International Journal of Logistics Research and

Applications
A Leading Journal of Supply Chain Management

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Investigating automation and AGV in healthcare

logistics: a case study based approach

Blandine Ageron, Smail Benzidia, Omar Bentahar & Julien Husson

To cite this article: Blandine Ageron, Smail Benzidia, Omar Bentahar & Julien
Husson (2018): Investigating automation and AGV in healthcare logistics: a case study
based approach, International Journal of Logistics Research and Applications, DOI:
10.1080/13675567.2018.1518414

To link to this article: https://doi.org/10.1080/13675567.2018.1518414

Published online: 21 Sep 2018.

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INTERNATIONAL JOURNAL OF LOGISTICS: RESEARCH AND APPLICATIONS
https://doi.org/10.1080/13675567.2018.1518414

Investigating automation and AGV in healthcare logistics: a case

study based approach
Blandine Ageron , Smail Benzidia, Omar Bentahar and Julien Husson
Université de Lorraine, CEREFIGE, CERAG, IAE de Metz, Metz, France

ABSTRACT ARTICLE HISTORY

In France, as in numerous countries, healthcare organisations are Received 25 November 2016
undergoing major transformations, leading them to rationalise their Accepted 23 August 2018
resources and optimize their flows. In this context, automation can play
KEYWORDS
an important role, enabling value creation and patient satisfaction. Logistics; automation;
Previous research has mainly focused on the technological aspects of healthcare organisation; AGV;
automation, neglecting the organisational issues related to the exploratory case study
implementation of this innovation and particularly the management of
the hospital staff, including logistics personnel, involved within the
organisational change process. The aim of this article is, at least, to
partly address this gap within the literature, and to propose, based on
an exploratory case study, an analysis grid of the challenges and
changes in terms of logistics flows (pharmaceutical, waste, laundry, etc.)
that impact staff involved in managing these flows in a hospital context.
Our results highlight the importance and necessity of anticipating the
building and deployment of new knowledge and skills in order to
efficiently and effectively design and manage automated logistics flows
with AGV system.

1. Introduction
France, like many developed countries, has experienced significant organisational transformations in
its healthcare sector, which is confronted with a new innovative mode of governance. The old system,
which generated a significant budget deficit and cumulative debt in these organisations, has been
assessed as very lax by the expenditure administration (Aptel, Pomberg, and Pourjalali 2009). In
this context, the French government proposed a new funding system by establishing new pricing
rules such as (T2A1) in 2005, followed by a series of legislative reforms and projects in the context
of two national plans, ‘Hospital 2007’ and ‘Hospital 2012’. The objective was primarily to introduce a
management culture based on cost control while continuing to ensure quality care for patients.
Indeed, the pressure of providing healthcare at lower costs has increased (OECD 2015).
This new orientation, related to a capitalist industrial rationale led directors and managers of
healthcare organisations to conduct further discussions to rationalise their resources and optimise
their flows. Aware of the importance of the management of logistics processes for their organisation,
many hospitals have institutionalised logistics as a function whose aims are to ensure better flow
exchanges and improve productivity throughout the supply chain (Aptel, Pomberg, and Pourjalali
2009; De Vries and Huijsman 2011; Dobrzykowski et al. 2014). Actually, the logistics costs in hos-
pital account for more than 30% of hospital expenditure and half of this cost could be eliminated
through logistics management (Poulin 2003; Kritchanchai, Hoeur, and Engelseth 2018). In this per-
spective, Van de Klundert, Muls, and Schadd (2008) observed that the management of hospital flows

CONTACT Blandine Ageron [email protected]

© 2018 Informa UK Limited, trading as Taylor & Francis Group
2 B. AGERON ET AL.

can be improved by adopting formalised work processes, standardising materials, or increasing the
use of information systems for better planning and control. Partnership relations with external sta-
keholders, including suppliers, or logistics outsourcing is also an opportunity to control the supply of
goods, to manage stocks more efficiently and to create more added value (Pan and Pokharel 2007;
Kumar, Ozdamar, and Zhang 2008; Meijboom, Schmidt-Bakx, and Westert 2011; Bailey et al.
2013) concluded that many problems in the healthcare sector are organisational and are related
to communication, patient safety, waiting times and integration. Moreover, because of decreasing
financial and human resources in the healthcare sector, the existing resources have to be reallocated
and the old modes of action have to be changed by looking for innovative working practices
(Kotonen, Tuominen, and Kuusisto 2013; Ageron, Benzidia, and Bourlakis 2018; Bélanger et al.
2018; Zhu, Johnson, and Sarkis 2018).
During recent years, a great number of studies have extended knowledge of operations and supply
chain management research in the healthcare sector (Dobrzykowski et al. 2014; Volland et al. 2017),
including the business process reengineering for sustainable healthcare design (Kumar and Rahman
2014), the automation of internal logistics to improve efficiency (Granlund and Wiktorsson 2013) or
the potential of RFID-enabled healthcare (Wamba, Anand, and Carter 2013) However, logistics and
supply chain management still remain fragmented and more seldom studied (De Vries and Huijs-
man 2011). Hospital logistics is seen as a complex process characterised by a diversity of activities,
products, and users requiring specific managerial responses (Rivard-Royer, Landry, and Beaulieu
2002; Bourlakis, Clear, and Patten 2011; Wieser 2011). Hence, logistics aims to reduce this complex-
ity by adopting new solutions, tools and methods to synchronise physical and information flows
internally and externally (Landry et al. 2000).
However, managerial tools and concepts of logistics and SC have not been systematically
implemented in healthcare. Managers are frequently left to their own experience to decide which
logistics solutions best fit their requirements. The potential of technologies to achieve productivity,
to improve patient care, to increase staff security and finally to improve organisational performance
has been largely demonstrated (Granlund and Wiktorsson 2013; Wamba, Anand, and Carter 2013;
Kumar and Rahman 2014; Volland et al. 2017; Kritchanchai, Hoeur, and Engelseth 2018). Different
technologies have been implemented in healthcare logistics (Feibert and Jacobsen 2015; Chikul,
Maw, and Soong 2017). Among these technologies, Radio-Frequency IDentification (RFID) as
well as Automated Guided Vehicle (AVG) emerges as the standards for hospitals and healthcare
centres (Chikul, Maw, and Soong 2017). The technology considered in this paper is AVG. This tech-
nology has been proven effective in transporting hospital supplies and including pharmacy, food,
linen, etc. to different wards, saving costs and improving security (Kumar and Rahman 2014; Lu
et al. 2017; Pedan, Gregor, and Plinta 2017). This choice is guided by our case study which focuses
mainly on physical flows and logistics issue. Moreover, AGVs system appears to offer not only a
logistical solution to deal with the complexity of hospital flows (Granlund and Wiktorsson 2014),
but a source of efficiency and flexibility to cope with varied demands, including different types of
material in different designed areas, at any hours of the day (Feibert and Jacobsen 2015; Marchet,
Melacini, and Perotti 2015). Most researches dealing with AGV concentrate on the design and
the control issues of the system from a technical/technological approach (Le-Anh and De Koster
2005; Vis 2006), including the number of AVGs used, the occupancy degree, the number of pick-
up and delivery points, etc. More recently, Fazlollahtabar and Saidi-Mehrabad (2015) and Bechtsis
et al. (2017) promote the use of a more holistic approach to the existing knowledge on AGVs to
address all the issues notably managerial and organisational ones. Although the economic ramifica-
tion of AGVs in logistics has been largely outlined, efforts have to be made to integrate in novel
researches, keys issues that companies face. In this perspective, the management of the resources
and particularly the human management resource is a crucial issue (Hohenstein, Feisel, and Hart-
mann 2014; Derwik, Hellström, and Karlsson 2016). In the healthcare logistics context, this challenge
has already be tackled for medical staff including nurses, who spent frequently time on indirect care
activities, often connected to logistics (Poulin 2003; Granlund and Wiktorsson 2013; Bélanger et al.
 INTERNATIONAL JOURNAL OF LOGISTICS RESEARCH AND APPLICATIONS 3

2018). Despite health logisticians are being central to overcoming the challenges facing hospitals,
there has been a paucity of research that systematically analyses the competencies that are important
for effective management of logistics in the context. The organisation of logistics functions and the
descriptions of functions are frequently insufficient and the education of the staff is inadequate
(Kotonen, Tuominen, and Kuusisto 2013; Derwik and Hellström 2017). This paper aims to fill
this gap and to give answers to the main two questions to be addressed to implement an AGV project
from a logistics point of view.

. Concerning the management of hospital flows: Which flows to automate and which priority
between automated flows?
. About the management of logistics human resources: What are the benefits and the drivers of
AGV project for logistics staff?

The final objective of the paper is to propose guidelines to logistics healthcare managers to deploy
and implement an AGV project.
By investigating the contributions of logistics flows automation through the in-depth case study of
AGV implementation in a newly built hospital, this paper intends to make at least two distinct con-
tributions. First, responding to the call to conduct research focused on the automation of logistics
flows from an organisational perspective (Baker and Halim 2007; Dobrzykowski et al. 2014), this
study empirically examines the major challenges that hospitals have to tackle to manage their deliv-
ery flows efficiently. Second, it confirms that logistics flow automation affects patient service quality
and the flexibility of the logistics system (Christopher, Lowson, and Peck 2004). Finally, it questions
the human dimension of such projects in terms of logistics staff including skills, competencies
(Landry and Beaulieu 2001; Hohenstein, Feisel, and Hartmann 2014; Derwik, Hellström, and Karls-
son 2016; Derwik and Hellström 2017) and working conditions (Marchet, Melacini, and Perotti
2015).
In the following section, we first describe the research framework. Then, we present the research
design, the case study and the results. Subsequently we discuss the results and highlight the major
contributions. Finally, the paper concludes with limitations and perspectives for future research.

2. Research background
As anticipated in the introduction, the paper focus on the main questions/issues that need to be
addressed to implement an AGV system for the management of logistics flows in a hospital context.
The literature review is therefore performed by analyzing related issues: the management of hospital
flows (section 2.1.) logistics automated systems (section 2.2.), and the human side of automation
with logistics staff (section 2.3.).

2.1. Logistics of hospital flows

There has been a growing interest in the field of healthcare logistics and SCM (Ageron, Benzidia, and
Bourlakis 2018) including, the management of material (Volland et al. 2017), the design of the ser-
vice delivery system (Dobrzykowski et al. 2014), the pharmaceutical supply chain (Narayana, Pati,
and Vrat 2014), the design of distribution network (El Mokrini, Benabbou, and Berrado 2018),
the implementation of greening practices (Zhu, Johnson, and Sarkis 2018). Nevertheless, the man-
agement of hospital flows is very different from other industries/sectors and is unique for several
reasons. Hospital is a complex system where a network of organisational units interacts to perform
various processes (Feibert and Jacobsen 2015). Several internal and external logistics practices are
developed in hospital including the management of material, information, financial, knowledge
and collaboration flows (Rakovska and Stratieva 2018). The uniqueness stems also from the diverse
range of products and services addressing heterogeneous characteristics that require special
4 B. AGERON ET AL.

treatment (Beier 1995; Bélanger et al. 2018). Furthermore, the patient plays an active role and con-
dition in the outcome of the health services. Finally, logisticians state that they cannot predict their
patient mix and ultimately their supply consumption (Kumar and Rahman 2014). As a result, trans-
posing the industrial methods to healthcare organisations requires adjustments and time (Volland
et al. 2017). Healthcare logistics concern different processes and flows, including patient flows,
bed logistics, waste management, laundry flows, surgical tools management, etc. (Feibert and Jacob-
sen 2015). Despite this importance of logistics in hospitals, this function remains undervalued by
decision-makers (Beaulieu and Landry 2002) and logistics practices currently lack resources, com-
petencies and managerial vision (Barati et al. 2016). If patient flows and surgical and laboratory
flows have been extensively explored in the literature, the study of other logistical healthcare
flows is limited (Wamba, Anand, and Carter 2013; Volland et al. 2017). In this sub-section, we
will present the major flows that hospital manages excepting patient one.

2.1.1. Pharmaceutical flows

A great deal of research has been conducted on the management of pharmaceutical flows focusing on
flows of drugs and medical devices because they represent significant volume and cost to healthcare
organisations (Van de Klundert, Muls, and Schadd 2008). Stock and supply management of drug
flows is highly complex and confronted with several constraints, such as consumption fluctuations,
expiry dates and unbroken cold chains. Some researchers have proposed automated storage, picking
solutions (Piccinini et al. 2013) and continuous improvement tools to improve drug chain control.
Medical equipment is divided into two categories, i.e. single-use medical consumables such as syr-
inges or gloves, and materials and multi-use instruments for operating blocks and theatres. The latter
requires specific logistics to control the sterilisation process because of the risk of contamination and
infection for patients and medicine staff. It also involves daily storage, control and monitoring (Van
de Klundert, Muls, and Schadd 2008).

2.1.2. Waste flows

In healthcare organisations, the management of medical and non-medical waste is a critical part of
the logistics process. The issues related to the management of these flows are numerous and various
and represent economic, security and environmental challenges (Askarian, Heidarpoor, and Assa-
dian 2010). Although much of this waste (75% to 90%), considered as ‘household’ waste, can be
eliminated without any danger, other infectious medical waste is generated (10% to 25%) that rep-
resent a significant danger to staff, patients, visitors and the environment (Chaerul, Tanaka, and
Shekdar 2007). The management of these flows involves collection, sorting, transport, storage, treat-
ment and final elimination (Chaerul, Tanaka, and Shekdar 2007). The associated processes depend
on the waste characteristics (solid, liquid, potentially infectious, radioactive) and the available and
necessary treatment (recycling, incineration, burying). Moreover, healthcare organisations must
implement practices and methods that meet regulatory environmental and security standards in
an environment where collection and processing chains are increasingly complex and involve
very high elimination and control costs (Blenkharn 2005).

2.1.3. Laundry flows

The management of laundry flows is complex (Banerjea-Brodeur et al. 1998) as it includes a set of
activities that require care to ensure better sanitation conditions to protect patients and staff from
infection risk and contamination (Yajuan et al. 2015). Moreover, these highly variable and irregular
flows weigh up to 5% of the hospital budget. To cope with these constraints, logistics must find new
solutions to supply and manage these dirty and clean laundry flows while mobilising resources and
respecting sanitary conditions (Florez et al. 2008). In this perspective, Yajuan et al. (2015) describe an
automatic clothing inventory and classification system manage with RFID, which can automatically
classify and count the clothes, record washing, disinfection and transportation processes and usage
condition of clothes.
 INTERNATIONAL JOURNAL OF LOGISTICS RESEARCH AND APPLICATIONS 5

2.1.4. Catering flows

Catering flows concern all patient, visitor and staff meals. The management of these flows is very
important, especially for patients, and requires rigorous organisation to deal with different economic
and security constraints (Züger et al. 2018). In this context, the logistics function implements an
optimal catering system by adopting an effective, flexible timetable to meet variable demands
depending on the medical condition of patients. This therefore requires a flexible service to avoid
any breakage or wastage of food (Barrie 1996).
In addition, the efficiency of the logistics function also depends on the constraints of food health
and safety principles in the certification process framework and the quality assurance system. The
role of logistics is to ensure good food quality within targeted food expenditure, which is often
blurred in hospitals. It also aims to coordinate all actors (nurses, logistics agents, other staff) involved
in the preparation, processing and distribution of food and raise their awareness of economic issues,
the principles of sanitary food, and best handling practices (Barrie 1996).

2.2. Automation in healthcare logistics

To face the various challenges of productivity, efficiency and customer service, the management of
internal and external logistics flows is becoming more and more strategic for organisations (Gran-
lund and Wiktorsson 2014). In the hospital context, several studies have investigated how the logis-
tics activities are performed to reduce cost (Kritchanchai, Hoeur, and Engelseth 2018) and to
improve processes by implementing initiatives such as just-in-time systems (Kumar, Ozdamar,
and Zhang 2008), organisational or managerial innovations (Lavastre et al. 2014; Bentahar, Benzidia,
and Fabbri 2016), Business Process Reengineering (Kumar, Ozdamar, and Zhang 2008) and auto-
mation (Granlund and Wiktorsson 2013). Indeed automation seems to be a research avenue in
healthcare logistics and SCM as the activities are often characterised by a large amount of manual
work, both time consuming and physically straining. Nevertheless, automation lives cases have
been mainly conducted in industrial sectors for manufacturing issues event if a transformation in
scope and in applications is undergoing (Granlund and Wiktorsson 2014; Fazlollahtabar and
Saidi-Mehrabad 2015). In this perspective Barros (2003) underlined the key role of automation in
the design of flexible production systems. Baker and Halim (2007) explored the issues related to
the project implementation of storage automation. More recently, Marchet, Melacini, and Perotti
(2015) studied the adoption of order picking systems in storage or distribution warehouses. For
these authors, automation offers potential benefits to companies including efficiency improvement,
customer service level increase, business activity growth adjustment, better security and comfort for
staff. It also challenges companies on several issues: investment costs compared to potential gains
from operational cost reduction; a lack of flexibility in the long term, difficulty of adapting the auto-
mation system to major changes in customer needs and business operations and dependency on
maintenance and informatics and programming skills.
The future role of information technologies in supporting the management and control of logis-
tics practices has been largely demonstrated (De Vries and Huijsman 2011; Volland et al. 2017;
Klumpp 2018). One of the technologies that have caught much attention in logistics area, including
hospital area, is radio frequency identification (RFID). Wamba, Anand, and Carter 2013 outlined
that the amount of publications on RFID-enabled healthcare has exploded since 2010. These publi-
cations mostly highlight the potential benefits of RFID and the technological issue. Among the
opportunity for future research, it seems that staff management has been understudied in compari-
son to patient management. Others technologies have been studied in healthcare logistics, including,
barcodes (Kumar, Ozdamar, and Zhang 2008), mobile devices and pneumatic tubes systems (Gran-
lund and Wiktorsson 2013), EDI (Kumar, Ozdamar, and Zhang 2008), conveyor systems and Auto-
mated Guided Vehicles (Kumar and Rahman 2014). All these technologies aim to track and trace,
plan and forecast or transport.
6 B. AGERON ET AL.

Automated system such as AGVs or pneumatic tube systems are gained more and more impor-
tance in organisations as they can improve logistics flows on transportations and delivery activities.
Designed to navigate autonomously upon a command, they are now mature technology/system that
are largely implemented in companies (Fazlollahtabar and Saidi-Mehrabad 2015). Compared to
others systems, AGVs outperform conventional conveyers in terms of flexibility, utilisation and
costs (Wang and Chang 2015). It also offers a capacity of automatic loading, transportation and
unloading (Ventura, Pazhani, and Mendoza 2015). AGVs yield a much more flexible transportation
plan not limited to the available human work power and also allow more frequent deliveries both
night and day time (Özkil et al. 2009). Largely used in manufacturing context and for transportation
issue, AGVs system is more and more diffusing in others fields and applications such as Healthcare
industry (Kumar and Rahman 2014), logistics (Lu et al. 2017) and retail (Granlund and Wiktorsson
2013).
However, the physical structure of the hospital is frequently a limitation when trying to AGVs, in
old buildings with for instance steep inclines/declines in culverts and narrow elevators. This is one
reason why, despite mature technology, it is still a costly investments. Moreover, the specifications of
AGVs differ per environment: 40 tons capacity for AGVs transporting container in ports, less
capacity for pallets in warehouse or trolley in hospital (Fazlollahtabar and Saidi-Mehrabad 2015).
From an academic point of view, AGVs are mainly studied from an optimisation perspective
based on mathematical methods, simulations studies, meta-heuristic techniques and artificial intelli-
gence (Fazlollahtabar and Saidi-Mehrabad 2015). Their design and control involve many issues that
belong to different levels of decision making. From a literature review, Le-Anh and De Koster (2005)
outline three different levels: Strategic, tactical and operational. The guide-path design can be seen as
a strategic issue. Estimating the number of vehicles and scheduling vehicle are tactical ones. Finally,
vehicle routine and deadlock resolution problems are addressed at operational level. About facility
layout, Wang and Chang (2015) propose a model that reduces not only the total cost of material
handling but also the solution time. Focusing on the pickup-dispatching and load-selection pro-
blems, Ho, Liu, and Yih (2012) propose a multiple-attribute method that can solve these two pro-
blems simultaneously. The proposed method contains four stages: preparation, clustering,
evaluation and execution. Evolving with increasing and constraining environment concerns, battery
management is becoming a central issue for companies and researchers (Ventura, Pazhani, and
Mendoza 2015; Kabir and Suzuki 2018).
Although lots of researches have been conducted on AGVs, most of them fail to integrate man-
agerial considerations, although, real case experiences outline that AGVs system has organisational
impacts (Pedan, Gregor, and Plinta 2017; Klumpp 2018). Lee and Leonard (1990) tackle the issue of
job creation and observe that could jeopardise job positions changing the working conditions and the
organisational structure. In it’s Spring Quarterly Report, the Automatic Guided Vehicle Systems
(AGVS) Industry Group of Material Handling Industry of America (MHIA) affirm that today
AGVs can reduce worker strain and provide ergonomic benefits while increasing operational
efficiency. Bechtsis et al. (2017) question the sustainability potential of AGVs on supply chain man-
agement and outline that if the economic benefits are largely identified, environmental and social
dimensions are less studied. More recently, Chikul, Maw, and Soong (2017) observed, in the specific
context of healthcare, that AGV system offers ergonomic benefits to the workforce by reducing the
distance travelled with load trolley. They also provides intangible long term benefits like possibility to
accommodate ageing workforce, better outcomes like decreased workplace injuries, staff turn-over
and increase people safety (Ventura, Pazhani, and Mendoza 2015). Finally, like others technology,
regardless of the robust functionality and advanced capabilities of the AGVs, the acceptability of
staff for such new devices has to be taken into account to predict if such a device will be utilised
by the workforce. Collaboration between human operators and artificial intelligent systems/
automated systems has to be evaluated and tested, otherwise, the risk of failure is imminent as
the human workforce cannot be educated and align with technology requirements (Klumpp
2018). This issue will be discussed in the next sub-section.
 INTERNATIONAL JOURNAL OF LOGISTICS RESEARCH AND APPLICATIONS 7

2.3. Logistics staff in hospitals

Organisational changes and recent modernisation in the hospital sector have impacted the logistics
function and increased its influence in healthcare strategy. In this regard, the logistics function has
adopted other industrial practices to control the various physical and information flows taking place
in hospitals. The management of logistics human resources supporting these flows (engineers, man-
agers and operators) through their skills development is also now an important issue for hospitals to
improve their logistics performance. Simultaneously, we observe, in developed word regions and
countries, a rising logistics competence requirements and a shortage of highly skilled workforce per-
sonnel (Klumpp 2018). This put pressure on organisations and increase competition for logistics
talent (Shi and Handfield, 2012). In this context, a central element of human resources management
is to ensure that talented employees with the right knowledge, skills, and motivation are placed into
the good jobs. From a structured overview of 109 peer reviewed articles, between 1998 and 2014,
Hohenstein, Feisel, and Hartmann (2014) identify seven main research streams: skills, knowledge
and abilities, training and development, HRM impact on performance, education and training, hir-
ing and recruiting, compensation and pay, global mindset. Derwik, Hellström, and Karlsson (2016)
study the nature of manager competence in logistics and supply chain management. Based on a in-
depth survey, they outline major propositions about the management of logistics resources. First,
companies might consider generalist profiles as well as logistics specialists for staff. Second, multi-
tasking ability is a prerequisite for logisticians to do his or her job. Their results suggest that logistics
and supply chain managers use business managerial, generic, and behavioural competences in prac-
tice rather than supply chain management expertise. Finally, from a systematic literature review con-
ducted on 98 articles on the subject of competence in logistics and SCM, Derwik and Hellström
(2017) identify different main stream researches including a focus on (1) competence for higher-
level decisions, such as strategic sourcing and the protection of core competences; (2) process
improvement orientation dealing with competence in processual arrangements, such as lean and
just-in-time; (3) competence to achieve logistics service quality and emerging issues such as fourth
party logistics (4PL) and reverse logistics; (4) education and training; (5) human resources manage-
ment, organisational learning, and employee-competence profiles; and finally, (6) collaborative com-
petences and the nature of relationships between stakeholders from different departments and
organisations. Their study also outlines that healthcare context concerns only two researches: one
analyse humanitarian logisticians (Bölsche, Klumpp, and Abidi 2013), the other explore the pharma
industry (Samuel and Spalanzani 2009).
Hence, researches remain limited, especially in emerging sectors such as hospitals, which are
nevertheless subject to a highly dynamic context that necessitates qualified logistics professionals
(Thai 2012). Myers et al. (2004) highlights that the logistics process is human-centric and organis-
ations should employ sufficient, optimal workforces to ensure services and guarantee greater value
for patients. In this perspective, the recruitment of quality logistics human resources (directors,
middle managers and operational staff) is important and involves evaluating three competencies,
i.e. technological and organisational skills and interpersonal relationships (Derwik, Hellström, and
Karlsson 2016). Myers et al. (2004) supplemented this research with four types of skills, i.e. social
competencies, decision-making competencies, problem-solving competencies and time management
competencies. However, Gammelgaard and Larson (2001) note that to achieve a high level of com-
petency in logistics and acquire sufficient knowledge depends not only on the upstream recruitment
quality but also on organisational experience. Regarding interpersonal skills, logistics managers
should adopt an efficient exchange mode through meetings and communication tools to increase sta-
keholders’ understanding of flow processes, the use of tools and the various challenges that logistics
represent/bring to healthcare organisations. Hospital managers feel that people management and
self-management skills are the most valuable for the efficient and effective management of hospitals,
followed by ‘hard management skills’ and skills related to the ability to think strategically (Pillay
2008). On the opposite, specific skills or knowledge related to health care delivery were perceived
8 B. AGERON ET AL.

to be least important. Hamidi and Eivazi (2010) highlight that a general lack of professional (human,
technical, computational) and communication skills contribute to managers’ inability to effectively
perform their function. Kotonen, Tuominen, and Kuusisto (2013) stress the importance of deep
cooperation between healthcare organisations and education providers to educate adequately logis-
tics staff for their job requirements. Howard (2015) demonstrates that healthcare managers often are
under-skilled and under-prepared with respect to the gravity of their role. More recently, Barati et al.
(2016) outline there is an urgent need, especially in developing countries, to develop and provide
different management modalities to enable hospitals to improve outcomes and drive healthcare pro-
visions forward.
This evolution of logistics activities also imposes the acquisition of information and communi-
cations technology (ICT) skills to better control physical flows in the hospital sector, which is com-
plex. Indeed, healthcare organisations must seize the opportunity offered by ICT to move towards a
new management based on financial, administrative and medical controls (Ahmadi, Ibrahim, and
Nilashi 2015). Thus, a double challenge emerges for these organisations, which need to trace all
of their flows in a safe way to avoid any health risk, and to reduce their logistics costs associated
with storage, registration and medical data processing time (Feibert and Jacobsen 2015). Finally,
logistics managers should be able to manage project techniques by coordinating physical and infor-
mation flows in coherence with their organisation strategic decisions. Moreover, they should manage
change and sensitise, involve and communicate with their human resources and/or collaborators by
helping them to understand the organisation logistics project (Derwik, Hellström, and Karlsson
2016).

3. Research design
To answer our research question, we follow a qualitative case study methodology. This is because
of the emerging aspect of this subject (very few studies have been conducted on the logistics
impacts of automation in the healthcare sector) and the lack of research carried out on the e
of AGV within hospitals from a logistics organisation perspective. Indeed, the current knowledge
of this topic is still in an exploration phase (Eisenhardt 1989), and the case study permit to cover
contextual conditions that we believe to be significant to the phenomenon we want to study (Yin
2009). Moreover, studying hospital logistics and obtaining information on this subject appears
difficult due to its recent emergence and complex processes. Finally, we aim to acquire an in-
depth understanding of logistics issues in experiences. The identification of a single, infor-
mation-rich case study encouraged us to choose this research methodology (McCutcheon and
Meredith 1993). This exemplar site provides a very good example of the observed phenomenon
and allowed us to answer our research question (Eisenhardt 1989). The hospital was a unique
pilot in logistics automation. Indeed, it was one of the first to be designed and constructed by
integrating an automation project of logistics flows from the early phase of drafting specifications.
Its construction was innovative, unlike other hospitals that have to integrate logistics flows auto-
mation into an existing system and infrastructure (including buildings), and it still remains a
reference for many other similar projects and hospitals that use it as a benchmark for future pro-
jects. Our privileged access to the hospital facilitated the achievement interviews with various
actors involved in flow management and the collection of empirical data.
Following Yin (2009), we established a research protocol to ensure reliability in our case study.
This protocol consists of creating and establishing our data-gathering instrument, namely a semi-
structured interview guide that includes questions designed to provide adequate coverage for the
purpose of the research. Simultaneously, we formulated our sampling strategy by defining the
characteristics of the respondents. Therefore, we stipulated whether actors were concerned according
to their job responsibilities, position and/or involvement in the project of logistics automation. They
were also chosen according to their capacity to provide the information needed for the research.
 INTERNATIONAL JOURNAL OF LOGISTICS RESEARCH AND APPLICATIONS 9

3.1. Semi-structured interview guide

The qualitative approach was based on an interview guide. We opted for a semi-structured interview
rather than a structured one because it offers sufficient flexibility to approach respondents differently
while covering the same areas of data collection. The interview guide was developed from three
sources of evidence. Thanks to the literature review, we highlight some key elements of hospital
logistics (flow traceability, flow automation, waste management, healthcare information technol-
ogies, and optimisation of medical practices). Informal conversations with some selected medical
actors (out of our field of study but in other hospital and/or healthcare contexts – with a logistics
manager of the Red Cross in Luxembourg, the logistics manager and director of the Nancy Hospital)
identified the challenges and issues of implementing an automation project. Printed material (news-
papers, professional journals) drew attention to the topicality and importance of the subject. More-
over, a preliminary hospital visit gave us insight into an automated logistics system, its operation and
issues. These multiple sources of evidence allowed us to develop a cross-cutting, complementary
vision of the subject on which our interview guide was built. Indeed, the interview guide based on
the flow management and automation literature has been modified and enriched through the discus-
sion with experts in the field of healthcare and logistics. It covers the following topics:

. Types and characteristics of hospital flows

. The limits of the previous organisation of flows
. The interest of automation through AGVs
. Feedback from the automation of flows
. The role and skills of the actors
. Potential improvements

Each interviewee was encouraged to give his or her personal view of the establishment and func-
tioning of an automated logistics system. After a brief presentation of the subject, we discussed the
various aspects of the automation project through issues related to project design (objectives, scope,
issues, stakeholders); project deployment and the logistics system operation, including questions on
flows, processes, actors, challenges and contributions; finally, the interview concluded by addressing
the performance of the logistics system in place and future automation projects.

3.2. Purposive sampling

To gain a holistic view and provide a detailed picture of this phenomenon, we interviewed all of the
concerned actors, both from the hospital and the AGV company.
At the hospital, we interviewed the director, project manager, current and previous logistics direc-
tors (that latter had been promoted to a new position since the deployment of the system), five man-
agers concerned and involved in the design and management of automated logistics flows, two
logistics technicians who use the automated system daily, two nurses, and two pharmacists who
are customers of the automated logistics system.
At the AGV company, we interviewed the project manager, logistics manager and sales manager.

3.3. Data collection and analysis

Data collection took place from November 2015 to April 2016. Fifthteen people concerned and
involved in the AGV project were interviewed. The interviews lasted from 25 to 121 min (Table 1).
All interviews were conducted face-to-face by at least two researchers. This data collection was
very rich and efficient. We interviewed only those actors that we considered to have sufficient knowl-
edge on the situation and notably involved and concerned with the automation project. Moreover,
we were able to clarify and/or specify some elements that our interlocutors did not understand or on
10 B. AGERON ET AL.

Table 1. List of interviews.

Organisation Interviewee Duration (in min) Date
Hospital Current logistics director 96; 77 02/11/2015; 18/12/2015
Previous logistics director 92; 90 25/11/2015; 28/04/2016
Hospital project manager 1 106 25/11/2015
Hospital director 75 10/12/2015
Logistics manager 1 63 21/12/2015
Catering manager 51 21/12/2015
Logistics manager 2 72 05/01/2016
Logistics agents 25; 33 05/01/2016
Druggists 60; 50 08/01/2016
Environment manager 51 16/02/2016
Nurses 35; 25 16/02/2016
Hospital project manager 2 121 28/04/2016
AGV company – DS Automotion (DSA) DSA logistics manager 30 08/01/2016
DSA commercial manager 55 15/03/2016
DSA project manager 45 07/03/2016

which they did not think we could answer. However, this face-to-face data collection is not exempt
from bias, including ‘social desirability bias’, which is when individuals attempt to answer survey
questions in ways that they consider socially desirable (Nederhof 1985). In order to limit this
kind of bias, all of our respondents were guaranteed anonymity and we compared their comments
with direct observation of working practices. Thanks to this comparison, we can affirm that no bias
was observed.
This data collection was completed by four non-participant observation situations. The four
researchers visited the hospital and observed the automated logistics system in operation through
the control room. Two of the researchers conducted two more in-depth visits (one day each) of
the hospital to directly observe the operation of the automation system and logistics flows. We
first visited the logistics station (starting point for all logistics flows to units), where we observed
the actual operation of the system and accompanied logistics technicians. Thanks to the AGV track-
ing path, we grasped technical, organisational and human system constraints. Our second visit was to
care units, where we followed the daily work of two nurses. Through informal discussions, we were
able to complement the interviews we had conducted and observe how the system could help them in
their day-to-day activities. In doing so, they explained the operation of the system, its advantages and
disadvantages. This complementary source of evidence provided new insights into the automated
logistics system. It contributed to compare discourses with practices and highlight differences. In
our case, we observed no difference between what was displayed and/or affirmed and what took
place in everyday activities.
Finally, we also had access to internal hospital documents on the automation project and its cur-
rent operation (personal documents of respondents, meeting reports, etc.) and external documents.
This documentary evidence compensated for the limitation of other methods and acted as a method
to cross-validate information gathered from interviews and observation situations. Thus, data quality
was enhanced based on the principles of idea convergence and the confirmation of findings.
Thanks to these multiple sources of evidence (interviews, observations, informal discussions and
documents), we augmented the construct validity of our case study (Yin 2009). The corroboration of
multiple qualitative techniques enhanced the validity and reliability of findings and enriched our
comprehension of the studied phenomenon (Bentahar and Cameron 2015).
All of the interviews were tape-recorded and saved to secure conversations and all important
information. The collected data were classified into categories to identify the relationship between
the automation flows and its implications on the organisation of the hospital (Miles and Huberman
1994). This data analysis was conducted by the four researchers in a dependent way. Given the num-
ber of interviews (twenty), the four researchers were easily able to analyze them to highlight major
and significant points.
 INTERNATIONAL JOURNAL OF LOGISTICS RESEARCH AND APPLICATIONS 11

4. Case study: Mercy Hospital in Metz

4.1. Case study description
The construction of Mercy Hospital (city of Metz in France) was part of the 2007 Hospital Plan,
whose goal was to build on the same site and in a specific building the maternity hospital and the
general hospital of Metz. Construction began in late 2009 and ended in late 2011. The hospital
was inaugurated in early 2012. Mercy Hospital was designed and built in a project combining
High Environmental Quality, precise architectural achievement and medical and surgical perform-
ance. From the design phase, the project emphasised a number of strengths, the most significant
being: advanced computing systems and automated and ecological production systems. The auto-
mation of logistics and the associated constraints and requirements of this function were therefore
included early in the project.
Flows involved in automation concern almost all hospital flows except for blood and patients’
flows that were not included in the initial project. The following are therefore automated: laundry,
catering, pharmaceutical, waste and sterilisation flows. The automation project was conducted with
the company DS Automotion, which is specialised in AGV technology. To meet transport needs
within the Mercy Hospital of Metz, twelve AGV were acquired. These vehicles are programmed
to take care of transportation. They receive an order and automatically go to the specified location,
using lifts if required. They load trolleys and transport them to their final destination until all flows
have been delivered. These twelve AGVs can manage campaigns involving up to forty trolleys (e.g.
for catering, which is definitely the most cumbersome campaign and is carried out twice a day). The
logistics system works by automatic campaigns and with trolleys dedicated to specific flows. These
campaigns are scheduled from 6am to 8.30pm from Monday to Sunday. For products with random
and non-scheduled flows, it was decided to maintain manual programming, including reducing the
number of trolleys in operation (only the waste stream is concerned by this manual system). After
four years of operation, all stakeholders describe the project as very successful, as all the flows initially
programmed in the project have been automated. The functioning of the system is effective and
meets the logistic objectives identified in the project phase. The partnership developed during the
project phase with the DS Automation provider continues today. It manages on behalf of the hospital
IS/IT issues (programming, reprogramming) and customer services (repair). After four years of
operation, the project is a real success in terms of technical, human and organisational aspects.

4.2. Case study findings

The analysis of the interviews was structured around key elements highlighted in the literature. We
concentrated on:

. Flows involved in the automated logistics system.

. Logistics staff roles and responsibilities in the new automated logistics system.

4.2.1. Flows and key elements of the automated logistics system

The case study reveals several important insights and findings regarding the implementation of the
automation system for the physical logistics flows. These important reflections led by the hospital
during the conception phase of the study focused on the choice of automated flows and the logistics
issues and consequences of this automation. An important issue also concerns the project boundary
and should lead to the examination and arbitration of important questions.
One of the first issues that the hospital had to deal with was the identification and selection of
physical flows to automate, which are numerous, different and complementary. These flows concern
catering and laundry (bed sheets and meals), pharmaceuticals and sterilised products, waste, blood
12 B. AGERON ET AL.

and patients. Mercy hospital decided not to automate all of these flows, but to focus only on the auto-
mated ones, as the hospital project manager 1 emphasised: ‘Waste management requires the manual
intervention of the agents especially downstream where it is necessary to rework, distinguish and sort
waste by hand’. The choice and selection of flows depends on several criteria: the regularity of the
flow:
Some flows such as meals have a certain consistency and therefore several campaigns are scheduled during the
day while for waste this is not possible because we do not control the rotation that depends on the variant
activity of the care units. We mainly targeted operating blocks that are big producers of waste (Hospital project
manager 1).

The second important criterion is the necessary flexibility needed to manage some flows, ‘All streams
do not require automation. Some must be kept manual to remain flexible and adaptable’ (Logistics
manager 1). The third criterion is the importance of these flows in the logistics organisation, in terms
of hard working conditions: ‘We select regular flows that meet the objective first to relieve and help
logistics operators in their daily activities’ (Logistics manager 1).
The second important issue concerns flow prioritisation to support an efficient and effective logis-
tics organisation. The identification of prioritised flows over secondary ones is associated with time
and health constraints (catering and pharmaceutical flows), as the environment Manager noted:
The waste flows are never prioritized. We will focus on drugs, food, laundry … When there is an incident, for
example the laundry that is delayed, the laundry remains in spite of this, a priority and we are sacrificing the
waste transport time slot.

Meanwhile, regarding the issue of flows automation, Mercy Hospital examined its organisation of
physical flows and more precisely the need to set up a new logistics organisation. It was immediately
obvious that automation of the current logistics system was not feasible and that it was necessary to
examine the flows organisation. Indeed, a simple transposition of the previous system toward the
new one was not conceivable since automation involves scheduled working day campaigns, as the
logistics director pointed out: ‘From the moment we automate we are constrained to reconsider
and re-examine our logistics flow system. Since dedicated software needs to be programmed to man-
age the AGV, we need to question the relevance of what exists’. In the new organisation, the logistics
flows were split in two. Once they are received from the suppliers in the central warehouse, products
are prepared and transported to care units by the AGVs. In the care units, trolleys are unloaded from
the AGVs and dealt with by the hospital agent whose role is to deliver products directly to the care
units (see section on actors and new job creation).
The consequences of automation are significant and also concern the flows organisation in the
care units. Indeed, to be closer to these services and offer them quality delivery, it was decided to
create intermediate stations where the AVGs come to drop off the logistics trolleys. Each floor
has three stations that also operate as delivery or picking areas for all logistics flows (bed sheets,
meals, etc.). They are an opportunity to organise and manage the AGV round-trip in a full-empty
or two-bins system, as the hospital project manager 2 indicated:
The automated flow is optimized since the AGVs are always moving at full speed and we are particularly sen-
sitive to the waste management where the problem is not that of the quantity of trolleys needed. The difficulty
lies in the preparation and the sending of an empty trolleys and the organization of its full return to the rubbish
dump.

Thanks to this system, the nurse workload is reduced and the replenishment more efficient as there is
no inventory or count taken at the ward level.
Our case study highlights that the automation system deployed a logistics system (for catering,
laundry, waste and pharmaceutical flows) that is not only more rigid, but also more reliable.
The rigidity results from the flows campaign delivery system, which is essential and compulsory
for the AGV operation, as the logistics agent 1 specified:
 INTERNATIONAL JOURNAL OF LOGISTICS RESEARCH AND APPLICATIONS 13

The drugs will be sent at 1 pm so this is a supply campaign trolley of pharmacy, here at this moment we are
managing the Laundry campaign. Before we had the lunch with groceries that we sent and in the morning, we
were on the warehouse. It’s square. We respect a schedule of reception of the trolleys and we are well up to
empty the trolleys in the stations for a new supply. Otherwise we will have an AGV that will block a station
and we can have 15 min, 20 min delay.

However, this rigidity ensures efficiency and reliability because,

The care staff no longer questions when products and trolleys will arrive at the units. They know that the differ-
ent flows campaigns are scheduled and that the hospital agents will deliver the units at a fixed time for specific
flows. They are no longer waiting for their medicine box because the logistics officer is late because of a broken-
down lift or a mistake in preparation or delivery (Logistics manager 1).

Thanks to this flow regularity, all actors concerned with the flows automation know exactly the pace
of AGVs and can organise their work according to delivery times, regardless of the time of day.
Indeed, AGVs operate at a constant average speed, which allows a
regularity in the work. In fact, an AGV will not change its pace, whether it’s 6 in the morning, 8 am, 3 pm or 9
pm, while at the end of the day, logistics agents work slower than in the morning (Logistics director).

Despite the rigidity of flow, the control remains flexible in its ability to manage irregular flows, such as
waste. Because these flows are not regular they cannot be planned and organised in campaigns. Never-
theless, when waste is deposited at intermediate stations it is loaded by AVG to be transported to the
initial station. This flexibility also extends to the care units due to the AGV system time lag, which cre-
ates a gap between the trolleys’ preparation, their station positioning and their delivery to the floors:
If the trolley preparations are done and transported the following morning, it has no particular impact. So there
is this flexibility and that trolleys can be prepared, positioned at the initial station and the AGV loads them later.
We can disconnect the upstream phase of the trolleys’ delivery to the care units and this is also very interesting
(Logistics director).

This flexibility is also necessary in some emergency circumstances. In this case, the flows automation is
transferred to manual operation, which is the standard response of the system to deal with unantici-
pated situations that are not easily programmable (emergency delivery of pharmaceuticals for
example). In this respect, the logistics director strongly insists on the fact that ‘When there was a break-
down, a problem and it happened 2–3 times, we had to switch to a manual system for drugs. It was DS
Automotion who was managing this initially. But now we manage it internally’ (Druggists).
Moreover, automation has enabled the hospital to reconsider its storage system. To give more sur-
face to care units (due to the high cost of a hospital-m2, close to 3,000 euro), a reduction of logistics
surfaces (buffer stock) was decided on, including storage in units.
Finally, all the actors concerned with the automated system agree that the system is transparent
and efficient in terms of traceability and information. With regard to traceability, the DSA logistics
manager insists that,
The new system ensures a real transparency in terms of the roles of the actors by controlling their schedule; the
system allows a real-time and effective monitoring by creating the alerts of blockages or long waiting of AGVs
for example.

This traceability is essential to generate a transparent logistics system for all actors and even more so
for logistics agents,
Because everything is paced and sequenced for the team logistics agents. We have arranged and organized their
working time; they work with schedules where from such a time to such a time they know what to do. As a
result, everything is transparent and we know where the agents are at all times.

4.2.2. Roles of logistics staff

The first challenge for Mercy Hospital was to ‘Automate flows to improve working conditions’, as the
logistics director emphasised. Indeed, one of the major issues for the current hospital logistics is to
14 B. AGERON ET AL.

relieve the workload of the logistics agents who often endure difficult working conditions: ‘Pushing
heavy trolleys down long corridors and loading up to forty kilos’ (Logistics manager 1). In this per-
spective, the hospital expects a reduction in musculoskeletal disorders thanks to AGVs, which take
over transport on long distances, with a heavy burden in terms of logistics, as the logistics Agent 1
indicated:
Compared to the previous system, our conditions are improved, before, we made all the trips by pushing the
trolleys, When you reach a certain age, it becomes painful, today, we do much less effort, because we receive the
trolleys in the floors that are near the care services.

The second significant challenge concerns the role of logistics agents in the logistics system. At Mercy
Hospital, the logistics function depends on the Finance Department, whose main mission is to man-
age supply flows for all units. Following the automation of flows and reshaping of the logistics sys-
tem, it was decided to create two levels of logistics organisation as mentioned above. To support this
new organisation, the logistics team was split into two agent categories: logistics agents, who work in
the logistics warehouse and whose mission is to position trolleys at the station to permit AGVs to
load and transport them to the nearest care units; and hospital agents on the floor nearest to the
care units, whose role is to take the AVG trolleys, store them in intermediate stations and take
the different products to the care personnel. ‘While the automation project, we have reduced our
staff, especially the logistics agents, the new system has created well defined process and roles’ (Pre-
vious logistics director).
This re-organisation of the logistics team has had two major consequences on the role of logistics
agents concerned by automation.

. Redefinition of logistics agents’ activity. Mainly related to transportation, this activity switched to
AGV and has been replaced mainly by handling activities. ‘Let’s say that before, the logistics
agents transported the trolleys to the care units. Today, AVGs take the lift by themselves’ (Logis-
tics manager 2).
. Specialisation of logistics agents in the management of some flows. The first flows on which logis-
tics agents specialised was bed sheets and laundry flows, explained the logistics manager 2:
We didn’t have a small team on the bed sheets flows, we had a 45-person team that managed both catering and
laundry flows. It was not necessarily helpful to have all those people, and there were too many interlocutors.
Today we have a team of 10. They manage all the bed sheets from the moment that they are cleaned until
they come back dirty. So, there are fewer staff and we are sure that the flow is optimized.

Automation also resulted in the creation of new roles within the logistics system at the interface
between the preparation of supply and the delivery to care units. These hospital agents, ‘take the trol-
leys to the intermediate stations and within the offices and then store the products in the units’
(Logistics director). They are the interface between logistics and care and improve communication,
allowing care staff to ‘intellectually offload this issue knowing that AVGs are there without necess-
arily knowing all the details’ (Logistics director). Thus, the care staff is discharged of the logistics
tasks of meal preparation, reheating, and bed sheet storage, which are the responsibility of the
internal logistics services. They can focus on their care activities, as the hospital director said:
We have been able to provide the nursing staff the time needed by giving them to focus solely on patients and
manage their tasks services. As you know, in many cases, patients need a real proximity to nursing staff; they
have a big medico-psychological role that needs to be protected.

At Mercy Hospital, following this automation of logistics flows ‘a true logistics function’ has emerged
whose role is to support all hospital staff (health and administrative) to improve patient manage-
ment, as the logistics director outlined:
That is to say, logistics in a hospital is secondary as it is not the heart of our mission. However, poorly organized
logistics has a huge impact on care staff as it disrupts all their work. So, it is really by structuring logistics and
 INTERNATIONAL JOURNAL OF LOGISTICS RESEARCH AND APPLICATIONS 15

their associated activities that health professionals can dedicate 100% of their job to care and patients and this is
for me essential.

However, the implementation of automation has brought new challenges for all stakeholders. The
skills and role of logistics and hotelier agents were questioned, as the logistics director highlighted:
It messed up their mission. Finally, it changed a little. They [Logistics agents] no longer transport from point A
to point B but organize and supervise flows. This disconcerted them so that they no longer really knew what
their missions, work, and values were in this new system. It was not that obvious.

The skills issue is even more crucial given that logistics agents needed to understand the structure,
operation and functioning of this new automation system. They deal less with executing tasks and
more with supervising them, which requires different kind of expertise, as the logistics manager out-
lined: ‘Flows automation will necessarily have an impact on skills … . AGV supervision requires a
different type of expertise, that’s for sure’. This surge of skills and acquisition confront logistics man-
agers with a new challenge in terms of operational logistics knowledge but also information technol-
ogy and information systems knowledge. Concerning recruitments, this point is essential for the
logistics director, who notes that, ‘When you recruit and renew the team, you realize that you
need people who understand logistics issues but also information and technology systems’.
Finally, automation has the effect of creating a logistics culture among care staff in relation to
logistics flow management. The challenge was to outline the significance and influence of these
actors in relation with logistics and hospital agents in the logistics system. Their understanding of
the system and its constraints is also a key element of the automation effectiveness as the logistics
manager stated:
When it comes to delays, for me this is something really new for care staff. That is to say that for them, when it
was done by logistics agents and something went missing, well we called them back to the unit as soon as poss-
ible. Today things are more planned. There is no longer anyone who calls every morning to say, I forgot this or
that. Now when something is forgotten, unless it is really urgent, they have to wait for the new scheduled deliv-
ery. { … … .} Logistics agents understand that automation will facilitate their day-to-day work and they will
carry fewer products. On the other side, care staff realized that logistics is really important and I think that
with this automation implementation, they have seen the benefits, especially being able to focus on their
core business.

5. Discussion
This study complements and extends existing research on healthcare logistics by highlighting the
difficulty that hospitals face in managing their flows with automated technologies. Based on an
in-depth case study, this paper makes several unique contributions to the healthcare logistics and
AGVs literature.
First, this research points out that logistics automation is an opportunity for hospitals to meet the
challenge of improving hospital services with respect to the equity, efficiency, costs and quality of
healthcare (Van de Klundert, Muls, and Schadd 2008; Kritchanchai, Hoeur, and Engelseth 2018).
While the implementation of AGV undoubtedly improves efficiency and increases the patient service
level (Marchet, Melacini, and Perotti 2015; Chikul, Maw, and Soong 2017), our case study highlights
some important issues that need to be tackled to ensure the success of such projects. AGVs fre-
quently operates on a genuine cross-docking principle. This has a direct impact on the stock
level, which decreases drastically, and also reduces the space dedicated to logistics operations (Papa-
dopoulos, Radnor, and Merali 2011). Good initial planning is also essential for good implementation
(Baker and Halim 2007). To be effective, this planning phase needs to define the perimeter of the
project, and more precisely which flows to automate and which flows to operate manually. Indeed,
as some flows require a higher level of flexibility (less predictable) than others (more predictable),
automated equipment will not necessarily respond positively to any changes that may occur in
the delivery of flows (Baker and Halim 2007). The complexity of the distribution networks in the
16 B. AGERON ET AL.

hospitals and the variability in demand make difficult to achieve automation for all flows. In this per-
spective, the hospital decides to keep manually the waste flow management because of its variability,
its diversity and its diversity of locations in the units (Granlund and Wiktorsson 2013). Moreover,
implementing automation involves changing ways of thinking and doing. Supply chains need to be
implemented effectively, and the logistics function has to be integrated to cope with various issues,
such as communication between stakeholders, flow traceability, regulatory standards and expenses
reduction (Aptel, Pomberg, and Pourjalali 2009; Volland et al. 2017). Thanks to AGVs, the hospital
reduces phone calls between medical and logistics department, administrative works for supply and
inventory management, transcribing errors (Kumar and Rahman 2014). The various flows have to be
rationalised to ensure better coordination between all internal and external stakeholders to provide
quality care to patients (Rakovska and Stratieva 2018). Moreover, our study confirms that the
implementation of AGVs reduced workload of nurses on several logistics activities including, inven-
tory management, transportation (Granlund and Wiktorsson 2013) Furthermore, this study
confirms that adopting automated logistics processes for hospitals can improve process performance
(Wamba, Anand, and Carter 2013; Feibert and Jacobsen 2015). It also outlines that logistics practices
within hospitals remain insufficient, even though, ‘many healthcare organisations recognize the
importance of adopting SCM practices’ (De Vries and Huijsman 2011, 159). The difficulty of health-
care organisations to adopt and implement techniques and tools from industrial sectors is still preva-
lent, indicating that a transition and adaptation time is still necessary (Van de Klundert, Muls, and
Schadd 2008; Feibert and Jacobsen 2015).
Second, this study reinforces and complements previous research on logistics automation that
establishes that automation projects improve the quality and traceability of flows and consequently
customer service (Dadzie and Johnston 1991; Piccinini et al. 2013; Pedan, Gregor, and Plinta 2017).
To implement an effective logistics system (for patient care quality) hospitals need to rethink their
processes for improvement and introduce a lean thinking approach that generates positive results
(Papadopoulos, Radnor, and Merali 2011). In this regard, our study outlines that the logistics service
quality has been improved mainly through a modification of the delivery process. Indeed, care staff
has been able to focus on their main activities (patient care) and devote more attention to patients
(value creation and service proposition) because they have been relieved of logistics tasks carried out
by logistics agents. This result confirms Dadzie and Johnston’s (1991) study, which demonstrates a
positive correlation between automation and customer service quality and complements studies by
Baker and Halim (2007) and Marchet, Melacini, and Perotti (2015), which explore the impact of the
failure of automation projects on short-term customer service reduction.
Furthermore, our research highlights a reduction of flow flexibility resulting from the integration
of AGVs and confirms the inflexible capacity issues associated with such systems (Baker and Halim
2007). This difficulty to respond to demand variations is more pronounced for two flows (pharma-
ceutical and catering) that are priorities and urgent for patients. On the contrary, waste flow manage-
ment benefits from more flexibility due to the possibility for 72-hour storage permitted by
regulations. The issue of flexibility following the implementation of automation projects has been
studied in different research projects with sometimes contradictory results. Christopher, Lowson,
and Peck (2004) observed that automation allows greater supply chain flexibility faced with rapid
changing demand in a dynamic environment. Baker and Halim (2007) outlined the risk of flexibility
loss for industrial storage systems that automation can generate. According to Marchet, Melacini,
and Perotti (2015) automation especially affects long-term flexible order-picking systems confronted
with major changes in customer needs. Our research confirms and sustains the results of Baker and
Halim (2007) and Marchet, Melacini, and Perotti (2015) and highlights that automation of phar-
macy and catering flows reduces the flexibility in both the long and short terms.
Third, the study complements the growing body of AGVs literature knowledge on the staffing
issue (Baker and Halim 2007; Bechtsis et al. 2017). The results confirm and/or amend the theory
by clarifying the relationship between AGVs and working conditions. Safety and employee comfort
have increased following the implementation of such projects, as logistics agents cover fewer
 INTERNATIONAL JOURNAL OF LOGISTICS RESEARCH AND APPLICATIONS 17

kilometres (Papadopoulos, Radnor, and Merali 2011) and carry fewer loads per day (Marchet, Mel-
acini, and Perotti 2015). The consequence is a reduction of absenteeism and turnover in the logistics
department. This issue of workforce stability is particularly problematic in the healthcare context as
hospitals frequently lack human resources with sufficient and appropriate levels of logistics experi-
ence, competencies and culture (Thai 2012; Barati et al. 2016). Furthermore, all logistics tasks are
transferred to the logistics department to allow care staff to focus on the core of their activities
and thus allocate more time to patients. This confirms the conclusions of Landry and Beaulieu
(2001) that flow automation instigates a redefinition of some logistics tasks previously managed
by care staff.
Extending early studies, our findings illustrate the importance of professionalising logistics staff
and adapting them to the new activities and tasks imposed and requisite by flows automation (Fei-
bert and Jacobsen 2015). Skills can be developed internally by developing training programmes on
logistics subjects to inculcate this culture in healthcare organisations (Kotonen, Tuominen, and Kuu-
sisto 2013). Logistics skills can also be managed externally by recruiting (Myers et al. 2004) or by
outsourcing tasks that are not easily achievable by internal staff (Pan and Pokharel 2007).
Moreover, an efficient and optimal recruitment policy can also be developed by assessing employ-
ees’ logistics skills before they join the organisation (Gammelgaard and Larson 2001; Feibert and
Jacobsen 2015; Derwik, Hellström, and Karlsson 2016). This professionalisation concerns not
only logistics competencies but also other skills and knowledge on IS/IT that support this function
(Ahmadi, Ibrahim, and Nilashi 2015). Hospital managers and directors explicitly mention that this
issue is essential to adapt their organisations to a technological environment, and reaffirm the inex-
tricable link between SCM and IS/IT and the importance of managing both aspects jointly and sim-
ultaneously (Pillay 2008; Pedan, Gregor, and Plinta 2017).
Finally, we observe that automation generates culture changes and requires fully involving the
whole workforce (Baker and Halim 2007). It is important to develop a logistics orientation in
order to solve organisational problems that occur in healthcare context and to diffuse it among all
employees (Meijboom, Schmidt-Bakx, and Westert 2011). This requires a deeper understanding
of logistics processes and issues by all actors involved in the supply chain (managers, logistics agents,
care staff, administration) (Granlund and Wiktorsson 2013).

6. Conclusion
The study of a pioneer case of AGV implementation in a French hospital allowed us to explore and
understand the value of automation and its impact on the organisation of flows, quality of service,
working conditions, and skills acquisition and development for actors.
By contributing to a better understanding of these issues and the implications of flows automation
in a hospital context, this study, on the one hand, participates in the already widespread debate on
the importance of logistics in this sector and the necessity of structuring it to ensure effectiveness for
hospital organisation, and on the other hand, corroborates and enriches the existing theory, provid-
ing managers with an overview to anticipate the issues and skills needed when designing and organ-
ising automated flows.
Automation is often discussed from a technological or performance point of view, but rarely from
an actors’ perspective. This study aims to fill in this gap and contributes to highlight the importance
of automation for flows optimisation, staff safety and comfort, and patient satisfaction. In this regard,
automation has improved the management of hospital flows through the adoption of a formalised,
standardised system. The circulation of flows is more efficient thanks to lower storage costs and
shorter administration and operational management times. The new organisation also satisfies the
trend for more transparent information. Overall, automation ensures reliability and real-time acces-
sibility on the circulation of flows. This has a positive impact on decision-making for managers and
makes the process more efficient. Along with these benefits, patient service quality is improved
because healthcare staff can concentrate on the core of their work, i.e. taking care of the sick.
18 B. AGERON ET AL.

However, given the complexity of the hospital environment and different constraints linked mostly
to the need for patient safety, this new flow management has lost some flexibility. Managers find
themselves having to reconcile a rigorous system with actor satisfaction and a quality service for
patients.
In addition, we question how automation contributes to the development of interpersonal and
technical skills. Our case analysis confirms the need for hospital logistics automation on three
levels, i.e. (i) the strategic level, which corresponds to the design and construction of the logistics
network (long term) refers, in our case study, to the identification and the selection of physical
flows to automate; (ii) the tactical level, which corresponds to network utilisation and matching
resources with needs (medium term) concerns the role of logistics agents in the logistics system
and more precisely the reorganisation of the logistics team which was split in two agent categories;
and (iii) the operational level, which focuses on logistics operations (short term) and logistics sys-
tem performance.
This research has several limits. First, the case of automated hospital logistics flows that we
studied is very specific in so far as the automation project was integrated into the initial reflection
during the design and the construction of Mercy Hospital in Metz. However, many hospitals cur-
rently question the automation of their logistics flows in an existing building environment. This gen-
erates other problems that our case study does not explore. Moreover, in this study, we focused on
the post-implementation phase of AGV automation and did not question the upstream phase pro-
ject, whereas the design, conception and management of logistics flows are critical to the success or
failure of such projects. Thus, we did not look at the issue of choice and sizing of flows, nor the equip-
ment and human resources necessary to manage logistics activities within care units.
Finally, it would be interesting in future research to study the design phase of automation projects
in a hospital context. Emilie Durkheim Hospital, which we visited recently, should provide an inter-
esting subject since it is in the pre-study phase of its AGV automation project. Thanks to this case-
study, we could follow the different paths of the project and identify the drivers and the barriers of
AVGs system design and implementation. In addition, this case study may lead to other comparative
studies in other hospitals or healthcare organisations to compare our results and develop our under-
standing of logistics automation issues. It could be interesting to investigate smaller hospitals which
frequently have fewer resources dedicated to IS/IT projects. In these small hospitals, we frequently
observed a relative absence of logistics function although our case study highlights the importance to
institutionalise this function to professionalise the staff. The logistics competences and skills are also
an important issue for hospitals. Complementary studies could be conducted on the range of com-
petences logistics staff (managers as well as operators) uses in their practice. Such researches could
help logistics directors to compare and benchmark their staff perceived competence profile with the
job requirements and thus obtain guidance to help logistics staff in their choice of in-service or aca-
demic training.

Note
1. (T2A) Price per activity is a new system for financing public and private health institutions in France. It is based
on the nature and the volume of business and no longer on lump-sum funding.

Disclosure statement
No potential conflict of interest was reported by the authors.

Acknowledgments
The authors are most grateful to three anonymous reviewers for their constructive and helpful comments on the earlier
version of the manuscript which helped to improve the presentation of the paper considerably.
 INTERNATIONAL JOURNAL OF LOGISTICS RESEARCH AND APPLICATIONS 19

ORCID
Blandine Ageron http://orcid.org/0000-0003-1723-368X
Omar Bentahar http://orcid.org/0000-0002-2047-7135

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