Health care administrators commonly employ two types of resource flexibilities (demand upgrades and staffing flexibility) to efficiently coordinate two critical internal resources, nursing staff and beds, and an external resource (contract nurses) to satisfy stochastic patient demand. Under demand upgrades, when beds are unavailable for patients in a less acute unit, patients are upgraded to a more acute unit if space is available in that unit. Under staffing flexibility, nurses cross-trained to work in more than one unit are used in addition to dedicated and contract nurses. Resource decisions (beds and staffing) can be made at a single point in time (simultaneous decision making) or at different points in time (sequential decision making). In this article, we address the following questions: for each flexibility configuration, under sequential and simultaneous decision making, what is the optimal resource level required to meet stochastic demand at minimum cost? Is one type of flexibility (e.g., demand upgrades) better than the other type of flexibility (e.g., staffing flexibility)? We use two-stage stochastic programming to find optimal resource levels for two nonhomogeneous hospital units that face stochastic demand following a continuous, general distribution. We conduct a full-factorial numerical experiment and find that the benefit of using staffing flexibility on average is greater than the benefit of using demand upgrades. However, the two types of flexibilities have a positive interaction effect and they complement each other. The type of flexibility and decision timing has an independent effect on system performance (capacity and staffing costs). The benefits of cross-training can be largely realized even if beds and staffing levels have been determined prior to the establishment of a cross-training initiative.

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B ecause of the interactive role employees play in service operations, their behaviors often affect the customer's experience directly. Employee behaviors, in turn, are often a function of the culture in which they are born and raised. To that end, it is critical to develop a national culture theory for service firms that need to operate in an increasingly global business environment and to study the extent of the impact of employees' national culture on a service firm's quality outcomes. Our review of the literature aims to increase the understanding of such links. We trace the impact of major cultural characteristics (adopted from the work of Geert Hofstede and the GLOBE project) on three dimensions of service operations: physical surroundings and products, employee behavioral aspects, and service supply chain operations. We also study the extent to which these relationships change in different segments of the same market. We develop a research framework, offer testable propositions for additional research, and identify future research directions to advance the field on these matters.

PurposeThe purpose of this study is to examine the effect of the use of unit-level functional flexibility on one particular patient outcome, unit-acquired pressure ulcers, and the potential moderating influences of coworker support and workload.Design/methodology/approachThis study uses an archival approach, examining data from 68 hospital units.FindingsThe results indicate that a unit's higher use of functionally flexible nurses in one-quarter was associated with a higher number of pressure ulcers among the unit's patients the following quarter. This detrimental effect was significantly diminished when coworker support within the unit was high. Unit-level nurse workload did not have any moderating influence.Research limitations/implicationsOne of the scholarly contributions of this study is that it links greater use of functionally flexible employees to a negative patient safety outcome at the unit level. As most of the variables used in the study were archival measures, future research could examine the replicability of these findings using other indicators and measures.Practical implicationsBeyond healthcare settings, the results prompt managers in industries where there has been growing use of functional flexibility (e.g., banking) to think about the associated unintended negative consequences. That said, the results also point to coworker instrumental support as a means by which to mitigate negative outcomes.Originality/valueAlthough functional flexibility has been shown to positively correlate with a number of organizational performance indicators, this is one of the very few studies that has examined its negative consequences, particularly on patient safety.

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