S. Loh, R.A. Kane, Budget variance analysis of a departmentwide implementation of a pacs at a major academic medical center. J. Digit. Imaging 19(1), 66 (2006) 16. C.P. Au-Yong, S. Ali Azlan, F. Ahmad, Participative mechanisms to improve office maintenance performance and customer satisfaction. J. Perform. Constructed Facil. 29(4), 04014103 (2015) 17. M. Pitt et al., An examination of facility management, customer satisfaction and service relationship in the Bangkok healthcare system. Indoor Built Environ. 25(3), 442–458 (2016) 18. F. Pagani, Peer review as a tool for co-operation and change: An analysis of an OECD working method. Afr. Secur. Rev. 11(4), 15–24 (2002) 19. R. Smith, Peer review: a flawed process at the heart of science and journals. J. R. Soc. Med. 99(4), 178–182 (2006) 20. L. Leventhal, The role of understanding customer expectations in aged care. Int. J. Health Care Quality Assur. 21(1), 50–59 (2008) 21. M.I. Okoroh et al., Adding value to the healthcare sector—A facilities management partnering arrangement case study. Facilities 19(3/4), 157–164 (2001)

94

5 Findings and Discussions

22. Ministry of Health (MOH), National Policy and Guidelines for Infection Prevention and Control in Health Care Settings 2015 10/0/2017]; Available from: https://www.ghanahealths ervice.org/downloads/National_Policy_and_Guidelines%20_for_Infection_Prevention_and_ Control_in_Health_Care_Settings_2015.pdf 23. J. Holloway et al., Identifying Best Practice in Benchmarking (CIMA Publishing, London, 1999) 24. J. Nunnally, Psychometric Methods (McGraw-Hill, New York, 1978) 25. M.J. Lebas, Performance measurement and performance management. Int. J. Prod. Econ. 41(1– 3), 23–35 (1995) 26. D. Vyas, A.E. Hozain, Clinical peer review in the United States: history, legal development and subsequent abuse. World J. Gastroenterol. WJG 20(21), 6357 (2014) 27. L. Rodríguez-Labajos, C. Thomson, G. O’Brien, Performance measurement for the strategic management of health-care estates. J. Facil. Manage. 16(2), 217–232 (2018) 28. L. Rasch, Employee performance appraisal and the 95/5 rule. Community College J. Res. Pract. 28(5), 407–414 (2004) 29. R. Selvarajan, P.A. Cloninger, The influence of job performance outcomes on ethical assessments. Personnel Review 38(4), 398–412 (2009) 30. N.A. Azizan, B. Mohamed, The effects of perceived service quality on patient satisfaction at a public hospital in state of Pahang, Malaysia. Encounter. 2(3) (2013) 31. J.J. Fenton et al., The cost of satisfaction: a national study of patient satisfaction, health care utilization, expenditures, and mortality. Arch. Intern. Med. 172(5), 405–411 (2012) 32. R. Amfo-Otu, Hospital Solid Waste Management Practices in Eastern Region of Ghana (Doctoral Dissertation). (University of Cape Coast, 2018) 33. S. Assaf et al., Factors affecting outsourcing decisions of maintenance services in Saudi Arabian universities. Property Manage. 29(2), 195–212 (2011) 34. D.I. Ikediashi et al., Analysis of risks associated with facilities management outsourcing: a multivariate approach. J. Facil. Manage. 10(4), 301–316 (2012) 35. H.A. Koleoso, M.M. Omirin, Y.A. Adewunmi, Performance measurement scale for facilities management service in Lagos-Nigeria. J. Facil. Manage. 15, 128–152 (2017). https://doi.org/ 10.1108/JFM-04-2016-0015 36. H.F. Kaiser, The application of electronic computers to factor analysis. Educ. Psychol. Measur. 20(1), 141–151 (1960) 37. E. Ferguson, T. Cox, Exploratory factor analysis: A users’ guide. Int. J. Sel. Assess. 1(2), 84–94 (1993) 38. D. Child, The Essentials of Factor Analysis. 3nd edn ed. (London: Bloomsbury Academic, 2006) 39. J. Pallant, A Step by Step Guide to Data Analysis Using SPSS (McGraw-Hill Education, Berkshire UK, 2010) 40. D. Amos, C.P. Au-Yong, Z.N. Musa, Developing Key Performance Indicators for Hospital Facilities Management Services: A Developing Country Perspective (Engineering, Construction and Architectural Management, 2020) 41. H.F. Kaiser, J. Caffrey, Alpha factor analysis. Psychometrika 30(1), 1–14 (1965) 42. D.I. Ikediashi, S.O. Ogunlana, I.A. Odesola, Service quality and user satisfaction of outsourced facilities management (FM) services in Nigeria’s public hospitals. Built Environ. Project Asset Manage. 5(4), 363–379 (2015) 43. J. Hinks, P. McNay, The creation of a management-by-variance tool for facilities management performance assessment. Facilities 17(1/2), 31–53 (1999) 44. V.T. Luu, S.-Y. Kim, T.-A. Huynh, Improving project management performance of large contractors using benchmarking approach. Int. J. Project Manage. 26(7), 758–769 (2008) 45. A.P.C. Chan, A.P.L. Chan, Key performance indicators for measuring construction success. Benchmarking: Int. J. 11(2), 203–221 (2004) 46. A. Parasuraman, V.A. Zeithaml, L.L. Berry, A conceptual model of service quality and its implications for future research. J. Mark. 49(4), 41–50 (1985)

References

95

47. N.F. Rad, A.P.M. Som, Y. Zainuddin, Service quality and patients’ satisfaction in medical tourism. World Appl. Sci. J. 10(1), 24–30 (2010) 48. R.K. Henson, J.K. Roberts, Use of exploratory factor analysis in published research: Common errors and some comment on improved practice. Educ. Psychol. Measur. 66(3), 393–416 (2006) 49. D. Amaratunga, D. Baldry, A conceptual framework to measure facilities management performance. Property Manage. 21(2), 171–189 (2003) 50. X. Meng, M. Minogue, Performance measurement models in facility management: a comparative study. Facilities 29(11/12), 472–484 (2011) 51. H. Heng, W. McGeorge, M. Loosemore, Beyond strategy: exploring the brokerage role of facilities manager in hospitals. J. Health Organ. Manage. 19(1), 16–31 (2005) 52. P. Aseweh Abor, Managing healthcare waste in Ghana: A comparative study of public and private hospitals. Int. J. Health Care Qual. Assur. 26(4), 375–386 (2013) 53. H.-J. Zhang et al., Investigation of medical waste management in Gansu province China. Waste Manage. Res. 31(6), 655–659 (2013) 54. S. Lavy, J.A. Garcia, M.K. Dixit, KPIs for facility’s performance assessment, Part II: identification of variables and deriving expressions for core indicators. Facilities 32(5/6), 275–294 (2014) 55. B. Atkin, A. Brooks, Total Facilities Management. 4th edn ed. (Wiley-Blackwell Publishers, New York, 2015) 56. A. Farooq, Z. Hussain, Balanced scorecard perspective on change and performance: a study of selected Indian companies. Procedia-Soc. Behavioral Sci. 24, 754–768 (2011) 57. S.U.R. Toor, S.O. Ogunlana, Beyond the ‘iron triangle’: Stakeholder perception of key performance indicators (KPIs) for large-scale public sector development projects. Int. J. Proj. Manage. 28(3), 228–236 (2010) 58. T. Kremic, O. Icmeli Tukel, W.O. Rom, Outsourcing decision support: a survey of benefits, risks, and decision factors. Supply Chain Manage. Int. J. 11(6), 467–482 (2006) 59. D. Borsboom, G.J. Mellenbergh, J. Van Heerden, The theoretical status of latent variables. Psychol. Rev. 110(2), 203 (2003) 60. T.Z. Keith, Multiple Regression and Beyond: An Introduction to Multiple Regression and Structural Equation Modeling. 2nd edn ed. (London, Routledge, 2014) 61. M. Sarstedt et al., On the emancipation of PLS-SEM: A commentary on Rigdon (2012). Long Range Plan. 47(3), 154–160 (2014) 62. I. Motawa, M.G. Oladokun, Structural equation modelling of energy consumption in buildings. Int. J. Energy Sect. Manage. 9(4), 435–450 (2015) 63. J.F. Hair, et al., A Primer on Partial Least Squares Structural Equation Modeling (PLS-SEM). 2nd edn ed. (Thousand Oaks: CA, Sage Publications, 2017) 64. W.W. Chin, The partial least squares approach to structural equation modeling. Mod. Meth. Bus. Res. 295(2), 295–336 (1998) 65. C. Fornell, D.F. Larcker, Evaluating structural equation models with unobservable variables and measurement error. J. Mark. Res. 18(1), 39–50 (1981) 66. J. Henseler, C.M. Ringle, M. Sarstedt, A new criterion for assessing discriminant validity in variance-based structural equation modeling. J. Acad. Mark. Sci. 43(1), 115–135 (2015) 67. R.B. Kline, Convergence of Structural Equation Modeling and Multilevel Modeling (Sage Publications, London, 2011) 68. A. Diamantopoulos, J.A. Siguaw, Formative versus reflective indicators in organizational measure development: a comparison and empirical illustration. Br. J. Manag. 17(4), 263–282 (2006) 69. J.F. Hair, C.M. Ringle, M. Sarstedt, Partial least squares structural equation modeling: rigorous applications, better results and higher acceptance. Long Range Plan. 46(1), 1–12 (2013) 70. R.T. Cenfetelli, G. Bassellier, Interpretation of Formative Measurement in Information Systems Research. MIS quarterly. pp. 689–707 (2009) 71. N. Kock, G. Lynn, Lateral collinearity and misleading results in variance-based SEM: An illustration and recommendations. J. Assocaition Inform. Syst. 13(7), 546–580 (2012)

96

5 Findings and Discussions

72. R.F. Falk, N.B. Miller, A Primer for Soft Modeling. A primer for soft modeling. (Akron, OH, US, University of Akron Press, 1992) xiv, 103-xiv, 103 73. J. Cohen, Statistical Power Analysis for the Behavioral Sciences. 2nd edn ed. (Hillsdale, NJ, Lawrence Erlbaum Associates, Publishers, 1988) 74. D.E. Miller, J.T. Kunce, Prediction and statistical overkill revisited. Meas. Eval. Guidance 6(3), 157–163 (1973) 75. J. Cohen, A power primer. Psychol. Bull. 112(1), 155 (1992) 76. J.A. Rahman, V. Coffey, M. Skitmore, Stakeholder service delivery expectations of military facilities management. Built Environ. Proj. Asset Manage. 2(2), 146–166 (2012) 77. D.Y. Golhar, S.P. Deshpande, Productivity comparisons between Canadian and US TQM firms: An empirical investigation. Int J. Qual. Reliab. Manage. 16(7), 714–722 (1999) 78. S. Gounaris, S. Dimitriadis, Assessing service quality on the web: evidence from business-toconsumer portals. J. Serv. Mark. 17(5), 529–548 (2003) 79. G. Abekah-Nkrumah, T. Dinklo, J. Abor, Financing the health sector in Ghana: A review of the budgetary process. Eur. J. Econ. Financ. Adm. Sci. 2009(17), 45–59 (2009) 80. C. Zehir et al., The indirect effects of servant leadership behavior on organizational citizenship behavior and job performance: Organizational justice as a mediator. Int. J. Res. Bus. Soc. Sci. 2(3), 1 (2013) 81 C.K.I. Che Ibrahim, S.B. Costello, S. Wilkinson, Key indicators influencing the management of team integration in construction projects. Int. J. Manag. Proj. Bus. 8(2), 300–323 (2015) 82 S. Njuangang, C. Lasanthi, A. Akintoye, Performance measurement tool (PMT) to control maintenance-associated infections. Facilities. 34(13/14), 766–787 (2016) 83. M.P. Joye, P.J. Blayney, Cost and Management Accounting Practices in Australian Manufacturing Companies: Survey Results. (1990). https://trove.nla.gov.au/work/7271923

Chapter 6

Conclusions and Recommendations

Abstract The concluding chapter summarizes the key findings of this study. The conclusions of the study are drawn based on the findings and the discussions presented in the previous chapters. This chapter also presents the contributions of the study to knowledge as well as the practical implications of the study. Finally recommendations and suggestions for future research are also outlined.

6.1 Conclusions of the Study The facilities management function is to support the organization’s core business by providing the enabling infrastructure and services. Although the primary function of a hospital is on clinical care, this is however facilitated by FM. Given that the performance of a hospital is influenced by its facilities, it is equally important to place emphasis on FM performance. Regrettably, most performance measurement initiatives in hospitals are centered on clinical care performance rather than FM that support the core processes. The review of literature shows a deficiency of performance measurement research in FM. Although a few studies have been conducted for hospital FM performance measurement, they are studies in developed countries. Due to the nascent stage of FM development in Ghana, application of performance measures and frameworks from such studies would require intense alterations to fit to the Ghanaian context. Against this backdrop, this study was motivated to examine performance measurement of FM services with focus on general hospital cleaning, waste and estate management services. By drawing on knowledge of existing performance measurement practices and literature, the study aimed to gain a deep understanding of the concept of facilities management performance measurement in Ghana’s public hospitals. Three research objectives were set, these included; identifying existing performance measurement techniques vis-à-vis their frequencies and level of effectiveness (RO1), determine key performance indicators (RO2) and to develop a structural model to investigate the relationships between the

© The Author(s), under exclusive license to Springer Nature Singapore Pte Ltd. 2021 D. Amos et al., Measurement of Facilities Management Performance in Ghana’s Public Hospitals, Management in the Built Environment, https://doi.org/10.1007/978-981-33-4332-0_6

97

98

6 Conclusions and Recommendations

key performance indicators and performance of FM (RO3). In order to achieve these objectives, an exploratory investigation through multiple case studies interviews was first conducted to establish key performance variables. Thereafter a questionnaire survey was conducted to test the generalizability of the performance measures to the research population. This was consistent with the exploratory sequential mixed methods approach that was adopted by the study. The insights derived from the case studies and general questionnaire survey have resulted in far reaching conclusions which is of utility to both academia and practice. The key findings are summarizes hereafter;

6.1.1 Research Question 1: What are the Performance Measurement Techniques Used for Evaluating FM Services? The identification of performance measurement techniques used for assessing public hospital FM was a first step towards garnering knowledge on FM performance measurement in Ghana’s public hospital, since little is known about the existing PM practices in literature. This novel investigation identified five key performance measurement techniques. These included; the Ghana health service peer review, performance appraisal for FM staff, inspections with standard check list, quality assurance and user satisfaction survey. The result of the case study interviews and the questionnaire survey both confirmed that inspections with standard checklist was the most frequently used and effective technique. The findings further confirmed that the Ghana health service peer review, performance appraisal for FM staff, quality assurance and user satisfaction survey were however fairly frequently used and somewhat effective for measuring FM performance. Evidently, this underscores the need for this research to develop a tailored model for FM performance assessment in Ghana’s public hospitals. It is worthy to note that five performance outcomes were deduced from the existing performance measurement techniques. These included the peer review scores, budget variance, infection prevention and control, FM support for core healthcare and complaints and feedback received. These outcomes measures were important to demonstrate FM‘s bottom line contribution to the healthcare delivery.

6.1.2 Research Question 2: What are the Key Performance Indicators for Performance Measurement of FM Services? The review of literature shows that the application of KPIs has not been rigors in FM. In line with any scientific investigation, and the quest to generate a broader list of KPIs that could be useful for the study, further literature review was conducted in

6.1 Conclusions of the Study

99

supply chain and construction management disciplines. This generated a total of 34 KPIs which was explored in the initial case study interviews (see Sect. 3.4, Table 3.2). The study adapted a Balanced Scorecard typology to pre-categorize the indicators. Specifically quality, finance, internal business, learning and growth aspects of FM performance. The case study interviews however synthesized the indicators into a total of 21. In order to improve the construct validity for the KPIs and also as a way of selecting the most important indicators amongst the groups, an Exploratory Factor Analysis (EFA)/principal component extraction was conducted. The EFA yielded 17 indicators under five factors. Following logical reasoning the factor “internal business” was divided into internal business operations and internal business strategic. Although, the KPIs established in this study through the EFA is largely consistent with previous studies in the literature review, the study confirmed two non-conventional financial indicators based on time and size of FM budget approved.

6.1.3 Research Question 3: How Do the Key Performance Indicators Influence Performance of FM? An important element of performance improvement, is establishing the relationships between KPIs and performance. This is paramount to determine critical performance indicators that could be considered to improve FM performance in public hospitals. Objective three (3) modelled the relationship between the key performance indicators and the performance outcomes established in research objectives (1) and (2). PLS-SEM was employed to investigate the linear contributions of these multiple performance dimensions to FM performance. In this regard, a hypothetical model was developed and was subsequently modelled with the PLS-SEM software. Five hypothesis were proposed using the exogenous KPIs constructs. In relation to the hypothesis, the study sought to establish the likelihood of a statistically significant relationship between the KPIs (quality of service delivery, finance, learning and growth, internal business strategic and operations) and FM performance. Internal business strategic (Hypothesis 4), however was not supported in the PLS-SEM analysis. The result of the SEM reinforces the need for more quality and strategic directed FM to improve performance. Again, the study confirmed the relative and absolute contributions of the five performance outcomes to performance. Specifically, the Ghana health service peer review, budget variance, FM contributions towards infections preventions and control, FM support for core healthcare and complaints and feedback received.

100

6 Conclusions and Recommendations

6.2 Contributions to Knowledge This study fulfils pertinent research gaps in facilities management performance measurement literature. The following are some of the study’s contribution to knowledge; 1. The study is the first attempt to provide empirical evidence on performance measurement techniques for facilities management services in public hospitals in the context of a developing country such as Ghana. Little is known or if any in extant literature on performance measurement for FM in Ghana’s public hospital, thus contributing to FM performance measurement literature and by extension to many other developing countries where FM is equally emerging. The findings also contribute to our understanding of how public hospitals measure the performance of FM services in public hospitals. Findings of this study theoretically implies that there is the need to strengthen performance measurement for FM as most of existing techniques are not tailored for performance assessment. 2. Through a rigors combination of literature review, case study interviews and questionnaire surveys, this study developed an adaptable scale of 17 key performance indicators which provides a theoretical foundation in an academic capacity to be used to measure FM performance. Theoretically the study adapted the Balanced Scorecard mechanism to categorise KPIs and provided important insights on key performance indicators that can improve FM performance. The developed scales are generic and could easily be adapted to different FM service sectors especially in most developing countries. 3. Using the predictive capabilities of PLS-SEM, this study investigated the interactions between key performance indicators and FM performance. The structural model developed in the study helps identify critical performance dimensions that can be considered to improve FM performance. The developed structural model of this study is generic and can be adapted by other researchers to investigate FM performance. The interpretations of the structural model developed in the study, theoretically implies the need for more quality and strategic driven FM practices to improve performance. Further, based on the results of the statistical bootstrapping, this study reinforces the relevance of FM in infection prevention and control in public hospitals. 4. Methodologically, the study also makes an important contribution. The study employs an exploratory sequential mixed methods approach to develop performance scales and applies Partial Least Squares Structural Equation Modelling (PLS-SEM) to successfully verify and validate the research model, thus increasing the attention of FM researchers towards the use of PLS-SEM since SEM is yet to gain grounds in FM research despite its appreciation in other academic disciplines.

6.3 Implications for Practice

101

6.3 Implications for Practice As there are limited studies that examines the role of FM to healthcare delivery more especially in developing countries, this study is one of the few that have attempted to measure FM in hospitals which should motivate hospital managers to acknowledge FM’s role in healthcare delivery. In practice, by examining performance measurement techniques, KPIs and performance outcomes, public hospitals FM managers’ can evaluate their level of performance and institute appropriate strategies to improve performance. Further, the proposed structural equation model is useful assessing the performance of FM services in public hospitals. By extension, the developed structural model is of invaluable use to many developing countries who share similar socio economic characteristics and are equally faced with the challenge to improve FM services delivery in public hospitals. Additionally, although the study context is public hospitals, the established KPIs could be applied to other sectors such as public educational institutions and offices that are similarly faced with the challenge to improve their FM practices.

6.4 Recommendations for Public Hospital Managers In order to ameliorate the performance of facilities management services in Ghana’s public hospitals, the following recommendations are suggested for hospital management; 1. This study recommends that the Health Administration and Support Services (HASS) division of the Ghana Health Service should spearhead FM performance measurement initiatives that would improve FM practices. This could lead to improved healthcare delivery and a reduction in infections as opposed to investing in treating infections and allied diseases that result from poor healthcare environment. 2. To facilitate efficient performance measurement, this study suggest a central coordination point for non-clinical services that can capture and handle performance information from the various FM departments. FM teams are encouraged to conduct performance analysis meetings as part of effective performance measurement. The central coordinating point is expected to enhance the strategic role of FM through PM. 3. Finally, public hospitals should change from the ad hoc FM practices to more quality and strategic focused FM. It is about time public healthcare managers acknowledges FM’s role and accord it the needed attention in hospitals. To achieve this however, FM departments must demonstrate their value adding capabilities to senior management rather than being seen as cost centres. Unarguably one way to prove FM’s contribution is through systematic assessment of FM performance.

102

6 Conclusions and Recommendations

6.5 Suggestions for Future Research 1. Healthcare delivery in Ghana is highly competitive between the private and the public sectors with each accounting for about 50% of the public healthcare delivery. Thus the contribution of the private sector is quite enormous. In this regard, related studies of FM performance measurement in the private sector could result in identification of best practices which could be of invaluable benefits to the public sector. 2. With rising public healthcare bills, there is the tendency to outsource more FM services in future. Subsequently performance of outsourcing contractors through stringent services levels agreements may be required. The strutural model confirmed the relevance of outsourcing performance in hospitals, neverthless, there is the need for an indepth investigation into performace measurement of outsourcing of FM in future. Although outsourcing has attracted signifcant research quite recently, majority of the studies lacked performance measurement essentials. 3. The performance indicators used in this study are largely generic and unquantified which suits the nascent FM industry in Ghana. As FM develops overtime, future research should aim at identifying appropriate quantitative measures for more objective assessment of FM performance. 4. It would also be of interest to conduct further research geared towards placing of weights on the indicators to determine the relative importance. To this end, future research can engage multi criteria decision analytical tools such as Analytical Hierarchical Process (AHP), Analytic Network Process (ANP), among others. 5. Given that performance measurement is not an end itself, but a tool for more effective management, future research in performance management for FM in Ghana’s public hospitals should be encouraged. This could lead to the systematic utilization of performance measures and information to improve hospital performance.

Appendix A

Protocol for Case Study Interviews

Please note that this interview questions runs through for all the respective facilities management services/support services selected for the study.

Introduction This interview section is part of an on-going Ph.D. research on performance measurement for hospital support services (facilities management services) in public hospitals in Ghana. The study aims to develop a framework for performance measurement of facilities management services in public hospitals. This we believe will improve healthcare delivery to the citizenry to help national development.

Underline Philosophy of the Study This study is built on the theoretical stands that facilities management services (largely referred to as non-clinical services or hospital support services) are very vital for the delivery of healthcare. It has been noted that FM has continued to live by its definition of creating the right enabling environment that supports the core mandate of rendering clinical and medical diagnostic services. However an optimum FM service delivery can be achieved by placing more emphasis on performance measurement, besides it is the key for the effective implementation of a facilities management strategy in a hospital. The following working definitions are provided for your ready reference: Performance Measurement Techniques; strategies and ways to assess the performance of hospital FM services to identify shortfalls and improve its future performance. © The Editor(s) (if applicable) and The Author(s), under exclusive license to Springer Nature Singapore Pte Ltd. 2021 D. Amos et al., Measurement of Facilities Management Performance in Ghana’s Public Hospitals, Management in the Built Environment, https://doi.org/10.1007/978-981-33-4332-0

103

104

Appendix A: Protocol for Case Study Interviews

Key Performance Indicators; represent a set of indicators (financial and nonfinancial) focusing on those aspects of FM performance that are the most critical for FM service delivery and performance. Performance of FM Service; the extent to which FM service and personnel make facilities support the aim and strategic objectives of public hospitals. It is also a measure of FM’s contribution and added value to the hospital. Facilities Management; The management of hospital infrastructure and support services to provide added value to achieve healthcare objectives at best cost. Facilities Management Services; are the services that support the clinical activities of a hospital. These include cleaning, waste management, estate management, catering, laundering, security services, and transport among others. 1.0 Section One—General State of Affairs in the Case Study 1.1 What is your position in this hospital? 1.2 How many years of experience do you have? (Please specify years of experience at current hospital as well total years of service/experience with the GHS/MOH). 1.3 What is the number of beds in this hospital? 1.4 How is the annual patient attendance in the hospitals (both in and out patients)? 1.5 What is the total staff strength in your hospital and preferably the composition of support service staff? 2.0 Section Two—Questions on Performance Measurement Techniques for FM Services 2.1 Can you please talk me through the nature of hospital support service(s) and how it operates in your hospital? 2.2 Can you please talk me through the performance measurement systems or techniques for assessing FM services performance in your hospital? Or in other words what mechanisms do you have in place to assess performance of FM services in your hospital? Can you please provide the details of the performance measurement techniques in-use? (Also probe on the frequency the performance tools as well) 2.3 If no, could you please consider the following performance measurement tools? • • • • • •

quality assurance techniques audit by domestic service performance measurement software such as the as BSC, SBSC user satisfaction surveys performance appraisal for domestic managers and staff financial reporting on FM services

2.5 What do you expect from your current performance measurement techniques and have these expectations been met? Or better still have the performance measurement techniques been able to improve performance measurement of FM services? (Probe).

Appendix A: Protocol for Case Study Interviews

105

2.6 If yes can you elaborates on how it has improved performance of FM services (Probe)? 2.7 If no, could you please elaborate why the performance techniques are not effective for measuring the performance of FM services? 3.0 Section Three—Questions on Key Performance Indicators for FM Services 3.1 Do you have Key Performance Indicators (KPIs) for Facilities Management services? If yes, could you please provide me details of the KPIs in use for FM/ hospital support services in your hospital? 3.2 If no, could you please consider the following Key Performance Indicators? 3.3 Could you please rate the level to which these KPIs are important to the performance of FM services in your hospital on a scale of 1-5, where 1= not important, 2 = slightly important, 3 = somewhat important, 4 = important and = 5 very important Performance dimension

Key performance indicators

Service quality

1. 2. 3. 4. 5. 6.

Financial

1. Prompt release of cash for FM service task 2. Proportion of FM budget approved by management 3. Cost effectiveness in delivering FM service

Learning and growth

1. 2. 3. 4. 5.

Staff development program/training Employee turnover Promotions made Competence of staff Change management

Internal business processes

1. 2. 3. 4. 5. 6. 7.

Stakeholders communication FM staff focus on goals and objectives Commitment from top management Availability of ICT Fulfilment of SLAs/performance based outsourcing Safety management and accidents Effectiveness of planning of the FM task

Service response time Service reliability Professional approach Responsiveness to problem Up to date functional/appearance of equipment Effective complaints/ help desk

4.0 SECTION FOUR—QUESTIONS ON PERFORMANCE OUTCOME 4.1 Based on the performance measurement techniques you are using and the KPIs discussed, how do you conceptualize performance of your FM department? Or in order words how do you know how well you have performed? 4.2 Do you have any comments or inputs for this research? (Discretionary) THANK YOU

Appendix B

Questionnaire Survey on KPIs for FM

Ref No…………..

Questionaire Survey on Key Performance Indicators for Hospital Support Services/Non Clincial Services In Ghana’s Public Hospitals Dear Sir/Madam, This survey is part of an on-going research on performance measurement for Facilities Management (FM) services (hospital support services) in public hospitals in Ghana. The study aims to develop a framework for performance measurement of facilities management services in public hospitals. This I believe will improve healthcare delivery to the citizenry to help national development. Please note that the study focuses on hospital general cleaning services, waste management services and estate management services. Following the outcome of the literature review and multiple case studies in some selected GHS facilities, a total of 21 key performance indicators were extracted. Please note that this section is to assess your perception on theimportanceof key performance indicators. As a working definition, KPIs are set of indicators (financial and non- financial) focusing on those aspects of FM performance that are the most critical for FM service delivery and performance. We would appreciate if you could spare us 25 min of your time to respond to the questionnaire. Be assured that your participation is highly valued and absolutely necessary, while precautions have been put in place to protect your privacy and anonymity. If you desire to have a copy of the outcome of this research, please indicate your email address at the personal characteristics section of the questionnaire. We will be glad to provide you with one after the data collection and analysis are completed.

© The Editor(s) (if applicable) and The Author(s), under exclusive license to Springer Nature Singapore Pte Ltd. 2021 D. Amos et al., Measurement of Facilities Management Performance in Ghana’s Public Hospitals, Management in the Built Environment, https://doi.org/10.1007/978-981-33-4332-0

107

108

Appendix B: Questionnaire Survey on KPIs for FM

Should you require any clarification, please do not hesitate to contact the Principal Investigator on +233 24 7293399 or [email protected] Please be informed that the completed questionnaire will be picked up by the Principal Investigator/Assistants two (2) weeks from the date of dispatch. Thanks in anticipation. Sincerely Yours, Daniel Amos. (Doctoral degree student) Dr. Zairul Nisham Bin Musa Dr. Au Yong Cheong Peng (Supervisors) Please tick the appropriate FM service A. Cleaning service [ ] B. Waste management service [ ] C. Estate management service [ ] √ Section one; personal characteristics (please indicate by ticking ( ) the most appropriate answer) PC01. Please indicate your present position in the hospital 1. Director of Administration [ ]

2. Deputy Director of Administration [ ]

3. Medical Superintendent

4. Head of Environment [ ]

[]

5. Head of Estate Management [ ]

6. Assistant Environmental Officer [ ]

7. Assistant Estate officer [ ]

8. Others (Please specify)………………………

PC02. Academic Qualification: 1. HND [ ] 2. BSc/Btech/BA [ ] 3. MSc/MBA/MPhil[ ] 4. MBBS/MBChB [ ]

5. PhD [ ]

6. Other (please specify)……………………

PC03. Years of experience in your present hospital 1. Less than 1 years [ ]

2. 1-5 years [ ]

4. 11-20 years [ ]

5. Above 20 years []

3. 6-10 years [ ]

PC04. Total years of experience in service with the Ghana Health Service/Ministry of Health (taking account of experiences which you may have had before your present hospital) 1. Less than 1 years [ ]

2. 1-5 years [ ]

4. 11-20 years [ ]

5. Above 20 years [ ]

3. 6-10 years [ ]

PC05. Email address (Optional) -------------------------------------------------

Appendix B: Questionnaire Survey on KPIs for FM

109

√ Section two hospital characteristics (please indicate by ticking ( ) the most appropriate answer) HC01. Please indicate the category of your hospital 1. Teaching hospital [ ] 2. Regional hospital [ ] 3. Municipal/Metropolitan/District hospital [ ] HC02. What is the approximate number of staff in your hospital? 1. 0—50 [ ] 2. 51—100 [ ] 3. 101—500[ ] 4. 501—1000[ ] 5. Above 1000[ ] HC03. What is the average number of patients (in patients and outpatients) in your hospital? (Annual) 1. Less than 20,000[ ]

2. 20,001 – 40,000[ ]

3. 40,001 - 60,000[ ]

4. 60,001 – 80,000[ ]

5. 80,001 - 100,000 [ ]

6. Above 100,000 [ ]

HC04. What is the number of beds in your hospital? 1. Less than 50 [ ]

2. 50 – 100 [ ]

4. 201 – 300 [ ]

5. Above 300 [ ]

3. 101 – 200 [ ]

Section three; questions on key performance indicators for Facilities Management (FM) services In your own view, please rate the level of importance of the key performance indicators to the performance of the FM service using a scale of 1-5, where 1= not important,2= slightly important,3= somewhat important,4= important and = 5 very important Code

Key performance indicator

Level of importance

Customer/service quality indicators Q1

Service response time

Q2

Reliability of service

Q3

Professional approach

Q4

Responsiveness to problems

Q5

Up to date functional and appearance of equipment

Q6

Effective complaints desk/ functional help desk

1

2

3

4

5

1

2

3

4

5

1

2

3

4

5

1

2

3

4

5

1

2

3

4

5

1

2

3

4

5

Financial indicator F1

Prompt release of cash for FM service/task

1

2

3

4

5

F2

Proportion of FM budget approved by management

1

2

3

4

5

F3

Cost effectiveness in delivery FM service

1

2

3

4

5

1

2

3

4

Learning and growth indicators LG1

Staff development programs/training

5 (continued)

110

Appendix B: Questionnaire Survey on KPIs for FM

(continued) Code

Key performance indicator

Level of importance

Customer/service quality indicators Q1

Service response time

1

2

3

4

5

LG2

Employee turnover (employee that leaves the hospital within a certain period)

1

2

3

4

5

LG3

Internal promotions made

1

2

3

4

5

LG4

Competence of staff with regard to the delivery FM task

1

2

3

4

5

LG5

Change management(process of adopting to 1 new approaches/techniques in delivery FM)

2

3

4

5

Internal business process indicators IB1

Stakeholders communication

1

2

3

4

5

IB2

Achievement of set goals and objectives

1

2

3

4

5

IB3

Commitment from top management

1

2

3

4

5

IB4

Availability of Information Communication 1 Systems(ICT)- computers/software, internet, intercoms etc.

2

3

4

5

IB5

Fulfilments of Service Level Agreements(SLAs) /performance based outsourcing contracts by outsourced FM service providers

2

3

4

5

IB6

Safety management & accidents

1

2

3

4

5

IB7

Effectiveness of planning of the FM task

1

2

3

4

5

1

Please provide additional comments or note in the space provided below Thank you for your participation.

Appendix C

General Questionnaire Survey

Ref No………….. GENERAL QUESTIONAIRE SURVEY Dear Sir/Madam, This survey is part of an on-going research on performance measurement for Facilities Management (FM) services (hospital support services) in public hospitals in Ghana. The study aims to develop a framework for performance measurement of facilities management services in public hospitals. This I believe will improve healthcare delivery to the citizenry to help national development. Please note that the study focuses on hospital general cleaning services, waste management services and estate management services. The following working definitions are provided for your ready reference: Performance measurement tools; refers to strategies and techniques to assess the performance of hospital support services/FM services to identify shortfalls and improve its future performance. Performance of FM service; the extent to which FM service and personnel make facilities support the aim and strategic objectives of public hospitals. The extent to which FM service and personnel make facilities support the aim and strategic objectives of public hospitals. It is also a measure of FM’s contribution and added value to the hospital. Key performance Indicators; KPIs are set of indicators (financial and non- financial) focusing on those aspects of FM performance that are the most critical for FM service delivery and performance. Facilities Management; The management of hospital infrastructure and support services to provide added value to achieve healthcare objectives at best cost. Facilities Management Service; are the services that support the core or primary activities of a hospital. These include cleaning, waste management, catering, laundering, repairs and estate management services, security services among others. © The Editor(s) (if applicable) and The Author(s), under exclusive license to Springer Nature Singapore Pte Ltd. 2021 D. Amos et al., Measurement of Facilities Management Performance in Ghana’s Public Hospitals, Management in the Built Environment, https://doi.org/10.1007/978-981-33-4332-0

111

112

Appendix C: General Questionnaire Survey

We would appreciate if you could spare us 45 min of your time to respond to the questionnaire. Be assured that your participation is highly valued and absolutely necessary, while precautions have been put in place to protect your privacy and anonymity. If you desire to have a copy of the outcome of this research, please indicate your email address at the personal characteristics section of the questionnaire. We will be glad to provide you with one after the data collection and analysis are completed. Should you require any clarification, please do not hesitate to contact the Principal Investigator on +233 24 7293399 or [email protected] Please be informed that the completed questionnaire will be picked up by the Principal Investigator/Assistants two (2) weeks from the date of dispatch. Thanks in anticipation. Sincerely Yours, Daniel Amos. (Doctoral degree student) Dr. Zairul Nisham Bin Musa Dr. Au Yong Cheong Peng (Supervisors)

Survey on Performance Measurement for Hospital Support Services/Non Clinical Services (Facilities Management Services) in Ghana’s Public Hospitals Please tick the appropriate FM service A. Cleaning service [ ] B. Waste management service [ ] C. Estate management service [ ] √ Section one; personal characteristics (please indicate by ticking ( ) the most appropriate answer) PC01. Please indicate your present position in the hospital 1. Director of Administration [ ]

2. Deputy Director of Administration [ ]

3. Medical Superintendent

4. Head of Environment [ ]

[]

5. Head of Estate Management [ ]

6.Assistant Environmental Officer [ ]

7. Assistant Estate officer [ ]

8. Others (Please specify)………………………

PC02. Academic Qualification: 1. HND [ ]

2. BSc/Btech/BA [ ] 3. MSc/MBA/MPhil[ ]

4. MBBS/MBChB [ ]

6. Other (please specify)……………………

5. PhD [ ]

PC03. Years of experience in your present hospital

Appendix C: General Questionnaire Survey

113

1. Less than 1 years [ ]

2. 1-5 years [ ]

4. 11-20 years [ ]

5. Above 20 years [ ]

3. 6-10 years [ ]

PC04. Total years of experience in service with the Ghana Health Service/Ministry of Health (taking account of experiences which you may have had before your present hospital) 1. Less than 1 years [ ]

2. 1-5 years [ ]

3. 6-10 years [ ]

4. 11-20 years [ ]

5. Above 20 years [ ]

PC05. Email address (Optional) -------------------------------------------------

√ Section two hospital characteristics (please indicate by ticking ( ) the most appropriate answer) HC01. Please indicate the category of your hospital 1. Teaching hospital [ ]

2. Regional hospital [ ] 3. Municipal/Metropolitan/District hospital [ ]

HC02. What is the approximate number of staff in your hospital? 1. 0 – 50 [ ]

2. 51 – 100 [ ]

3. 101 – 500[ ]

4. 501 – 1000[ ] 5. Above 1000[ ]

HC03. What is the average number of patients (in patients and outpatients) in your hospital? (Annual) 1. Less than 20,000[ ]

2. 20,001 – 40,000[ ]

3. 40,001- 60,000[ ]

4. 60,001 – 80,000[ ]

5. 80,001-100,000 [ ]

6. Above 100,000 [ ]

HC04. What is the number of beds in your hospital? 1. Less than 50 [ ]

2. 50 – 100 [ ]

4. 201 – 300 [ ]

5. Above 300 [ ]

3. 101 – 200 [ ]

Section three (a); performance measurement tools in use for domestic Facilities Management (FM) services The table below outlines five (5) performance measurement techniques for public hospitals FM/support services identified through case study interviews. If you are currently using any of the √ tools listed in the table below in your hospitals, please indicate by ticking as ( ) the frequency of use of the performance measurement tool for the respective FM services using the scale below; A. Weekly [ ] B. Monthly [ ] C. Quarterly [ ] D. Bi-Annual [ ] E. Annually []

114

Appendix C: General Questionnaire Survey

F. More than 1 year [ ] G. Not applicable [ ] Please tick scale G, if you are not using the tool/s (i.e. Not applicable). Performance measurement techniques Peer review program A.Weekly [ ] by the Ghana health service E. Annually [ ] Inspection with A.Weekly [ ] standard checklist E. Annually [ ] Quality Assurance

A.Weekly [ ] E. Annually [ ]

Performance A.Weekly [ ] appraisal for FM staff E. Annually [ ] User surveys

satisfaction A.Weekly [ ] E. Annually [ ]

Frequency of use B.Monthly [ ]

C.Quarterly [ ]

F.more than 1 year [ ] B.Monthly [ ]

G. Not applicable [ ]

C.Quarterly [ ] D.Bi-Annual[ ]

F.more than 1 year [ ] B.Monthly [ ]

G. Not applicable [ ]

C.Quarterly [ ] D.Bi-Annual[ ]

F.more than 1 year [ ] B.Monthly [ ]

G. Not applicable [ ]

C.Quarterly [ ] D Bi-Annual[ ]

F.more than 1 year [ ] B.Monthly [ ]

D.Bi-Annual[ ]

G. Not applicable [ ]

C.Quarterly [ ] D.Bi-Annual[ ]

F.more than 1 year [ ]

G. Not applicable [ ]

Section three (b); level of effectiveness of performance measurement techniques for Facilities Management (FM) services Please indicate the level of effectiveness of the Performance measurement tool you have selected above in measuring the performance of FM service using a scale of 1-5, where; 1= Not Effective, 2 = slightly Effective, 3 = somewhat effective, 4 = Effective and 5 = very effective. Performance measurement techniques

Level of effectiveness

Peer review program by the Ghana health service

1

2

3

4

5

Inspection with standard checklist

1

2

3

4

5

Quality Assurance

1

2

3

4

5

Performance appraisal for domestic FM staff

1

2

3

4

5

User satisfaction surveys

1

2

3

4

5

Section four; questions on key performance indicators for Facilities Management (FM) services

Appendix C: General Questionnaire Survey

115

In your own view, please rate the level of achievement of the key performance indicators for the FM service delivery using a scale of 1-5, where; 5—Very high level of achievement (more than 70%) 4—High level of achievement (60-69%) 3—Moderately high level of achievement (50-59%) 2—Low level of achievement (40-49%) 1—Very low level of achievement (below 40%) Code

Key performance indicator

Level of achievement

Q1

Service response time

1

2

3

4

5

Q2

Reliability of service

1

2

3

4

5

Q3

Professional approach

1

2

3

4

5

Q4

Responsiveness to problems

1

2

3

4

5

Financial indicator

1

2

3

4

5

F1

Prompt release of cash for FM service/task 1

2

3

4

5

F2

Proportion of FM budget approved by management

1

2

3

4

5

F3

Cost effectiveness in delivery FM service

1

2

3

4

5

Learning and growth indicators

1

2

3

4

5

LG1

Staff development programs/training

1

2

3

4

5

LG2

Employee turnover (employee that leaves the hospital within a certain period)

1

2

3

4

5

LG3

Competence of staff with regards to the delivery FM task

1

2

3

4

5

Internal business process indicators

1

2

3

4

5

IB1

Stakeholders communication

1

2

3

4

5

IB2

Achievement of set goals and objectives

1

2

3

4

5

IB3

Commitment from top management

1

2

3

4

5

IB4

Availability of Information 1 Communication Systems(ICT)computers/software, internet, intercoms etc

2

3

4

5

IB5

Fulfilments of Service Level Agreements(SLAs) /performance of outsourced FM service providers

2

3

4

5

IB6

Safety management & accidents

1

2

3

4

5

IB7

Effectiveness of planning of the FM task

1

2

3

4

5

Customer/service quality indicators

1

Section 5; performance of Facilities Management (FM) services In your own view and considering the performance of FM services in your hospital, please evaluate by circling the most appropriate assessment of the performance of

116

Appendix C: General Questionnaire Survey

FM services relative to your major competitors (based on the five(5) performance measures) using the scales 1 -5, where 1 = very poor, 2 = below average, 3 = average, 4 = above average and 5 = excellent CODE

Performance measure

Level of performance

PM1

Peer review score

1

2

3

4

5

PM2

Complaints/feedback received

1

2

3

4

5

PM3

Support for service on core healthcare delivery

1

2

3

4

5

PM4

Contributions of FM service towards infections prevention and control

1

2

3

4

5

PM5

Budget variance (financial performance) 1

2

3

4

5

Please provide additional comments or note in the space provided below ………………………………………………………………………………… ………………………………………………………………………………… …………………………………………………………………………………

Appendix D

PLS-SEM Evaluation

Assessment of reflective measurement model

Test required

Evaluation criterion

Guidelines

References

Internal consistency

Composite reliability(CR)

CR > 0.6-0.9

Hair et al. (2017)

Reflective constructs indicators reliability(factor loadings)

Indicator loadings

Load > 0.70, Hair et al. (2017) ** however loads less than 0.7 can be considered provided AVE and CR meet threshold and provided other indicators compensate

Convergent validity

Average variance AVE > 0.50 Extracted (AVE)

Hair et al. (2017)

Discriminant validity

cross loading criterion

Chin (1998)

indicator loads for designated constructs should receive the highest loads

Fornell & Lacker The square root of Criterion the AVE of a construct should be larger than the correlations between the construct and other constructs in the model

Fornell and Larcker (1981)

(continued) © The Editor(s) (if applicable) and The Author(s), under exclusive license to Springer Nature Singapore Pte Ltd. 2021 D. Amos et al., Measurement of Facilities Management Performance in Ghana’s Public Hospitals, Management in the Built Environment, https://doi.org/10.1007/978-981-33-4332-0

117

118

Appendix D: PLS-SEM Evaluation

(continued) Test required

Evaluation criterion

Guidelines

References

Hetero-trait –Monotrait ratio (HTMT) of correlations

*HTMT 0.85 (strict Henseler et al. criterion, Kline, (2015) 2011) *HTMT 0.90(Conservative) HTMT inference based on bootstrapping -1 < HTMN < 1

Assessment of formative measurement model Collinearity Variance among indicators Inflation Factor(VIF)

Significance and relevance of outer weights

VIF > 5

Hair et al. (2013)

VIF > 3.3

Diamantopoulos and Siguaw, (2006)

Outer weights from Hair et al. (2017) bootstrapping should be significant to be maintained. Conversely if weight is not significant, consider outer load. Load > 0.50 and must be significant Consideration can also be given to retain formative indicator on grounds of content validation

Diamantopoulos and Winklhofer, (2001)

VIF ≤ 3.3

Diamantopoulos and Siguaw, (2006)

VIF ≤ 5.0

Hair et al. (2017)

0.26—substantial 0.13—moderate 0.02—weak

Cohen (1989)

Assessment of the structural model Lateral collinearity

VIF

Coefficient of determination

R2

Significance of constructs

Path coefficient p P values < 0.05 and t values T > 1.645(in a one tail test)

Hair et al. (2017)